BLS, ACLS, & PALS

STUDY GUIDE

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 TABLE OF CONTENTS

BLS Study Guide pp. 01 - 02

ACLS Study Guide pp. 03 - 23

PALS Study Guide pp. 24 - 65

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 BLS
STUDY GUIDE

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Elite Medical Training | Page 01
Elite Medical Training | Page 02
 ACLS
STUDY GUIDE

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 The purpose of this study guide is to assist you in successfully completing the AHA
ACLS course. It includes sections on:
ECG Rhythm Interpretation
ACLS Drugs
ACLS Algorithms

ECG Rhythm Interpretation

Electrical Conduction System
⇒ SA Node. Primary pacemaker. Rate 60-100
⇒ The impulse travels through the Interatrial Pathways to innervate the atria.
⇒ The impulse reaches the AV Node where electrical activity is delayed to allow for
more complete filling of ventricles.
⇒ AV Junction is comprised of the AV Node and the Bundle of His. Secondary
pacemaker. Rate 40-60.
⇒ The impulse then travels into the Right and Left Bundle branches. Conducts
electrical activity from Bundle of His to Purkinje Network.
⇒ The Purkinje Network are fibers that spread throughout the ventricles that carry
impulses directly to ventricular muscle cells. Our last pacemaker site. Rate 20-40

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P wave:
• Represents Atrial depolarization
PRI:
• Represents the time it takes the impulse to travel from the SA Node through the
interatrial pathways in atria to the AV junction and the delay at the AV node.
• Interval from start of P wave to start of QRS, measures 0.12-0.20 sec.

QRS:
• Represents conduction of impulse from Bundle of His through the ventricular
muscle.
• Represents ventricular depolarization.
• Should measure less than 0.12 sec

T wave:
• Follows ST segment. Slightly rounded, positive deflection
• Represents ventricular repolarization, “resting phase “of cardiac cycle,

Absolute Refractory Period:

No outside stimulus can cause cells to depolarization
From beginning of the QRS complex to the middle of the T wave

Relative Refractory Period:

A dangerous period. A strong outside stimulus can initiate depolarization of the only
partially recharged cells. Possibly causing a lethal arrhythmia
From the middle of the T wave to its end

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5 Steps for Analyzing a Strip:

Heart Rate:
Bradycardia <60, Normal 60-100, Tachycardia >100
⇒ Count the # of R waves in a 6 second rhythm strip, then multiply by 10
⇒ Find an R wave that lands on a bold line. Count the # of large boxes to the next R
wave. If the second R wave is 1 large box away the rate is 300, 2 boxes - 150, 3 boxes -
100, 4 boxes - 75, 5 boxes – 60
⇒ Divide 300 by the number of large boxes separating the R waves

Heart Rhythm:
⇒ Look at the R – R distances, are they regular or irregular

P Wave:
⇒ Are there P waves?
⇒ Do the P waves all look alike?
⇒ Do the P waves occur at a regular rate?
⇒ Is there one P wave before each QRS

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PR Interval:
⇒ Is the PRI between 0.12-0.20?
⇒ Is it consistent across the strip?
⇒ If it varies is there a pattern?

QRS Complex:
⇒ Do all of the QRS Complexes look alike?
⇒ Are they regular?
⇒ Is the duration 0.04 – 0.12

Normal Sinus Rhythm

This rhythm represents the normal state with the SA node functioning as the lead
pacer with normal conduction through the heart. The intervals should all be consistent
and within normal ranges.

Looking at the ECG you'll see that:

• Rhythm - Regular
• Rate - (60-100 bpm)
• QRS Duration - Normal
• P Wave - Visible before each QRS complex
• P-R Interval - Normal (<5 small squares. Anything above and this would be 1st
degree block)
• Indicates that the electrical signal is generated by the sinus node and travelling in a
normal fashion in the heart.

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Sinus Bradycardia

The sinus beats are slower than 60 BPM. The origin may be in the SA node or in an
atrial pacemaker. This rhythm can be caused by vagal stimulation leading to nodal
slowing, or by medicines such as beta blockers, and is normally found in some well-
conditioned athletes. The QRS complex, and the PR interval may slightly widen as the
rhythm slows below 60 BPM. However, they will not widen past the upper threshold of
the normal range for that interval. For example, the PR interval may widen, but is
should not widen over the upper of 0.20 seconds

Looking at the ECG you'll see that:

• Rhythm - Regular
• Rate - less than 60 beats per minute
• QRS Duration - Normal
• P Wave - Visible before each QRS complex
• P-R Interval - Normal
• Usually benign and often caused by patients on beta blockers

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Sinus Tachycardia

It is an excessive heart rate above 100 beats per minute (BPM) that originates from
the SA node. Causes include stress, fright, pain, dehydration, and exercise. Not usually
a surprise if it is triggered in response to regulatory changes (e.g. shock).

Looking at the ECG you'll see that:

• Rhythm - Regular
• Rate – Usually between 100 – 150 beats per minute • QRS Duration - Normal
• P Wave - Visible before each QRS complex
• P-R Interval - Normal
• The impulse generating the heartbeats are normal, but they are occurring at a faster
pace than normal. Seen during exercise

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Atrial Flutter

A single irritable focus in the atria fires in a rapid repetitive fashion at a rate of 150 –
350 beats/min. The F waves appear in a saw toothed pattern such as those in this
ECG. The QRS rate is usually regular and the complexes appear at some multiple of
the P-P interval.

Looking at the ECG you'll see that:

• Rhythm – Usually regular

• Rate – Usually fast 110-150 beats per minute
• QRS Duration - Usually normal
• P Wave - Replaced with multiple F (flutter) waves, usually at a ratio of 2:1 (2F - 1QRS)
but sometimes 3:1
• P Wave rate - 300 beats per minute
• P-R Interval - Not measurable

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Atrial Fibrillation

Atrial fibrillation is the chaotic firing of numerous atrial pacemaker cells in a totally
haphazard fashion. The result is that there are no discernible P waves. And the QRS
complexes are innervated haphazardly in an irregularly irregular pattern. The
ventricular rate is guided by occasional activation from one of the pacemaking
sources. Because the ventricles are not paced by anyone site, the intervals are
completely random.

Looking at the ECG you'll see that:

• Rhythm - Irregularly irregular

• Rate - usually 100-160 beats per minute but slower if on medication
• QRS Duration - Usually normal
• P Wave - Not distinguishable as the atria are firing off all over • P-R Interval - Not
measurable
• The atria fire electrical impulses in an irregular fashion causing irregular heart rhythm

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Supraventricular Tachycardia (Narrow complex Tachycardia) (SVT)

SVT is a narrow complex tachycardia originating above the ventricles. SVT can occur
in all age groups.

Looking at the ECG you'll see that:

• Rhythm - Regular
• Rate - > 150 beats per minute
• QRS Duration - Usually normal
• P Wave - Often buried in preceding T wave
• P-R Interval - Depends on site of supraventricular pacemaker

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1st Degree AV Block

1st Degree AV block is caused by a conduction delay through the AV node but all
electrical signals reach the ventricles. This rarely causes any problems by itself and
often trained athletes can be seen to have it. The normal P-R interval is between 0.12s
to 0.20s in length or 3-5 small squares on the ECG.

Looking at the ECG you'll see that:

• Rhythm - Regular
• Rate - Normal
• QRS Duration - Normal
• P Wave - Ratio 1:1
• P Wave rate - Normal
• P-R Interval - Prolonged (>5 small squares)

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 2nd Degree Block Type 1 (Wenckebach)

Mobitz Type I is also know as Wenckebach (pronounced WEEN-key bock). It is caused

by a diseased AV node with a long refractory period. The result is that the PR interval
lengthens between successive beats due to increasing delayed conduction through
the AV junction until a beat is dropped. At that point, the cycle starts again.

Looking at the ECG you'll see that:

• Rhythm - Regularly irregular

• Rate - Normal or Slow
• QRS Duration - Normal
• P Wave - Ratio 1:1 for 2,3 or 4 cycles then 1:0.
• P Wave rate - Normal but faster than QRS rate
• P-R Interval - Progressive lengthening of P-R interval until a QRS complex is dropped

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 2nd Degree Block Type 2

In 2nd degree Type 2, the impulse either passes through the AV junction normally or is
blocked completely. It is an all-or-nothing type of thing. Beats are intermittently non
conducted and QRS complexes dropped, usually in a repeating cycle of every 3rd (3:1
block) or 4th (4:1 block) P wave

Looking at the ECG you'll see that:

• Rhythm - Regular
• Rate - Normal or Slow
• QRS Duration - Prolonged
• P Wave - Ratio 2:1, 3:1
• P Wave rate - Normal but faster than QRS rate
• P-R Interval - Normal or prolonged but constant

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 3rd Degree Block

3rd-degree block or complete heart block occurs when the impulse travels through
the atria normally but is blocked completely at the junction. The atria and ventricles
are firing separately – each to its own drummer, so to speak. The atrial rhythm can be
bradycardic, normal or tachycardic. The escape beat can be junctional (normal QRS)
or ventricular (wide QRS).

Looking at the ECG you'll see that:

• Rhythm - Regular
• Rate - Slow
• QRS Duration – Usually wide, but if ventricular impulse is generated low in the
junction it could be normal.
• P Wave - Unrelated
• P Wave rate - Normal but faster than QRS rate
• P-R Interval - Variation

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Wide Complex Tachycardia (usually monomorphic ventricular tachycardia)
Abnormal

Ventricular tachycardia is simply the presence of three or more ectopic ventricular

complexes in a row with a rate above 100. Originates from one irritable focus so the
rhythm is regular. Poor cardiac output is usually associated with this rhythm

Looking at the ECG you'll see that:

• Rhythm - Regular
• Rate – Fast usually 180-190 Beats per minute
• QRS Duration - Prolonged
• P Wave - Not seen
• Results from abnormal tissues in the ventricles generating a rapid and irregular heart
rhythm.

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Polymorphic V-Tach (Torsades de Pointes)

Similar to ventricular tachycardia

Morphology of QRS complexes shows variations in width and shape
Resembles a turning about or twisting motion along baseline
May result from hypokalemia, hypomagnesemia, tricyclic antidepressant drug
overdose, the use of antidysrhythmic drugs, or a combination of these
Seen in alcoholics, eating disorders, and the debilitated patients

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Ventricular Fibrillation (VF)

Disorganized electrical signals cause the ventricles to quiver instead of contract in a

rhythmic fashion. A patient will be unconscious as there is no cardiac output and
blood is not pumped to the brain. Immediate treatment by defibrillation is indicated.
This condition may occur during or after a myocardial infarct.

Looking at the ECG you'll see that:

Rhythm - Irregular
Rate - 300+, disorganized
QRS Duration - Not recognizable
P Wave - Not seen
This patient needs to be defibrillated!! QUICKLY

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Pulseless Electrical Activity (PEA)

PEA occurs when any heart rhythm (other than V-Tach or V- Fib) is observed on the
monitor and does not produce a pulse. PEA can be any rhythm (sinus, bradycardia,
tachycardia). There is organized electrical activity without a pulse.

Prognosis for PEA invariably is poor unless an underlying cause can be identified
and corrected
The highest priority of care is to maintain circulation for the patient with basic and
advanced life support techniques while searching for a correctable cause.

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 Asystole – Abnormal

Asystole refers to the absence of any electrical cardiac activity. It is defined by < 10
non-perfusing complexes per minute.

Looking at the ECG you'll see that:

Rhythm - Flat or an occasional p wave or QRS complex. The QRS complexes when
they occur are wide and bizarre
Rate - 0 Beats per minute
QRS Duration - None
P Wave - None

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ACLS Drugs

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 PALS
STUDY GUIDE

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2020

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