November, 2013
ACLS Prep
• Preparation is key to a successful ACLS experience.
– Please complete the ACLS Pretest and
– Please complete this ACLS Prep.
ACLS Prep
• Preparation is key to a successful ACLS experience.
– An ACLS Pretest is required for admission to the course.
NO ONE will be admitted without printed pretest results.
The pretest must be accessed online at:
www.heart.org/eccstudent and enter code: compression.
Eighty percent achievement is recommended on the
pretest. **Because this test is online, we recommend you
attempt to access it about 1-week before your course
date**.
ACLS Prep
• Preparation is key to a successful ACLS experience.
– This Powerpoint program has more questions that will
highlight key points not addressed in the pretest. Please
take the time to look up the information in the Provider
Manual.
– The answers to the questions can be found on the page
numbers provided.
– As of January, 2014, we will no longer ask these questions
in the class. Your opportunity to review them is now.
ACLS Prep
• Please be familiar with:
1. The algorithms: Bradycardia, Tachycardia, Pulseless
Arrest, ROSC.
2. These drugs: adenosine, amiodarone, atropine,
epinephrine, vasopressin.
3. These drips: Dopamine for bradycardia and hypotension
and Epinephrine for bradycardia and hypotension.
4. The reversible causes: the Hs and Ts.
ACLS: BLS
Q. Why are chest compressions advantageous for a pulseless
patient?
R. Page 14.
ACLS: BLS
Q. Why are chest compressions advantageous for a pulseless
patient?
R. Chest compressions provide circulation especially through
the heart and brain.
Page 14
ACLS: BLS
Q. Chest compressions are started within how many seconds of
determining unresponsiveness?
R. Page 13.
ACLS: BLS
Q. Chest compressions are started within how many seconds of
determining unresponsiveness?
R. 10 seconds.
Page 13
ACLS: BLS
Q. Chest compressions may be interrupted for procedures,
chest compressions are re-started within how many
seconds?
R. Page 14.
ACLS: BLS
Q. Chest compressions may be interrupted for procedures,
chest compressions are re-started within how many
seconds?
R. 10 seconds.
Page 14
ACLS: General Principles
Q. What is the purpose of the Rapid Response Team?
R. Page 26
ACLS: General Principles
Q. What is the purpose of the Rapid Response Team?
R. Rapid Response Teams provide early assessments and
interventions for a person who is declining physiologically
with the hope of stabilizing the person and preventing a code
blue.
Q.
26
ACLS: Airway
Q. The new standard is to maintain SpO2 between 94% and
99%. Do not leave a patient with an SpO2 of 100% for a
prolonged period of time; the PO2 will be between 80 and
300 mmHg. Why is a high PO2 problematic?
R. Pages 28, 96-97, www/heart.org/eccstudent
ACLS: Airway
Q. The new standard is to maintain SpO2 between 94% and
99%. Do not leave a patient with an SpO2 of 100% for a
prolonged period of time; the PO2 will be between 80 and
300 mmHg. Why is a high PO2 problematic?
R. The patient may develop oxygen toxicity and coronary
arteries constrict in the presence of high oxygen
concentrations. Think of oxygen as a drug and just as with
most drugs too high of a dose will cause toxicity.
Pages 28, 96-97
ACLS: Airway
Q. How is an oropharangeal airway measured?
R. Pages 42-43.
ACLS: Airway
Q. How is an oropharangeal airway measured?
R. Measure an OPA from the corner of the mouth to the angle
of the mandible.
Pages 42-43
ACLS: Airway
Q. Review the process for suctioning a patient. The step of
applying suction while the suction tube is in the airway is
limited to how many seconds?
R. Page 45-46
ACLS: Airway
Q. Review the process for suctioning a patient. The step of
applying suction while the suction tube is in the airway is
limited to how many seconds?
R. 10 seconds.
Q.
Page 45-46
ACLS: Defibrillation
Q. During a pulse check the patient has no pulse and is still in
ventricular fibrillation and the decision is made to
defibrillate. What order is given while the defibrillator is set
up and charged?
R. Page 63.
ACLS: Defibrillation
Q. During a pulse check the patient has no pulse and is still in
ventricular fibrillation and the decision is made to
defibrillate. What order is given while the defibrillator is set
up and charged?
R. Resume CPR.
Page 63
ACLS: Defibrillation
Q. Why is it a bad idea to allow oxygen to blow over the chest
during defibrillation?
R. Page 64
ACLS: Defibrillation
Q. Why is it a bad idea to allow oxygen to blow over the chest
during defibrillation?
R. Fire may result
Q.
Page 64
ACLS: Defibrillation
Q. Why are pads preferred over paddles for defibrillation and
synchronized cardioversion?
R. Page 64.
ACLS: Defibrillation
Q. Why are pads preferred over paddles for defibrillation and
synchronized cardioversion?
R. Even though paddles and pads deliver the same amount of
electricity, pads allow for a more rapid shock and reduces
the likelihood of arcing.
Page 64
ACLS: Airway
Q. Continuous Wave Form Capnography (CWFC) is
recommended after intubation. There are three uses for
capongraphy during resuscitation. What are the three uses?
R. Pages 67, 73, 74, 75, 76
ACLS: Airway
Q. Continuous Wave Form Capnography (CWFC) is
recommended after intubation. There are three uses for
capongraphy during resuscitation. What are the three uses?
R. 1. Assess placement of ET tube (capnography is the gold
standard for assessing placement of ET tubes).
2. Assess quality of chest compressions
(PETCO2 > 10 mm Hg)
3. Assess Return of Spontaneous Circulation (ROSC)
(PETCO2 = 35 – 40 mmHg)
Q.
Pages 67, 73, 74, 75, 76
ACLS: General Principles
Q. A visitor has collapsed in the lobby of the hospital; IV access
is needed. Where is the IV started?
R. Pages 69-70.
ACLS: General Principles
Q. A visitor has collapsed in the lobby of the hospital; IV access
is needed. Where is the IV started?
R. A peripheral IV is preferred; if an peripheral IV cannot be
establish use an IO. Avoid starting a central line because CPR
must be interrupted; an existing central line may be used.
Pages 69-70
ACLS: ROSC
Q. What is the ACLS Survey?
R. Pages 14 to16, 62.
ACLS: ROSC
Q. What is the ALCS Survey?
R. The ACLS Survey is:
A – Airway
B – Breathing
C – Circulation
D – Differential Diagnosis.
Please look at the content on pages 14 to 16 especially
Table 2.
Pages 14 to 16, 62
ACLS: ROSC
Q. What are the top 2 treatment priorities for a patient who
has achieved ROSC?
R. Page 73 and 74.
ACLS: ROSC
Q. What are the top 2 treatment priorities for a patient who
has achieved ROSC?
R. Airway and breathing are the top 2 treatment priorities for
someone with a pulse; ensure the airway is secured and the
patient is supported with ventilations and oxygen if needed.
Page 73 and 74
ACLS: ROSC
Q. Nimrod Jones was resuscitated successfully, but remains
hypotensive even after a fluid bolus. Dopamine drip is
ordered; what is the starting dose range for a Dopamine drip
for hypotension?
R. Page 73 and 76.
ACLS: ROSC
Q. Nimrod Jones was resuscitated successfully, but remains
hypotensive even after a fluid bolus. Dopamine drip is
ordered; what is the starting dose range for a Dopamine drip
for hypotension?
R. Start Dopamine for hypotension within the range of 2 to 10
mcg/Kg/min.
Page 73 and 76
ACLS: ROSC
Q. Nimrod Jones was resuscitated successfully, but remains
hypotensive even after a fluid bolus. Epinephrine drip is
ordered; what is the starting dose range for a Epinephrine
drip for hypotension?
R. Page 73 and 76.
ACLS: ROSC
Q. Nimrod Jones was resuscitated successfully, but remains
hypotensive even after a fluid bolus. Epinephrine drip is
ordered; what is the starting dose range for a Epinephrine
drip for hypotension?
R. Start Epinephrine for hypotension within the range of 0.1 to
0.5 mcg/Kg/min.
Page 73 and 76
ACLS: General Principles
Q. According to the AHA, what is the target systolic blood
pressure?
R. Pages 73, 76.
ACLS: General Principles
Q. According to the AHA, what is the target systolic blood
pressure?
R. 90 mm Hg (we understand that certain specialties will
tolerate higher or lower target blood pressures, but for the
purposes of the course we will use 90 mm Hg for the
standard for SBP).
Pages 73, 76
ACLS: ROSC
Q. Nimrod Jones has been successfully resuscitated; in the
immediate post-code period Nimrod’s BP is 78/52. A fluid
bolus of NS has been ordered. According to the AHA what is
the appropriate fluid volume range for a fluid bolus?
R. Page 73, 76.
ACLS: ROSC
Q. Nimrod Jones has been successfully resuscitated; in the
immediate post-code period Nimrod’s BP is 78/52. A fluid
bolus of NS has been ordered. According to the AHA what is
the appropriate fluid volume range for a fluid bolus?
R. One to two liters (we understand that some specialties will
want to give smaller volumes of fluid; for the purposes of the
course we need a standard volume and we will use 1-2 L. In
real life adjust the fluid volume for the individual patient).
Page 73, 76
ACLS: ROSC
Q. A resuscitation patient has ROSC, but remains unconscious.
What order is considered?
R. Pages 73 and 77.
ACLS: ROSC
Q. A resuscitation patient has ROSC, but remains unconscious.
What order is considered?
R. Therapeutic hypothermia is considered; if ordered lower the
body temperature to 32 degrees C to 34 degrees C for 12 to
24 hours.
Pages 73 and 77
ACLS: Airway
Q. Avoid hyperventilation. Why?
R. Page 75
ACLS: Airway
Q. Avoid hyperventilation. Why?
R. Hyperventilation may lead to:
1. increased intrathoracic pressure and limit cardiac output
2. cerebral artery constriction thus reduced blood flow
through the brain.
NOTE: hyperventilation causes a loss of CO2
Q.
Page 75
ACLS: Airway
Q. Read the tips for securing an ET tube. Why is it a bad idea to
secure an ET tube around the neck?
R. Page 75
ACLS: Airway
Q. Read the tips for securing an ET tube. Why is it a bad idea to
secure an ET tube around the neck?
R. Do not secure the ties around the neck obstructing the
jugular veins and venous return from the brain.
Q.
Page 75
ACLS: ROSC
Q. Some patients who are resuscitated have an acute MI or
STEMI. What is a top priority for those patients?
R. Page 77.
ACLS: ROSC
Q. Some patients who are resuscitated have an acute MI or
STEMI. What is a top priority for those patients?
R. Coronary reperfusion is an important priority after the
airway, breathing, and blood pressure are stabilized.
Page 77
ACLS: Pulseless Arrest
Q. Nimrod Jones is in Sinus Rhythm with a HR of 78, but has no
pulse. What is the condition and how is it treated?
R. Page 82 to 85.
ACLS: Pulseless Arrest
Q. Nimrod Jones is in Sinus Rhythm with a HR of 78, but has no
pulse. What is the condition and how is it treated?
R. Nimrod is in PEA and the treatment is CPR, epinephrine 1 mg
every 3-5 minutes, and treat the cause.
Page 82 to 85
ACLS: Pulseless Arrest
Q. Analyze this strip. This flat line may be one of three things.
What are the three things?
R. Pages 86 to 89.
ACLS: Pulseless Arrest
Q. Analyze this strip. This flat line may be one of three things.
What are the three things?
R. This flat line may be:
1. Equipment failure like the leads have popped off of the patient.
2. Asystole.
3. Fine ventricular fibrillation.
If the equipment is OK, check the rhythm in a second lead, if the rhythm
remains flat the patient is in asystole, if it gets bigger and wigglier it is
VF.
Page 86 to 89
ACLS: Pulseless Arrest
Q. Nimrod Jones is in asystole and has no pulse. What is the
treatment?
R. Page 82, 86 to 89.
ACLS: Pulseless Arrest
Q. Nimrod Jones is in asystole and has no pulse. What is the
treatment?
R. The treatment is CPR, epinephrine 1 mg every 3-5 minutes,
and treat the cause.
Page 82, 86 to 89
ACLS: ACS
Q. Nimrod Jones is on your unit and complains of epigastric
pain. The blood pressure is 120/70; respirations are 14/min.,
non-labored, and easy; and SpO2 is 96% on room air. What is
the next intervention?
R. Page 96-97, 119, 136, & 140
ACLS: ACS
Q. Nimrod Jones is on your unit and complains of epigastric
pain. The blood pressure is 120/70; respirations are 14/min.,
non-labored, and easy; and SpO2 is 96% on room air. What is
the next intervention?
R. A 12 lead EKG. If the patient is stable the next step is
assessment; not all chest pain is cardiac in nature. This
principle applies to all situations, if the patient is stable
conduct assessments first.
Q.
Page 96-97, 119, 136, & 140
ACLS: ACS & Stroke
Q. The Nimrod Jones Memorial hospital is a STEMI center.
Currently all of the cardiac cath lab staff are involved in
emergent STEMI cases and no one is left to care for any more
patients. A patient is in an ambulance on the way to the
STEMI Center; what needs to happen to the patient in the
ambulance?
R. Page 96, 139
ACLS: ACS & Stroke
Q. The Nimrod Jones Memorial hospital is a STEMI Center.
Currently all of the cardiac cath lab staff are involved in
emergent STEMI cases and no one is left to care for any more
patients. A patient is in an ambulance on the way to the
STEMI Center; what needs to happen to the patient in the
ambulance?
R. Divert the patient to a STEMI Center who can take the
patient right away. This principle applies to Stroke Centers
when a stroke center cannot provide prompt care.
Q.
Page 96, 139
ACLS: ACS
Q. What are contraindications for nitroglycerin?
R. Page 97.
ACLS: ACS
Q. What are contraindications for nitroglycerin?
R. The contraindications for nitroglycerin are:
1. Inferior wall MI and RV failure,
2. Hypotension,
3. Bradycardia,
4. Tachycardia,
5. Phosphodiesterase* inhibitor use within 24 to 48 hours.
*Sildenafil, tadalafil, vadenafil, udenafil, anavafil.
NOTE: phosphodiesterase inhibitors are used for erectile
dysfunction and pulmonary hypertension.
Page 97
ACLS: Bradycardia
Q. Your patient is in respiratory distress and becomes apneic.
His HR drops from 122 to 48. How is the bradycardia
treated?
R. Page 111.
ACLS: Bradycardia
Q. Your patient is in respiratory distress and becomes apneic.
His HR drops from 122 to 48. How is the bradycardia
treated?
R. Your patient has an identifiable cause of the bradycardia,
respiratory arrest and hypoxia. Thus treat the cause by
supporting the patient with ventilations and oxygen.
Page 111
ACLS: Bradycardia
Q. Nimrod Jones is hypotensive, pale, cool, and diaphoretic
after his HR drops from 95 to 40. The cause of the
bradycardia is not known, what is the first intervention?
R. Page 109 and 110.
ACLS: Bradycardia
Q. Nimrod Jones is hypotensive, pale, cool, and diaphoretic
after his HR drops from 95 to 40. The cause of the
bradycardia is not known, what is the first intervention?
R. Give 0.5 mg of Atropine and the dose may be repeated up to
a total of 3 mg.
Page 109 and 110
ACLS: Bradycardia
Q. Nimrod Jones is hypotensive, pale, cool, and diaphoretic
after his HR drops from 95 to 40. The cause of the
bradycardia is not known. In spite of 2 doses of 0.5 mg
Atropine, he remains bradycardic and symptomatic. What
are the choices for the second intervention?
R. Page 109 to 114.
ACLS: Bradycardia
Q. Nimrod Jones is hypotensive, pale, cool, and diaphoretic
after his HR drops from 95 to 40. The cause of the
bradycardia is not known. In spite of 2 doses of 0.5 mg
Atropine, he remains bradycardic and symptomatic. What
are the choices for the second intervention?
R. The second intervention for symptomatic bradycardia are:
1. Transcutaneous pacing,
2. Dopamine drip,
3. Epinephrine drip.
Page 109 to 114
ACLS: Bradycardia
Q. Nimrod Jones has a HR of 38 in spite of 2 doses of 0.5 mg
Atropine IV push. Dopamine drip is ordered; what is the
starting dose range for a Dopamine drip for bradycardia?
R. Pages 109 and 110.
ACLS: Bradycardia
Q. Nimrod Jones has a HR of 38 in spite of 2 doses of 0.5 mg
Atropine IV push. Dopamine drip is ordered; what is the
starting dose range for a Dopamine drip for bradycardia?
R. Starting dose range for Dopamine for bradycardia is 2 to 10
mcg/Kg/min.
Pages 109 and 110
ACLS: Bradycardia
Q. Nimrod Jones has a HR of 38 in spite of 2 doses of 0.5 mg
Atropine IV push. Epinephrine drip is ordered; what is the
starting dose range for a Epinephrine drip for bradycardia?
R. Pages 109 and 110.
ACLS: Bradycardia
Q. Nimrod Jones has a HR of 38 in spite of 2 doses of 0.5 mg
Atropine IV push. Epinephrine drip is ordered; what is the
starting dose range for a Epinephrine drip for bradycardia?
R. Starting dose range for Epinephrine for bradycardia is 2 to 10
mcg/min.
Pages 109 and 110
ACLS: Tachycardia
Q. Nimrod Jones has a regular narrow complex tachycardia with
a HR of 179. He is pale, cool, diaphoretic with a BP of 80/60.
What is the first intervention?
R. Page 118 to 120.
ACLS: Tachycardia
Q. Nimrod Jones has a regular narrow complex tachycardia with
a HR of 179. He is pale, cool, diaphoretic with a BP of 80/60.
What is the first intervention?
R. The first intervention is immediate synchronized
cardioversion.
Page 118 to 120
ACLS: Cardioversion
Q. Complete this sentence: Synchronize cardiovert the
________ and defibrillate the __________.
R. Page 121.
ACLS: Cardioversion
Q. Complete this sentence: Synchronize cardiovert the
________ and defibrillate the __________.
R. Synchronize cardiovert the living and defibrillate the dead
(or soon to be dead/very, very, very unstable).
Page 121
ACLS: Cardioversion
Q. What are the recommended energy settings during
synchronized cardioversion for atrial fibrillation, SVT/atrial
flutter, and VT?
R. Pages 121-122.
Page 121
ACLS: Cardioversion
Q. What are the recommended energy settings during
synchronized cardioversion for atrial fibrillation, SVT/atrial
flutter, and VT?
R. The answers are given for biphasic defibrillators.
For less serious rhythms like SVT/Aflutter start at 50 to 100J.
For more serious rhythms like VT start at 100J.
For atrial fibrillation start at 120 to 200 J.
Page 121-122
ACLS: Tachycardia
Q. Nimrod Jones has a regular narrow complex tachycardia with
a HR of 179, but is stable. What are the first 2 interventions.
R. Page 127 and 129.
ACLS: Tachycardia
Q. Nimrod Jones has a regular narrow complex tachycardia with
a HR of 179, but is stable. What are the first 2 interventions.
R. Start with vagal maneuvers and if needed Adenosine 6 mg
rapid IV push (second dose is 12 mg).
Page 127 and 129
ACLS: Tachycardia
Q. Nimrod Jones has a regular wide complex tachycardia with a
HR of 180, but is stable. What are the suggested
interventions.
R. Page 127 to 129.
ACLS: Tachycardia
Q. Nimrod Jones has a regular wide complex tachycardia with a HR of
180, but is stable. What are the suggested interventions.
R.
Always assume a regular wide complex tachycardia is VT until
proven otherwise. The treatment for stable VT is Amiodarone 150
mg IV over 10 minutes. This is an appropriate first intervention.
The regular wide complex tachycardia may be SVT with aberrancy
(SVT with a wide QRS complex) and the AHA recommends
Adenosine as an appropriate drug for this rhythm, if Adenosine is
not successful use an antidysrhythmic like Amiodarone 150 mg IV
over 10 minutes. Adenosine works on SA node and the AV node
and is appropriate for SVT, but not for VT.
Page 127 to 129
ACLS: Tachycardia
Q. Irregular rhythms are complex, who are you going to call?
R. Page 127 to 130.
ACLS: Tachycardia
Q. Irregular rhythms are complex, who are you going to call?
R. An expert.
Page 127 to 130
ACLS: Airway
Remember there needs to be a fair amount of anxiety about
keeping chest compressions going when someone is pulseless.
THE END