ACLS Guia Estudio 2006

ACLS
Study Guide
Mandatory pre-course test included.
ACLS Course Agenda

ACLS Provider
Day 1
0900-0910
Welcome / Course Overview
0910-0920
Precourse Self-Assessment Review
0920-0940
Importance of CPR Lecture
0940-1010
EKG Review
1010-1030
BLS Primary Survey & ACLS Secondary Survey Video
1030-1040
Break
1040-1120
1st rotation of Respiratory Arrest and CPR/AED Practice and Test
1120-1200
2nd rotation of Respiratory Arrest and CPR/AED Practice and Test
1200-1300
Lunch
1300-1335
Stroke Video and Lecture
1335-1355
Megacode & Resuscitation Team Practice Video
1355-1455
Pulseless Arrest VF/VT Learning Station in Groups
ACLS Course Agenda

ACLS Provider
Day 2
0900-0935
Acute Coronary Syndromes Video and Lecture
0935-1035
Bradycardia/Asystole/ PEA and Stable/Unstable Tachycardia

Learning Station in Groups
1035-1045
Break
1045-1145
Putting It All Together Learning Station in Groups
1145-1245
Lunch
1245-1345
Megacode Testing
1345-1355
ACLS Jeopardy
1355-1435
Written Exam
1435-1505
Wrap-up
ACLS Course Agenda

ACLS Renewal
0900-0910
Welcome / Course Overview
0910-0920
Precourse Self-Assessment Review
0920-0940
ACLS Update Video
0940-1000
Importance of CPR Lecture
1000-1010
Break
1010-1050
1st rotation of Respiratory Arrest and CPR/AED Practice and Test
1050-1130
2nd rotation of Respiratory Arrest and CPR/AED Practice and Test
1130-1150
Stroke Video
1150-1250
Lunch
1250-1310
Megacode & Resuscitation Team Practice Video
1310-1410
Megacode Practice in Groups - Putting It All Together
1410-1510
Megacode Testing
1510-1520
Break
1520-1530
ACLS Jeopardy
1530-1610
Written Examination
1610-1640
Wrap-up
American Heart Links

There are several resources available to you on the American Heart Association website
at www.americanheart.org. Here are some helpful links:
You can find statistics on cardiovascular diseases and risk factors at

http://www.americanheart.org/presenter.jhtml?identifier=2007
You can find out your risk for heart disease at

You can access information on the warning signs of heart attack and stroke at
You can find out how to lead a healthy lifestyle at

You can also go to the Emergency Cardiovascular Care (ECC) website at

http://www.americanheart.org/presenter.jhtml?identifier=3011764, where you can
find out about other American Heart Association CPR or First Aid courses and
even find a course in your area.
To find any other topic, use the Heart and Stroke Encyclopedia at this link:
2006 American Heart Association
11/20/05
ACLS Pulseless Arrest Algorithm.
IV-68
Circulation
December 13, 2005
Figure 1. Bradycardia Algorithm.
Figure 2. ACLS TachycardiaAlgorithm.
IV-90
Circulation
December 13, 2005
Figure 1. Acute Coronary Syndromes Algorithm.
IV-112
Circulation
December 13, 2005
Goals for Management of Patients With Suspected Stroke Algorithm.
A L G O R I T HM R EV I EW
Always start with the ABCD survey!

VENTRICULAR FIBRILLATION / PULSELESS VENTRICULAR TACHYCARDIA
Remember: Good ACLS starts with good BLS
Algorithm: Pulseless Arrest
CPR
Shock
CPR
VasopressorEpi 1 mg q 3-5 min OR 1 dose of Vasopressin 40 U IV/IO to replace 1st or
2nd dose of Epi
CPR
Shock
AntiarrythmicAmiodarone 300 mg IV/IO once or Lidocaine 1-1.5 mg/kg up to 3mg/kg
CPR
Shock
Note: We initiate CPR as soon as possible; after each shock we resume CPR immediately for 5
cycles prior to evaluating the rhythm and pulse; and minimize interruptions to chest compressions.
PULSELESS ELECTRICAL ACTIVITY
Remember: PEA
P = Possible causes (6 Hs, 5 Ts)
E = Epi, 1mg q 3-5 min OR 1 dose of Vasopressin 40 U IV/IO to replace 1st or
2nd dose of Epi
A = Atropine, 1mg IV/IO q 3-5 min to max 3mg (only if electrical rate is < 60)
Note: use the 6 Hs and the 5 Ts to remember the most common reversible causes of PEA
Hypovolemia
Toxins
Hypoxia
Tamponade, cardiac
Hydrogen Ion (acidosis)
Tension Pneumothorax
Hypo-/Hyperkalemia
Thrombosis (coronary or pulmonary)
Hypoglycemia
Trauma
Hypothermia
Note: PEA is a problem with the pump, pipes, or volume, not an electrical problem. The electrical
system of the heart is still functioning, but the mechanical part of the system is not working.
ASYSTOLE
Remember: DEAD
D = Determine whether to initiate resuscitative efforts
E = 1mg Epinephrine IV/IO q 3-5 minutes or 1 dose of Vasopressin 40 U IV/IO to
replace 1st or 2nd dose of EPI
A = 1mg Atropine IV/IO (max 3 mg)
D = Are they still dead? Consider reversible causes or ceasing efforts; check blood glucose;
check core temperature; and consider Naloxone
ACUTE CORONARY SYNDROMES

Remember: Consider MONA for patients with suspected ACS
Algorithm: Acute Coronary Syndromes
Morphine
Oxygen
Nitroglycerine
Aspirin
but in the order Oxygen, Aspirin, Nitro, Morphine
BRADYCARDIA
Remember: All Trained Dogs Eat

Algorithm: Bradycardia
A = Atropine .5mg-1mg IVP for SB & 1st, 2nd #1 AV Block
T = Transcutaneous pacing (preferred for 2nd#2 & 3rd)
D = Dopamine 5-10 mcg/kg/min
E = Epinephrine drip 2 to 10mcg/min
Note: Atropine is not indicated, and may actually be harmful, for 2nd #2 & 3rd degree heart blocks.
Proceed directly to pacing instead.
TACHYCARDIA
Remember: If the patient is unstable, go directly to cardioversion
Algorithm; Tachycardia With Pulses
For Regular Narrow Complex Tachycardia
1. Vagal maneuvers
2. Adenosine 6 mg rapid IV push. If no conversion, give 12 mg, then another 12, mg
3. Consider expert consultation
For Irregular Narrow Complex Tachycardia
1. Consider expert consultation
2. Control rate with Diltiazem or -blockers
1.
2.
3.
For Regular Wide Complex Tachycardia

Consider expert consultation
Amiodarone 150 mg over 10 minutes
Elective cardioversion
1.
2.
3.
For Irregular Wide Complex Tachycardia

Consider antiarrhythmics
If Torsades, give magnesium 1-2 g over 5-60 minutes
Medication Review
The information on medications in this study guide meets the same standard set by the 2005 American Heart Association for
Advanced Cardiac Life Support. It does not supersede local protocols or medical control; consult with your medical director for
the most up-to-date guidelines on medication administration.
A Note on ET Tube Administration of Medications: This route of medication administration is being

deemphasized by the AHA. The IV or IO routes are the preferred routes. However, the ET route can still
be used if unable to gain access by IV/IO. If using the ET route, the dosage must be increased, typically 22.5 times the IV/IO bolus dosage. 10 ml of normal saline should follow the medication. Use the mnemonic
NEAL or LEAN to remember which meds can be administered by the ET route: Narcan Epi
Atropine Lidocaine.
A Note on Fluids: Use normal saline as the initial IV/IO fluid in an arrest situation. IV/IO medications
should be administered during CPR. It is also recommended to flush the medication with 20 ml of fluid after
each administration as well as elevating the extremity. Always use large bore catheters if possible.
ADENOSINE
Class:
Endogenous nucleoside
Indicated for:
PSVT or Narrow Complex
Tachycardia
IV Bolus Dosage:
6 mg - 1st dose
12 mg 2nd dose
12 mg 3rd dose
Comments: Doses are followed by a saline flush. Two subsequent doses of 12 mg each may be administered
at 1 2 minute intervals. Use the port closest to cannulation. The AHA recommends that the dose be cut by
half if administering through a central line, or in the presence of Dipyridamole or Carbamazepine. Larger
doses are required in the presence of caffeine or Theophylline.
AMIODARONE
Class:
Indicated for:
Antiarrhythmic
V-Fib / Pulseless V-Tach
Arrhythmias
Infusion dose: 540 mg IV/IO over 18 hours (.5 mg/min)
IV/IO Bolus Dosage:

300 mg 1st dose
150 mg 2nd dose
150 mg over 10 minutes (rapid)

360 mg over 6 hours (slow)
Comments: Cumulative doses >2.2 g/24 hours are associated with significant hypotension. Do not
administer with other drugs that prolong QT interval (i.e., Procainamide). Terminal elimination is extremely
long half life lasts up to 40 days.
ASPIRIN
Class:
Non-steroidal anti-inflammatory
PO Dose: 160mg 325mg
Suppository Dose: 300mg
Indicated for:
Chest pain / ACS
IV/IO Bolus Dosage:

N/A
Comments: In suspected ACS, Aspirin can block platelet aggregation, and arterial constriction. Also helps
with pain control. May cause or exacerbate GI bleeding. The goal is to give Aspirin to ACS patients within
minutes of arrival.
ATROPINE
Class:
Parasympathetic Blocker
Indicated for:
Bradycardia
PEA, Asystole
IV/IO Bolus Dosage:

.5mg every 3-5 minutes as needed
1mg every 3-5 minutes
Comments: Only used in bradycardias for symptomatic patients. Only used in PEA if rate is slow. The
maximum dosage is 3mg. Doses of Atropine < .5mg may result in paradoxical slowing of the heart. Not
indicated in second degree type I or third degree heart block.
DIGOXIN
Class:
Cardiac Glycoside
Antiarrhythmic
Indicated for:
A-Fib / A-Flutter
IV Bolus Dosage:
10-15g/kg lean body weight
Comments: Reduce Digoxin dose by 50% when initiating Amiodarone due to drug interaction. Toxicity may
cause serious arrhythmias.
DILTIAZEM
Class:
Calcium Channel Blocker
Indicated for:
A-Fib / A-Flutter
IV Dosage:
15-20 mg over 2 minutes
Comments: Do not use in wide-QRS tachycardias of uncertain origin. May cause hypotension.
DOPAMINE
Class:
Catecholamine
Indicated for:
Symptomatic Bradycardia
Hypotension
IV Drip Dosage:
1-5g/kg/min - renal perfusion
5-15g/kg/min cardiac dose
10-20g/kg/min vasopressor dose
Comments: Titrate to patient response. Correct hypovolemia with volume replacement before initiating
Dopamine. May cause tachyarrhythmias. Do not mix with Sodium Bicarbonate.
EPINEPHRINE
Class:
Catecholamine
Indicated for:
V-Fib/Pulseless V-Tach
PEA, Asystole
Symptomatic Bradycardia
IV/IO Bolus Dosage:

1mg every 3-5 minutes
Infusion dosage: 1mg in 500ml of D5W or NaCl at 1g/min titrated to effect.

Comments: First line drug in all pulseless rhythms. Bolus given in 10ml of a 1:10,000 solution. May cause
myocardial ischemia, angina, and increased myocardial oxygen demand. ET route is discouraged, but if used
2-2.5mg diluted in 10ml NaCl.
LIDOCAINE
Class:
Antiarrhythmic
Indicated for:
V-Fib/Pulseless V-Tach
Stable V-Tach
Infusion dosage: 1-4mg/min (30-50g/kg/min)
IV/IO Bolus Dosage:

1-1.5 mg/kg
Comments: May repeat at 0.5-0.75mg/kg every 5-10 minutes to maximum dose 3mg/kg. Prophylactic use
in AMI is contraindicated. Use with caution in presence of impaired liver. Discontinue infusion if signs of
toxicity develop.
MAGNESIUM SULFATE
Class:
Electrolyte
Indicated for:
Cardiac arrest if torsades or
Hypomagnesemia
IV Dosage:
1-2g in 10ml D5W over 20 minutes
Comments: Occasional fall in blood pressure with rapid administration. Use with caution in renal patients.
MORPHINE SULFATE:
Class:
Opiate
Analgesic
Indicated for:
Chest pain
Pulmonary edema
IV Bolus Dosage:
2-4mg every 5-30 minutes
Comments: Administer slowly and titrate to effect. May cause respiratory depression be prepared to
support ventilations. May cause hypotension. Naloxone is reversal agent.
NALOXONE
Class:
Opiate Antagonist
Indicated for:
Narcotic overdose
IV/IO Bolus Dosage:

0.4-2mg
Comments: If needed, can administer up to 10mg in 10 minutes. Monitor for recurrent respiratory
depression. May cause opiate withdrawal. ET route discouraged, but can be used if IV/IO access not
available.
NITROGLYCERINE
Class:
Vasodilator
Indicated for:
Chest pain/ACS
IV Bolus Dosage:
12.5-25g
Comments: Most commonly given sublingually as a tablet or spray. The dose is 0.3-0.4mg. Repeat up to 3
doses at 5 minute intervals. Hypotension or bradycardia may occur. Do not use with Viagra and similar
drugs.
NITROPRUSSIDE
Class:
Vasodilator
Indicated for:
Hypertensive crisis
IV Dosage:
0.1g/kg/min, titrate upward to effect
Comments: May cause hypotension. Use with caution with Viagra and similar drugs. Light-sensitive, bag
and tubing must be covered with opaque material.
OXYGEN
Class:
Atmospheric Gas
Indicated for:
Any cardiopulmonary
emergency
Suspected stroke
Flow
1-15 liters
Comments: Pulse oximetry provides a useful method of titrating oxygen administration; however, it may be
inaccurate in low cardiac output states.
PROCAINIMIDE
Class:
Antiarrhythmic
Indicated for:
Wide variety of arrhythmias
IV Drip Dosage:
20mg/min
Infusion dosage: 1-4mg/min

Comments: Maximum dosage is 17mg/kg. In presence of cardiac or renal dysfunction, reduce max dose to
12mg/kg. Can cause arrhythmias in presence of AMI, hypokalemia, or hypomagnesemia. Use with caution
with other drugs that prolong the QT interval such as Amiodarone.
SODIUM BICARBONATE
Class:
Buffer
Indicated for:
Acidosis, hyperkalemia
IV Bolus Dosage:
1 mEq/kg
Comments: Not recommended for routine use in cardiac arrest patients. If available, use arterial blood gas
analysis to guide bicarbonate therapy.
VASOPRESSIN
Class:
Hormone
Indicated for:
V-Fib/V-Tach
PEA, Asystole
IV/IO Bolus Dosage:

40 U IV/IO
Comments: Only given on time. May cause cardiac ischemia and angina. May replace first or second dose of
Epi. Not recommended for responsive patients with coronary artery disease.
VERAPAMIL
Class:
Calcium Channel Blocker
Indicated for:
A-Fib/A-Flutter
PSVT
IV Bolus Dosage:
2.5-5mg over 2-5 minutes
Comments: Alternative drug after Adenosine to terminate PSVT with adequate blood pressure and
preserved LV function. Can cause peripheral vasodilation and hypotension. Use with extreme caution in
patients receiving oral -blockers.
ELECTRICAL THERAPY
Defibrillation
Fibrillation is a disorganized rhythm that, if present in the ventricles, is life threartening. A
defibrillatory shock uses electrical current to terminate all electrical activity of the irregularly beating
heart. The hope is that following defibrillation, the heart will resume beating in a coordinated
fashion. Early delivery of electrical therapy, combined with immediate CPR following the arrest, is
critical to survival from sudden cardiac arrest.
Cardioversion
Synchronized cardioversion is a treatment option for V-Tach with a pulse, SVT, and unstable atrial
fibrillation or flutter. The shock is delivered in coordination with the QRS complex of the heart in
hopes of returning to a normal sinus rhythm. The standard sequence of energy levels for
synchronized cardioversion are as follows: 100J, 200J, 300J, & 360J monophasic energy dose (or
clinically equivalent biphasic energy dose). If the patient receiving the electrical therapy is conscious,
consider sedation prior to cardioversion.
Pacing
External cardiac pacing, or transcutaneous pacing, stimulates heart activity with an electrical impulse
delivered across the chest wall. It is a recommended therapy for symptomatic and hemodymanically
compromised bradycardias. If the patient receiving the therapy is conscious, consider sedation. The
general guideline for pacer settings is starting from zero, turn the milliamps up until capture is
achieved, then set the rate at 20 beats per minute above the monitored heart rate, with a minimum
rate of 50 bpm.
Normal Sinus Rhythm
Sinus Tachycardia
(Jim never has a second cup at home
home))
(Also known NSR or RSR)

Rhythm
Regular
Rhythm
Regular
100 - 160
Rate
60 - 100
Rate
P waves
P waves
PRI
Normal in configuration and

direction; one P wave precedes
each QRS complex
Normal (0.12 - 0.20 seconds)
PRI
Normal in configuration and

direction; one P wave precedes
each QRS complex
QRS
Normal (0.10 seconds or less)
QRS
Sinus Bradycardia
Rhythm
Regular
Rate
40 - 60
P waves
Normal in configuration and direction;

one P wave precedes each QRS
PRI
QRS
Premature Atrial Contraction (PAC)
Rhythm
Underlying rhythm usually regular, irregular with

pause
Rate
Rate of the underlying rhythm
P waves
P wave is premature and abnormal in size,

shape or direction. Abnormal P wave is often
found in the T wave distorting it's contour.
PRI
Normal or prolonged (>0.20 seconds) usually

differs from underlying rhythm
QRS
Sinus Arrhythmia
Supraventricular Tachycardia
Rhythm
(Regularly)
Irregular
Normal (60-100) or slow (less than
60)
Normal in configuration and direction;
one P wave precedes each QRS
Rhythm
Regular
Rate
150 - 250
P waves
Hidden in preceding T wave.
PRI
PRI
Not measurable
QRS
QRS
Rate
P waves
Paroxysmal Supraventricular Tachycardia (PSVT)
Rhythm
Regular
Rate
150 - 250
P waves
Abnormal (often pointed); usually hidden in preceding T

wave.
PRI
Not measurable
QRS
ATRIAL FIBRILLATION
ATRIAL FLUTTER
Junctional Escape Rhythm
Rhythm
Regular
Rate
40-60
P waves
Inverted in Lead II and will occur immediately before

the QRS, immediately after the QRS, or hidden within
the QRS.
PRI
Short (0.10 seconds or less)
QRS
Premature Junctional Contraction

Rhythm
Underlying rhythm usually regular,

irregular with PJC
Rate
Rate of the underlying rhythm
P waves
P wave associated with PJC will be inverted in Lead II

and will occur immediately before the QRS, immediately
after the QRS, or hidden within the QRS.
PRI
QRS
Accelerated Junctional Rhythm
Rhythm
Regular
Rate
60-100
P waves
Inverted in Lead II and will occur

immediately before the QRS, immediately
after the QRS, or hidden within the QRS.
PRI
QRS
Introducing the Funny Looking Beat
(Is that a PVC?)
Junctional Tachycardia
The 2 types and

several flavors of
Premature
Ventricular
Contraction
Rhythm
Regular
Rate
> 100 bpm
P waves
Inverted in Lead II and will occur immediately before,

after, or hidden within the QRS.
PRI
QRS
Ventricular Tachycardia
Rhythm
Usually regular
Rate
100 (usually 140 to 250)
Ventricular Fibrillation
Rhythm
Irregular. The baseline is totally chaotic.
Rate
Cannot be determined since there are no discernible waves or complexes.
P waves
SA node usually still beats; P wave is usually hidden in the

QRS
P Waves
There are no discernible P Waves.
PRI
Not measurable
PRI
There is no PRI.
Wide (0.12 seconds or greater)
QRS
There are no discernible QRS complexes.
QRS
.20 Sec
ASYSTOLE
PRI
First-Degree AV Block
Rhythm
Regular
Rate
Heart rate is that of underlying

rhythm (usually sinus) both atrial
and ventricular rates will be the
same.
P waves
Sinus; one P wave precedes each

QRS complex
PRI
Prolonged (> 0.20 seconds);

remains constant
QRS
SecondSecond-Degree AV Block Type II
Second-Degree AV Block Type I

(Mobitz I or Wenckebach)
Rhythm
Atrial: Regular
Ventricular: Irregular
Rate
Heart rate is that of underlying rhythm (usually

sinus) both atrial and ventricular rates will be
the same.
P waves
Sinus; one P wave precedes each QRS

complex
PRI
PR varies. PR progressively lengthens until a P

wave occurs without a QRS. A pause follows
the dropped QRS.
QRS
Rhythm
Atrial: Regular
Ventricular: Will be regular unless AV conduction
varies
Rate
Atrial: Rate of underlying rhythm

Ventricular: Rate will depend on AV conduction. Less
than the atrial rate.
P waves
Sinus; two or three P waves (sometimes more) before

each QRS
PRI
May be normal or prolonged; remains constant
QRS
Normal (if block located in bundle of His)

Wide (if blocked located in bundle branches)
Summary of BLS ABCD Maneuvers for Infants, Children, and Adults (Newborn Information Not Included)
MANEUVER
Adult
Lay Rescuer: 8 Years
HCP: Adolescent and older
AIRWAY
Child
Lay Rescuer: 1 to 8 Years
HCP: 1 Year to Adolescent
Infant
Under 1 Year of Age
Head Tilt-Chin Lift (HCP: suspected trauma, use jaw thrust)
BREATHING
(INITIAL)
2 Breaths at 1 Second/Breath
2 Effective Breaths at 1 Second/Breath
HCP: Rescue breathing without chest compressions
10 to 12 Breaths/Minute
(approximate)
(1 Breath Every 5-6 Seconds)
12 to 20 Breaths/Minute (approximate)
8 to 10 Breaths/Minute (approximate)
HCP: Rescue breaths for CPR with advanced airway

Foreign Body Airway Obstruction (FBAO)
Abdominal Thrusts
Back Slaps and Chest Thrusts
Circulation HCP: Pulse check ( 10 seconds)
Carotid
Brachial or Femoral
Compression Landmarks
Lower Half of Sternum
Just Below Nipple Line

(Lower Half of Sternum)
Compression Method:
- Push Hard and Fast
- Allow Complete Recoil
Heel of One Hand;

Other Hand On Top
Compression Depth
1 to 2 Inches
Compression Rate
Compression-Ventilation Ratio
Defibrillation AED
Heel of One Hand, or

As For Adults
2 or 3 Fingers
HCP (2 Rescuer):
2 Thumb-Encircling Hands
Approximately 1/3 to the Depth of the Chest

Approximately 100 Compressions/Minute
30:2 (One or Two Rescuer)

Use Adult Pads
Do Not Use Child Pads
USE AED AS SOON AS
POSSIBLE
NOTE: Maneuvers Used By Only Healthcare Providers Are Indicated By HCP.
30:2 (1 Rescuer)
HCP: 15:2 (2 Rescuer
Use AED After 5 Cycles of CPR
(out of hospital).
Use Pediatric System for Child 1 to
8 years if available.
HCP: For sudden collapse (out of
hospital) or in-hospital arrest, use
AED as soon as possible.
No Recommendations for Infants

< 1 Year of Age
ACLS PROVIDER MANUAL STUDENT CD FAQ

1. I cannot access the ACLS Precourse Self-Assessment Test.
-
Internet Explorer must be open before the CD is inserted. Remove the CD from the tray; close
all other applications, then insert the CD
If you have a pop-up blocker, remove the CD from the tray, re-insert the CD while holding down
the Ctrl key so Macromedia Flash can run.
OR you can go to My Computer > Right Click On the CD-ROM drive > Explore> Double Click on
PC_Start or MAC_Start
Make sure you are using Internet Explorer 6.0 or higher (Not AOL, FireFox, Mozilla or
Netscape)
Check to make sure Active X Controls are enabled by going to Internet Explorer> Tools>
Internet Options> Security Tab> Custom Level> Active X Controls and Plug-ins> Enable
Check to make sure Allow Active Content CDs to run on my Computer is checked by going to
Tools>Internet Options> Advanced Tab> Security
Download Adobe Flash Player and Adobe Reader from www.adobe.com if you do not have it
already installed on your computer. Restart the computer after you have installed the Adobe
Flash Player
2. I cannot play the CD more than two, three, four times

- Delete Temp Files Internet Explorer > Tools > Internet Options > General > Delete Files. Click
on OK
- Close other programs running in the background
- Restart the Computer
3. I cannot open ACLS Core Drugs or any other PDF files on the CD
- Make sure you have Adobe installed on your computer, otherwise download Adobe Acrobat
Reader from www.adobe.com.
4. I can't hear any sound. What do I do?
- Make sure the speakers are turned on and the volume is turned up
- Check the Volume and Mute settings on your computer. Make sure Mute is not checked, and
adjust Volume as needed.
There are multiple ways to check these settings:
Click on the speaker icon in your system tray. Adjust Volume if needed and make sure
Mute is not checked.
Go to Start > Settings > Control Panel>Sounds and Audio Devices>Volume. Make sure
Mute is not checked. Then go to Advanced. Adjust Volume if needed and make sure
Mute is not checked.
Go to Start > Programs > Accessories > Entertainment > Volume Control.
- Make sure the volume on the video clip is turned up. The Volume Control button is located at
the bottom of the screen on the left.
ACLS Course
CPR/AED Testing Checklist
Adult 1-Rescuer CPR and AED Test
Name: ______________________________________________ Date of Test: _____________________
Skill
Step
Adult/Child CPR
With AED
Critical Performance Steps
if done correctly
Checks unresponsiveness
Tells someone to call 911 and get an AED
Opens airway using head tiltchin lift
Checks breathing
Minimum 5 seconds; maximum 10 seconds
Gives 2 breaths (1 second each)
Checks carotid pulse

Minimum 5 seconds; maximum 10 seconds
Bares victims chest and locates CPR hand position
Delivers first cycle of compressions at correct rate

Acceptable <23 seconds for 30 compressions
Gives 2 breaths (1 second each)
AED arrives
AED
1
Turns AED on
AED
2
Selects proper AED pads and places pads correctly
AED
3
Clears victim to analyze

(Must be visible and verbal check)
AED
4
Clears victim to shock/presses shock button (Must be visible and

verbal check) Maximum time from AED arrival <90 sec
Student continues CPR

10
Delivers second cycle of compressions at correct hand position

Acceptable >23 of 30 compressions
11
Gives 2 breaths (1 second each) with visible chest rise
The next step is done only with a manikin with a feedback device, such as a clicker or light.
If no feedback device, STOP THE TEST.
12
Delivers third cycle of compressions of adequate depth with full

chest recoil Acceptable >23 compressions
STOP THE TEST
Test Results
Indicate Pass or Needs

Remediation:
NR
Skills Station Competency Checklist
Management of Respiratory Arrest

BLS Primary Survey and Interventions
Establishes unresponsiveness
Activates EMS and gets AED
or
Directs 2nd rescuer to activate the emergency response system and get the
AED
Opens the airway (head tiltchin lift or, if trauma is suspected, jaw thrust
without head extension)
Checks for breathing (look, listen, and feel; at least 5 seconds but not more
than 10 seconds)
If breathing is absent or inadequate, gives 2 breaths (1 second per breath) that
cause the chest to rise
Checks carotid pulse. Notes that pulse is present. Does not initiate chest compressions or attach AED.
Performs rescue breaths at the correct rate of 1 breath every 5 to 6 seconds
(10 to 12 breaths/min)
ACLS Secondary Survey Case Skills
Inserts oropharyngeal and nasopharyngeal airway (student should demonstrate both)
Performs correct bag-mask ventilation
Administers oxygen
Reassesses pulse about every 2 minutes
Critical Actions
Performs Primary ABCDs
Properly inserts OPA or NPA
Can ventilate with bag-mask
Gives proper ventilationrate and volume
Rechecks pulse and other sign of circulation. Does not initiate chest compressions.
if done
correctly
Learning Station Competency Checklist

VF/Pulseless VT
1
PULSELESS ARREST
BLS Algorithm: Call for help, give CPR
Give oxygen when available
Attach monitor/defibrillator when available
2
Shockable
Not Shockable
Check rhythm
Shockable rhythm?
VF/VT
Asystole/PEA
4
Give 1 shock
Manual biphasic: device specific
(typically 120 to 200 J)
10
Note: If unknown, use 200 J
Resume CPR immediately for 5 cycles

When IV/IO available, give vasopressor
Epinephrine 1 mg IV/IO
Repeat every 3 to 5 min
or
May give 1 dose of vasopressin 40 U IV/IO to
replace first or second dose of epinephrine
AED: device specific

Monophasic: 360 J
Resume CPR immediately
Give 5 cycles of CPR*
No
Check rhythm
Shockable rhythm?
Consider atropine 1 mg IV/IO

for asystole or slow PEA rate
Repeat every 3 to 5 min (up to 3 doses)
Shockable
Continue CPR while defibrillator is charging

Give 1 shock
(same as first shock or higher dose)
Give 5 cycles
of CPR*
11

Monophasic: 360 J
Resume CPR immediately after the shock
When IV/IO available, give vasopressor during CPR
(before or after the shock)
or
Check rhythm
Shockable rhythm?
No
Check rhythm
Shockable rhythm?
12
If asystole, go to Box 10
If electrical activity, check
pulse. If no pulse, go to
Box 10
If pulse present, begin
postresuscitation care
Not
Shockable
13
Shockable
Go to
Box 4
Shockable
During CPR

Give 1 shock

Monophasic: 360 J
Consider antiarrhythmics; give during CPR
amiodarone (300 mg IV/IO once, then
consider additional 150 mg IV/IO once) or
lidocaine (1 to 1.5 mg/kg first dose, then 0.5 to
0.75 mg/kg IV/IO, maximum 3 doses or 3 mg/kg)
Consider magnesium, loading dose
1 to 2 g IV/IO for torsades de pointes
After 5 cycles of CPR,* go to Box 5 above
Push hard and fast (100/min)

Ensure full chest recoil
Rotate compressors every

2 minutes with rhythm checks
Search for and treat possible

contributing factors:
Hypovolemia
One cycle of CPR: 30 compressions
Hypoxia
then 2 breaths; 5 cycles 2 min
Hydrogen ion (acidosis)
Hypo-/hyperkalemia
Avoid hyperventilation
Hypoglycemia
Secure airway and confirm placement
Hypothermia
Toxins
Tamponade, cardiac
After an advanced airway is placed,
Tension pneumothorax
rescuers no longer deliver cycles
Thrombosis (coronary or
of CPR. Give continous chest compulmonary)
pressions without pauses for breaths.
Trauma
Give 8 to 10 breaths/minute. Check
rhythm every 2 minutes
Minimize interruptions in chest
compressions
80_
8 PM

PEA/Asystole
1
PULSELESS ARREST
BLS Algorithm: Call for help, give CPR
Give oxygen when available
Attach monitor/defibrillator when available
2
Shockable
Not Shockable
Check rhythm
Shockable rhythm?
VF/VT
Asystole/PEA
4
Give 1 shock
(typically 120 to 200 J)
10
Resume CPR immediately for 5 cycles

When IV/IO available, give vasopressor
or

Monophasic: 360 J
Resume CPR immediately
No
Check rhythm
Shockable rhythm?
Consider atropine 1 mg IV/IO

for asystole or slow PEA rate
Repeat every 3 to 5 min (up to 3 doses)
Shockable

Give 1 shock
Give 5 cycles
of CPR*

Monophasic: 360 J
When IV/IO available, give vasopressor during CPR
or
Check rhythm
Shockable rhythm?
No
11
Check rhythm
Shockable rhythm?
12
If asystole, go to Box 10
If electrical activity, check
pulse. If no pulse, go to
Box 10
If pulse present, begin
postresuscitation care
Not
Shockable
13
Shockable
Go to
Box 4
Shockable
During CPR

Give 1 shock

Monophasic: 360 J
Consider antiarrhythmics; give during CPR
amiodarone (300 mg IV/IO once, then
consider additional 150 mg IV/IO once) or
lidocaine (1 to 1.5 mg/kg first dose, then 0.5 to
0.75 mg/kg IV/IO, maximum 3 doses or 3 mg/kg)
Consider magnesium, loading dose
1 to 2 g IV/IO for torsades de pointes
After 5 cycles of CPR,* go to Box 5 above
6_Part5.indd 62
Push hard and fast (100/min)

Ensure full chest recoil
Rotate compressors every

2 minutes with rhythm checks
Search for and treat possible

contributing factors:
Hypovolemia
One cycle of CPR: 30 compressions
Hypoxia
then 2 breaths; 5 cycles 2 min
Hypo-/hyperkalemia
Avoid hyperventilation
Hypoglycemia
Secure airway and confirm placement
Hypothermia
Toxins
Tamponade, cardiac
After an advanced airway is placed,
rescuers no longer deliver cycles
of CPR. Give continous chest compulmonary)
pressions without pauses for breaths.
Trauma
Give 8 to 10 breaths/minute. Check
rhythm every 2 minutes
Minimize interruptions in chest
compressions

Bradycardia
1
BRADYCARDIA
Heart rate <60 bpm and
inadequate for clinical condition
2
Maintain patent airway; assist breathing as needed

Give oxygen
Monitor ECG (identify rhythm), blood pressure, oximetry
Establish IV access
3
Signs or symptoms of poor perfusion caused by the bradycardia?
(eg, acute altered mental status, ongoing chest pain, hypotension or other signs of shock)
4A
Observe/Monitor
Adequate
Perfusion
Poor
Perfusion
Reminders
If pulseless arrest develops, go to Pulseless Arrest Algorithm
Search for and treat possible contributing factors:
Hypovolemia
Toxins
Hypoxia
Tamponade, cardiac
Hydrogen ion (acidosis) Tension pneumothorax
Hypo-/hyperkalemia
Thrombosis (coronary or pulmonary)
Hypoglycemia
Trauma (hypovolemia, increased ICP)
Hypothermia
4
Prepare for transcutaneous pacing;
use without delay for high-degree block
(type II second-degree block or
third-degree AV block)
Consider atropine 0.5 mg IV while
awaiting pacer. May repeat to a
total dose of 3 mg. If ineffective,
begin pacing
Consider epinephrine (2 to 10 g/min)
or dopamine (2 to 10 g/kg per minute)
infusion while awaiting pacer or if
pacing ineffective
5
Prepare for transvenous pacing
Treat contributing causes
7/

Tachycardia
1
Screened boxes 9, 10, 11, 13, and
14 are designed for in-hospital use
with expert consultation available.
TACHYCARDIA
With Pulses
Assess and support ABCs as needed

Give oxygen
Monitor ECG (identify rhythm), blood pressure, oximetry
Identify and treat reversible causes
Establish IV access
Obtain 12-lead ECG
(when available)
or rhythm strip
Is QRS narrow (<0.12 sec)?
Stable
Perform immediate
synchronized cardioversion
Symptoms Persist
Is patient stable?
Unstable signs include altered
mental status, ongoing chest pain,
hypotension or other signs of shock
Note: rate-related symptoms
uncommon if heart rate <150/min
Unstable
Establish IV access and give

sedation if patient is conscious; do not delay cardioversion
If pulseless arrest develops,
see Pulseless Arrest Algorithm
Wide (0.12 sec)

Narrow
12
NARROW QRS*:
Is Rhythm Regular?
Regular
WIDE QRS*:
Is Rhythm Regular?
Expert consultation
advised
Irregular
11
Attempt vagal maneuvers

Give adenosine 6 mg rapid
IV push. If no conversion,
give 12 mg rapid IV push;
may repeat 12 mg dose once
Irregular Narrow-Complex
Tachycardia
Probable atrial fibrillation or
possible atrial flutter or MAT
(multifocal atrial tachycardia)
Control rate (eg, diltiazem,
-blockers; use -blockers with
caution in pulmonary disease
or CHF)
8
Does rhythm
convert?
Note: Consider
expert consultation
Converts
9
Does Not Convert

10
If rhythm does NOT convert,
possible atrial flutter,
ectopic atrial tachycardia, or
junctional tachycardia:
Control rate (eg, diltiazem,
-blockers; use -blockers with
caution in pulmonary disease
or CHF)
Treat underlying cause
If rhythm converts,
probable reentry SVT
(reentry supraventricular
tachycardia):
Observe for recurrence
Treat recurrence with
adenosine or longeracting AV nodal blocking
agents (eg, diltiazem,
-blockers)
*Note: If patient becomes

unstable, go to Box 4.
Regular
13
14
If ventricular
tachycardia or
uncertain rhythm
Amiodarone
150 mg IV over 10 min
Repeat as needed
to maximum dose of
2.2 g/24 hours
Prepare for elective
synchronized
cardioversion
If SVT with aberrancy
Give adenosine
(go to Box 7)
Treat possible contributing factors:
Secure, verify airway

and vascular access
when possible
Consider expert
consultation
Prepare for
cardioversion
Hypovolemia
Hypoxia
Hypo-/hyperkalemia
Hypoglycemia
Hypothermia
If atrial fibrillation with

aberrancy
See Irregular NarrowComplex Tachycardia
(Box 11)
If pre-excited atrial
fibrillation (AF + WPW)
Expert consultation
advised
Avoid AV nodal
blocking agents (eg,
adenosine, digoxin,
diltiazem, verapamil)
Consider antiarrhythmics (eg, amiodarone
150 mg IV over 10 min)
If recurrent polymorphic
VT, seek expert consultation
If torsades de pointes,
give magnesium
(load with 1-2 g over
5-60 min, then infusion)
During Evaluation
Irregular
Toxins
Tamponade, cardiac
pulmonary)
Trauma (hypovolemia)
ACLS Megacode Case A: Sinus Bradycardia

(BradycardiaVF/Pulseless VTAsystole)
Name: ____________________________________________________ Date of Test:____________________
Megacode Testing Checklist 1/2

BradycardiaVF/Pulseless VTAsystole
Out-of-Hospital Scenario
You are a paramedic and arrive on-scene to find a 57-year-old woman complaining of indigestion. She is cold, clammy, and diaphoretic. She tells you she
is about to faint. EMS responders have obtained vital signs: HR 38, BP 70/P,
RR 16. No other assessment or management has been done. Now you assume
the role of team leader.
Initial
Assessment
Bradycardia
Algorithm
Rhythm: Sinus
Bradycardia
Pulseless Arrest
Algorithm
(VF/VT)
Pulseless Arrest
Algorithm
(Asystole)
if done correctly

Team Leader
Ensures high-quality CPR at all times
Assigns team member roles
This woman may have an acute coronary syndrome.

The case focus, however, is bradycardia. The team
leader should begin to take a history and direct team
members to start oxygen (if not initiated) and an IV and
place monitor leads. Nitroglycerin at this point would
be inappropriate in the absence of typical ischemictype discomfort and vital signs (severe bradycardia
and hypotensioncontraindicated.)
Bradycardia Management
The student is presented with bradycardia and needs

to follow the Bradycardia Algorithm. A critical action is
noting that symptoms are due to bradycardia requiring management. Actions at this point should include
at least an initial dose of atropine and preparation for
transcutaneous pacing.
Recognizes VF
The patient suddenly develops VF. The team leader will

follow the Pulseless Arrest Algorithm. Now the student
team leader will assign additional team functions and
monitor for high-quality CPR. The case should continue
through safe defibrillation, administration of a vasopressor, and consideration of an antiarrhythmic drug.
Administers appropriate drug(s) and doses
After a shock the patient becomes asystolic. The student continues to monitor high-quality CPR and follows
the asystole pathway of the Pulselss Arrest Algorithm.
If the team continues giving high-quality CPR and
appropriate drugs, you can end the case with the
patient in NSR. Otherwise you can end the case and
discuss calling the code.
Immediately resumes CPR after rhythm checks
Starts oxygen, places monitor, starts IV

Places monitor leads in proper position
Recognizes symptomatic bradycardia
Verbalizes the need for TCP
VF/Pulseless VT Management
Clears before ANALYZE and SHOCK

Immediately resumes CPR after shocks
Appropriate airway management
Appropriate cycles DrugRhythm Check/ShockCPR
Asystole Management
Recognizes asystole
Verbalizes potential reversible causes of asystole/PEA (Hs and Ts)
Stop the Test
Test
Results
Indicate Pass or Needs Remediation:
NR
Instructor signature affirms that skills tests

were done according to AHA guidelines.
Instructor Signature: ____________________________________
Save this sheet with course record.
Print Instr Name: ________________________ Date: __________
ACLS Megacode Case A: Mobitz Type II

AV Block
(BradycardiaVF/Pulseless VTAsystole)
In-Hospital Scenario
You are a evaluating a 57-year-old woman complaining of indigestion. She is
brought immediately from triage (arrived by personal car) and placed in ED
room 2. She is cold, clammy, and diaphoretic. She states that she feels as if
she is about to faint. The triage nurse is working with you and has obtained
vital signs: HR 38, BP 70/P, RR 16.
Initial
Assessment
Bradycardia
Algorithm
Rhythm:
Mobitz Type II
AV Block
Pulseless Arrest
Algorithm
(VF/VT)
Pulseless
Arrest
Algorithm
(Asystole)
This woman may have an acute coronary syndrome. The case focus, however, is bradycardia.
The team leader should begin to take a history
and direct team members to start oxygen (if not
initiated) and an IV and place monitor leads.
Nitroglycerin at this point would be inappropriate
in the absence of typical ischemic-type discomfort and vital signs (severe bradycardia and hypotensioncontraindicated.)
The student is presented with bradycardia and
needs to follow the Bradycardia Algorithm. A
critical action is noting that symptoms are due to
bradycardia requiring management. Actions at this
point should include at least an initial dose of atropine and preparation for transcutaneous pacing.
Name: ____________________________________________________ Date of Test:____________________
Megacode Testing Checklist 1/2

BradycardiaVF/Pulseless VTAsystole
if done correctly

Team Leader
Bradycardia Management
Recognizes symptomatic bradycardia
Verbalizes the need for TCP
Recognizes VF
Asystole Management
Recognizes asystole
The patient suddenly develops VF. The team

leader will follow the Pulseless Arrest Algorithm.
Now the student team leader will assign
additional team functions and monitor for highquality CPR. The case should continue through
safe defibrillation, administration of a vasopressor, and consideration of an antiarrhythmic drug.
After a shock the patient becomes asystolic. The
student continues to monitor high-quality CPR
and follows the asystole pathway of the Pulseless
Arrest Algorithm. If the team gives high-quality CPR
and appropriate drugs, you can end the case with
the patient in NSR. Otherwise you can end the
case and discuss calling the code.
Verbalizes potential reversible causes of asystole/PEA (Hs and Ts)

Immediately resumes CPR after rhythm checks
Stop the Test
Test
Results
NR

ACLS Megacode Case B: Tachycardia

(VT)Cardioversion
(TachycardiaVF/Pulseless VTPEA)
Name: _____________________________________________________ Date of Test:____________________
Megacode Testing Checklist 3

TachycardiaVF/Pulseless VTPEA
Out-of-Hospital Scenario
You are a paramedic and arrive on-scene to find a 65-year-old man complaining of palpitations and chest discomfort. He is cold, clammy, and diaphoretic. He states that he feels as if he is about to faint. EMS responders
have placed oxygen and obtained vital signs: HR 160, BP 70/P, RR 16.
if done correctly

Team Leader
Initial
Assessment
Tachycardia
Algorithm
Rhythm:
Regular WideComplex
Tachycardia
(VT)
This man may have an acute coronary syndrome.

The case focus, however, is initially a tachycardia. The student should begin to take a history,
start oxygen and an IV, and attach monitor electrodes or pads to the patient. Nitroglycerin at this
point would be inappropriate and contraindicated
because of hypotension. Aspirin may be given.
Tachycardia Algorithm
The student is presented with tachycardia and

needs to follow the Tachycardia Algorithm. A critical
action is noting that symptoms are due to tachycardia requiring management. The monitor shows a
wide-complex tachycardia: VT. The student should
recognize that the patient is symptomatic and prepare for immediate cardioversion. Consideration of
drug therapy should not delay cardioversion.

Recognizes unstable tachycardia
Recognizes symptoms due to tachycardia
Performs immediate synchronized cardioversion
Recognizes VF
PEA Algorithm
Pulseless Arrest
Algorithm
(VF/VT)
Pulseless Arrest
Algorithm
(PEA)
The patient should suddenly develop VF. The student will follow the VF/VT pathway of the Pulseless
Arrest Algorithm. Now the student team leader will
assign team functions and monitor for high-quality CPR. The case should continue through safe
defibrillation, administration of a vasopressor, and
consideration of an antiarrhythmic drug.
The patient is now in PEA. The student continues to monitor high-quality CPR and follows the
PEA pathway of the Pulseless Arrest Algorithm.
Although the patient is likely in cardiogenic shock,
the student should say a differential diagnosis of
PEA. You can end the case and discuss indications
to call a code.
Recognizes PEA
Verbalizes potential reversible causes of PEA/asystole (Hs and Ts)
Immediately resumes CPR after rhythm and pulse checks
Stop the Test
Test
Results
NR

ACLS Megacode Case B: Tachycardia

(VT)Drug Therapy
(TachycardiaVF/Pulseless VTPEA)
Name: ____________________________________________________ Date of Test:____________________
Megacode Testing Checklist 4

TachycardiaVF/Pulseless VTPEA
In-Hospital Scenario
In the ED you are evaluating a 65-year-old man complaining of palpitations.

He is in no distress. He has a history of coronary artery disease and had a
stent in the past. Otherwise he is healthy with no other medical problems.
His vital signs are: HR 170, BP 110/70, RR 16.
Team Leader
if done correctly

Tachycardia Algorithm
Initial
Assessment
Tachycardia
Algorithm
Rhythm:
Regular NarrowComplex Stable
Tachycardia
(SVT)
Pulseless Arrest
Algorithm
(VF/VT)
Pulseless Arrest
Algorithm
(PEA)
This man has mild symptoms and is hemodynamically stable. The case focus, however, is initially a
tachycardia. The student should begin to take a
history, start oxygen and an IV, and place a monitor.
Nitroglycerin at this point would be inappropriate
because of the rapid tachycardia. Aspirin may be
given.
The student is presented with tachycardia and

needs to follow the Tachycardia Algorithm. A
critical action is noting that the patient is asymptomatic except for palpitations and is hemodynamically stable. He does not require immediate cardioversion. Note or show that he has a regular narrow-complex tachycardia. The team leader should
follow the algorithm and indicate vagal maneuvers
and initial therapy with adenosine.
During this treatment the patient suddenly develops VF. The student will follow the VF/VT pathway
of Pulseless Arrest Algorithm. Now the student
team leader will assign team functions and monitor for high-quality CPR. The case should continue
through safe defibrillation, administration of a
vasopressor, and consideration of an antiarrhythmic
drug.
After a shock the patient is now in PEA. The student
continues to monitor high-quality CPR and follow
the PEA pathway of the Pulselss Arrest Algorithm.
Although the patient is likely in cardiogenic shock,
the student should verbalize a differential diagnosis of
PEA. You can end the case and discuss indications to
call a code.

Recognizes tachycardia (specific diagnosis)
Recognizes no symptoms due to tachycardia
Attempts vagal maneuvers
Gives appropriate initial drug therapy
Recognizes VF
PEA Algorithm
Recognizes PEA
Verbalizes potential reversible causes of PEA/asystole (Hs and Ts)
Immediately resumes CPR after rhythm and pulse checks
Stop the Test
Test
Results
NR

ECC
American Heart Association
Advanced Cardiovascular
Life Support
Written Precourse
Self-Assessment
October 2006
ACLS Provider Course

Written Precourse Self-Assessment Answer Sheet
Name _________________________________
Date_____________________
Circle the correct answers.
Question
Answer
Answer
Question
1.
16.
2.
17.
3.
18.
4.
19.
5.
20.
6.
21.
7.
22.
8.
23.
9.
24.
10.
25.
11.
26.
12.
27.
13.
28.
14.
29.
15.
30.
Please fill in the correct rhythm for questions 31 40.
31.
_____________________________
36.
_____________________________
32.
_____________________________
37.
_____________________________
33.
_____________________________
38.
_____________________________
34.
_____________________________
39.
_____________________________
35.
_____________________________
40.
_____________________________
ACLS Written 2006 Precourse Self-Assessment

1.
Ten minutes after an 85-year-old woman collapses, paramedics arrive and start CPR for the
first time. The monitor shows fine (low-amplitude) VF. Which of the following actions should
they take next?
a. Perform at least 5 minutes of vigorous CPR before attempting defibrillation
b. Insert an endotracheal tube, administer 2 to 2.5 mg epinephrine in 10 mL NS through the tube
and then defibrillate
c. Deliver up to 3 precordial thumps while observing the patients response on the monitor
d. Deliver about 2 minutes or 5 cycles of CPR, and deliver a 360-J monophasic or equivalentcurrent biphasic shock
2.
A cardiac arrest patient arrives in the ED with PEA at 30 bpm. CPR continues, proper tube
placement is confirmed, and IV access is established. Which of the following medications is
most appropriate to give next?
a.
b.
c.
d.
3.
Which of the following actions helps deliver maximum current during defibrillation?
a.
b.
c.
d.
4.
Calcium chloride 5 mL of 10% solution IV

Epinephrine 1 mg IV
Synchronized cardioversion at 200 J
Sodium bicarbonate 1 mEq/kg IV
Place alcohol pads between the paddles and skin

Reduce the pressure used to push down on the defibrillator paddles
Apply conductive paste to the paddles
Decrease shock energy after the 2nd shock
Which of the following actions is NOT performed when you clear a patient just before
defibrillator discharge?
a. Check the person managing the airway: body not touching bag mask or tracheal tube, oxygen
not flowing directly onto chest
b. Check yourself: hands correctly placed on paddles, body not touching patient or bed
c. Check monitor leads: leads disconnected to prevent shock damage to monitor
d. Check others: no one touching patient, bed, or equipment connected to patient
ACLS Precourse Written Self-Assessment

5.
A woman with a history of narrow-complex PSVT arrives in the ED. She is alert and oriented
but pale. HR is 165 bpm, and the ECG documents SVT. BP is 105/70 mm Hg. Supplemental
oxygen is provided, and IV access has been established. Which of the following drug-dose
combinations is the most appropriate initial treatment?
a.
b.
c.
d.
6.
Which of the following facts about identification of VF is true?

a.
b.
c.
d.
7.
Intubation of the esophagus

Intubation of the left main bronchus
Intubation of the right main bronchus
Bilateral tension pneumothorax
Which of these statements about IV administration of medications during attempted

resuscitation is true?
a.
b.
c.
d.
9.
A peripheral pulse that is both weak and irregular indicates VF

A sudden drop in blood pressure indicates VF
Artifact signals displayed on the monitor can look like VF
Turning the signal amplitude (gain) to zero can enhance the VF signal
Endotracheal intubation has just been attempted for a patient in respiratory arrest. During
bag-mask ventilation you hear stomach gurgling over the epigastrium but no breath sounds,
and oxygen saturation (per pulse oximetry) stays very low. Which of the following is the most
likely explanation for these findings?
a.
b.
c.
d.
8.
Adenosine 6 mg rapid IV push

Epinephrine 1 mg IV push
Synchronized cardioversion with 25 to 50 J
Atropine 1 mg IV push
Give epinephrine via the intracardiac route if IV access is not obtained within 3 minutes
Follow IV medications through peripheral veins with a fluid bolus
Do not follow IV medications through central veins with a fluid bolus
Run normal saline mixed with sodium bicarbonate (100 mEq/L) during continuing CPR
A 60-year-old man (weight = 50 kg) with recurrent VF has converted from VF again to a widecomplex nonperfusing rhythm after administration of epinephrine 1 mg IV and a 3rd shock.
Which of the following drug regimens is most appropriate to give next?
a.
b.
c.
d.
Amiodarone 300 mg IV push

Lidocaine 150 mg IV push
Magnesium 3 g IV push, diluted in 10 mL of D5W
Procainamide 20 mg/min, up to a maximum dose of 17 mg/kg

10. While treating a patient in persistent VF arrest after 2 shocks, you consider using
vasopressin. Which of the following guidelines for use of vasopressin is true?
a. Give vasopressin 40 U every 3 to 5 minutes
b. Give vasopressin for better vasoconstriction and -adrenergic stimulation than that provided by
epinephrine
c. Give vasopressin as an alternative to a first or second dose of epinephrine in shock-refractory
VF
d. Give vasopressin as the first-line pressor agent for clinical shock caused by hypovolemia
11. Which of the following causes of PEA is most likely to respond to immediate treatment?
a.
b.
c.
d.
Massive pulmonary embolism

Hypovolemia
Massive acute myocardial infarction
Myocardial rupture
12. Which of the following drug-dose combinations is recommended as the initial medication to
give a patient in asystole?
a.
b.
c.
d.
Epinephrine 3 mg IV
Atropine 3 mg IV
Epinephrine 1 mg IV
Atropine 0.5 mg IV
13. A patient with a heart rate of 40 bpm is complaining of chest pain and is confused. After
oxygen, what is the first drug you should administer to this patient while a transcutaneous
pacer is brought to the room?
a.
b.
c.
d.
Atropine 0.5 mg
Epinephrine 1 mg IV push
Isoproterenol infusion 2 to 10 g/min
Adenosine 6 mg rapid IV push
14. Which of the following statements correctly describes the ventilations that should be
provided after endotracheal tube insertion, cuff inflation, and verification of tube position?
a.
b.
c.
d.
Deliver 8 to 10 ventilations per minute with no pauses for chest compressions

Deliver ventilations as rapidly as possible as long as visible chest rise occurs with each breath
Deliver ventilations with a tidal volume of 3 to 5 mL/kg
Deliver ventilations using room air until COPD is ruled out

15. A patient in the ED reports 30 minutes of severe, crushing, substernal chest pain. BP is
110/70 mm Hg, HR is 58 bpm, and the monitor shows regular sinus bradycardia. The patient
has received aspirin 325 mg PO, oxygen 4 L/min via nasal cannula, and 3 sublingual
nitroglycerin tablets 5 minutes apart, but he continues to have severe pain. Which of the
following agents should be given next?
a.
b.
c.
d.
Atropine 0.5 to 1 mg IV
Furosemide 20 to 40 mg IV
Lidocaine 1 to 1.5 mg/kg
Morphine sulfate 2 to 4 mg IV
16. Which of the following agents are used frequently in the early management of acute cardiac
ischemia?
a.
b.
c.
d.
Lidocaine bolus followed by a continuous infusion of lidocaine

Chewable aspirin, sublingual nitroglycerin, and IV morphine
Bolus of amiodarone followed by an oral ACE inhibitor
Calcium channel blocker plus IV furosemide
17. A 50-year-old man who is profusely diaphoretic and hypertensive complains of crushing
substernal chest pain and severe shortness of breath. He has a history of hypertension. He
chewed 2 baby aspirins at home and is now receiving oxygen. Which of the following
treatment sequences is most appropriate at this time?
a.
b.
c.
d.
Morphine then nitroglycerin, but only if morphine fails to relieve the pain
Nitroglycerin then morphine, but only if ST elevation is >3 mm
Nitroglycerin then morphine, but only if nitroglycerin fails to relieve the pain
Nitroglycerin only, because chronic hypertension contraindicates morphine
18. A 50-year-old man has a 3-mm ST elevation in leads V2 to V4. Severe chest pain continues
despite administration of oxygen, aspirin, nitroglycerin SL 3, and morphine 4 mg IV. BP is
170/110 mm Hg; HR is 120 bpm. Which of the following treatment combinations is most
appropriate for this patient at this time (assume no contraindications to any medication)?
a.
b.
c.
d.
Calcium channel blocker IV + heparin bolus IV

ACE inhibitor IV + lidocaine infusion
Magnesium sulfate IV + enoxaparin (Lovenox) SQ
Fibrinolytic + heparin bolus IV
19. A 70-year-old woman complains of a moderate headache and trouble walking. She has a
facial droop, slurred speech, and difficulty raising her right arm. She takes several
medications for high blood pressure. Which of the following actions is most appropriate to
take at this time?
a. Activate the emergency response system; tell the dispatcher you need assistance for a woman
who is displaying signs and symptoms of an acute subarachnoid hemorrhage
b. Activate the emergency response system; tell the dispatcher you need assistance for a woman
who is displaying signs and symptoms of a stroke
c. Activate the emergency response system; have the woman take aspirin 325 mg and then have
her lie down while both of you await the arrival of emergency personnel
d. Drive the woman to the nearby ED in your car

20. Within 45 minutes of her arrival in the ED, which of the following evaluation sequences
should be performed for a 70-year-old woman with rapid onset of headache, garbled speech,
and weakness of the right arm and leg?
a. History, physical and neurologic exams, noncontrast head CT with radiologist interpretation
b. History, physical and neurologic exams, noncontrast head CT, start of fibrinolytic treatment if CT
scan is positive for stroke
c. History, physical and neurologic exams, lumbar puncture (LP), contrast head CT if LP is
negative for blood
d. History, physical and neurologic exams, contrast head CT, start fibrinolytic treatment when
improvement in neurologic signs is noted
21. Which of the following rhythms is a proper indication for transcutaneous cardiac pacing?
a.
b.
c.
d.
Sinus bradycardia with no symptoms

Normal sinus rhythm with hypotension and shock
Complete heart block with pulmonary edema
Asystole that follows 6 or more defibrillation shocks
22. Which of the following causes of out-of-hospital asystole is most likely to respond to
treatment?
a.
b.
c.
d.
Prolonged cardiac arrest

Prolonged submersion in warm water
Drug overdose
Blunt multisystem trauma
23. A 34-year-old woman with a history of mitral valve prolapse presents to the ED complaining
of palpitations. Her vital signs are as follows: HR = 165 bpm, resp = 14 per minute, BP =
118/92 mm Hg, and O2 sat = 98%. Her lungs sound clear, and she reports no shortness of
breath or dyspnea on exertion. The ECG and monitor display a narrow-complex, regular
tachycardia. Which of the following terms best describes her condition?
a.
b.
c.
d.
Stable tachycardia
Unstable tachycardia
Heart rate appropriate for clinical condition
Tachycardia secondary to poor cardiovascular function
24. A 75-year-old man presents to the ED with a 1-week history of lightheadedness, palpitations,
and mild exercise intolerance. The initial 12-lead ECG displays atrial fibrillation, which
continues to show on the monitor at an irregular HR of 120 to 150 bpm and a BP of
100/70 mm Hg. Which of the following therapies is the most appropriate next intervention?
a.
b.
c.
d.
Sedation, analgesia, then immediate cardioversion

Lidocaine 1 to 1.5mg/kg IV bolus
Amiodarone 300 mg IV bolus
Seek expert consultation

25. You prepare to cardiovert an unstable 48-year-old woman with tachycardia. The
monitor/defibrillator is in synchronization mode. The patient suddenly becomes
unresponsive and pulseless as the rhythm changes to an irregular, chaotic, VF-like pattern.
You charge to 200 J and press the SHOCK button, but the defibrillator fails to deliver a shock.
Why?
a.
b.
c.
d.
The defibrillator/monitor battery failed

The sync switch failed
You cannot shock VF in sync mode
A monitor lead has lost contact, producing the pseudo-VF rhythm
26. Vasopressin can be recommended for which of the following arrest rhythms?
a.
b.
c.
d.
VF
Asystole
PEA
All of the above
27. Effective bag-mask ventilations are present in a patient in cardiac arrest. Now, 2 minutes after
epinephrine 1 mg IV is given, PEA continues at 30 bpm. Which of the following actions should
be done next?
a.
b.
c.
d.
Administer atropine 1 mg IV
Initiate transcutaneous pacing at a rate of 60 bpm
Start a dopamine IV infusion at 15 to 20 g/kg per minute
Give epinephrine (1 mL of 1:10 000 solution) IV bolus
28. The following patients were diagnosed with acute ischemic stroke. Which of these patients
has NO stated contraindication for IV fibrinolytic therapy?
a.
b.
c.
d.
A 65-year-old woman who lives alone and was found unresponsive by a neighbor
A 65-year-old man presenting approximately 4 hours after onset of symptoms
A 65-year-old woman presenting 1 hour after onset of symptoms
A 65-year-old man diagnosed with bleeding ulcers 1 week before onset of symptoms
29. A 25-year-old woman presents to the ED and says she is having another episode of PSVT. Her
medical history includes an electrophysiologic stimulation study (EPS) that confirmed a
reentry tachycardia, no Wolff-Parkinson-White syndrome, and no preexcitation. HR is 180
bpm. The patient reports palpitations and mild shortness of breath. Vagal maneuvers with
carotid sinus massage have no effect on HR or rhythm. Which of the following is the most
appropriate next intervention?
a.
b.
c.
d.
DC cardioversion
IV diltiazem
IV propranolol
IV adenosine

30. A patient with an HR of 30 to 40 bpm complains of dizziness, cool and clammy extremities,
and dyspnea. He is in third-degree AV block. All treatment modalities are present. What would
you do first?
a.
b.
c.
d.
give atropine 0.5 to 1 mg IV

give epinephrine 1 mg IV push
start dopamine infusion 2 to 10 g/min
begin immediate transcutaneous pacing, sedate if possible
Identify the Following Rhythms

31.
Normal Sinus Rhythm
Monomorphic Ventricular Tachycardia
Sinus Tachycardia
Sinus Bradycardia
Atrial Fibrillation
Atrial Flutter
Reentry Supraventricular Tachycardia

Polymorphic Ventricular Tachycardia

Second-Degree Atrioventricular Block
Third-Degree Atrioventricular Block
32.
Normal Sinus Rhythm
Sinus Tachycardia
Sinus Bradycardia
Atrial Fibrillation
Atrial Flutter
33.
Normal Sinus Rhythm
Sinus Tachycardia
Sinus Bradycardia
Atrial Fibrillation
Atrial Flutter


34.
Normal Sinus Rhythm
Sinus Tachycardia
Sinus Bradycardia
Atrial Fibrillation
Atrial Flutter
35.
Normal Sinus Rhythm
Sinus Tachycardia
Sinus Bradycardia
Atrial Fibrillation
Atrial Flutter

10
36.
Normal Sinus Rhythm
Sinus Tachycardia
Sinus Bradycardia
Atrial Fibrillation
Atrial Flutter
37.
Normal Sinus Rhythm
Sinus Tachycardia
Sinus Bradycardia
Atrial Fibrillation
Atrial Flutter

11
38.
Normal Sinus Rhythm
Sinus Tachycardia
Sinus Bradycardia
Atrial Fibrillation
Atrial Flutter
39.
Normal Sinus Rhythm
Sinus Tachycardia
Sinus Bradycardia
Atrial Fibrillation
Atrial Flutter

12
40.
Normal Sinus Rhythm
Sinus Tachycardia
Sinus Bradycardia
Atrial Fibrillation
Atrial Flutter

13
ACLS Written 2006 Precourse Self-Assessment

Answer Key
1. The correct answer is d.

See ACLS Provider Manual, pages 38 and 43.
2. The correct answer is b.
See ACLS Provider Manual, page 53
3. The correct answer is c.
See ACLS Provider Manual, page 37.
5. The correct answer is a.
See ACLS Student CD, pages 22-23
See ACLS Provider Manual, page 58-59
See ACLS Provider Manual page 72.
See ACLS Student CD, ACLS Core Drugs

14

See ACLS Provider Manual page 72.
See ACLS Provider Manual, page 76 and 78
See ACLS Provider Manual, pages 106 and 112-113.
See ACLS Provider Manual, pages 99
See ACLS Provider Manual, pages 93-95 and 99
See ACLS Provider Manual, pages 45. 48, 53 and 62
See ACLS Provider Manual, pages 83 and 86

31. Normal Sinus Rhythm
See ACLS Student CD Nonarrest Rhythms

32. Second Degree Atrioventricular Block

33. Sinus Bradycardia

34. Arial Flutter

35. Sinus Bradycardia

15
36. Third Degree Atrioventricular Block

37. Atrial Fibrillation

38. Monomorphic Ventricular Tachycardia

39. Polymorphic Ventricular Tachycardia

40. Ventricular Fibrillation
See ACLS Student CD Core Arrest Rhythms

16

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ACLS

ACLS Course Agenda

Welcome / Course Overview

Precourse Self-Assessment Review

Importance of CPR Lecture

BLS Primary Survey & ACLS Secondary Survey Video

1st rotation of Respiratory Arrest and CPR/AED Practice and Test

2nd rotation of Respiratory Arrest and CPR/AED Practice and Test

Stroke Video and Lecture

Megacode & Resuscitation Team Practice Video

Pulseless Arrest VF/VT Learning Station in Groups

ACLS Course Agenda

Acute Coronary Syndromes Video and Lecture

Bradycardia/Asystole/ PEA and Stable/Unstable Tachycardia

Putting It All Together Learning Station in Groups

ACLS Course Agenda

Welcome / Course Overview

Precourse Self-Assessment Review

ACLS Update Video

Importance of CPR Lecture

1st rotation of Respiratory Arrest and CPR/AED Practice and Test

2nd rotation of Respiratory Arrest and CPR/AED Practice and Test

Megacode & Resuscitation Team Practice Video

Megacode Practice in Groups - Putting It All Together

American Heart Links

You can find statistics on cardiovascular diseases and risk factors at

You can find out your risk for heart disease at

You can find out how to lead a healthy lifestyle at

You can also go to the Emergency Cardiovascular Care (ECC) website at

2006 American Heart Association

ACLS Pulseless Arrest Algorithm.

December 13, 2005

Figure 1. Bradycardia Algorithm.

Figure 2. ACLS TachycardiaAlgorithm.

December 13, 2005

Figure 1. Acute Coronary Syndromes Algorithm.

December 13, 2005

Goals for Management of Patients With Suspected Stroke Algorithm.

Always start with the ABCD survey!

ACUTE CORONARY SYNDROMES

Remember: All Trained Dogs Eat

For Regular Wide Complex Tachycardia

For Irregular Wide Complex Tachycardia

A Note on ET Tube Administration of Medications: This route of medication administration is being

V-Fib / Pulseless V-Tach

Infusion dose: 540 mg IV/IO over 18 hours (.5 mg/min)

IV/IO Bolus Dosage:

150 mg over 10 minutes (rapid)

IV/IO Bolus Dosage:

IV/IO Bolus Dosage:

IV/IO Bolus Dosage:

Infusion dosage: 1mg in 500ml of D5W or NaCl at 1g/min titrated to effect.

IV/IO Bolus Dosage:

IV/IO Bolus Dosage:

Infusion dosage: 1-4mg/min

IV/IO Bolus Dosage:

Normal Sinus Rhythm

(Also known NSR or RSR)

Normal in configuration and

Normal in configuration and

Normal (0.10 seconds or less)

Normal (0.10 seconds or less)

Normal in configuration and direction;

Normal (0.12 - 0.20 seconds)