www******************wwww**wwww

Etffi*
Dear ACLS Parlicipant:

Thank you for choosing Redlands Community Hospital to further your clinical education through
our Advanced Cardiac Life Support course. There are two options: (l) a two day class for
those seeking first time certification or desiring a comprehensive review of the guidelines, or
who have an expired card, or (2) a one-day recertifrcation class.
Check-in will be at 8:45 a.m. with course time being 0900-1700. Course location is in the
Weisser Education Pavilion. Continental breakfast will be provided, and lunch will be on your
own.

Although we do not require proofofBasic Life Support (BLS) certification before registration, it
is expected that you will be proficient in BLS and possess a current card before participating in
this course. Your BLS skills will be evaluated during the ACLS clinical cases. Also, it is a
prerequisite that you complete a Basic Arrhythmia Recognition (BART) course prior to the
cerlification class or have a strong background in anhlthmia recognition.

It cannot be emphasized enough that for maximum benefit and the greatest success in this course,
participants should be well prepared for the first day ofclass. The AHA's Advanced
Cardiovascular Life Support Provider Manual (511 1) is the required reference for this course
and is available through the Education Department for $35 and at various clinical bookstores.
This study packet is meant to assist you in studfng for the course testing session; it is not
intended to replace the textbook.
Please bring these materials with you to class. Meeting your needs is our priority. We look
forward to working with you and hope you find this a valuable leaming experience. Ifyou have
any questions, please feel free to contact the RCH Education Department (909/335-5530).

,ii*
(

ww* *

***** **x******

2012

***x* # *#*#w

ww

Upon completion of the course the participant will:

I.

Be famiiiar with [Link] to implement the algoritbms of the American

Heart Association guidelines for BLS and ACLS.

tr.

Describe the pharmacology of the "code" drugs ofchoice and their appropriate

application to a given situation.

Itr.

Recognize potential and actuai lethal dysrhythmias and choose the

appropriate algorithm of treatment.

IV.
V.

Demonstrate correct and safe operational skills with the defibriliator'

Demonstrate proficiency with airway management devices that fall within

their scope of practice.

VI. Successfrrliy fulction

as a Team Leader

in a Megacode, which includes:

[Link] recogrrition and treatment, patient assessment, supervising the team and problem

solvins.

ViL

Pass the

written exam by

84Yo

or gteater.

PULSELESS ARREST
BLS Algoriihm: Callfor help, gi\re CPR
Give orygen lvhen avaiiable
Aitach monitor/deflbrillator when avaitable

Shockabtre

Give 1 shock
. ManLral biphasic: devtce specific
(q/oically 120 to 200 J)

.
.

to

Note:1: unknowr us 200 J

Resume CPR immediatety tor 5 cyctes

AED: device specific

Monophasic: 360 J

wren lvllo available, give vasopressor

Resume CPB immedtately

C've 5 :Xcies oi gpq_

Epinephrine 1 mq lvllo
Repeat every 3 to 5 min

May give 1 dose of vasopressin 40 U

ri'st

[Link] CoB wh, o def [Link] s cha19,n9

Give 1 shock
. Manual biphasic: device speciiic
(same as first shock or higher dose)
Note ti unkrowr. use 2C0
AED: device specific
Monophasrc:360 J

'
'

lvlto to

o. seco.d dose ol [Link]

'eO aLa

Give 5 cycles
of cPR+

11

Resume CPR immediately after the shocK

lV lO [Link]. grle !dsop,esJor d,Jr1g Coq
(oerore or afier the shock)
' Epinephrine 1 mg lvlto
Bepeal every 3 to 5 min

W'er

'

i4ay give 1 dose of vasopressin 40 U tvlto io

'eo ace [Link] o- s-co'ld oose o. epinephrine

Give

5 cycios ot

.
.

lf asystole, go to gox 10
lf electrical act,viiy, check
pulse. It no pulse, go to

lf pulse present, begin

Postresuscitation care

CPRa

Box

i\ioi
Shockable

1O

Shockab;
During CpR
Coniinue CPR while defibrifleior is charging
Give 1 shock
. Manual biphasic: device specific
{same as ftrsi shock oi high,.r dose)

.
'

Note: ii !nknov/.. dse 200 J

AEDi devtce specafic

Monophasic: 360 J

Resume CPR immediaiely after the shocK

aonsde' antiarrhythmics: g(e du...B Cpq
lOerore or after the shock)
amrodarone (300 mg tV,4O once. tr,en
Lr rs'de- add liordi -0
V lO or.-r o-

-g
{i to ' 5 -g^q n-st oose. iae, 0.5 to
/'
: T94.9 iV O. ma,,rrun r doses or 3 -rglqgl
Cor]sider
magnesium, loading dose
lrclocaine

to 2 g lV/tO for torsades de pointes

Aiter 5 cycles of CPR,- got to Box 5 ebove

.
.
.
.
.
.
*

('loolmin)
reco

Push hard and fast

Ensure tufl chest

Minimize interruptions in chest

Rotate compressors every

2 minutes wrth rh,,thm checks
Search for and treat possibte

contibuting factors:

One cycle of CPFI: 30 cornpressons

then 2 breathst 5 cycles :2 m n

Avoid hyperventilailon

Sec!re airway and conirm placemeni

Hypovolernia
Hypoxia
Hydrogen ron {acidosis)
Hypo-/hyperkaiemia
Flypoglycemia
Hypothermia

After an advanced a'rway s ptacd, - Tamponade. cardiac

- Tension pneurnothorax
rescuers no longer deliver "cycles"
_ Thrombosis
{coronary or
of CpFt_ cive co;iinous chesi compresslons withoul pauses lor breaths. pulmonary)
_ Trauma
Give 8 to 10 breathvminuie. Check
dr)4hnr every 2 minutes

Aher can ileart Assocraiion

Source: Amedcan Hean Associabon
-D \r, o.

'

.P r^l I /.LIOF

ACLS STUDY

CUI

E
.C./.

Responsive? lBreathing?

cnil ror

h,rrp

Iot ^/

an"""n";,

:FtlL\},i

&il
[,]"

-=

!!,allr.
srARr cpR

.l/ -*.-

S
!-_--L.l_.

r_=.t-=r-_l

lvFl
I PIrLSILESSVT
*_-=l-

fPEn,"fi-l

Check pulse
CPR til Defib avail

Check

--T---

pulse

CPR/Air-way Adjuncts/IV Access

Shock 360J
(200J Biphasic)

Epinephrine'[Link] IVP

(repeat q 3 rnins)

CPR X 2 mins
I

Pulse

IV Access
I

y'

'e

Consider and give specific Tx for:

y'

Pulse
Shock 360J
(200J Biphasic)
Airway Adjuncts

Puhnonary/coronary thronrbosis
Acidosis
Tension pneumothorax
Cardiac Tarnponade

Epinephrine I mg IVP

Amiodarone 300mg IVP OR

Ilypoxia

OR
Vasopressin 40U IVP

Lidocaine l-l.5mg/kg IVP

Hypovolemia
Hypothermia
Hypoglycenria
IIyper/Hypoelecrrolyre
Dnrg OD

dose only)
I
I

CPR

X 2 mins

CPR X 2 mins
I

Pulse y'
Shock 360J
(200J Biphasic)

Allernative drue choice:

Magnesium Sulfate l-2g IV

*May use one-time dose of Vasopressin 4OtJ IVP

as an alternative to any lr)pinephrinc dose.

Copyright 1994 Susan [4ar'

r-@*-*-1

IASYSTOLE*

ERAfiCARilI
*-------r----.

Check pulse/Check Flat Line prorocor

Check pulse (< 60 beatsimin)

I

? Signs or Symptoms?

NO

CPWAirway AdjunctsnV Access

2" AV Block

Epinephrine [Link] IVp

Type

(fepatq3mins)or
Vasopressin 40U IVP

(l

dose only)

Pulse

t,

y'

- *L_

f-yt:

2" AV Block
Type

II

of

or

Sinus

3" AV Block

of
Junctional

Prepare for pacer

I;"'"*l

'nn
[ Block
Atro$ine.5mg TrarT[iiiius

9!!!pt

J" |

(ifneeded, repeat
q 3-5 mins up to
total 3mg)

Pacing

I
I
I

Observe

!
I
I

transvenous ol
permanent pacer
is ftrnctional

t
Consider treatable causes:

Hypoxia

AND/OR

_l
I

ranscutaneous pacing

t-

Use external pacer

until

lransvenous or permanent

Hyper K+
Flypo K+

pacer is functional

Hypothermia

OR

Pre-existing acidosis

Dopamine 2- I 0mcg/kg/ min

Epinephrine 2-1 0mcg/min

Drug OD
Tension Pneumothorax

fV Infusions

*Check for DNR orders

&/or consider
ultimate outcome to resuscitation

--

Cease efforts after acceptable timeframe

rc|33uz7/{l

Have transcutaneous
in place until

PULSE PRESENT

STABLE

UNSTABLE
> 150 bpm, chest pain
SOB,+LOC,\'BP, CHF)

(rate

Or, fV Access

Airway Adj uncts, [V Access

Sedation whenever possible

V TACH or

Now also consider:

-Is cardiac function
normal or impaired?
-Duration < or > 48 HR?

-wPw?

Vagal Maneuvers
I

Adenosine 6-12mg raoid IVP

I

Adenosine l2mg raoid tVP

(ifneeded again, 1-2 mins
after 1" dose was given)

I
I
Possible TX's:

Anticoagulation

Now also consider:

- Is it Junctional, Ahial

Amiodarone

or PSVT? 'WPW?
- Cardiac function normal
or impaired?

Diltiazem
Beta Blockers

Digoxin

Now also consider:

-Identical or variable
waveform?
-Cardiac function normal
or impaired?

-Pre-VT QT Interval
-Treatable underlying
causes?
I

Possible TX's:

Amiodarone
Lidocaine
Magnesium
Beta Blockers

Amiodaron
Diltiazm

Adenosine

Beta Blocke$

Elective
Cardioversion

acrsstd3

7,/

01I

Cardioversion

PSVT-_.._
A Flufter j'"Y'rd

ot

Cardioversion

50J

- pulsey'

vT

100J

measufement?

Possible TX's:

Synchronized Cardioversion

pulse

AFib

starr at

- -

200J

pube
300J

pulse

y'

y'
y'

DRUG

ACTION/USE

ATROPINE

AC'I'ION:

- { SA node firrng rate

- Improve AV node conduction
- Curtail vagal effects

EPINEPHR]NE

PRECAUTIONS
- 4'workload & 02 demand on heart
- Use cautiously in acute MI - mayf
i

schernia/darnage

Rarely VTach

Beta stirnulation may plave to be too halsh

& VFib rnay follow

use

[Link] S inus BradycardiaJunctional & 2""-AV blocks

ACI'ION:

.5mg IV Push every 3-5 min for

bradys

Not to exceed 3mg total maximunr

USL,:

DOSAGE

Alpha & Beta stimulator

Causes peripheral vasoconstriction

- f brain/heart perfusion during CPR

- t HR,'}BP,'l confactility of head,

Give lmg bolus IV Push (10m1 of

1:10,000 solution)
Must repeat dose every 3 rnin (dnrg's
halfJife is 3 min)

,l'cardiac output

on ischemic heart

High doses &/or cunulative doses may be

.-

neurotoxtc
Drug action is irnpaired in acidosis
Drug action inactivated by Na+ Bicalb

USI!.:

VASOPRESSIN

VFib, Asystole, PEA

ACTION:
Pressor

& anti-diuletic homone

Confraction ofvascular smooth

muscle; !!g Beta effects on heart

time dose

brain&eart perfusion during CPR

Copyright 9/2002 susan marder

vpdafc

lf

code continues after this tirne{iame,

tetum to Epinephrine dosing.&

schedule

Alternative lo Fpi in cade- esp in

presence of acute
damage

ll

Duation of effect is approx l5 mrn,

therefore this drug is a single, one-

USIi:

}.o

.-

activities

.' f

40 units IV Push

iritability &/or

Potent peripheral vasoconstrictor

tperipheral vascular resistance may create
angina,/ischemia

Contraindicated in non-alrest Pts with

coronary adery disease

ACTIONruSE
LIDOCAINE

initial IV bolus l-l.5mg/kg

ACI'ION:

of ventr. arhythmias
by.l,vontr, irritability/autornaticity
May,l fibrillation threshold
Suppression

^. Most toxic

S/S ale CNS disturbances:

restlessness, sluned speech, bluned vision,

Give .5-.75mg/kg every 5-8 min until

3mg/kg total maxirnum given

UST:,:

AMIODARONE

PVC's. VTach. VFib

ACTION:

.-

Slowing of conduction

&

prolongation of reftactoriness in
AV node,( &,B blockade, K+ &
Na+ chalnsl 61o"L"0"

Vasodilatation

U,S,:

MAGNESIUM

Acute recurring SVT's

Unstable VTach, VFib

& VTach's

ACTION:

For recuning tachyarrhythmias:

Initial loading bolus of 150ng in
l00cc DSW over 10 min (lsmg/min)
Then infusion of lrng/min over 6 hrs
Then.l4o .5mg/min over next l8 [Link]

Essential in

\1+/l(+

pump function

Hlpomagnesemia associated with;

anhyhmias, cardiac insuffi ciency,
sudden cardiac death

Maximum oumulative dose is 2.2g over 24

hrs

^- Hypotonsion &/or bradycardia if infused

too rapidly
- Contraindicated in cardiogenic shock, sinus
brady, 2"d"& 3'dLV block-s
.' May prolong QT interval (potential for

**For persisting VFib/VTach codes:

300mg IV PUSH; consider repeat
dose of l50ms IV
1-2g diluted in l0ml D5W:
Give over 2-5min in VTach
Give IV Push in VFib
Continue maintenance IV infusi<x
titrated to Mg+ lab values

6mg-12m9 RAprp rv

dose

USE:

numbness of ,lipVtongue, seizures

rl,dose whenJCO, liver failure & Pts > ?0
Use % normal dose
vrs.
-Contraindicated
in z"d"& :'dhv blocks

Torsades de Pointes)

Hypotension, bradycardia, flushing,

sweating, weakness,
Hyper Mg+: Jrefl exes/CNS [Link],
respiratory paralysis, circulatory collapse
Contraindicated in heart block. mvocardial
darnase

Torsades de Pointes, post-Ml

from hypomagnesemia

ADENOSINE

ACTION:

Transient*in conduction through

AV Node
Interrupts re-entry pathways

USE:

PUSH WITH
20ML MLUSH (& elevate extremity)
12mg repeat dose may be given after
i min & again in I min following this

Half-life of drue approx 6 sec

Copyright 9/2002 susan nrarder

lo

t( update-

Transient effects while drug is active:

dyspne4 chest pain, flushing, "feeling of
impending doom", bradycardia, asystole
May stimulate bronchospasm in asthmatics
Theophylline, caffeine block effects
NQI effective on VTach, AFib, AFlutter

DRUG

AC'I'ION/USE

DILTAZEM
GA+CHANNEL
BLOCKERS)

DOSAGE

ACT]ON:

- *conduction

&'|refractorin

ess

in

AV node
Blocks influx of Ca+ & Na+
OHR,*conhactility,tvasodilation

USE:

BETA BLOCKERS

Varies wrth each drug choice in this

category - all should be administered

- Hypotension, CHF
^- Bronchospasm
* Conhaindicated in severe bradycardia or

- {HR,{ BP,{ contractility,

* myocardial 02 consumption
Slows ventricular response

slowly
Monitor BP, EKG, S/S

DOPAMINE

AFib, AFlutter, SVT's

Ventriculal arrhythmias

lV infusion titrated to BP effect;

ACTION:

po NOT mix withFBlockers

Cardioversion may cause bradycardia

Alpha

&

Beta stimulator

Low-Mid doses

per dose

2-l0mcglkg/min:

- dilates renal/mesenteric vessels

-/rcO, minimal-moderat
peripheral vasoconstriction
- mild-moderate Beta effect
High doses = > l0rncg/kg/min
- peripheral vasoconstriction'l$
- greater Alpha effect

(./:;L:

^- Hypotension with S/S shock

- Cardiogenic shock (with cautioir)

(iopyr ight 9/2002 srtsan ntarclcr

Io l\ upd,..+<-.

AV blocks

U,SE:

Hypotension
Hemodynamic compromise in Pts with
severe L ventricular dysfirnction

AFib, AFlutter, PSVT

ACNON:

PRECAUTIONS

l5-20mg IV bolus over 1-2 min

May repeat in 15 min with 25mg over
2-5 min
Titrat maintenance infusion of
5-15mg^r to HR & arrhythmia
conhol

Low Dose 2-5mc e/kglmin

Mid Dose

5- l0mcg,&g/min
(known as "cardiac doses")

High Dose I 0-20mcg,&g/min

(known as "vasopressor doses")

Potential adverse effects if mixed with

other, similar anti-arrhyhmic agents
CONSTANT BP monitoring
May cause tachydysrhlthnias

Taper drug gradually

MAO inlibitors potentiate drug action
Na+ Bicarb inactivates drus

F'OR PRE-COURSE PRACTICE

_../

ADVANCED CARDiAC

LiFi

SUPPORT

THEMPEUTIC I4ODALITI

E5

Directions:

.
2.
3,
I

r.

Assume
Labe

0,,

1V an0 LfK have been i nsti

the dysrhythmi

and

Assum the dys rhythmi

tuted when appropriate.

Iist the course of

treatment in approoriate orCer-.

does noi change during

,v J<3t utu |llolE

vmnf nr:r < .
Dr'l o

the course'of treatment.

bl ood

70/ 40.

!--l

RHYTHH:

TREAT]4ENT PLAN:

-t

2.

41 year old male admitted to ER.

S)4nptoms: Acute crushing chest pain, bl ood pressure fa11ing, ncrlEA/60.

RHYTHM:

TREATI'IENT PLAN:

3.

86 year

old male fainted while on conmode at the nursing horne wher he rasraes.
Hjstory of heart disease. Occasionally confused - usuaily
at n j-ahr.
Syrnptoms: Confused, paiq, head bleeding, blood pressure -OOlqO lrt var:::,..
-.-..T''t:

.*l---.:-

RHYTHI'4:

TREATI4ENT PL/II'I :

-2-

66 year old male admi:ted

t0

6-^-

Emergency t\uurrr

-3r^d
l Li

^''reart
disease.
I
trv r)lqrJ vi
Syinptons: Pal e, cyanot;c, diaphoretic in rerrir
66/ 30.

ql ltul|lct

lrr.,.i-^
? r9 r-^^^F^
LrtrLrJrrc
lic

crr5<ipnrr'l
Jw!Jv9i.|q,r,giii'

n:'in

RHYTHM:

TREATMENT PLAN:

5.

arrive at city Park. CPR isin progress on a 36 year olo [Link];ho

ihi'ie jogging Y/ith friends. There is no known history of c3rcjac

Paramedjcs

collapsed

disease. lihen olaced on cardjac rnonjtor the fol lowing

was noted:

tl

RHYTHI'{

TREATI'IENT PLAN:

-J-

day you are carrying a Code B'lue beeper' it-goes off iusi
bedside of a 52 year old
iit., you start eating'1unch. you- arijve at the
executive who had [Link]-second large myocardial infarction 3 days ago, This
in,i1'r aour noi produce a pulse ior 6looA pressure; the patient is c-vanctic
and unresponsive.

This is the

fir'st

THE CLINICAL SITUATION DEI'IONSTMTiS:

TREAT}IENT PLAIi:

Paranedics sunmoned to collapsed anci unresponsive v.i cti m on gol f course.

Hiddle aged male, average sjze, no knowrr history of heart di sease acccr'iing

tc victim's friends.

il..1.-..1-.-..

RHYTHI'i:

TREATI'1EI{T PLAN:

FOR PRE-COURSE PRACTICi

[Link]?I{MIA RECOGNITION PRACTIC! TRACINGS

1.

2.

3.

4.

5.

ATRIAL FIBRIILAT]ON. V-FIE- SINU'S BRADYCARDIAg

3'N

DEGREE IIEART

BLOCII SvT

7.

[Link]

SR D'liT DEGREE HEART

ATRIAT FLLITER BIGEMI-NI

BLOCK 2i DSGME TGART BLOCK

(i4ENCKEBACH},

TYPS

'

11

1r.

14.

15.

ASYSTOLE- 2'd DEGREE HEART BLocK TtrpE II-

RL'N._-

oF V-TACH. ARTIFAcT- [Link] Rnyrt{pr

16.

18.

19.

20.

ACCELERATD IL.N_-CTIONAT Ri{YTtS,'. 3'DEGREE HEART BI-O(TC STNU'S TACi|YCARDIA FACED R}ryTI{MV-TACH ([Link] de POI$IES)

o"'T:lli:,T#

&

Learn and Liyc

ACLS Precourse Self-Assessment

Ten minutes after an 8s-year-old woman collapses, paramedics arrive and start CpR for the
first time. The monitor shows fine (low-amplitude) VF. Which of the following actlons should
they take next?

a
b
c
d
2.

A cardiac arrest patient arives in the EO with PEA at 30 bpm. CPR continues, proper tube
placement is continned, and lV access is established. Which ofthe following medications is
most appropriate to give next?

a
b
c
d
3

b
c
o

Svnchionrzed cardioversron ai 200 J

Sodium bicarbonate 1 mEq/kg ]V

Place alcohol pads between the paddles and skin

Reduce the pressure used to push down on the dellbrillator paddles
Apply conductive pasle lo the paddles
Decrease shock energy after the 2nd shock

Check the person mana_eing the airwayt body not touching bag mask or tracheal tube, oxygen
nol flowing drfectly onto chesl
Check yourself: hands correctly placed on paddles. body not touching paiient or bed
Check mondcr leads: leads drsc4nnecied lo prevent shock da!'iaqe io monitor
Check oihers no one touchrng patreni. bed or equipment connecled to patienl

Adenosjne 6 mg rapid lV push

Eprnephrlne 1 mg lV push
Svnchronized cardioversion with 25 to 50 J
Alfoprne 1 mg lV push

Which of the lollowing facts about identification of VF is kue?

a
b
c
o
7

solulion lV

A woman with a history of [Link] PSVT arrives jn the ED. Sne is alert and [Link]
but pale. HR is 165 bpm, and the FCG docurnents SW. BP h 105O0 mm itg. Supplemental
orygen is provided, and lV access has been established. Which ot the following drug-dose
combinations is the most appropriate initialtreatment?

e
b
c
d
6.

10olo

Which of the following actioos ls NOT performed when you "clear" a patient just betore
detibrillator discharge?

Calcium chloride 5 mL of
Epinephrine 1 mg lV

Which of the following actions helps deliver maximum current durirg defibrillation?

a
b
c
d
4

Perform al Jeasl 5 minutes of vigorous CPR befofe attempting dellbrillaiion

Insert an endotracheal tube, administer 2 to 2 5 mE epioephrine in 10 nL NS through the tube
and then defibrillate
Deliver up lo 3 precordial thumps while observing the patient s response on the monitor
De|ver aboul 2 minutes oa 5 cycles of CPR, and delivef a 360-J monophasic or equivalentcurrent brphasic shock

A peripheral pulse that is both weak and ifiegular rndrcates VF

A sudden droo in blood oressure indlcates VF
Anrfact srgnals drsplayed on the monitor can look ||ke VF
Turnrng lhe signal amplitude ('gain") lo zero can enhance the VF stgnal

Endotracheal intubation has ilst been attempted for a patient in respiratory arresl. Dudng
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 !!99!
likely explanation for these findings?

a
b
c
r

lntubalron of the esophagJs

lntubation of the left main bfonchus
Intubation of the right marn bronchus
Bilateral tension pneumolhorax

Which of these statements about lV administration of medicaiions during attempted

resuscitation is true?
Give epinephrine via the intracardiac route if lV access is not obtained within 3 minutes
Follow lV medications through perpheElveins with a fluid bolus
Do not follow lV medictions thaough cenhal veins with a fluid bolus
Run normal saline mixed with sodium bicarbonate (100 mEqlL) during continuing CPR

a.
b
d.

A 60-year'old man (weight: 50 kg) rvrth reeurrent VF has converted from VF again to a wide.
complex nonperfusing rh)'thm after administration of epinephrine 1 mg IV and a 3E shock.
Which of the following drug regimens is most [Link] to give !94?

a.
b
c.
d
10

Amiodarone 300 mg lV push

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

VVhile treatiog a patient

in persistent VF arrest after 2 shocks, you consider using

vasopressin. Which ofthe following guidetines for use [Link] is true?

a
b.
c

Give vasopressin 40 U everv 3 to 5 minutes

Give vasopressin fo. better vasoconstriction and Fadrenergjc stjmulation than thal provjded by
eoineohrine
Grve vasopressin as an alternative to a flrst or second dose of epinephrine in shock-refractory

d.

Give vasopressin as the llrst-line presso. agent for clinicat shock caused by hypovotemta

11. Which of the following causos of PEA is

a
b
c
d

0gg! likety to respond to immediate treatment?

l\rassive pulmonary embolism

Hypovolernia
Massive acute myocardial infarction
Mvocardial ruoture

12. Which of the following [Link] combinations is recommended as the initial medication
to
give a patient ln asystole?
a.
b.
c.

o.

13.

Epinephrine 3 mg lV
Atropine 3 mg lV
Epinephrine 1 mg lV
Atropine 0.5 mg lV

a patient with a heart |.ate of 40 bpm is complaining of chest paln and is coofused. After

oxygen, what is the flrst drug you should admlnister to this patient while a transculaneous
pacer is brought to the room?

a.
b.
c.
d.

Atroplne 0.5 mg
Epinephrjne 1 mg lV push
lsoproterenol infusion 2 to 10 [g/min
Adenosine 6 mg fapid lV puSh

Which ofthe following statements coffecfly describes the ventilatio.|s that should be
provided after endotracheal tube insertion, cuff inflation, and verification of tube Dosition?
b.

c
d.

Deliver 8 to 10 ventilations per minute with no pauses lor chest compressions

Deliver ventilations as rapidly as possible as long as visible chest nse occufs with each breath
Deliver ventilations with a tidalvolume of 3 to 5 mL/ko
De|ver ventilalions using room air untrl COPD rs rule; od

15. A patientin the

ED reports 30 mjnutes ofsevere, crushing, substernal [Link]

110/70 mm Hg, HR is 58 bpm, and the monitor shows regiiar
sinus bradycarota. Tbe patient

32s,mg po, oxygen 4 Umin via nas;t cannuta, and 3 sublingual

:1:^'::_"-,]:d :.I'Il"
fltroglycerin
tablels 5 minutes apart, but he continues to have severe pain_ Whi;h of
the
rolowrng agents should be given nexl?

a
b
c
d.

Atropine 0 5 to 1 mg lV
Furosemide 20 io 40 mg lV
Ljdocaine 1 to 1.5 mg/kg
Morphine sulfate 2lo 4 mg tV

Ameican

Hea

r1

As6oclation

16. Which of the following agents are used frequently in the early manageftent of acute cardiac
ischemia?

a
b.
c
d

Lidocaine bolus followed by a con$nuous infusion of lidocaine

Chewable [Link], sublingual [Link], and IV mophine
Bolus of amiodarone followed bV an oral ACE inhibitor
Calcium channel blockef plus lV furosenide

17. A 50-year-old man who

is profusely diaphoretic and hypertensive complains of crushing

substemal chest pain and severe shortness of breath. He has a history of hypertensioo. He
chewed 2 baby aspirins at home and is now receiving orygen. Which ofthe following
treatrhent sequences is Igg appropriate at thls time?

a
b
c
d

Moehjne then ndroglycein, but only if morphine fails to Elieve the parn
Nitfoglycerin then morphine, but only if Sl elevation js >3 mm
Nitroglycerin then morphine, but only if nitroglycerin fails 1o relieve the parn
Nitroglycerin only, because chronic hyperiension contraindicates moehine

18. A so-year-old man bas a 3-mm ST elevation in leads

V, to V.- Severe chest pain continues

despite administration of oxygen, aspirin, nitroglycerln SL x 3, and morphine 4 mg lV. Bp is
'170f110 mm Hg; HR is t20 bpm. Which of the following treatment combinations is most
appropriate for !!!9 patient at this time (assume no contEindications to any medication)?

a.
b
c
d

Calcium channei blocker lV + heparin bolus IV

ACE inhibitof lV + lidocaine infusron

Magnesium sLrifate IV + enoxaparin (Lovenox) SQ
Fibnnoly,tic + [Link] 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 riqht arm. She takes "several
medications" for high blood pressure. Which ofthe following actions is !!9Sl! appropriate to
take at this time?

a.
b
c.
d.

Activate the emergency response system; tell the dispatcher you need assistance for a woman
who is displaying signs and symptoms of an acute subaGctlnoid hemonhage
Activate the emergency rcsponse system; tell the dispatcher you need assistance for a woman
who is displaying signs and symptoms of a stroke
Actrvate the emergency response systen; have the woman take aspirin 325 mg and then have
her lie down while both ofyou awai{ the arrival of emergency peisonnel
[Link] the woman to the [Link] ED in your car

20. Within 45 minutes of her arrival in the

ED, which of the following evaluation sequences

should b [Link] for a 70-year-otd woman with rapid onset of headache, garbled speech,
and weakness of the right arm and leg?

a
b
c.
d

History, physical and neurotogic exams, norcortrEst head CT with radiologist jnterpretation
History, physical and neurotogic exams, [Link] head CT, stan offbrinolytic treatment if CT
scan is positjve for stroke
History, physical and neurotcic exams, lumbar punclure (Lp), contrasl head CT if Lp is
negative for blood,
History, physjcal and neurologic exams. clntrasf head CT, start fbrinolytic treatment when
rmprovement in heurologic signs is noted

?1. which ofthe following rhythms

a
b
c
d

is a proper indication for tra nsc utanaous cardiac pacing?

Sinus bradycardia with no symptorns

Normalsinus rhythm with hypotension and shock
Conrplete heart block with pulmonary edema
Asystole that follows 6 or more defibrillation shocks

22. Which of

the following causes of out-of-hospital asystote is most likely

treatment?

a.
b
c.
d.

Pfolonged cardiac [Link]

Prolonged submersion inwarm water
Drug overdose
Blunl moltisystem trauma

lo respond to

A 34-year-old woman with a history of mitral yalve prolapse prcsents to the ED complaining
of palpitatiohs. Her vital signs are as follows: HR = t65 bpm, r5p = 14 per minute, BP =
118/92 mm Hg, and 02 sat = 98%, He. lungs sound ctear, and she repofts no shortness of
breath or dyspnea on exertion. The ECG and monitor display a naraow-complex, regulat
tachycardia. Which of the following terms !gq! describes her condition?

a
b
cd

Stable tachycardia
Unstable tachycardia
Heart rate appropriate for clinicat condition
-fachycadia
secondary to poor crdiov"scular function

A 75-year-old man presents to the ED with a [Link] history of lightheadedness, patpitaflons,

and mild exercise intoleiance. The initial '12-lead ECG displays atrial fit rillation, which
continues to show on the monitor at an inegula. HR of 120 to 150 bpm and a BP of
100,70 mm Hg. Which of the following therapies is the most appropriate !g{! intervention?

a.
b.
c.
d

Sedation, analgesia, then immediate c2rdioversion

Lidocaine 1 to 1.5m9/kg lV bolus
Amiodarone 300 mg lV bolus
Seek expert consultatjon

You prepare to cardiovert an unstable 48-year-old woman with tachycardia. The

monito./defibrillator is in "synchrcnization" mode, The patient suddenly becomes
unresponsive and pulseless as the r+tythm changes to an inegular, chaotic, VF-like pattem.
You charge to 200 J and press the SHOCK bltton, but the defibrillato. fails to detiver a shock.

a
b
c.
d.

The defibrillator/monitor battery faited

The 'sync' switch fa'led
You canoot shock VF in'sync" mode
A monitor lead has lost contact, producing the "pseudo-VF' rh!,thm

26. Vasopressin can be rcommended for which of the followirg arrest rhythms?

b
C
d

Asystole
PEA
Allof the above

27. Effective [Link] ventitations are present in a patient in cardiac arrest- Now, 2 mihutes after
epinephrine 1 mg lV is given, PEA continues at 30 bpm. Which ofthe tollowing aciions should
be done next?

b.

c.
d.

Adm'nister atropine 1 mg lV
Initiate transcutaneous pacing at a .ate of60 bpm
Start a dopamine lV intusion at 15 to 20 pg/kg per minute
Give epinephdne (1 mL of 1:10 000 solution) tV bolus

28. The following patients were diagnosed with acute ischemic [Link]. Which of these Datients

has NO stated contraindication for lV fibrinotytic therapy?

a
b
c
d

A
A
A
A

65-year-oid woman who lives alone and was found unresponsive by a neighbor
65,year-old man presenting approximately 4 hours after onset of symptoms
Gtyear-old woman presenting t hour after onset ofsymptoms
65-year-old man diagnosed with bleeding ulcers 1 week before onset ot symptoms

29. A 2s-year-old woman presents to the ED and says she is having another episode of PSVT. Her
medical history inctudes an electrophysiologic stimulation study (EpS) that contirmed a
reentry tachycardia, no [Link]-While syndrome, and no [Link]- HR is 180
bpm- The patient reports palpitations and mild shortness of breath. Vagal maneuvels wath
carotid sinus massage have no effect on HR o. rhythm. Which of the folowing is the most
. appropriate next intervention?

a.
b.
c
d

DC cardioversion
lV diltiazem
lV 9rooranolol
lV adenosine

30. A patient with an HR of 30 to 40 bpm cornplains of dizziness, cool and clammy extremlties,
and dyspnea. He is in thiddegre AV block. All treatment modalities are prosnt What would

you do iirst?

a.
b
c.
d

give atropine 0.5 to 1 mg lV

give epinephrine 1 mg tV push
start dopamine infusion 2 to 10 pg/min
begin immediate [Link] pacing, sedate if possible

Question

Answer
a

bc

ac

2.
a

4.

5.

0.

Question
16.

ii

17.

ba
bt

18.

.14

bc

zv-

bo

21.

Answer
a

I
b

a
o

b
b

7.

rD

bc

22

z.

Oc

23.

1.1.

b.

24.

ai

?5.

i 0.

l't.

Oc
bO

a1

a
14.

I5.

bt

bc
oc

d
d

od
co
cd
cd

od
od
cd

co
ad
ca

cd

26.
27.

cd

29.

30.

ad
c)

ca

Table

Summary of Key BLS Components for Adutts, Children, and lnfants'

Unresponslve (for a i ages)

No breaihiirg or no normal
breathing (ie. only gasping)

Recognition

No breathing or onty gasprng

No pulse palpated within 10 seconds ior all ages (HCP only)

Allow cornplete

Chest wall recoil

recorT

between compressions

HCPs roiate compressors everv 2 minutes

30:2
Single rescuer

3A:2
'1
or 2 rescuers

15:.2

2 HCP rescuers

Ventiletions: when rescuer

untrained or trained and

Compressrons only

Atiach and use AED as soon as avaiiable. [Link] interruptrons in chest compaessions before and after shock;
resume CPR beginning with compressions immediately after each shock.

Defibntlation
abbtYEioG: AeD auiomaled exlmal
'Elcrld,ng

defibarraio.: a9 aninoFposienor: cpE. cad opu nooary rcsrscrianoi: Hce heatihcae provder

lhe ne'ny born in whom ihe eiiotory

of.. ae

Team Resuscitation
2O1A (New): fhe steps in the BLS atgorithm have traditionalty
been presented as a sequence to help a single rescuer
pflor'tize actions. There is increased focus on Drovidjnc
CPR as a team because resusc,lalions rn most FMS aid
healthcare systems involve ieams of rescuers, with rescuers
performing several actions simultaneously. For example, one
rescuer actrvates lhe emergency response system whiie a
second begins chest compressions. a third is either providing
veniilations or retrjeying the bag-mask for rescue breathjng.
and a fourth is retneving and setting up a deflbrillator.

Why: Some resuscrtaiions start with a lone rescuer who

calls for help, whereas other resuscjtations begin with several
willing rescuers. Training should focus on building a team
as each rescuer arrives, or on designating a team leader if
multiple rescuers are present, As additional personnel arrive
responsibrtities for tas(s tt-at would ordinarily be [Link]
sequentially by fewer rescuers may now be delegated to a team
of providers who perfo.m them simultaneously. For this reason.
BLS healthca'e prov'der t?ining should no1 onlv teach individual
skills but should also teach rescuers to work in effective teams.

Comparison of Key Elements of Adutt, Child,

and Infant BLS

2OOS (Old):

fhe steps of BLS consisi of a sen-es of sequential

assessments and aciions. The inteni of the algonthm js to
present the steps in a logical and concise manner
that will be
easy for each rescuer io Iearn. rememttrer. and Oerform.
Anerican

Heari

Associalron

As in the 2005 AHA Guidelines for CpF and ECC, the 20i 0 AHA
Guideljnes for CPR and ECC contain a comparison table that lists
the key etemenis of adult. chitd, and infant BLS (excluding CpR for
newly born infants). These key elements are included in Table 1

Figure 4
Circular ACLS Algorithm

Shout for Help/Activate Emergency Response

CPR Quality
. Push hard {>2 inches 15 cml) and fast (>1oO/nrin)and allow complete
chest recoi
. l\/ln nrize inienupiions in compressions
. Avoid excessive ventilation
. Rotate cofapressor every 2 mrnutes
. ll no advanced aLtuay. 30:2 compresslon-ventilation ratro

.
.

Beturn ot SPontaneous
Post-Cardiac
Arrest Care

Drug Therapy
lVllO access
Epinephrne every 3-5 mrnuies
[Link] for reiractory VF,A/T

,l\4 \
\_l
\

\o

\,\4.

Consider Advanced Ait'waY

Quantitalive waveform capnography

Treat Feversrble Causes

g)

.=ae.=

=f

*6 !;
iin:.:.

t!\

tL6

P!lse and blood Pressure

Abrupt sustained increase in Pflco,

(typLcaLly >40 mrn Hg)

Spontaneous anerial pressure waves with intTa-erterral monitornq

Shock Energy
. Biphasic: t\,4anuiacturer recommendation (120-200 J)r f unknown

use maximura avajlable Second and subsequent doses shoulci be

equivalent. and higher doses rnay t'e cons dered.

Monophasic:360

Drug Therapy
. Epinephrine lv/lo Dose: 1 mg every 3-5 m nutes
. Vasopressin IV/IO Dose: 40 units can replace f rst or second dose
Amiodarone IV/IO Dose: Fllst dos: 300 mq bolus. Second dose; T50 mg

Advanced AirwaY

.
.
.

Supraglott c advanced airway or endotracheal intubation

Waveform capnography to confirm and monitor FT tube placemenl
8-10 breaths pe. minute with continuous chest compresslons

Beversible Causes

=
.Y, E

.
.

Hypovolemra

4>

N<
()5

aneral pressure
li relaxatron phase ldlastolic) pressure <20 mm l-lg. attempt to
iriprove CPR quaiity

Tntra

Retum ot Spontaneous Circulation (ROSC)

/,#
e-/

Olrantitaiive weveiorm capnograpny

lf PETco, <10 mrn Hg, attenrpt to improve CPR quality

Tension pnelrrnothorax

Hydrogen ion (ac dosis)

Hypo-/hyperka emra

Hypo rernr a

Thr.-h.<ic.--nr'1

OV
LIFE SUPPORT

Summary of Key Issues and Major Changes

The major changes in advanced cardiovascular l;fe support
(ACLS) for 2010 inctude the fo owing:

.
.

Quantitative waveform capnography is recommended for

confirmation and monitoring of endotracheal tube placement
and CPR quality.
The traditional cardiac arrest algorithm was simplified and an

alternative conceptual design was created to emphasize the

rmportance of high-quality CpR.

.
.

There is an increased emphasis on physiologic monitoring to

optimize CPR quality and detect ROSC.

At opine is no longer recommended for routine use in the

management of pulseless electrical activjty (pEA)/asystole.

Chronotropic drug infusions are recommended as an

alternative to pacing in symptomatic and unstable bradycardia.
Adenosine is recommended as safe and potentially
effective for both treatment and diagnosis in the initial
management of undifferentiated regular monomorohic widecomplex tachycardia.
Systematic post-cardiac arrest care after ROSC should
continue in a critical care unit with expert multidisciplinary
management and assessment of the neurologic and
physiologic status of the patient. This often includes the use
of therapeutic hypothermia.

Ca pnog ra phy Recomme

ndation

2O1O (New): Continuous quantitative waveform capnography

is now recommended for intubated patients throughout the

periarrest period. When quantitative waveform capnography

is used for adults, applications now include recommendations
for conflrming tracheai tube placement and for monitoring CpR
quality and detecting BOSC based on end-tidal carbon dioxide
(PF|co, values (Figures 3A and 3B).

Figure 3
Capnography Waveforms

50

37.5

25

Before intubation

lntubated

A.
capnograPhy to confirm endotracheal fube placement. This capnography tracing displays the padial pressure of exhaled carbon dioxide
(PErco-) in mm Hg on the ve{ical axis over time when intubaiion is perforrned. Once'the patient is jniubated. exhaled
carbon droxide is detected.
confirming tracheal tube placernent The Pfico, varies during the respiraiory cyc e, with highest values at end-expiration.

r
E
E

50

37.5
25
12.5
0

CPR

ROSC

B.
Capnography to monitor effectiveness of resuscitation efforts. Thls second capnography tracing displays the Pflco, in mm Hg on the
veriical axls over tlme. This patrent is intubated and recerving CPR Note thai the ventilation rate is approximately B to 1b oreaths oer mtnute_
Chesl compressions are given coniinuously at a rate of slight y faster than 100/min but are not visible with this tracing- The initial pflco^
ls less than 12.5 mm Hg during the firsi minuie. rndicating very low blood flow. The PErco2 increases to between 12.5 and 25 mrn Hg during
the second and third minutes, consistent with the increase n blood ilow with ongoing resuscitation. Return of spontaneous circlrlation
{ROSC)
occurs during the foufth minute. ROSC is recognized by the abrupi increase in the Pflco? {visible just after the fourth vert/caJ trneJ to over
40 mm Hg, which is consisteni vr'ith a subsiantial iorprovement in blood flow

Hightights of the 2olo aHA Guidetines for cpR anct Ecc (B

American Heart
Association

o
rt"

2010 Interim Materials

ACLS Provider Manual

Comparison Chart
Based on 2010 AHA Guidelines br CPR and ECC
BLS Changes
(c-A-B)
New science indicates the following order for
healthcare providers:
Check rhe patient for responsiveness
and prescnce/abscncc of normal
breathing or gasping.

2.
3.

4.
5.

Call for hclp.

check the pulse for no more than 10
scconds.

Give 30 compressions.
Open the airway and givc 2 breaths

Take no longr than l0 seconds to

pulsc. Ife pulse is not detcated within
scconds, bcgin chest compressions.

l0

least 100/min. Each set of 30 compressions

should tak approximatcly 18 scconds or less.

.
.
r

Previously, after responsivoness was

8ssssed, & ooll for hlp was made, the
Birway was opened, the patient was checked
for breathing, and 2 breaths were given,
followed by a pulse check and compressions

resuscitation, vidence shows that comprcssions

are the critioal elcmeDt in adult rcsuscitation ln the
A-B-C sequence, compressions are often delayed.

Adults; st least 2 inches (5 cm)

Chlldren: at lc8st one third the depth
ofthe chest, approximately 2 inches
(5 cm)
Infants; at lesst one third thc depth
ofthe chest, approximatelY l%

and breathing were assessd, ventilstions

were givcn, and pulscs were oheoked.

were to bc civen 8t a rate

about 100/min. Each cycle of30
compressions was io be complotcd in 23

.
o
.

Adults: 1% to 2 inchos
Children: one thlrd to onc half thc
diameter ofthe ohest
Infants: one third to onc halftho
diameter ofthe chcst

resuscitation, cvidenoc shows that complessions

are thc critical elcment in adult resuscitetion
Compressions arc often deleyed while providers
open the airway and deliver breaths
lfa pulsc is not dcteoted wlthin l0 seoonds, do
astcr comprcssions are required to gcncrate thc
pressurs necessary to perfuse the coronary and

Deeper comprcssions are required to gcncrale

pressures necessary to perfuse the coronary and
cerebral arteries.

Airway
and
Breathing

Cricoid pressure is no longer routinely

recommended for use with venliladons.

If

an adequate number oflescuers were

available, one could apply cricoid pressure.

Randomized studies have dcmonstrated that

cricoid pressure still allows for aspiration. It is also
difiicult to properly traln providers to peform the
maneuver corfectlv.

"Look, listen, and feel for breathing" has been

"Look, listen, and feel for breathing" was

used to assess breathing after the ainray was

With the new chest compression-first sequence,

CPR is pcrformed ifthe adult victim is
unresponsive and not brcathi[g or not breathilg

removed from the sequence for assessment of

breathing after opening the airway. Heelthcare
providers brietly check for breathing when
checking responsiveness to detect signs of
catdiac anest. Affer delivery of30
compressions, lonc rescuers open th victim's
airway and deliver 2 breaths.

opened,

normally (ie, not breathing or only gasping) and

begins with comprcssions (C-A-B scquence).
Therefore, breathing is bricfly checked as part ofa
check for cardiac anest. After the first set ofchcst
compressions, the airway is opcncd and the rcscuer
delivers 2 breaths.

AED Use

For children from I to 8 ycars ofagc, an AED

with a pediatric dose-attcnuetor systcm should
be used ifavailable. Ifan AED with a dose
attcnuator is not available, a standard AED

This does not rcpresent a change for the

child. ln 2005 thcre was not sufficient
evidence to recommend for or against the use
ofan AED in infants.

may be used.
For infants (<1 year ofage), a manual
dcfibrillator is prcferred. lfa manual
defibrillator is not available, an AED with a

The lowest cnergy dose for effective defibrillation

in infants and children is not known. The uppcr
limit for safe defibrillation is also not knom, but
doses >4 J/kg (as high as 9 J/tg) havc provldcd
effective dclibrillation in children and animal
models ofpediatric arrcst, with no slgnificant
adverse effects.

AEDS with relatively high energy doses have been

used successfully in infants in cardiac arrest, with
no clear adverse effects.

pediatic dose attenuator is desirable. If

neither ls available, an AED without a dose
attcnuator mav bc uscd.

ALS Chanses
New

Airway
and
Breathing

@ 2010

Continuous quantitative wavefonn

capnography is now recommended for
intubatcd adult patients throughout the
periarrest period. \\4ren quantitative
waveform capnography is used for adults,
applications now include recommendatlons
for confirming endofacheal tube placement
and for monltorlng CPR quality and dctectlng
ROSC bascd on end-tidal carbon dioxide
(PETco,) values.
Once circulation is restored, arterial
oxvhemoqlobin saturation should be

old
An exhaled cafbon dioxide dctcctoi or an
esophageal detector device was
recommcndcd to confirm endotracheal tube
placement. The ,005 AHA Guldellnesfor
CPR and ECC r]ot]d that PPTcor monitoring
could be useful as a nonlnvasive indicator of
cardiac output gcnerated during CPR.

Ratlonale
Continuous waveform capnography is the rnost
reliable method ofconfirmlng and monitoring
correct placemcnt ofan cndotracheal tube.
Although other means of confirming endotmcheal
tubc placement are availabl., thcy are not mofe
rcliable than continuous w$veform capnography,
Providers should observe a persistent
capnographlc wavcform with vcntllation to
confirm and monitor endotrachal tube Dlaccment.

No specific information about weaning the

In effect, the oxyhemoglobin saturation should be

Datient off suDDlemcntary oxygen was

maintaind at 94yo to 99% whcn Dossiblc.

American Heart Association. ACLS krterim Materials. Use for AHA ACLS Courses until 2011 ACLS materials are released. R 12-6-10

monilored, It may be reasonable, when the

appropriate equipmcni is available, to titrate
oxygen adminirtration to maintain the artrial
oxyhemoglobin saturation >940l0.

provided.

Supplementary oxygen is not needed for

patients without evidence of respiratory
distress or when oxyhemoglobin saturation is

Oxygen was recommended for all patients

with overt pulmonary edema or afierial
oxyhomoglobin saturation <90%. lt wes also
reasonable to administr oxygen to all
patients with ACS for the first 6 hours of
therapy.

>94Y6.

Pharmacology

Atropine is not recommended for routine use

in the management ofPEA./asystole and has
becn removed from the ACLS Cardiac Arrcst

Atropinc was includd in the ACLS

Pulselers Arrest Algorithm: for a patient in
asystole or slow PEA, atropine could be

Algorithm. The heatment of PEdasystole is

considered.

now consistent in thc ACLS and pediatric

advanced life support recommendations and

alcorithms,
Adenosine may be considered in the inltial
diagnosis of stable, undifferentiated, regular,

monornorphic, wide-complex tarhycardia. It

should not be used ifthe pattcm is ircgular,

For the treatment ofadults with symplomatic

and unstable bradycardia, chronotropic drug
infusions are recomrnended as an altemative
!o paclng.

In th Taohycardia Algorithm, adenosine uas

recommended only for suspected rggular,
narow-complex reentry suprBvcntricular
tachycsrdia.

In tha Bradycardi8 Algorithm, chlonotropic

drug infusioN were listed in thc algorithm
aftcr atropine and rvhile awBiting I pacer or
pacing was ineffective,

if

Although the ACLS Task Foroe oftho 2010

Intometional Coosgllsus on CPR and ECC Soience
With Treatmert Recommendations did not find
sufficient cvidenc to recommend a specific
weaning protocol, a recent study documentad
harmful effects ofhvDeroKia after ROSC.
Emergency medical services providers administer
oxygen dudng the initial assossment ofpatients
with suspectd ACS. Howevr, ther is insuflicient
evideoce to support its routine uso in
uncomplicated ACS, lfthe patient is dyspneic. is
hypoxemic, or has obvious slgns of hoart failure,
providers should titrate oxygen therapy to maintain
oxvhemoclobin saturatiort >9 4Vo,
There ale several importent ahanges rogarding the
managment of symptomatio arrhlthmias in
adults, Available evidence suggests that the
routine use ofBtropin during PEA or asystole is
unlikely to have a thcmpeutic benefit. For this
reason, atropine has been removed from the
Cardlaa Arrest Alcodthm.
On the basis ofnew evidence of safety and
potcntial efhcacy, adenosine can now be
considcrd in thc initial asscssment and trestnent

of undiffcrentiated regular, monomorphic, widecomplex tachycardia when the rhythm is regular to

diagnose and treat patients with wide-complex
tachyoardias who actually havc supravcnf i0ular
tachvcardia with aberrant conduction.
For symptomatic or unstable bradycardia,
iltravenous infusion ofcluonotropic agents is now
recommended as an pquelly effective alternativc to
external transcutaneous paeing when atropin is

ineffective,
Morphine should be given \vith caution to
patients with unstable angina.

@ 2010 American Heart Assooiation.

Molphin was the analgesic of choice for

pain unrcsponsive to nitrates, but it was not
recommended for use in patients with
possible hypovolemia.

Morphine is indicated in STEMI when chost

discomfort is urresponsive to nitrates, Morphine
should be used with caution in unstable
angina,inon-STEMl. because morphine
admidstrstion was associatcd with increascd
mortalitv in e larce reEistry.

ACLS Interim Materials. Use for AHA ACLS Courses until 2011 ACLS materials are released. R 12-6-10

Defibrillation

The recommended initial biphasic energy dose

1br cardioversion ofatrial tibfillation is 120 to
200 J. The initial monophasic dose for
cardioversion ofatrial fibrillation is 200 J.
Cardioversion ofadult atrial flutter and other
supraventricular [Link] generally requires
less enrgy; an initial energy of50 to 100 J
with either a monophasic or a biphasic device
is often sufficient. Ifrhe initial cardioversion

shock fails, providers should increase the dose

in a steDwise fashion.

The recommended initial monophasic energy

dose for cardioversion of atrial fibrillaiion
was 100 to 200 J, Cardioversion rvith
biphasic wavclorms was available, but the
optimal doses for cardioversion with biphasic
waveforms had not been established with
certainty, Extrapolation liom published
experienae lyith elective cardioyersion of
atrial fibrillation with the use ofrectilinear
and truncated exponentiaL waveforms
supported an initial dose of 100 to 120 J with
escalation as needed. This initial dose has
been shown to be 80% to 85o'o effective in

The witing group reviewed intrim data an all

biphasic studies conducted since the 200J .4ffA
Guidellnes for CPR curd ECC were published and
made minor changes to update cardioversioo dose
recommendations. A number ofstudies atlest to

ofbiphasia waveform cardioversion of

atrial fibfillation with energy settings trom 120 to
200 J. depending on the specific !{avcform.
the eflicacy

terminating atrial fibrillation, Until further

evidence becomes available, this information
can be used to extfapolate biphasic
cardioversion doses to other

Adult stable monomorphic VT responds well

to monophaslc or biphasic waveform
cardioversion (synchronized) shocks at initial
energies of 100 J. Ifther is no tosponse to the
first shock, it may be reasonable to incfease
the dose in a stepwise fashion. No interim
sludis were found that addressed this rhythm,
so the recommendations were made by writing

tachyarrhythmias,
There was insufficient evidence to
recommend a biphasic dose for cardioversion
ofmonomorphic [Link] 2005 AHA
Guidelines for CPR and -6CC recommended
use ofan unsyncfuonized shock for treatment
ofthe unstable patient with polymorphic VT.

The witing group agreed that it would be helpf l

to add a biphasic dose rcommendation to the
2010 AHA Guidelinesfor CPR and ECC for
cardiovcrsion of monomorphic VT but wanted to
emphasize the need to treat polymorphic VT as
unstable and as an arrest rhythm using an
unsynchronized shock.

qrouD exDcn consensus,

@ 2010

American Heart Association. ACLS Interim Materials. Use for AHA ACLS Courses until 201I ACLS materials are released. R 12-6-10

Algorithm
Update

The conventional ACLS Cardiac Arrst

Algorithm has been simplilied and

streamlined io emphasize the importance of
high-quality CPR (including providing
compressions ofadequate rato and depth,

allowing completo chest rccoil after each

compression, minimizing interruptions in
chcst compressions, and avoiding cxcessive
ventilation) and the faot that ACLS aclrons
should be orgenized arourd uninterrupted
periods ofCPR, A new circular algorithm has
also been introduced,

The seme priorities were cited in the 2005

AHA Guidelines/or CPR qnd [Link]-anow algorithm listed key actions
pqformed dudng the resuscitation in a
squential fashion.

For thc trcatment ofcardiac arest, ACLS

interventions build on the BLS foundation ofhighquality CPR to increase the likelihood ofROSC.
Before 2005, ACLS courscs assumed that
excellent CPR was provided, and they focused
mainly on addd interventions ofmanual
defibrillation, drug therapy, and advanoed airway
managcment, as wll as alternativc and additional
monagemcnt options for special rosuscitation
situations. Although adjunotive drug therapy and
advanced airway managemcnt are still part of
ACLS, in 2005 thc emphasis in advanced life
support retumed to the basics, with an inorcascd
emphasis on what is known to work: [Link]
CPR (providing comprcssions ofadequatc rate end
depth, allowing complete chcst recoil after csch
compression, mlnlmizing interruptiom ln chest
compressions, and avoiding excessive ventilation),
The 2010 AHA Guldelinetfor CPR and ECC
continuc this emphasis, The 2010 AHA Guldellnes
Iot CPR and ECC \ote that ideally CPR is guided
by physiologic monltoring (eg, continuous
wavcform capnography) and inoludes adequate
oxygonation and early defibrillatlon while thc

ACLS provider assesses and t!ctr possiblc

underlying causes of!h arrest. There is no
definitive clinical evidence that early intubation or
drug therapy improves neurologically intact
survival to hosDitsl discharce.

@ 2010 American Heart Assooiation'

ACLS Interim Materials. Use for AHA ACLS Courses until 2011 ACLS materials are released. R 12-6-10