Therapeutics 1 Tutoring Sarah Darby shodge7@uthsc.edu September 16, 2016

Lectures Covered ACLS Supraventricular arrhythmias

ACLS Which cardiac rhythm is shockable? Ventricular fibrillation Pulseless ventricular tachycardia Pulseless electrical activity Asystole A and B C and D

ACLS Identify the rhythm Sinus bradycardia Sinus tachycardia Ventricular tachycardia Pulseless electrical activity www.wolfscience.com

ACLS Identify the rhythm Asystole Ventricular fibrillation Ventricular tachycardia Pulseless electrical activity Ekg.academy.com

ACLS Identify the rhythm Asystole Ventricular fibrillation Ventricular tachycardia Pulseless electrical activity Medlibes.com

ACLS Identify the rhythm Sinus bradycardia Sinus tachycardia Ventricular tachycardia Pulseless electrical activity Learningcentral.health.unm.edu

ACLS Identify the rhythm Asystole Ventricular fibrillation Ventricular tachycardia Pulseless electrical activity Studentsofmedicineplus.weebly.com

ACLS Identify the rhythm Sinus bradycardia Sinus tachycardia Ventricular tachycardia Pulseless electrical activity Lifeinthefastlane.com

ACLS Identify the rhythm First degree AV block Second degree AV block type 1 Second degree AV block type 2 Third degree AV block Ekgacademy.com

ACLS Identify the rhythm Pulseless electrical activity Ventricular tachycardia Ventricular fibrillation Torsades de pointes Ekgacademy.com

ACLS What is the preferred initial catecholamine in ACLS? Norepinephrine Epinephrine Vasopressin Phenylephrine

ACLS JY is a 65 yo WM (80kg) who was found down at home by his wife. EMS arrived and began CPR. En route to the hospital, the first dose of Epinephrine is given. Which is appropriate? 1mg every 1 minute 1mg every 3 minutes 5mg every 1 minute 5mg every 3 minutes

ACLS How many milliliters of Epinephrine should EMS administer if they have a 30mL vial (1:1000)? 1mL 2mL 5mL 10mL

ACLS How many milliliters of Epinephrine should EMS administer if they are using a prefilled 10ml syringe (1:10,000)? 1mL 2mL 5mL 10mL

ACLS Which statement is true about Amiodarone? It is only used in patients with preserved left ventricular function The initial bolus dose is 150mg IV or IO It is a class III antiarrhythmic drug It has no effect on sodium or potassium channels

ACLS Which statement is true about Lidocaine? It is first line therapy for pVT and VF It causes less asystole than epinephrine It is superior to Amiodarone according to the ALIVE trial It should be dose adjusted in hepatic impairment

ACLS The physician asks you to dose the initial IV lidocaine bolus for a 75kg patient. Which is appropriate? 50mg 100mg 150mg 200mg

ACLS Which is the maximum cumulative dose of lidocaine that a 60kg patient can receive? 90mg 100mg 180mg 300mg

ACLS Lidocaine is part of the ACLS algorithm for pVT and VF. True or False.

ACLS Which statement is true about magnesium? It should be given rapid IV push. It should only be given in Mg deficiency. It is indicated for drug-induced Torsades. Mg has no effect on cardiac cell depolarization.

ACLS Which statement is true about adenosine? It is used to treat bradycardia It has a half life of 5 minutes It accelerates SA and AV nodal conduction It is contraindicated in pts with heart blocks

ACLS WT arrives in the ED with an EKG showing SVT and HR of 180. Which dose of adenosine is appropriate for this patient? 6mg rapid bolus 6mg infusion over 10 minutes 12mg rapid bolus 12mg infusion over 10 minutes

ACLS Which of the following side effects do you not expect to see with adenosine? Chest pain Flushing Vomiting Dyspnea

ACLS What do you recommend for a patient who is taking both adenosine and carbamazepine? Reduce the initial adenosine dose to 3mg Increase the initial adenosine dose to 9mg Reduce the carbamazepine dose Avoid adenosine altogether

ACLS Which statement is not true about atropine? It can cause tachycardia It increases sinus node automaticity It is first line for PEA Slow infusions should be avoided

ACLS During cardiac arrest, _______ tissue perfusion may lead to acidemia and the need for ____________ therapy. Poor; sodium bicarbonate High; sodium bicarbonate Poor; adenosine High; adenosine

ACLS Which statement is true about sodium bicarbonate? It improves survival and ROSC May induce hyponatremia May potentiate simultaneously administered catecholamines May help correct an existing metabolic acidosis

ACLS JT is an IV drug user, and the nurse is having trouble getting an IV placed. The nurse convinces the physician to use IO for administration. Which of JT’s meds can NOT be given IO? Epinephrine Amiodarone Adenosine Magnesium

ACLS Remember! IO = MAVEL Magnesium Amiodarone + Atropine Vasopressin Epinephrine Lidocaine

ACLS Which agent should not be administered down an ET tube? Lidocaine Amiodarone Epinephrine Atropine

ACLS Remember! Endotracheal tube = NAVEL Narcan Atropine Valium/Vasopressin Epinephrine Lidocaine

ACLS EB requires epinephrine but has an ET tube. What dose do you recommend? 1mg 2.5mg 5mg 10mg

ACLS Which patient is most likely to be a candidate for therapeutic hypothermia? Pt who is sitting up in bed talking one day after cardiac arrest Pt who is unresponsive after achieving ROSC in the ER Pt who is unresponsive and cannot maintain ROSC Pt on ventilator but can squeeze your hand when directed

ACLS EMS arrive on scene to find patient down. CPR is immediately started. The EKG shows VF. What is the first time point that epinephrine can be given? Before the first shock After the first shock After the second shock After the third shock

ACLS EMS arrive on scene to find patient down. CPR is immediately started. The EKG shows VF. What is the first time point that amiodarone can be given? Before the first shock After the first shock After the second shock After the third shock

ACLS EMS arrive on scene to find patient down. CPR is immediately started. The EKG shows PEA. What is the preferred course of action? (multiple answers) Administer a shock Give epinephrine every 3-5 minutes Give amiodarone after the third shock Continuous CPR Assess for reversible causes

Supraventricular Arrhythmias RT complains of sudden onset of palpitations and chest discomfort that spontaneously resolves. This most often occurs after exercising. What arrhythmia is described? AFib Paroxysmal SVT Ventricular tachycardia

Supraventricular Arrhythmias RT’s current BP is 85/45 and HR is 184. Vagal maneuvers and adenosine were attempted without desired effect. What treatment do you recommend? DCC Metoprolol Diltiazem Verapamil

Supraventricular Arrhythmias What if RT’s BP had been 135/90 and HR was 115? Vagal maneuvers and adenosine were attempted without desired effect. What treatment is not appropriate? Metoprolol Diltiazem Verampamil Amlodipine

Supraventricular Arrhythmias Which of the following is not an example of a vagal maneuver? Carotid massage Valsalva Coughing Hot water immersion

Supraventricular Arrhythmias MT is a 68 yom who has struggled with AFib for years. He and his physician decide that attempting to maintain NSR is no longer desired. Classify his AFib. Paroxysmal Persistent Long-standing Permanent/chronic

Supraventricular Arrhythmias MT presents to the ED with dizziness and fatigue that started 12 hours ago. His BP is 80/45 and HR is 192. The EKG shows a regularly irregular heart rhythm. Which statement is false? MT is hemodynamically unstable. MT is at an increased risk of stroke. DCC is an appropriate choice at this time. Oral anticoagulation should occur before DCC

Supraventricular Arrhythmias Which agent is not appropriate for acute rate control? Metoprolol tartrate Atenolol Esmolol Propranolol

Supraventricular Arrhythmias KT is a 63 yo WM who presents to the ED with SOB and dizziness. EKG confirms that he is in AFib. PMH: HTN, asthma, DM. Which agent for acute rate control is most appropriate? Esmolol Diltiazem Dronedarone Digoxin

Supraventricular Arrhythmias Which agent exerts its effects through vagal stimulation? Atenolol Verapamil Digoxin Amiodarone

Supraventricular Arrhythmias FK is a 58 yo AAM who was admitted after experiencing ongoing breathing trouble for 1.5 weeks. In the ER his EKG showed AFib. The team decides to utilize pharmacological cardioversion on hospital day 2. Which agent is not appropriate? Amiodarone Flecainide Ibutilide Dofetilide

Supraventricular Arrhythmias Which patient is not eligible for “pill in the pocket” pharmacological conversion? 68 yo w/ NYHA class 3 HF 34 yo w/ QT prolongation 38 yo w/ no hx of heart disease 55 yo w/ AV block

Supraventricular Arrhythmias Which agent for maintenance of NSR is appropriate for patients with HF? Amiodarone Sotalol Dofetilide Flecainide A and C B and D

Supraventricular Arrhythmias BD (80kg, CrCl=50ml/min) has been successfully converted out of AFib using DCC. The team wants to initiate Sotalol to maintain NSR. What dose do you recommend? 80mg BID 80mg daily 80mg QOD Do not use Sotalol in this patient

Supraventricular Arrhythmias Which agent requires admission into the hospital for initiation of therapy? Sotalol Dronedarone Dofetilide Ibutilide A and C B and D

Supraventricular Arrhythmias DR is a 59 yo male requiring pharmacologic conversion. The team plans to continue him on this agent for maintenance therapy. PMH: HF, CKD. Dronedarone Flecainide/Propafenone Amiodarone Ibutilide

Supraventricular Arrhythmias TH requires DCC for SOB and dizziness that has been coming and going for the past 2 weeks. EKG shows Afib. Choose the best sequence of events for cardioversion. DCC immediately. No therapy needed after successful cardioversion. Perform TEE. If no clot formation, DCC. No therapy needed afterward. Perform TEE. If no clot formation, DCC. Use anticoagulant for 4 weeks after. Use anticoagulant for 3 weeks before cardioversion. Discontinue after. Use anticoagulant for 1 week before cardioversion. Continue for 4 weeks after.

Supraventricular Arrhythmias MH is a 66 yo female. She is currently being treated for HTN, DM, COPD, and glaucoma. What is her CHA2DS2-VASc score? 1 2 3 4 5

Supraventricular Arrhythmias CP is a 79 yo male. He has a history of CHF (LVEF=35%), PVD, HTN, and DM. What is his CHA2DS2-VASc score? 3 4 5 6 7

Supraventricular Arrhythmias CP is a 79 yo male. He has a history of CHF (LVEF=35%), PVD, HTN, Afib and DM. According to his CHA2DS2-VASc, he is considered high risk. What do you recommend to prevent stroke? No treatment recommendation Warfarin Aspirin Enoxaparin

Supraventricular Arrhythmias CP is a 79 yo male. According to his CHA2DS2-VASc, he is considered high risk. He desires to use a NOAC to avoid INR monitoring with Warfarin. His CrCl=25ml/min. Which agent is appropriate for him? Dabigatran 150mg BID Rivaroxaban 15mg daily Apixaban 5mg BID Edoxaban 30mg daily

Therapeutics 1 Tutoring Questions? Sarah Darby shodge7@uthsc.edu September 16, 2016