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Sharp ESO Exam | Actual Questions and Answers Latest Updated 2024/
(Graded A+)
End Tidal CO2 - ✔✔the maximum CO2 concentration at the end of each tidal breath, which can be used to assess disease severity and response to treatment. Reflects cardiac output during CPR. Can be used to measure the effectiveness of cardiac compressions and assessment of return of spontaneous circulation (ROSC) after cardiac event ROSC - ✔✔Return of spontaneous circulation is established with the presence of palpable pulse, blood pressure, abrupt sustained increase in end tidal CO2 (typically > 40mmHg) after cardiac arrest therapeutic hypothermia - ✔✔Core temperature 32-36 C (89.6-96.8 F) joules for defibrillation - ✔✔Defibrillation Joules: 200 joules joules for cardioversion - ✔✔Cardioversion joules: 200 joules Physicians may order 75- 120 - 150 - 200 for conditions not covered in ESO policy For the patient not following commands after 120 minutes of ROSC - ✔✔Consider initiation of therapeutic hypothermia Treatment of pulseless arrests - ✔✔Provide 2 minutes of CPR-avoiding interruptions in compressions Asystole treatment - ✔✔i. CPR (2 min.) ii. O2 at 15 L/min. ambu bag iii. Epinephrine 1 mg IVP/IO (use epinephrine 0.1 mg/ml), repeat q 3-5 minutes iv. Repeat CPR and Epinephrine administration if no signs of ROSC Unstable Bradycardia - ✔✔i. O2 at minimum 10 L/min. NRBM
ii. If transvenous leads or epicardial pacing wires present, connect to a pulse generator and initiate pacing per protocol. If no response, perform the following: iii. Atropine 1 mg IVP/IO, repeat q 3-5 minutes max 3 mg iv. Transcutaneous pacing as soon as possible If above algorithm is ineffective: v. Start dopamine 400 mg/250 ml D5W infusion at 5 mcg/kg/minute. Titrate to patient response up to 20mcg/kg/minute If above algorithm is ineffective, start epinephrine 2 mg/ 250 ml NS @ 2 mcg/min., titrate to patient response up to 10 mcg/minute Pulseless Electrical Activity - ✔✔i. CPR 2 minutes and assess for possible causes The H's:
- Hypovolemia
- Hypoxia
- Hydrogen ion (acidosis)
- Hypokalemia
- Hyperkalemia
- Hypoglycemia
- Hypothermia The T's:
- Toxins
- Cardiac Tamponade
- Thrombosis
- Trauma
- Tension pneumothorax ii. O2 at 15 L/min ambu bag iii. Epinephrine 1 mg IVP/IO (use epinephrine 0.1 mg/mL), repeat q 3-5 minutes iv. Repeat CPR and Epinephrine administration if no signs of ROSC
Rapid Response Team - ✔✔A team PF health care professionals who bring critical care expertise to the patient bedside CPR (cardiopulmonary resuscitation) - ✔✔Includes circulation with compressions, airway assessment and breathing (C-A-B) Intraosseous (IO) Therapy - ✔✔Specialty Catheter inserted into the intraosseous space by a trained physician or IO insertion validated RN. Safe and alternative route to IV therapy is initiated when IV access is urgently needed but is not available Comatose Adult - ✔✔No eye opening to pain and no purposeful motor response Unstable - ✔✔Serious signs and symptoms related to the life-threatening rhythm or conditions which may include: Signs: tachypnea; apnea; respiratory depression; tachycardia; bradycardia; arrhythmias; hypotension; decreased O2 saturation; dyspnea; change in level of consciousness; increased intracranial pressure (ICP); status epilepticus Symptoms: Dizziness; lightheadedness; shortness of breath; chest pain; weakness; cold; diaphoretic; heart palpitations; anxiousness Titrate to patient's response: - ✔✔For the purpose of this policy, "patient response" means improvement in the patient's symptom for which the intervention was intended to relieve Circumstance under which an ESO Competent RN may perform ESO standarized procedures: - ✔✔Emergency standing orders will be initiated by ESO competency-validated RNs in the absense of a physician. Scope of Supervision - ✔✔The ESO standarized procedure will be institued only in the absence of a physician and in accordance with the patient's code status Notification of patient's physician - ✔✔When a patient presents with a life-threatening condition, the following steps will be taken:
A. Code Blue will be called immedicately, if appropriate (cardiac of respiratory arrest) B. Rapid Response Team may be called whenever critical care expertise is needed. C. Appropriate physicians will be notified immediately. Availability of medications required for ESOs: - ✔✔Medications that are part of an ESO must be readily available for administration to the patient General Procedure for all Life-Threatening Patient Conditions - ✔✔A. Obtain intravenous (IV)/intraosseous (IO) access (large bore cannula in the antecubital vein should be the first target for IV access if a central line is not present. B.Begin IV infustion of normal saline (NS) to keep vein open (KVO) c. If IV access is unavailable, naloxone, atropine, and epinephrine may be administered via endotracheal route at doses 2-2 1/2 times the IV dose diluted in 10ml NS flush. d. Flush IV with 20ml NS after each IV medications given and elevate extremity if applicable. e. In applicable situations, treatment (ex: O2) will be administered concurrently. Obtain oxygen (O2) saturation per pulse oximeter if readily available. Proper assessment and intervention techniques using circulation, airway, and breathing would be used: i. Compressions and ventilation should be performed at a rate of 30:2 compression-ventilation ratio if no advanced airway in place, or continuous compression rate of 100-120/min. and ventilation of 1 breath every 6 seconds (!0 breaths/min.) if advanced airway in place, for two minutes "push hard, push fast", allowing complete chest recoil, and minimizing interruptions in chest compressions after each intervention. ii. Consider EtCO2 to assess CPR quality and evaluate ROSC. iii. All external electrial therapy will use biphasic monitors using appropriate energy dose as designed by condition. a. Defibrillation joules: 200 b. Cardioversion joules: 200 (physician may order 75- 100 - 150 - 200 for conditions not covered in ESO policy f. Consider initiation of therapeutic hypothermia for the patient not following commands of showing purposeful movement within 120 minutes after ROSC antecubital vein - ✔✔First target for IV access if a central line is not present
xi. If rhythm persists, defibrillate, CPR, epinephrine 1mg IVP/IO (Use epinephrine 0.1mg/ml) every 3 to 5 minutes until ROSC is achieved. Chest Pain - ✔✔i. O2 start at minimum 4L/min. NC and titrate to maintain SPO2 greater than or equal to 94%. ii. Nitroglycerin 0.4mg sublingual if SBP greater than or equal to 90 mmHg and HR greater than 50. May repeat every 3-5 minutes x2. iii. Morphine sulfate 2mg IVP/IO, if SBP greater than or equal to 90 mmHg every 5 minutes up to a total of 10mg. iv. Give aspirin 325 mg non-enteric coated, chewed or crushed. If not contraindicated and no dose give on this date. v. If hypotension develops and no evidence of pulmonary congestion, give 250ml NS IV/IO (may be substituted with LR if currently infusing) and resume treatment for chest pain if not relieved. vi. 12 lead EKG Hypotension: Symptomatic - ✔✔i. O2 at minimum 10L NRBM ii. If hypovolemia is known or suspected, infuse 250ml NS (may be substituted with LR if currently infusing). Repeat in 5 minutes if no clinical improvement. iii. If SBP is less than 90mmHg, start dopamine 400mg/250ml D5W infuse at 5mcg/kg/minute. Titrate until SBP greater than or equal to 90mmHg and/or MAP greater than 60mmHg or up to 20mcg/kg/min. iv. In the presence of obvious blood loss, draw a stat H/H and Type and Cross 2 units PRBCs. v. If suspecting Sepsis, follow Suspected Sepsis Algorithm. a. O2 at minimum 10L/min. NRBM. b. Infuse 250ml NS may be substituted with LR if currently infusing. Repeat in 5 minutes if no clinical improvement. c. If fluid bolus ineffective, Ephedrine 5mg IVP/IO d. If no improvement within 3 minutes, repeat Ephedrine at 10mg IVP/IO. e. In the presence of obvious blood loss draw stat H/H and type and cross 2 units PRBCs. Hypoglycemia - ✔✔Follow the Hypoglycemic Standardized procedure for any patient with a serum glucose or fingerstick less than 70mg/dl (less than 60 mg/dl if pregnant).
Increased Cranial Pressure - ✔✔In the neurologically impaired patient with examination that suggests elevated intracranial pressure: unilateral of bilateral fixed and dilated pupils, decorticate or decerebrate posturing (Note: Implement only in the absence of specific ICP orders.) i. Raise HOB at least 30 degrees if patient is not hypotensive place patient's head in midline position. ii. Hyperventilate the intubated patient with FiO2 100% to maintain pCO2 26-30 mmHg. iii. Draw serum K+, Na+, BUN, Cr, Glucose, serum osmolality and ABG. Respiratory Depression - ✔✔Associated with prior narcotic or benzodiazepine administration. i. O2 at minimum 10L/min. NRBM ii. Narcotic-associated respiratory depression: Administer naloxone (Narcan) as follows (maximum dose of 0.4mg): a. Apnea: 0.4mg IVP/IO once b. RR less than 10: 0.1 mg IVP/IO Narcan every minute, may repeat x3. iii. For benzodiazepine-associated respiratory depression (apnea to RR less than 10) administer flumazenil (Romazicon) 0.2mg IVP/IO over 15 seconds. May repeat repeat in 45 seconds based on patient's response, not to exceed 0.6mg. Respiratory Distress - ✔✔Demonstrated by change in respiratory rate and/or use of accessory muscles, altered level of consciousness of cyanotic nail beds. i. O2 at minimum 10L/min. NRBM ii. STAT portable x-ray iii. In the presence of bronchospasm: Albuterol 0.5ml in 3ml NS aerosol inhalation iv. The Rapid Response Team or ICU RN in the ICU may obtain an ABG of VBG if unable to obtain ABG. v. The Rapid Response Team or ICU RN in the ICU may initiate non-invasive ventilation (NIV) for the following conditions in the absence of any contraindications a. Exacerbation of: COPD; asthma; acute CHF b. As a bridge to mechanical ventilation c. Contraindications for NIV: i. Respiratory Arrest ii. Inability to maintain a patent airway or clear secretions iii. Risk for aspiration of gastric contents (nausea, vomiting, or bowel obstruction)
Suspected Sepsis Algorithm - ✔✔i. If hypovolemia known or suspected, infuse 250ml NS (may be substituted with LR if currently infusing). Repeat in 5 minutes after infusion is complete if no improvement ii. Evaluate if patient meets at least 2 SIRS criteria: a. WBC count greater than 12,000 or less than 4,000 or greater than 10% bands b. Heart rate greater than 90bpm c. Respiratory rate greater than 20 per minute d. Temperature greater than 38.3 C or less than 36 C iii. If patient meets two SIRS criteria, assess for infection (confirmed of suspected) and organ dysfunction (any one of the below criteria): a. SBP less than 90, MAP less than 65 or decrease in SBP greater than 40mmHg b. Lactate greater than 2 c. Creatinine greater than 2 or UOP less than 0.5ml/kg/hr d. Bili greater than 2 e. Platelets less than 100, f. INR greater than 1.5, aPTT greater than 60 seconds g. New onset respiratory failure requiring BIPAP or intubation h. New mental status changes iv. If criteria in #3 met: a. Obtain serum lactate if not done within 6 hours: repeat in 4 house if initial level greater than 2). Rapid Response Team may order a POC lactate b. Obtain blood cultures x2. c. ICU/RRT RN Only if SBP less than 90mmHg after 250ml fluid bolus times two i. Start norephinephrine 4mg/250ml NS @ 2mcg/min. Titrate until SBP greater than or equal to 90 mmHg and/or MAP greater than 65mmHg up to 32 mcg/min. ii. LR or NS fluid bolus order of 30ml/kg @ 126ml/hr d. Consocumult RRT and call physician Documentation for nurse instituting ESO - ✔✔a. Life threatening condition b. Precipitating factors
c. Specific ESO implemented (medication and/or treatment) d. Patient's response e. When and which physician was notified ESO Documentation - ✔✔a. Interdisciplinary note b. Provider communication note c. Code Blue record and critique form-- for respiratory and cardiopulmonary arrest d. Rapid Response Team record will be completed for all RRT events that utilize ESOs One cycle of CPR - ✔✔-2 minutes of 100-120 compressions/min.
- O2 delivered by 15L by bag mask (10 breaths/min.)
- Use 30 compressions/2 ventilation ratio without an advanced airway Time event recognized to first chest compression - ✔✔Less than one minute Time event recognized to first defibrillation (initial rhythm is VF or pulseless VT) - ✔✔Less than 3 minutes Subsequent shock delivered - ✔✔2 minutes from previous shock- allow full 2 minutes of chest compressions Time pulselessness recognized to first IV/IO Epinephrine - ✔✔Less than 5 minutes Time event recognized to first assisted ventilation - ✔✔Less than a minute Targeted Temperature Management-TTM (Therapeutic hypothermia) - ✔✔Should be considered for all patients not following commands or not showing purposeful movement within 120 minutes after return of spontaneous circulation
are independent of each other (atrial rhythm and ventricular rhythm are regular). There are no consistent PR intervals. If IV access unavailable: - ✔✔Atropine, naloxone (narcan), and epinephrine may be administered via endotracheal route at doses of 2-2 1/2 the IV dose. Dilute the recommended dose in 10ml normal saline and inject directly into ETT. Do not interrupt CPR during administration. Following administration, reconnect the ambu bag to the ETT and continue ventilation at a rate of 10 per minute. Treat unstable bradycardia (HR less than 50 BPM) with: - ✔✔a. O2 at minimum 10L/min. nonrebreather mask (NRBM) b. If transvenous or epicardial pacing wires present, connect to a pulse generator and initiate pacing. If no response: c. Atropine 1mg IVP/IO, repeat every 3 to 5 minutes up to a maximum of 3mg d. Transcutaneous pacing as soon as possible If above algorithm is ineffective: e. Start Dopamine 400mg/250ml D5W infuse at 5mcg/kg/min. Titrate until systolic blood pressure (SBP) more than 90mmHg or up to 20mcg//kg/min. f. If Dopamine is ineffective, start Epinephrine 2mg/250ml NS at 2mcg/min. Titrate to patient response up to 10mcg/min. *Assess patient for adequate intravascular volume and volume status when using vasoconstrictors Pulseless Electrical Activity (PEA) - ✔✔1. PEA is the presence of electrical activity (other than V-Fib or ventricular tachycardia (V TACH) that fails to generate a detectable pulse.
- PEA is often associated with clinical states that can be reversed when identified early and treated appropriately. Treat PEA with: - ✔✔a. CPR (2 minutes) and assess for possible causes: i. Hs and Ts(H: hypovolemia, hypoxia, hydrogen ion (acidosis), hypo/hyperkalemia, hypoglycemia, hypothermia T: toxins; tamponade; thrombosis; trauma; tension pneumothorax b. O2 at 15L ambu bag (10 breaths/min.) c. Epinephrine 1mg IVP/IO, (use epinephrine 0.1mg/ml), repeat every 3-5 minutes
d. Repeat CPR and Epinephrine administration if no signs of ROSC e. If hypovolemia known or suspected: Infuse 250ml NS. Repeat in 5 minutes if no clinical improvement. If LR already infusing- may use LR. f. STAT chest x-ray (CXR) 3 types of Ventricular Tachycardia: - ✔✔1. Stable
- Unstable
- Pulseless Ventricular Tachycardia (VT) (V-TACH) - ✔✔Defined as three or more beats of ventricular origine in succession at a rate greater than 100 bpm. The rhythm is usually regular and may be monomorphic (QRS have same shape) or polymorphic (QRS with varying shapes). Atrioventricular dissociation usually is present. P waves may be recognized but are not usually associated with the QRS complexes. Stable V TACH - ✔✔-Patient is consious
- SBP more than 90
- No unstable signs or symptoms Treat Stable VT with: - ✔✔a. Call physician for orders b. O2 at minimum 4L/min. and adjust per patient status c. Obtain 12 lead ECG d. Draw serum potassium and magnesium Unstable VT: - ✔✔-Patient must be symptomatic, exhibiting one or more of the 'unstable' symptoms related to tachycardia
- The patient should be immediately cardioverted
- If time permits and patient is awake and responsive: Provide sedation with midazolam (Versed) prior to cardioversion Treat unstable VT with: - ✔✔a. O2 at minimum 10L/min. NRBM
k. Epinephrine 1mg IV/IO l. Defibrillate: Biphasic 200 joules m. Amiodarone 150mg IV/IO n. Resume CPR immediately for 2 minutes o. If rhythm persists, repeat, and continue alternating CPR, Epinephrine, and defibrillation Chest pain - ✔✔The most common presentation of an acute coronary syndrome (ex: unstable angina; non-Q wave MI; Q-wave MI Chest pain suggestive of ischemia may be described as: - ✔✔a. Uncomfortable pressure, fullness, squeezing, or pain in the center of the chest lasting several minutes (usually more than 15 minutes) b. Pain spreading to the shoulders, neck, arms, jaw; or pain in the back or between the shoulder blades c. Chest discomfort with light-headedness, fainting, sweating, nausea, or shortness of breath d. A global feeling of distress, anxiety or impending doom It is important to respond immediately when symptoms of myocardial ischemia are present. A high priority is to provide pain relief. Treat Chest Pain with: - ✔✔a. O2 at minimum 4L/min. NC to achieve saturations more than 94% b. NTF 0.4mg sublingual (SL) is SBP is over 90 and/or mean arterial pressure (MAP) >60mmHg and HR more than 50 bpm, may repeat twice every 3 to 5 minutes c. Morphine sulfate 2mg IVP/IO every 5 minutes up to a total of 10mg if SBP is more than 90 d. Aspirin 325mg non-enteric coated, (chewed or crushed) if not contraindicated and no dose given on this date e. If hypotension occurs and no evidence of congestive heart failure (CHF), give 250ml NS IV/IO (or LR if currently infusing) f. 12 lead ECG (assists in decision making, classification and treatment approach. ST segment elevation of more than 2mm in 2 contiguous leads or the onset of a new BBB suggests STEMI. Goal for ST elevation myocardial infarction (STEMI) is percutaneous coronary intervention (PCI) or thrombolytics in less than 90 minutes. If ECG is suggestive of STEMI, call RRT (STEMI Algorithm) Symptomatic hypotension - ✔✔Generally defined as SBP less than 90mmHg. The reduced BP produces clinical signs or tissue hypoperfusion. Clinical manifestations differ according to cause and compensatory
mechanisms in effect. Clinical signs that may indicate inadequate tissue perfusion include cool, clammy skin, oliguria, increased heart rate (cardiac compensation), impaired sensorium (decreased level of consciousness, confusion) *The patient must be symptomatic, exhibiting one of more of the 'unstable' symptoms related to the hypotension If hypotension/shock is associated with an arrhythmia: - ✔✔Rate that is too fast or too slow- treat the rhythm not the hypotension/shock Treatment for hypotension due to hypovolemia - ✔✔Fluid replacement *Vasopressors play a secondary role to increase systemic vascular resistance (when circulating volume is adequate) Hypotension that occurs post anesthesia: - ✔✔Treated with fluid replacement and Ephedrine Treat symptomatic hypotension with: - ✔✔a. O2 at minimum 10L/min. NRBM b. If hypovolemia known or suspected: infuse 250ml NS. Repeat in 5 minutes if no clinical improvement. If LR already infusing may use LR. c. If SBP remains less than 90mmHg, start Dopamine 400mg/250ml D5W at 5mcg/kg/min. Titrate to maximum of 20mcg/kg/min to achieve SBP more than 90mmHg and/or MAP more than 60mmHg d. If obvious blood loss, draw STAT H&H and type and cross 2 unites PRBC e. If sepsis suspected follow suspected sepsis algorithm Hypoglycemia - ✔✔Follow the hypoglycemia standardized procedure for any patient with a serum glucose or fingerstick less than 70mg/dl or 60mg/dl if pregnant Increased Intracranial Pressure - ✔✔The first sign of increased intracranial pressure (ICP) is a decreased level of consciousness; later signs include hemiparesis, decorticate or decerebrate posturing, or signs of herniations such as unilateral or bilateral fixed and dilated pupils. If ICP is being monitored, increased ICP is defined as ICP more than 15mmHg or as specified by the MD.
- Patient must be neurologically impaired with dilating pupil associated with other signs of impending herniation without specific ICP physician orders.
Respiratory Distress - ✔✔Demonstrated by a change in respiratory rate and/or use of accessory muscles, altered level of consciousness or cyanotic nail beds
- Can be caused by pulmonary disorders such as: *Bronchospasm *Cardiogenic or Noncardiogenic pulmonary edema *parenchymal infiltrates *Pneumothorax *Hemothorax *Atelectasis Therefore, obtaining a STAT portable x-ray is important Treat Respiratory distress with: - ✔✔a. O2 at minimum 10L/min. NRBM b. STAT portable CXR c. In presence of broncospasm, albuterol (Ventolin) 0.5ml in 3ml NS aerosol inhalation d. Rapid Response Team or ICU RN in the ICU may initiate non-invasive ventilation (NIV) for the following conditions in the absence of any contraindications i. Exacerbation of chronic obstructive pulmonary disease (COPD), asthma, acute CHF ii. As a bridge to mechanical ventilation iii. Contraindications for NIV:
- Respiratory arrest
- Inability to maintain a patent airway or clear secretions
- Risk for aspiration of gastric contents (nausea, vomiting, or bowel obstruction)
- Pre-existing pneumothorax without chest tube or pneumomediastinum
- Epistaxis
- Recent facial, oral, or skull surgery or trauma
- Encephalopathy/altered mental status
- Hypotension due to suspected intravascular volume depletion
- Unable to tolerate NIV (BiPap)
Status Epilepticus - ✔✔A condition associated with generalized tonic-clonic (grand mal) movements lasting more than 3 minutes or recurrent seizures without return of consciousness.
- Can be caused by withdrawal from anticonvulsant medications; acute alcohol withdrawal; central nervous system (CNS) infections, brain tumors, metabolic disorders; or cerebral edema
- During a seizure, the patient's airway is vulnerable therefore, maintaining a patent airway is essential. *Lorazepam (ativan) is the drug of choice for seizures Treat status epilepticus with: - ✔✔a. Protect airway, position patient in lateral decubitus position, protect patient from injury b. O2 at minimum 10L/min NRBM c. Lorazepam (ativan) 2mg IVP/IO over 1 minute d. Draw sodium; potassium; calcium; glucose; BUN; CR and anticonvulsant levels if appropriate Severe anaphylaxis - ✔✔Anaphylactic reactions may occur as a result of attempted hyposensitization, administration of drugs or contrast material, or certain foods. It may present with stridor, wheezing, respiratory distress, pallor, cyanosis or clinical signs of shock. Cardiovascular collapse is a common manifestation caused by vasodilatory and loss of plasma from blood compartment. Epinephrine Severe Anaphylaxis - ✔✔Considered to be the most important drug for any severe anaphylactic reaction. It works best when given early after the onset of reaction. Adverse effects are rare when given IM. Antihistamines and coritcosteroids are used adjunctively in the management of anaphylaxis. The former helps counter histamine release and the latter helps avert late sequelae. Treat severe anaphylaxis with: - ✔✔a. O2 at minimum of 10L/min. NRBM b. Epinephrine 0.3mg IM (Use Epinephrine 1mg/ml) Repeat in 5 minutes if no clinical improvement c. Place patient supine and elevate lower extremities d. Infuse 250ml NS. Repeat in 5 minutes if no clinical improvement e. In the presence of bronchospasm: Albuterol 0.5ml in 3ml NS aerosol inhalation f. Diphenhydramine (Benadryl) 25mg IVP/IO g. Hydrocortisone (Solucortef) 100mg IVP/IO
