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Critical Concepts
Advanced
Cardiovascular
Life
Support
Precourse
Study Guide
Presented by:
Critical Concepts Corp.
3201 W. Griffin Rd.
Suite 205
Fort Lauderdale, FL 33312
Phone: 954-322-8883
Fax: 954-322-8817
Toll Free: 1-800-427-6355
Website: www.criticalconceptsusa.com

Copyright 2006 S. Lunsford 1

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NEED PRIVATE TRAINING AT YOUR OFFICE? SEE BELOW INFORMATION

We welcome you to Critical Concepts Corporation and the
American Heart Associations Advanced Cardiac Life Support
Course. We provide a Stress-Free program to all individuals who
participate in our hands-on training program.

Please note if you are registered in the one-day re-certification
course a current card is required and you will need to bring this to
class. The re-certification course provides a brief update then into
testing and hands-on skills. We recommend the renewal course for
clinicians who utilize their ACLS skills frequently and can interpret
rhythm strips. The two-day Initial ACLS Course is for a thorough
review of ACLS with extensive practice and is enjoyed by all.
Our organization has faculty consisting of MDs, RNs, Paramedics,
Firefighters and Emergency Care Professionals. We teach need to
know information in an enjoyable Stress-Free environment.

For any questions or concerns feel free to contact us at
jpacheco@criticalconceptsusa.com or call at 1-800-427-6355.

If you are rusty on EKGs no problem, simply purchase our
Basic EKG Guide at www.CriticalConceptsUsa.com

Critical Concepts

ACLS Course Agenda

2 Day Course16 hours
1 Day Renewal 8 hours

IMPORTANT: PLEASE SEE START TIME LISTED AT YOUR FACILITY OR
CHECK WITH THE DIRECTOR/MANAGER. START TIME VARIES BY
LOCATION. AGENDA MAY VARY ACCORDING TO PARTICIPANTS NEEDS
(i.e some individuals may need more help with one subject of the other)

Day 1
10 min Welcome/Introductions
10 min Lesson 1 ACLS Course Overview
5 min Lesson 2 Course Organization
20 min Lesson 3 BLS Primary Survey and ACLS Secondary Survey

Divide class into 2
groups
Lesson 4
Management of Respiratory Arrest
Learning Station
Lesson 5
CPR Practice and Competency
Test
1 hour Group 1 Group 2
15 min Break Break

One large group
15 min Lesson 6 Technology Review
1 hour Lunch
30 min Lesson 7 The Megacode and Resuscitation Team Concept

Divide class into 2
groups
Lesson 8
Pulseless Arrest VF/VT
Learning Station
Lesson 8
Pulseless Arrest VF/VT
Learning Station
1 hour 30 min Group 1 Group 2

One large group (or 2 small groups)
35 min Lesson 9 ACS
15 min Break

Divide class into 2
groups
Lesson 10
Bradycardia/Asystole/PEA
Learning Station
Lesson 11
Tachycardia, Stable and Unstable
Learning Station

One large group (or 2 small groups)
35 min Lesson 12 Stroke
End of Day 1
Critical Concepts
ACLS Course Agenda

Day 2

Divide class into 2
groups
Lesson 13
Putting It All Together
Learning Station
Lesson 13
Putting It All Together
Learning Station

One large group
5 min Lesson 14 Course Summary and Testing Details
15 min Break

Divide class into 2
groups
Lesson 15
Megacode Test
Lesson 15
Megacode Test

One large group (as students finish Megacode test)
1 hour Lesson 16 Written Test
Class Ends/Remediation

Critical Concepts
ACLS Study Guide
2006

Read Prestudy Material. Guidelines have recently changed and certain American Heart
Association Textbooks/Materials/Handbooks will be available at different intervals.
Please check with your educator for library AHA books or order by calling Channing Bete
at 1.800.611.6083 and keep them on you.

Please also take the pre-test in the back of this book and use the checklists to prepare.

By the end of this course you must be able to demonstrate during a simulated VF (Ventricular
Fibrillation) arrest scenario:
assessing a victim by the Primary and Secondary ABCDs
effective adult 1 and 2 rescuer CPR
using an AED on an adult
safe defibrillation with a manual defibrillator
maintaining an open airway
confirmation of effective ventilation
addressing vascular access
stating rhythm appropriate drugs, route and dose
consideration of treatable causes

What happens if I do not do well in the course?
The Course Director or Instructor will first remediate (tutor) you and allowed to continue in the
course.

Any questions please contact this office.

Critical Concepts

What is ACLS?
ACLS is an assess then manage approach for those at risk of or in cardiac arrest. This
approach is outlined in algorithms within you materials.

Instructor to assess learning needs of students.

Primary and Secondary ABCDs
This is a methodical assess-then-manage approach used to
treat adults in respiratory distress and failure, stable and unstable arrhythmias
and pulseless arrest. Algorithms are menus that guide you through
recommended treatment interventions.
Know the following ABCDs approach because it begins all ACLS
case scenarios. The information you gather during the assessment will determine
which algorithm you choose for the patients treatment.
Primary ABCDs: these refer to CPR and the AED.
Assess: Tap and ask: Are you OK?
Send someone to call 911 and bring an AED.
If alone call 911, get an AED and return to victim.

Airway: Open with the head-tilt/chin lift.

Breathing: Assess for adequate breathing.
If inadequate: give 2 breaths over 1 second each.
Each breath should cause a visible chest rise.
Use mouth-to-mask or barrier, bag-mask-ventilation (BMV) or mouth-to-
mouth.
Give oxygen (O2) as soon as it is available.

Circulation: Check carotid pulse for no more than 10
seconds.
If not definitely felt, give 30 compressions in center of chest, between the
nipples.
Compress the chest wall 1
1
/
2
- 2 inches.
One cycle of CPR is 30 compressions and 2 breaths
Give 5 cycles of CPR, (about 2 minutes).
Minimize interruptions to compressions.

2-rescuers: the compressor PAUSES while 2 breaths are given.
Change compressors after 5 cycles to avoid fatigue and ineffective
compressions.
Critical Concepts

Defibrillation: When an AED arrives, immediately
power it on!
Follow the voice prompts.
Use adult pads on adults.

Secondary ABCDs:
Airway: Use bag-mask connected to 100%O2.
Give each breath over 1 second each.
Compressor pauses to allow the 2 breaths to go in.
Consider inserting an advanced airway (see Advanced Airway on next page).

Breathing: Look for visible chest rise during each
breath.
Confirm advanced airway tube placement (see Advanced Airway on next
page).
Secure the airway tube.
Compressor now gives 100 continuous compressions per minute.
Ventilator gives 8-10 breaths per minute (one every 6-8 seconds).

Circulation: Obtain vascular access with an IV
(intravascular) or IO (intraosseous) cannula.
Give drugs as recommended per algorithm.

Diagnosis: Why is the patient in the rhythm? Look
for any possible causes to treat:

6 Hs 5 Ts
Hypoxia
Hypovolemia
Hypothermia
Hypoglycemia
Hypo / Hyperkalemia
Hydrogen ion (acidosis)
T amponade
T ension pneumothorax
T oxins poisons, drugs
T hrombosis coronary (AMI) pulmonary
(PE)
T rauma
Spacing separations may help as a memory aid.

Critical Concepts

Airway Skills
During the course you will be expected to participate in manikin practice and
demonstrate the below skills.

Basic Airway:
Oxygen:

Open the Airway:
Use the head tilt-chin lift when assessing for adequate breathing.

Use a jaw thrust for unresponsive-unwitnessed, trauma or drowning
victims.
If unable to open the airway with a jaw thrust, use head-tilt chin
lift.

Maintain:
Insert an oropharyngeal airway when unconscious with no cough or gag
reflex.

Insert a nasopharyngeal airway when a cough or gag reflex is present
(better tolerated).

Ventilate: Give each breath over 1 second using enough volume to
see the chest rise.
2-rescuer CPR: give 2 breaths during the pause following 30
compressions.
Rescue breathing: when a pulse is present, give 10-12
breaths/minute (one each 5-6 seconds).

Advanced Airway:
Laryngeal Mask Airway (LMA): requires the least training for insertion.
Inserts blindly into the hypopharynx.
Regurgitation and aspiration are reduced but not prevented.
Confirm placement: see chest rise and listen for breath sounds over
lung fields.
Contraindications: gastric reflux, full stomach, pregnancy or morbid
obesity.

Critical Concepts
Combitube: requires more training for insertion than the LMA.
Inserts blindly into esophagus (80% of the time) or the trachea.
Ventilation can occur whether the tube is the esophagus or the
trachea.
Confirm placement: clinical exam and a confirmation device (see
below).
Advanced Airway (Cont):

Contraindications: gag reflex, esophageal disease, caustic ingestion,
under 16 yr. or 60 in.

Endotracheal Tube (ETT): requires the most training, skill and frequent
retraining for insertion.
Inserts by direct visualization of vocal cords.
Isolates the trachea, greatly reduces risk of aspiration, and provides
reliable ventilation.
High risk of tube displacement or obstruction whenever patient is
moved.
Confirm placement: clinical exam and a confirmation device (see
below).

Immediately confirm tube placement by clinical assessment and a device:
Clinical assessment:
Look for bilateral chest rise.
Listen for breath sounds over stomach and the 4 lung fields (left and
right anterior and midaxillary).
Look for water vapor in the tube (if seen this is helpful but not
definitive).

Devices:
End-Tidal CO2 Detector (ETD): if weight > 2 kg
Attaches between the ET and Ambu bag; give 6 breaths with the Ambu
bag:
- Litmus paper center should change color with each inhalation and
each exhalation.

Original color on inhalation = Okay O2 is being inhaled: expected.
Color change on exhalation = CO2!! Tube is in trachea.

Original color on exhalation = Oh-OH!! Litmus paper is wet: replace ETD.
Tube is not in trachea: remove ET.
Cardiac output is low during CPR.

Critical Concepts
Esophageal Detector (EDD): if weight > 20 kg and in a perfusing rhythm
Resembles a turkey baster:
o Compress the bulb and attach to end of ET.
o Bulb inflates quickly! Tube is in the trachea.
o Bulb inflates poorly? Tube is in the esophagus.
No recommendation for its use in cardiac arrest.

Critical Concepts
Arrhythmias
During the course you will be expected to demonstrate your ability to identify the below
arrhythmias.

Pulseless Rhythms
(Arrest Rhythms)

Shockable
VF (Ventricular Fibrillation)
VT (Ventricular Tach Pulseless)
Torsades de Pointes
Non-Shockable
PEA (Pulseless Electrical Activity)

Asystole (Silent Heart)
Perfusing Rhythms
(Non-Arrest Rhythms)
Tachycardias: Narrow QRS

Regular Rhythms:
Sinus Tachycardia
Atrial Flutter
Supraventricular Tachycardia
Junctional Tachycardia

Irregular Rhythms:
Atrial Flutter
Atrial Fibrillation
Multifocal Atrial Tachycardia
Tachycardias: Wide QRS
Regular Rhythm:
Ventricular Tachycardia- monomorphic
Irregular Rhythms:
Ventricular Tachycardia-polymorphic
Torsades de pointes
Bradycardia

Sinus Bradycardia
Junctional Rhythm
Idioventricular Rhythm

Artioventricular Block:
1
st
Degree
2
nd
Degree: Mobitz Type I
(Wenckebach)
Mobitz Type II
3
rd
Degree
(Complete Heart Block)

Critical Concepts
Electrical Therapy
During the course you will practice and then demonstrate safe, effective technique
and know indications.

Defibrillation: High energy single shocks with manual defibrillator:ECC handbook p.9
Recommended shock dose: biphasic = 120- 200 J (per manufacturer)
Recommended shock dose: monophasic = 360 J

Synchronized Cardioversion: Timed low energy shocks: ECC Handbook p.14
Timed to QRS to reduce risk of R-on-T: a shock that hits the T wave may cause VF

Transcutaneous Pacer: Noninvasive emergent bedside pacing: ECC Handbook p. 62.
Apply pacer pads.
Verify pacer capture.

Vascular Access
Be prepared to discuss

Peripheral: Preferred in arrest due to easy access and no interruption in CPR
Use a large bore IV catheter.
Attempt large veins: antecubital, external jugular, cephalic, femoral
Can take 1-2 minutes for IV drugs to reach the central circulation.
Follow IV drugs with a 20ml bolus of IV fluid, and elevate extremity for 10-20 seconds.

Intraosseous (IO): Inserts into a large bone and accesses the venous plexus.
May use if unable to obtain intravascular access.
Drug delivery is similar to that via a central line.
Safe access for fluids, drugs, blood samples and
Commercial kits are available for adult IO access.
Drug doses are the same as when given IV.

Central Line: Not needed in most resuscitations.
Insertion requires interruption of CPR.
If a central line is already in place and patent, it can be used.

Endotracheal: Some drugs may be given via the ETT in the absence of a IV/IO.
Drug delivery is unpredictable thus IV/IO delivery is preferred.
Drug blood concentration stays lower than when given IV.
Increase dose given to 2 - 2.5 times the recommended IV dose.
Drugs that absorb via the trachea:
N aloxone
A tropine
V asopressin
E pinephrine
L idocaine
Critical Concepts

ACLS Drugs

Look up drug dosages in the ECC Handbook .You may be allowed to use it as a reference in
class.

The Primary focus in cardiac arrest is effective CPR and early defibrillation.
Drug administration is secondary and should NOT interrupt CPR.
Know the timing of drug administration in CPR as shown:
The Class of Recommendation number denotes potential benefit versus risk.

General Statements:

Pulseless arrest, all: Give a Vasopressor drug Epinephrine or Vasopressin
Vasopressors cause peripheral vasoconstriction, which shunts increased blood flow to the heart and
brain.

Pulseless ventricular rhythms: Consider antiarrhythmics Amiodarone, Lidocaine, or
Magnesium
May make myocardium easier to defibrillate and/or more difficult for it to again fibrillate after
conversion.

Bradycardia: Give a Speed Up drug - Atropine
Atropine blocks vagal input and stimulates the SA node, which can increase heart rate.

Consider dopamine and epinephrine infusions if unresponsive to atropine and waiting on a pacer.
Dopamine and epinephrine may increase heart rate but also increase myocardial oxygen demand.

Tachycardia, Reentry SVT: Give a drug to interrupt the rhythm - Adenosine
Adenosine blocks the AV node for a few seconds, which may break the re-entry pattern.

Tachycardia, AFib or AFlutter: to convert rhythm Amiodarone.
to slow rate Beta Blocker.
Dilitazem:

Tachycardia, VT, stable: to convert rhythm Amiodarone.
or Sync Cardiovert:

Acute Coronary Syndromes: First line treatment is MONA : ECC
Oxygen increases the oxygen available to the ischemic or injured heart muscle.
Aspirin decreases platelet clumping, the first step in forming a new blood clot. ***
Nitroglycerin dilates coronary arteries so more oxygenated blood can reach the muscle and decrease
pain; also dilates peripheral vessels decreasing the resistance the heart has to pump against.
Morphine decreases pain not relieved by nitroglycerin; also dilates peripheral vessels decreasing
resistance against which the heart has to pump.
*** If allergic to Aspirin (ASA): Give Clopidogrel (Plavix) affects platelet clumping similar to ASA.
Critical Concepts

ACLS Core Cases 1-10
Study the algorithms and drugs well in the 2006 ECC Handbook. The following may help.

1. Respiratory Arrest Case
The skills listed on p. 4-5 of the study guide will be practiced in most case scenarios.

2. VF Treated with CPR and AED Case
You are walking down the hall and the person in front of you suddenly collapses
Assess:
- Tap, ask: Are you Okay?
- No Movement or response, call 911 and get the AED!!!
or if a second person is present, send them to call and get the AED

Primary ABCD Survey:
- Airway: Open and hold (Head tilt Chin lift or Jaw Thrust), Look, listen &
Feel
- Breathing: Give 2 breaths (1 second each) that make the chest rise
Avoid rapid or forceful breaths.
- Circulation: Check carotid pulse at least 5 but no longer than 10 seconds
Begin CPR if a definite pulse is not felt.
o 30 Compressions: 2 ventilations = 1 cycle
o Push hard: 1 -2 inches deep
o Push fast: 100 compressions per minute
o Allow the chest wall to completely recoil ( take weight off
hands)
o Minimize interruptions

Recheck pulse after 5 cycles of CPR (Approx. 2 minutes)
2 Rescuer CPR, basic airway: Pause compressions to ventilate

- Defibrillation: Automated External Defibrillator
1. Power On Turn power on. (Some AEDs automatically turn on)
2. Attachment Select Adult Pads, Attach pads to patient (upper right sternal border
and cardiac apex), Attach cables to AED, if needed.
3. Analysis Announce, Analyzing rhythm stand clear! Press Analyze, if needed.
4. Shock If shock indicated, Announce, Shock is indicated. Stand Clear! Im going
to shock Verify no one is touching the patient. Press shock button when signaled
to do so.
If no shock indicated, follow prompts from AED.

Unacceptable actions:
Did not provide effective CPR.
Did not follow AEDs commands.
Did not clear patient before shock (unsafe defibrillation)

Critical Concepts

3. Pulseless Arrest: VF / Pulseless VT Case. ECC Handbook p. 7 left side
You respond to a patient monitor alarm, to find the patient is unresponsive. Call for help and begin
CPR (primary ABC survey). A team member arrives with the crash cart, which has a manual
defibrillator and advanced equipment. The patient is attached to the monitor and you identify and
verify VF or PVT.

Primary D: Defibrillation: Shock #1
o After verifying the rhythm, Resume CPR while the defibrillator is charging.
o Once Charged, Clear!!! Ensure that no one is touching the patient or bed.
o Give 1 shock: biphasic defibrillators = Mfg recommendation, if unknown 200J
Monophasic defibrillators = 360J
o Immediately resume CPR for 5 cycles
o After 5 cycles: check rhythm (shockable?), check pulse (5-10 seconds)

Secondary ABCD Survey: conducted between 1
st
and 2
nd
shock and Ongoing
o Airway:
o BVM with 100% O2
o Consider advanced airway placement: LMA, Combitube, or ETT
o Breathing:
o Check for visible chest rise with BVM
o Confirm advanced airway placement by exam and confirmation device
o Secure advanced airway in place with tape or a commercial device
o Give 8-10 breaths/min and continuous compressions at 100 per minute.
o Circulation: Establish Vascular access via IV or IO
o Do not interrupt CPR for access.
o Differential Diagnosis Use the Hs and Ts mnemonic
Defibrillation: Shock #2
o After 5 cycles of CPR: Check rhythm (shockable?), Check pulse (5-10 seconds)
o Resume CPR while defibrillator is charging
o Once charged, Clear!!! Ensure no one is touching the patient or bed.
o Give 1 Shock: biphasic defibrillators = Mfg recommendation, if unknown 200J
Medications: Administer either: Give during CPR
Epinephrine 1mg IV/IO (every 3 5 minutes) or
Vasopressin 40U IV/IO to replace first or second dose of epinephrine.
Defibrillation: Shock #3
o After 5 cycles of CPR: Check rhythm (shockable?), Check pulse (5-10 seconds)
o Resume CPR while defibrillator is charging
o Once charged, Clear!!! Ensure no one is touching the patient or bed.
o Give 1 Shock: biphasic defibrillators = Mfg recommendation, if unknown 200J
Medications: Consider Antiarrhythmics: Give during CPR
o Amiodarone 300mg IV/IO once, then consider additional 150mg IV/IO once.
o Lidocaine 1-1.5mg/kg first dose then 0.5-0.75mg/kg IV/IO, max 3 doses or
3mg/kg
o Magnesium 1-2g IV/IO loading dose for torsades de pointes

Did not clear before shock
Did not confirm advanced airway placement
Did not give a vassopressor
Critical Concepts

4. Pulseless Arrest: Pulseless Electrical Activity (PEA) Case
5. Pulseless Arrest: Asystole Case

You find that a patient is unresponsive. Call for help and begin CPR (primary ABC survey). A team
member arrives with the crash cart, which has a manual defibrillator and advanced equipment. The
patient is attached to the monitor and you identify and verify Asystole or PEA.

Primary D: Defibrillation: NO Shock indicated for Asystole or PEA

Secondary ABCD Survey: Ongoing
o Airway:
o BVM with 100% O2
o Consider advanced airway placement: LMA, Combitube, or ETT
o Breathing:
o Check for visible chest rise with BVM
o Confirm advanced airway placement by exam and confirmation device
o Secure advanced airway in place with tape or a commercial device
o Give 8-10 breaths/min and continuous compressions at 100 per minute.
o Circulation: Establish Vascular access via IV or IO
o Do not interrupt CPR for access.
o Medication: Give a Vasopressor
Epinephrine 1mg IV/IO (repeat every 3-5 minutes)
Vasopressin 40 U IV/IO to replace first or second dose of epinephrine.
Consider Atropine 1mg for Asystole or PEA rate less than 60
o Check rhythm, check pulse after 2 minutes of CPR (5 cycles)

o Differential Diagnosis Use the Hs and Ts mnemonic

6 Hs 5 Ts
Hypovolemia
Hypoxia
Hydrogen ion (acidosis)
Hypo-/hyperkalemia
Hypoglycemia
Hypothermia
Toxins (Drug overdose)
Tamponade, cardiac
Tension pneumothorax
Thrombosis (coronary or pulmonary)
Trauma
o Consider Family members:
Did not confirm advanced airway placement.
Did not give a vasopressor.
Did not look for reversible causes to treat.
Attempted defibrillation.
Attempted transcutaneous pacing for asystole

Critical Concepts

6. Acute Coronary Syndromes (ACS) Case

Your neighbor complains of feeling weak and is sweaty, short of breath and slightly nauseated.
You are worried this is an acute coronary problem and call 911. While waiting for their arrival, you
ask if he can take aspirin. He says yes, and you have him chew 2-4 baby aspirin (81mg)

EMS arrival:
o Attach monitor, Start IV
o Give MONA:
o Obtain 12-lead ECG if available:
o Notify hospital and transport
o Begin fibrinolytic checklist:
Arrival at ED: Assess
12 Lead ECG

ST segment
Elevation
(STEMI)
ST segment
Depression
(Non-STEMI or NSTEMI)
ST segment T wave
Normal

Injury Ischemia Non-
diagnostic
Drug Therapy:
Beta blockers: myocardial work
Clopidogrel: platelet clumping
Heparin: fibrin so new clot doesnt form

Goal is reperfusion by:

Fibrinolytic: lyses fibrin in
If <12 hours from onset
If no contraindications
ED door to drug goal = 30

Or PCI (percutaneous intervention:
Angioplasty and/or stents)
If < 12 hours from onset
ED door to balloon goal = 90 min

After reperfusion give:
Resume above drugs
ACE-inhibitor: myocardial work
Statin: inflammation and arrhythmias

Drug Therapy:
Nitroglycerin: work
Beta blockers
Clopidogrel
Heparin
IIb /IIIa inhibitor: platelet-
fibrin bonding

Goal is revascularization:
PCI or possible surgery

After revascularization
give:
Resume above drugs as
needed
ACE-inhibitor
Statin

Consider admit to ED bed:
Serial enzymes + Troponin:
ECC Handbook p. 37
Repeat ECGs
Monitor ST segment
Consider stress test

Admit to hospital bed if:
Troponin positive
ST segment deviates
Refractory chest pain
Ventricular Tachycardia
Becomes unstable

Discharge if:
No ischemia/ injury evolves
Give follow-up directions

Critical Concepts
Did not give oxygen and aspirin to a suspected chest pain patient.
Did not attempt to control chest pain.
Did not obtain 12 lead ECG.

Critical Concepts
7. Bradycardia Case

A patient appears pale and complains of dizziness and fatigue. The pulse rate is 56, blood
pressure is 86/60 and on the monitor you identify a bradycardia rhythm.

o Maintain patent airway; assist breathing as needed
o Give oxygen
o Monitor ECG (identify rhythm), blood pressure, oximetry
o Establish IV access

Assess rhythm and perfusion:

Is the heart rate <60 bpm
or
Inadequate for clinical condition

Signs or symptoms of poor perfusion caused by the Bradycardia?
(eg, acute altered mental status, ongoing chest pain, hypotension, or other signs of shock)

Prepare for transcutaneous pacing;
use without delay for high-degree block
(type II second-degree block or third-degree
AV block)

Consider Atropine 0.5mg IV while
awaiting pacer. May repeat to a total
dose of 3mg. If ineffective, begin pacing

Consider epinephrine (2 to 10 ug/min)or
dopamine (2 to 10 ug/kg per min)
infusion while awaiting pacer or if pacing
ineffective
Adequate
Perfusion
Observe /
Monitor
Critical Concepts
Prepare for transvenous pacing
Treat contributing causes
Consider expert consultation
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
-Hypoglycemia pulmonary)
-Hypothermia -Trauma (hypovolemia,
Increased ICP)
Poor
Perfusion

Did not identify a high-degree block
Did not initiate TCP immediately for high-degree block
Treated asymptomatic patient as if had poor perfusion

8. Unstable Tachycardia Case
9. Stable Tachycardia Case

A patient appears pale and complains of dizziness and fatigue. The pulse rate is 170, blood
pressure is 100/60 and on the monitor you identify a tachycardia rhythm.

o Assess and support ABCs as needed
o Give Oxygen
o Monitor ECG (identify rhythm), blood pressure, oximetry
o Identify and treat reversible causes

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 Perform Immediate synchronized Cardioversion
o Establish IV access and give sedation if patient is conscious: do not delay
Cardioversion
o Consider expert consultation
o If pulseless arrest develops, see Pulseless Arrest Algorithm
Stable See chart below.
o Establish IV access
o Obtain 12-lead ECG (when available or rhythm strip)
o Is QRS narrow (<0.12sec)?
Critical Concepts

Narrow QRS:
Is Rhythm regular?
Attempt vagal maneuvers
Give Adenosine 6mg rapid IV
push. If no conversion, give
12mg rapid IV push; may repeat
12mg dose once
Does rhythm
convert?
Note: Consider
expert
consultation
Regular Irregular Irregular Regular
Irregular Narrow-Complex
Tachycardia
Probable atrial fibrillation or
possible atrial flutter or MAT
(Multifocal atrial tachycardia)
Consider expert consultation
Control rate (eg, diltiazem,
B-blockers, use B-blockers
with caution in COPD and CHF
Does Not Convert
If rhythm does NOT convert,
possible atrial flutter,
ectopic atrial tachycardia,
or Junctional tachycardia:
- Control rate
- Treat underlying cause
- Consider expert
consultation
Converts
If ventricular
tachycardia or
uncertain rhythm

Amiodarone
150mg IV over
10 min Repeat as
needed to max
dose of 2.2g/24hr
Prepare for
elective
Synchronized
Cardioversion

If SVT with
aberrancy:
Give Adenosine
6mg rapid IV
push. If no
conversion, give
12mg rapid IV
push, may repeat
12mg dose once
If atrial fibrillation with
aberrancy
See Irregular Narrow
Complex tachycardia

If pre-excited atrial
fibrillation (AF+ WPW)
Expert consultation
advised
Avoid AV nodal
blocking agents (eg,
adenosine, digoxin,
diltiazem, verapamil)
Consider
antiarrhythmics (eg,
amiodarone 150mg IV
over 10 min)

If recurrent
pol ymorphic VT, seek
expert consultation

If torsades de pointes,
give magnesium
(load with 1-2g over
5-60 min, then infusion)
If rhythm converts,
probable reentry
SVT:
- Observe for
recurrence
- Treat recurrence
with adenosine or
longer-acting AV
nodal blocking agent
Wide QRS: Is Rhythm regular?
Expert consultation advised
10. Acute Stroke Case

You find a normally alert, active adult in a chair staring blankly at the television and leaning to one
side.

Identify signs of possible stroke
o Critical EMS assessments and actions
Support ABCs; give oxygen if needed
Perform prehospital stroke assessment:
- The Cincinnati Prehospital Stroke Scale
o Facial Droop (have the patient show teeth or smile)
o Arm Drift (patient closes eyes and extends both arms
straight out with palms up, for 10 seconds)
o Abnormal Speech (have the patient say you cant teach
an old dog new tricks)
- Los Angeles Prehospital Stroke Screen ECC Handbook p. 18
Establish time when patient last known normal (symptoms onset)
Transport; consider triage to a center with a stroke unit if appropriate;
consider bringing a witness, family member, or caregiver
Alert Hospital
Check glucose if possible

Critical Concepts
o ED Arrival: Immediate general assessment and stabilization < 10min
Assess ABCs, vital signs
Provide oxygen if hypoxemic
Obtain IV access and blood samples
Check glucose; treat if indicated
Perform neurologic screening assessment
Activate stroke team
Order emergent Non-contrast CT scan of brain
Obtain 12-lead ECG
o ED Arrival: immediate neurologic assessment by stroke team < 25min
Review patient history
Establish symptom onset
Perform neurologic examination (NIH Stroke Scale)
o Does CT scan show any hemorrhage? < 45min
Hemorrhage Consult neurologist or neurosurgeon; consider transfer
No Hemorrhage
- Probable acute ischemic stroke; consider fibrinolytic therapy
o Check for fibrinolytic exclusions ECC Handbook p.20
o Repeat neurologic exam: are deficits rapidly improving?
Patient remains candidate for fibrinolytic therapy?
- Not a candidate
o Administer aspirin
- Candidate < 60min
o Review risks/benefits with patient and family:
o If acceptable-
Give tPA
No anticoagulants or antiplatelet treatment for
24 hours


PRINTED Name___________________________

ACLS Precourse Self-Assessment
Answer Sheet

Circle the correct answers
1. A B C D
2. A B C D
3. A B C D
4. A B C D
5. A B C D
6. A B C D
7. A B C D
8. A B C D
9. A B C D
10. A B C D
11. A B C D
12. A B C D
13. A B C D
14. A B C D
15. A B C D
16. A B C D
17. A B C D
18. A B C D
19. A B C D
20. A B C D
21. A B C D
22. A B C D
23. A B C D
24. A B C D
25. A B C D
26. A B C D
27. A B C D
28. A B C D
29. A B C D
30. A B C D

Please fill in the correct rhythm for
questions 31-40

31._____________________________

32._____________________________

33._____________________________

34._____________________________

35._____________________________

36._____________________________

37._____________________________

38._____________________________

39._____________________________

40._____________________________

ACLS Precourse Self-Assessment
Answer Key

Circle the correct answers
1. D
2. B
3. C
4. C
5. A
6. C
7. A
8. B
9. A
10. C
11. B
12. C
13. A
14. A
15. D
16. B
17. C
18. D
19. B
20. A
21. C
22. C
23. A
24. D
25. C
26. D
27. A
28. C
29. D
30. D

Please fill in the correct rhythm for
questions 31-40

31. Normal Sinus Rhythm

32. Second Degree Atrioventricular
Block

33. Sinus Bradycardia

34. Arial Flutter

35. Sinus Bradycardia

36. Third Degree Atrioventricular
Block

37. Atrial Fibrillation

38. Monomorphic Ventricular
Tachycardia

39. Polymorphic Ventricular
Tachycardia

40. Ventricular Fibrillation

Critical Concepts

References: American Heart Association 2005 ECC Guidelines

We look forward to providing an
enjoyable, informative learning
experience.

Please call us directly for any questions or
concerns at 1.800.427.6355 x 201 and
speak with Jesus Pacheco, Administrator

Or

Shawn Nies, RN,EMT-P
Director of Education

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