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IU Health ACLS Study Guide
Preparing For Your Upcoming ACLS Class
UPDATED May 2016
Course Curriculum: 2015 American Heart Association (AHA) Guidelines for Advanced Cardiac Life Support (ACLS) AHA recommends the following to prepare for the course:
- Able to perform high-quality CPR and use an AED
- Understand the 10 cases in the ACLS Provider Manual
- Understand the ACLS algorithms for the cases in the ACLS Provider Manual
- Complete the online ACLS Pre-course Self-Assessment, Rhythm Identification, Pharmacology, and Practical Application with a minimum score of 70%. Recommended Resources for Course Preparation: *Advanced Cardiac Life Support Provider Manual (2015) Optional Resources for Course Preparation: *AHA Pocket card – ACLS Cardiac Arrest, Arrhythmias, and Their Treatment *AHA Pocket card – ACLS Acute Coronary Syndromes and Stroke *AHA 2015 Handbook of Emergency Cardiovascular Care for Healthcare Providers *ACLS Student Website supplementary resources
**** The Precourse Self-Assessment is mandatory. Link can be found on page ii of the ACLS Provider Manual and http://www.heart.org/eccstudent**. The password is acls. You must pass with a score of 70% or better. This is a requirement from the AHA. Please bring a printed copy or electronic picture of your completed assessment with you to class. **
To successfully pass the ACLS course, AHA requires you to pass a written exam with a
score of ≥ 84% and to successfully manage a simulated megacode. A megacode is a hands- on, dynamic, in real time practice of treating a life-threatening cardiac emergency. The cardiac
emergency will progress in the following sequence of rhythms: 1) an arrhythmia with a pulse, 2)
a SHOCKABLE, pulseless rhythm, 3) a NON-SHOCKABLE, pulseless rhythm, and finally 4) a return of spontaneous circulation. Each potential scenario can be found in the Appendix section
of the ACLS Provider Manual. In managing the megacode as the team leader, you will be required to: 1) recognize and
correctly identify the cardiac rhythms or arrhythmias, 2) assess the patient’s general condition,
- effectively treat the patient according to ACLS algorithms, 4) utilize the recommended drugs
and dosages, and 5) safely administer any recommended electrical or shock treatment using a manual defibrillator.
Course preparation is highly recommended to make your experience valuable, as well
as to ensure your successful completion. You are encouraged to purchase or borrow an ACLS Provider Manual to assist you in preparation for your course and the written exam. Any of the
other AHA resources listed above may also be helpful. You will be allowed to use AHA resources for the megacode and the written exam.
This study guide is not to be considered a replacement for the ACLS Provider Manual , the
online pre-course assessment, and other resources offered by the AHA.
BLS CPR
The sequence for CPR is “CAB”: Compressions – Airway – Breathing. Here are the basic steps in the BLS assessment :
- Scene Safety
- Check for responsiveness
- Call for help and an AED (in hospital, call Medical Alert-Code Blue)
- Simultaneously scan the chest for breathing and pulse
- If no pulse, begin compressions – give 30 compressions then give two breaths—continue 30:2 ratio; maintain a rate of 100-120 compression/min at a depth of 2-2.4 inches
- Apply the AED as soon as it arrives
Bradycardia - Any rhythm disorder with a rate <50/min in a symptomatic patient. The
clinical picture is important here to determine if the patient needs monitoring or treatment. The goal in the management of symptomatic bradycardia is clinical improvement.
SINUS BRADYCARDIA
1 ST^ DEGREE HEART BLOCK
2 ND^ DEGREE HEART BLOCK (Mobitz Type I Wenkebach)
2 nd^ DEGREE HEART BLOCK (MOBITZ Type II)
3 RD^ HEART BLOCK
Monomorphic Ventricular Tachycardia with a pulse (VT/V-Tach)
SUSTAINED - rapid, regular uniform, wide complex (monomorphic) tachycardia lasting >
seconds
Identify and treat underlying causes: open airway, assist breathing, O 2 administration, apply monitors, 12 lead ECG, establish IV/IO access, obtain labs, and seek expert consultation.
Is your patient stable or unstable? STABLE
- Seek expert consultation
- Consider antiarrhythmic infusion – Amiodarone 150 mg over 10 minutes (Procainamide, Sotalol are other antiarrhythmic options)
UNSTABLE – showing signs of poor perfusion or shock (hypotension, ischemic chest pain, weak, clammy, cold, ashen, faint, acute mental status changes)
- Deliver immediate synchronized cardioversion at 100 Joules
- Evaluate the rhythm post cardioversion. If continued VT with a pulse, consider a second attempt at a higher energy level
Ventricular Fibrillation (V-Fib/VF)
Pulseless Ventricular Tachycardia (VT/V-Tach)
Both V-Fib and Pulseless V-Tach require immediate defibrillation. Once you determine your patient has one of these arrhythmias (completed your BLS survey and identified the rhythm), proceed as follows:
- Initiate Code Blue and begin chest compressions
- Defibrillate asap
- Immediately resume CPR for 2 minutes
- During this 2 minute cycle: o Obtain IV or IO access o Prepare your first drug: Epinephrine 1 mg o Begin discussing reversible causes
- After 2 minutes, perform a rhythm check – if unchanged: o Defibrillate asap (2nd^ shock) o Resume CPR o Administer Epinephrine 1 mg o Prepare second drug: Amiodarone 300 mg
- Continue to work in 2 minute cycles. After each subsequent defibrillation: o If appropriate, administer the drug you have prepared o Prepare your next drug o Continue to talk about reversible causes (Hs and Ts)
Asystole – There is no electrical or mechanical activity. Asystole is a pulseless, non-
shockable rhythm that requires immediate intervention.
Pulseless Electrical Activity (PEA) – Electrical activity without mechanical
contractility. There is an organized rhythm, but the heart is not pumping. PEA is a pulseless,
non-shockable rhythm that requires immediate intervention.
Once you determine your patient has one of the above rhythms (completed your BLS survey
and identified the rhythm), proceed as follows:
- Initiate Code Blue and begin chest compressions
- Administer Epinephrine 1 mg
- Work in 2 minute CPR cycles
- Epinephrine 1 mg given every other cycle or every 3-5 minutes
NO PULSE
ACLS Pharmacology
Drugs for Bradycardia Atropine: 0.5mg IV/IO IV Push followed by a flush; repeat every 3-5 minutes. Max total dose: 3 mg (6 doses) -First-line drug for symptomatic bradycardia
Dopamine drip: 2-20 mcg/kg/min as an IV Infusion -Titrate to patient response -Second-line drug for symptomatic bradycardia
Epinephrine drip: 2-10 mcg/min as an IV Infusion
- Titrate to patient response -Second-line drug for symptomatic bradycardia
Drugs for SVT Adenosine: 6 mg rapid IV Push followed by an immediate 20 ml flush; may repeat with a 12 mg dose if needed. -Fast push and fast acting drug that results in a short period of asystole
Drugs for Stable Wide Complex VT Antiarrhythmic Options: Amiodarone: 150 mg IV over 10 min. May repeat every 10 min. prn Procainamide: 20-50 mg/min. IV until symptoms subside or max dose: 17 mg/kg Sotalol: 100 mg (1.5 mg/kg) IV over 5 min. Lidocaine: 0.5-0.75 mg/kg and up to 1-1.5 mg/kg IV. May repeat every 5-10 min. Max total dose: 3 mg/kg
Drugs for Pulseless Arrest - VF/VT Epinephrine (1:10,000 concentration) : 1 mg IV/IO Push followed by a flush; repeat throughout code every 3-5 minutes. There is no max total dose.
Amiodarone: 300 mg IV/IO Push followed by a flush. Second dose (if needed) 150 mg. Max total dose: 450 mg
(Lidocaine is an alternative to Amiodarone, though Amio is recommended.. The dose of Lidocaine is 1-1.5 mg/kg)
Magnesium Sulfate is recommended for use in cardiac arrest only if torsades de pointes or suspected hypomagnesemia is present. The dose of Mag Sulfate is 1-2 grams diluted and administered over 5 to 60 minutes.
Drugs for Pulseless Arrest - Asystole/PEA Epinephrine (1:10,000 concentration): 1mg IV/IO Push followed by a flush; repeat throughout code every 3-5 minutes. There is no max total dose.
Drugs for ACS (Acute Coronary Syndromes): MONA M = Morphine O = Oxygen (for oxygen saturation less than 90%) N = Nitrates A = Aspirin
Morphine: Initial dose is 2 to 4 mg IV over 1 to 5 min. May repeat 2-8 mg every 5-15 min. -May administer to patients with suspected ischemic pain unresponsive to nitrates -Contraindications:
- Hypotension -Re-evaluate patient between doses
Nitroglycerin: 1 tablet (0.3-0.4 mg) sublingually; may be repeated every 5 min. up to a total of 3 doses OR 1-2 sprays (over 0.5-1 second) sublingually – max 3 sprays within 15 minutes -First-line drug for suspected ischemic chest pain in ACS -Vasodilator - improves blood flow and reduces ischemic chest discomfort
-Contraindications:
- Hypotension
- Bradycardia
- Tachycardia
- RV Infarction
- Use of phosphodiesterase inhibitors in past 24-48 hrs
Aspirin: 160 mg to 325 mg given/chewed; non-coated baby or adult aspirin -Indications — Standard therapy for all patients with symptoms suggestive of ACS -May use rectal suppository for patients who cannot take orally -Inhibits platelet aggregation (stops clot formation) -Contraindications:
- Allergy to aspirin
- Active GI Bleed
References
Advanced Cardiac Life Support Provider Manual, (2016). Dallas, Texas: American Heart
Association.
2015 Handbook of Emergency Cardiovascular Care for Healthcare Providers, (2015), American
Heart Association.
ACLS Acute Coronary Syndromes and Stroke Pocket Card, (2016), American Heart Association.
ACLS Cardiac Arrest, Arrhythmias, and Their Treatment Pocket Card, (2016), American Heart
Association.
