Approach in simulations:
First steps: O₂ → IV → monitor + pads.
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If no pulse → start CPR immediately.
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Rhythm changes every 2 min of CPR → reassess + follow algorithm.
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Stay calm, delegate tasks, and verbalize steps.
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Airway & Ventilation
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Nasopharyngeal airway → conscious with gag reflex; measure nose → earlobe.
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Oropharyngeal airway → unconscious, no gag; measure mouth → angle of jaw.
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Bag-mask ventilation:
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1 breath every 6 sec (10/min).
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Each breath over 1 sec.
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Only half the bag (avoid overventilation → ↓ venous return + cardiac output).
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Bradycardia (HR <50 with pulse)
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Stable → monitor.
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Unstable (hypotension, chest pain, shock, HF, AMS):
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1st line: Atropine 1 mg q3–5 min (max 3 mg).
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Works for sinus brady, 1° block, 2° type I.
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Not effective for 2° type II or 3°.
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If atropine ineffective or contraindicated:
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Transcutaneous pacing (preferred).
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Dopamine 5–20 mcg/kg/min or Epinephrine 2–10 mcg/min.
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If refractory: Transvenous pacing (expert consult).
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Pacing rate: ~60 bpm (can go 60–80, but 60 is standard).
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Sedate if possible before pacing.
Tachycardia (HR ≥150 with pulse)
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Stable:
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Narrow → vagal maneuvers → Adenosine 6 mg → (then 12 mg if needed).
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Avoid in asthma/COPD (bronchospasm risk).
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If Afib/flutter → skip adenosine; use β-blocker or Ca²⁺-channel blocker.
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Wide → consider adenosine (if monomorphic), otherwise → antiarrhythmics:
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Procainamide, Amiodarone (150 mg IV over 10 min), Sotalol.
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Unstable (hypotension, chest pain, shock, HF, AMS):
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Immediate synchronized cardioversion.
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Sedate if available.
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Never cardiovert sinus tach.
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Pulseless Rhythms
VFib / Pulseless VTach
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CPR + O₂ + IV access.
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First action = Defibrillate ASAP.
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Shock 120 J → CPR 2 min → rhythm check.
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Shock 150 J → CPR 2 min + give Epinephrine 1 mg.
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Shock 200 J → CPR 2 min + give Amiodarone 300 mg (or Lidocaine 1–1.5 mg/kg).
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Alternate Epi (1 mg) and Amio/Lido with each cycle.
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Amio 2nd dose = 150 mg.
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Lidocaine 2nd dose = 0.5–0.75 mg/kg (max 3 mg/kg).
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Switch compressors q2min.
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For torsades → Magnesium 1–2 g in 10 mL NS over 20 min.
PEA / Asystole
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CPR + O₂ + IV access.
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Give Epinephrine 1 mg ASAP.
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No defibrillation.
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Continue CPR cycles: Epi → nothing → Epi → nothing.
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Search for H’s & T’s (hypovolemia, hypoxia, H⁺, hypo/hyperkalemia, hypothermia, tamponade, tension pneumo, thrombosis PE/MI, toxins).
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LVAD patients may have pseudo-PEA → check hum/perfusion, not pulse.
Post-ROSC Care
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Primary survey (ABCDE):
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Airway: intubate if needed.
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Breathing: O₂, ventilation, ETCO₂ monitoring (goal 35–40; >10 = good CPR).
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Circulation: ECG, BP, fluids, pressors (norepi/epi/dopamine).
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Disability: neuro exam (pupils, LOC).
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Exposure: look for trauma, bleeding, burns.
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Targeted Temperature Management (TTM):
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32–36°C for unresponsive patients post-ROSC.
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STEMI:
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Aspirin 162–325 mg chewed.
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Oxygen if sat <90%.
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Nitroglycerin (avoid if hypotensive, RV infarct, PDE-5 inhibitor).
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PCI goal: ≤90 min from first medical contact.
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Fibrinolysis: ≤12 hrs from onset.
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Stroke (ACLS adjunct)
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FAST exam: facial droop, arm drift, speech.
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Determine last known well time.
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CT head within 20 min, read by 45 min.
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tPA (alteplase): 3–4.5 hr window; BP <185/110 before giving.
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Endovascular therapy: ≤24 hrs.
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Glucose check mandatory (hypoglycemia can mimic stroke).
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Admit to stroke or neuro ICU.
Cardioversion vs Defibrillation vs Pacing
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Synchronized cardioversion: unstable tachycardia with pulse.
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Unsynchronized (defibrillation): pulseless VF/VT.
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Pacing: unstable bradycardia (2° type II or 3° block → skip atropine).
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CPR only: PEA & asystole.
Drug Quick Review
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Atropine: 1 mg q3–5 min (max 3 mg).
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Epinephrine (arrest): 1 mg q3–5 min.
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Amiodarone (arrest): 300 mg → 150 mg.
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Lidocaine: 1–1.5 mg/kg → 0.5–0.75 mg/kg (max 3 mg/kg).
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Adenosine: 6 mg → 12 mg.
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Magnesium (torsades): 1–2 g over 20 min.
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Pressors (post-ROSC): norepi, epi, dopamine.
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