ACLS Study Guide

tylerwise's version from 2015-04-27 03:48

Rhythm Strips

Question Answer
Normal sinus rhythm
Atrial fibrillation
Multiple random atrial "firings" between ventricular discharges
Atrial flutter
Multiple "sawtooth" shaped atrial discharges between ventricular discharges
First degree heart block
Regular, widened PR interval (>20 ms)
Second degree heart block - Type I
PR interval increases with each beat until a QRS is completely missed
Second degree heart block - Type II
Regular, unchanging PR interval with random, missed QRS complexes
Sinus bradycardia
Sinus tachycardia
Third degree heart block
Complete atrial/ventricular dissociation
Ventricular fibrillation
Seemingly random ventricular discharges (no pattern)
Ventricular tachycardia (monomorphic)
Fast, regular ventricular discharges with "sawtooth" pattern
Polymorphic does not appear this way
Torsades de Pointes

BLS Survey

StepAssessment Action
OneCheck for responsiveness
Tap and shout to arouse patient
Check for absent or abnormal breathing for 5-10 seconds
TwoActivate emergency response and get AED
or send someone to call for help
ThreeCheck for a carotid pulse for 5-10 seconds
If no pulse, begin CPR with 30:2 ratio
If there is a pulse, start rescue breathing (1 breath every 5-6 seconds)
Check for shockable rhythm with AED when it arrives
Shock as indicated, followed by CPR

ACLS Survey (ABCD)

StepAssessment Action
Maintain airway patency in unconscious patients

Use advanced airway if needed
>Confirm proper integration of CPR and ventilation
>Confirm proper placement of advanced airway devices
>Secure the device to prevent dislodgment
>Monitor airway placement with continuous quantitative waveform capnography
Give supplementary oxygen when indicated
>100% oxygen for cardiac arrest
>Maintain values >94% in all others

Monitor the adequacy of ventilation and oxygenation

Avoid excessive ventilation
Monitor CPR quality (PETCO2 > 10)

Attach monitor/defibrillator for arrhythmias or cardiac arrest rhythms

Provide defibrillation/cardioversion

Obtain IV/IO access

Give appropriate drugs to manage rhythm and BP

Give IV/IO fluids PRN
DDifferential diagnosis
Search for, find, and treat reversible causes
>Hs and Ts

Facts and Tips

Question Answer
Factors of High-Quality CPRRate at least 100bpm
Compression depth at least 2 inches
Allow full chest recoil between compressions
Minimize interruptions
Avoid excessive ventilation
PETCO2 < 10mmHg indicates...Poor quality CPR
Pulse checks last...At least 5 seconds, but no more than 10 seconds
Steps for AED Operation1) Power on the AED
2) Attach electrode pads
3) Analyze the rhythm
4) Clear the patient if shock is advised
>Press shock button when ready
List of HsHypovolemia
Hydrogen ion (acidosis)
List of TsTension pneumothorax
Tamponade, cardiac
Thrombosis (pulmonary)
Thrombosis (coronary)
Arrest drugs okay for endotracheal administrationEpinephrine
Drugs and doses to treat hypotensionTreat to SBP > 90 or MAP > 65
IV fluids (normal saline or lactated Ringer's (1-2 L)
Epinephrine drip (0.1-0.5 mcg/kg/min)
Dopamine drip (5-10 mcg/kg/min)
Norepinephrine drip (0.1-0.5 mcg/kg/min)
When to use unsynchronized shocksVfib
Pulseless Vtach
Irregular rhythms only!
When to use synchronized shocksUnstable SVT
Unstable Afib
Unstable Aflutter
Unstable monomorphic tachycardia with pulses
Ventilation rate for cardiac arrestBag-mask: 2 ventilations after every 30 compressions
Advanced airway: 1 ventilation every 6-8 seconds
Ventilation rate for respiratory arrestBag-mask: 1 ventilation every 5-6 seconds
Advanced airway: 1 ventilation every 5-6 seconds

Hs and Ts Interventions

Question Answer
HypovolemiaVolume infusion
HypoxiaOxygenation, ventilation, advanced airway
Hydrogen ion (acidosis)Ventilation, sodium bicarbonate
HyperkalemiaCalcium chloride
Insulin + glucose
Sodium bicarbonate
HypokalemiaAdd magnesium if cardiac arrest
Potassium IV
HypothermiaRewarm according to local protocol
Tension pneumothoraxNeedle decompression
Tube thoracostomy
Tamponade, cardiacPericardiocentesis
ToxinsIntubation, antidotes
Thrombosis (pulmonary)Surgical embolectomy, fibrinolytics
Thrombosis (coronary)Surgical embolectomy, fibrinolytics

Respiratory Arrest

Question Answer
Steps in respiratory arrest1) BLS survey
>Check for responsiveness
>Call for help and AED
>Check for pulse (if no pulse, consider cardiac arrest)
>Begin rescue breathing (1 breath every 5-6 seconds)
>Attach AED to check rhythms

2) ACLS survey
>Airway: use head tilt-chin lift, OPA or NPA
>Breathing: give O2 to maintain sats > 94%
>Circulation: monitor for arrhythmias or cardiac arrest
>Differential diagnosis
OPA indicationsUnresponsive patient with no cough or gag reflex
OPA placement steps1) Clear mouth and pharynx of blood, vomit, or other fluids
2) Select proper size (corner of mouth to angle of mandible)
3) Insert turned 90 or 180 degrees and turn into position to avoid pushing tongue back
4) Check for spontaneous respirations before reinitiating respirations
NPA indicationsMay be used in patients with intact cough or gag reflex as well as those without
NPA placement steps1) Select proper size
>Diameter: size of patient's pinky
>Length: tip of nose to earlobe
2) Lubricate the NPA with water-soluble lube or anesthetic jelly
3) Insert the NPA, rotating slightly if there is resistance

Vfib and Pulseless Vtach

Question Answer
First drug for VF/VT arrest
Epinephrine 1mg IV/IO every 3-5 minutes
Vasopressin 40 units IV/IO in place of first or second epinephrine dose
Second drug for VF/VT arrest
Amiodarone 300mg IV/IO bolus x 1
If second dose is needed, 150mg IV/IO bolus x 1
If amiodarone unavailable, Lidocaine 1-1.5mg/kg IV/IO x 1 dose
Then 0.5-0.75 mg/kg every 5 to 10 minutes (max of 3mg/kg total dose)
Drug for torsades de pointes
Magnesium sulfate 1-2g IV/IO bolus over 5-20 minutes (diluted to 10mL)

PEA and Asystole

Question Answer
Definition of PEAAny organized rhythm without a pulse
Pulseless rhythms excluded from PEAVfib
Two most common/reversible causes of PEAHypovolemia

Acute Coronary Syndrome

Question Answer
Initial pharmaceutical treatmentMONA
> Avoid in right ventricular infarct
Oxygen (for pOx < 94%)
Nitroglycerin tablets
> Avoid in right ventricular infarct
> Avoid in hypotension, bradycardia (<50bpm), tachycardia
Aspirin (160-325mg)


Question Answer
Rhythms associated with bradycardia"Any rhythm disorder with a heart rate < 60/min"
Sinus bradycardia
First-degree AV block
Second-degree AV block Type I (Wenckebach/Mobitz)
Second-degree AV block Type II (Mobitz II)
Third-degree AV block
Symptoms of bradycardiaChest discomfort or pain
Shortness of breath
Decreased consciousness
Signs of bradycardiaHypotension
Orthostatic hypotension
Pulmonary congestion on physical examination or chest x-ray
Frank CHF or pulmonary edema
Key clinical question regarding bradycardiaIs the bradycardia causing the patient's symptoms or is an underlying illness causing the bradycardia?
First-line treatment for symptomatic bradycardiaAtropine 0.5mg bolus every 3-5 minutes (maximum total dose of 3mg)
Second-line treatments for symptomatic bradycardiaTranscutaneous pacing
Dopamine infusion 2-10 mcg/kg/min
Epinephrine infusion 2-10 mcg/min


Question Answer
Signs and symptoms of unstable tachycardiaHR > 150/min (usually)
Acutely altered mental status
Signs of shock
Ischemic chest discomfort
Acute heart failure
Contraindications for cardioversionSinus tachycardia (shock may increase HR)
Stable (non-symptomatic) tachycardia
Synchronized cardioversion "doses"Narrow regular: 50-100J
Narrow irregular: 120-200J
Wide regular: 100J
Wide irregular: defibrillation dose (not synchronized)
Adenosine indicationsRegular narrow rhythm (stable or unstable)
Main treatment in stable tachycardiaExpert consultation
Treatments for stable wide regular tachycardiaAmiodarone 150mg over 10 minutes
>Repeat x 1 for VT
>Then 1mg/min infusion over first 6 hours

Procainamide 20-50mg/min
>Until arrhythmia suppressed, hypotension, QRS duration increases >50%, or 17mg/kg given
>Then 1-4mg/min

Sotalol 100mg (or 1.5mg/kg) over 5 minutes

Avoid procainamide and sotalol in prolonged QT

Acute Stroke

Question Answer
General assessment and stabilization time goalWithin 10 minutes of ED arrival
Neurologic assessment by stroke team time goalWithin 25 minutes of ED arrival
Acquisition of head CT scan time goalWithin 25 minutes of ED arrival
CT scan interpretation time goalWithin 45 minutes of ED arrival
Administration of fibrinolytics time goalWithin 60 minutes of ED arrival
Within 3 hours (or 4.5 hours) of symptom onset
Admission to hospital time goalWithin 3 hours of ED arrival
Basic fibrinolytic inclusion criteriaIschemic stroke with measurable neurologic deficit
Onset of symptoms <3 hours before treatment
Age > 18 years old
Important fibrinolytic exclusion criteriaPrior stroke within last 3 months
Symptoms/signs of hemorrhage
Previous intracranial hemorrhage
BP > 185/110
Platelets < 100,000
Current anticoagulation (INR > 1.7)
Blood glucose < 50
Age > 80 (for 4.5 hours)
History of diabetes and prior ischemic stroke (for 4.5 hours)
BP control to meet inclusion criteriaTarget BP is <185/110
1st line: Labetalol 10-20mg IV over 1-2 minutes (may repeat x 1)
2nd line: Nicardipine 5mg/hr (titrate up by 2.5mg/hr every 5-15 minutes [max 15mg/hr] until target BP), then decrease to 3mg/hr
3rd line: Enalaprilat or hydralazine
BP control during/after tPATarget BP is <180/105
1st line: Labetalol 10mg IV x 1, then 2-8mg/min infusion
2nd line: Nicardipine 5mg/hr (titrate up by 2.5mg/hr every 5-15 minutes)
3rd line: Sodium nitroprusside if BP not controlled or DBP >140mmHg