ACLS Guia Estudio 2006

8/10/2019 ACLS Guia Estudio 2006

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LS

Study Guide

Mandatorypre-course test included.


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ACLS Course Agenda

ACLS Provider

Day 1

0900-0910 Welcome / Course Overview

0910-0920 Precourse Self-Assessment Review

0920-0940 Importance of CPR Lecture

0940-1010 EKG Review

1010-1030 BLS Primary Survey & ACLS Secondary Survey Video

1030-1040 Break

1040-1120 1strotation of Respiratory Arrest and CPR/AED Practice and Test

1120-1200 2nd rotation of Respiratory Arrest and CPR/AED Practice and Test

1200-1300 Lunch

1300-1335 Stroke Video and Lecture

1335-1355 Megacode & Resuscitation Team Practice Video

1355-1455 Pulseless Arrest VF/VT Learning Station in Groups


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ACLS Course Agenda

ACLS Provider

Day 2

0900-0935 Acute Coronary Syndromes Video and Lecture

0935-1035 Bradycardia/Asystole/ PEA and Stable/Unstable TachycardiaLearning Station in Groups

1035-1045 Break

1045-1145 Putting It All Together Learning Station in Groups

1145-1245 Lunch

1245-1345 Megacode Testing

1345-1355 ACLS Jeopardy

1355-1435 Written Exam

1435-1505 Wrap-up


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ACLS Course Agenda

ACLS Renewal

0900-0910 Welcome / Course Overview

0910-0920 Precourse Self-Assessment Review

0920-0940 ACLS Update Video

0940-1000 Importance of CPR Lecture

1000-1010 Break

1010-1050 1strotation of Respiratory Arrest and CPR/AED Practice and Test

1050-1130 2nd rotation of Respiratory Arrest and CPR/AED Practice and Test

1130-1150 Stroke Video

1150-1250 Lunch

1250-1310 Megacode & Resuscitation Team Practice Video

1310-1410 Megacode Practice in Groups - Putting It All Together

1410-1510 Megacode Testing

1510-1520 Break

1520-1530 ACLS Jeopardy

1530-1610 Written Examination

1610-1640 Wrap-up


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2006 American Heart Association 11/20/05

American Heart Links

There are several resources available to you on the American Heart Association websiteatwww.americanheart.org.Here are some helpful links:

You can find statistics on cardiovascular diseases and risk factors athttp://www.americanheart.org/presenter.jhtml?identifier=2007

You can find out your risk for heart disease athttp://www.americanheart.org/presenter.jhtml?identifier=3003500

You can access information on the warning signs of heart attack and stroke athttp://www.americanheart.org/presenter.jhtml?identifier=3053

You can find out how to lead a healthy lifestyle athttp://www.americanheart.org/presenter.jhtml?identifier=1200009

You can also go to the Emergency Cardiovascular Care (ECC) website athttp://www.americanheart.org/presenter.jhtml?identifier=3011764,where you canfind out about other American Heart Association CPR or First Aid courses andeven find a course in your area.

To find any other topic, use the Heart and Stroke Encyclopedia at this link:

http://www.americanheart.org/presenter.jhtml?identifier=10000056
http://www.americanheart.org/http://www.americanheart.org/http://www.americanheart.org/http://www.americanheart.org/presenter.jhtml?identifier=2007http://www.americanheart.org/presenter.jhtml?identifier=3003500http://www.americanheart.org/presenter.jhtml?identifier=3053http://www.americanheart.org/presenter.jhtml?identifier=1200009http://www.americanheart.org/presenter.jhtml?identifier=3011764http://www.americanheart.org/presenter.jhtml?identifier=3011764http://www.americanheart.org/presenter.jhtml?identifier=10000056http://www.americanheart.org/presenter.jhtml?identifier=10000056http://www.americanheart.org/presenter.jhtml?identifier=10000056http://www.americanheart.org/presenter.jhtml?identifier=3011764http://www.americanheart.org/presenter.jhtml?identifier=1200009http://www.americanheart.org/presenter.jhtml?identifier=3053http://www.americanheart.org/presenter.jhtml?identifier=3003500http://www.americanheart.org/presenter.jhtml?identifier=2007http://www.americanheart.org/


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ACLS Pulseless Arrest Algorithm.


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Figure 1. Bradycardia Algorithm.

IV-68 Circulation December 13, 2005


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Figure 2. ACLS TachycardiaAlgorithm.


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Figure 1. Acute Coronary Syndromes Algorithm.



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Goals for Management of Patients With Suspected Stroke Algorithm.



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ALGORITHM REVIEWAlways start with the ABCD survey!

VENTRICULAR FIBRILLATION / PULSELESS VENTRICULAR TACHYCARDIARemember: Good ACLS starts with good BLS

Algorithm: Pulseless Arrest

CPR Shock

CPR

VasopressorEpi 1 mg q 3-5 min OR 1 dose of Vasopressin 40 U IV/IO to replace 1stor2nddose of Epi

CPR

Shock

AntiarrythmicAmiodarone 300 mg IV/IO once or Lidocaine 1-1.5 mg/kg up to 3mg/kg

CPR

ShockNote: We initiate CPR as soon as possible; after each shock we resume CPR immediately for 5cycles prior to evaluating the rhythm and pulse; and minimize interruptions to chest compressi

PULSELESS ELECTRICAL ACTIVITYRemember: PEA


P= Possible causes (6 Hs, 5 Ts)

E= Epi, 1mg q 3-5 min OR 1 dose of Vasopressin 40 U IV/IO to replace 1 stor2nddose of Epi

A=Atropine, 1mg IV/IO q 3-5 min to max 3mg (only if electrical rate is < 60)Note: use the 6 Hs and the 5 Ts to remember the most common reversible causes of PEA

Hypovolemia ToxinsHypoxia Tamponade, cardiacHydrogen Ion (acidosis) Tension PneumothoraxHypo-/Hyperkalemia Thrombosis (coronary or pulmonary)Hypoglycemia TraumaHypothermia

Note: PEA is a problem with the pump, pipes, or volume, not an electrical problem. The electrsystem of the heart is still functioning, but the mechanical part of the system is not working.

ASYSTOLERemember: DEAD


D= Determine whether to initiate resuscitative efforts E= 1mg Epinephrine IV/IO q 3-5 minutes or 1 dose of Vasopressin 40 U IV/IO to

replace 1st or 2nd dose of EPI

A= 1mg Atropine IV/IO (max 3 mg)

D= Are they still dead? Consider reversible causes or ceasing efforts; check blood glucocheck core temperature; and consider Naloxone


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ACUTE CORONARY SYNDROMESRemember: Consider MONA for patients with suspected ACS

Algorithm: Acute Coronary Syndromes

Morphine

Oxygen

Nitroglycerine

Aspirinbut in the order Oxygen, Aspirin, Nitro, Morphine

BRADYCARDIARemember:All Trained Dogs Eat

Algorithm: Bradycardia

A= Atropine .5mg-1mg IVP for SB & 1st, 2nd #1 AV Block

T= Transcutaneous pacing (preferred for 2nd#2 & 3rd)

D= Dopamine 5-10 mcg/kg/min

E= Epinephrine drip 2 to 10mcg/min

Note: Atropine is not indicated, and may actually be harmful, for 2nd#2 & 3rddegree heart blocks.

Proceed directly to pacing instead.

TACHYCARDIARemember: If the patient is unstable, go directly to cardioversion

Algorithm; Tachycardia With Pulses

For RegularNarrow Complex Tachycardia1. Vagal maneuvers2. Adenosine 6 mg rapid IV push. If no conversion, give 12 mg, then another 12, mg3. Consider expert consultation

For IrregularNarrow Complex Tachycardia1. Consider expert consultation2. Control rate with Diltiazem or -blockers

For RegularWide Complex Tachycardia1. Consider expert consultation2. Amiodarone 150 mg over 10 minutes3. Elective cardioversion

For IrregularWide Complex Tachycardia1. Consider expert consultation2. Consider antiarrhythmics3. If Torsades, give magnesium 1-2 g over 5-60 minutes


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Medication Review

The information on medications in this study guide meets the same standard set by the 2005 American Heart Associat

Advanced Cardiac Life Support. It does not supersede local protocols or medical control; consult with your medical dir

the most up-to-date guidelines on medication administration.

A Note on ET Tube Administration of Medications:This route of medication administration is being

deemphasized by the AHA. The IV or IO routes are the preferred routes. However, the ET route can still

be used if unable to gain access by IV/IO. If using the ET route, the dosage must be increased, typically 2-

2.5 times the IV/IO bolus dosage. 10 ml of normal saline should follow the medication. Use the mnemonic

NEAL or LEAN to remember which meds can be administered by the ET route: Narcan Epi

Atropine Lidocaine.

A Note on Fluids: Use normal saline as the initial IV/IO fluid in an arrest situation. IV/IO medications

should be administered during CPR. It is also recommended to flush the medication with 20 ml of fluid afte

each administration as well as elevating the extremity. Always use large bore catheters if possible.

ADENOSINE

Class: Indicatedfor: IVBolusDosage:

Endogenous nucleoside PSVT or Narrow Complex 6 mg -1stdose

Tachycardia 12 mg 2nd

dose

12 mg 3rddose

Comments: Doses are followed by a saline flush. Two subsequent doses of 12 mg each may be administere

at 1 2 minute intervals. Use the port closest to cannulation. The AHA recommends that the dose be cut

half if administering through a central line, or in the presence of Dipyridamole or Carbamazepine. Larger

doses are required in the presence of caffeine or Theophylline.

AMIODARONE

Class: Indicated for: IV/IOBolusDosage:

Antiarrhythmic V-Fib / Pulseless V-Tach 300 mg 1st

dose

150mg 2nd

dose

Arrhythmias 150 mg over 10 minutes (rapid)

360 mg over 6 hours (slow)

Infusion dose:540 mg IV/IO over 18 hours (.5 mg/min)

Comments:Cumulative doses >2.2 g/24 hours are associated with significant hypotension. Do notadminister with other drugs that prolong QT interval (i.e., Procainamide). Terminal elimination is extremelylong half life lasts up to 40 days.


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ASPIRIN

Class: Indicated for: IV/IO Bolus Dosage:Non-steroidal anti-inflammatory Chest pain / ACS N/APO Dose: 160mg 325mg

Suppository Dose: 300mg

Comments: In suspected ACS, Aspirin can block platelet aggregation, and arterial constriction. Also helpswith pain control. May cause or exacerbate GI bleeding. The goal is to give Aspirin to ACS patients within

minutes of arrival.

ATROPINE

Class: Indicated for: IV/IO Bolus Dosage:Parasympathetic Blocker Bradycardia .5mg every 3-5 minutes as needed

PEA, Asystole 1mg every 3-5 minutes

Comments:Only used in bradycardias for symptomatic patients. Only used in PEA if rate is slow. Themaximum dosage is 3mg. Doses of Atropine < .5mg may result in paradoxical slowing of the heart. Not

indicated in second degree type I or third degree heart block.

DIGOXIN

Class: Indicated for: IV Bolus Dosage:Cardiac Glycoside A-Fib / A-Flutter 10-15g/kg lean body weightAntiarrhythmic

Comments: Reduce Digoxin dose by 50% when initiating Amiodarone due to drug interaction. Toxicity maycause serious arrhythmias.

DILTIAZEM

Class: Indicated for: IV Dosage:Calcium Channel Blocker A-Fib / A-Flutter 15-20 mg over 2 minutes

Comments:Do not use in wide-QRS tachycardias of uncertain origin. May cause hypotension.

DOPAMINE

Class: Indicated for: IV Drip Dosage:Catecholamine Symptomatic Bradycardia 1-5g/kg/min - renal perfusion

Hypotension 5-15g/kg/min cardiac dose

10-20g/kg/min vasopressor dose

Comments: Titrate to patient response. Correct hypovolemia with volume replacement before initiatingDopamine. May cause tachyarrhythmias. Do not mix with Sodium Bicarbonate.


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EPINEPHRINE

Class: Indicated for: IV/IO Bolus Dosage:Catecholamine V-Fib/Pulseless V-Tach 1mg every 3-5 minutes

PEA, AsystoleSymptomatic Bradycardia

Infusion dosage: 1mg in 500ml of D5W or NaCl at 1g/min titrated to effect.

Comments:First line drug in all pulseless rhythms. Bolus given in 10ml of a 1:10,000 solution. May causemyocardial ischemia, angina, and increased myocardial oxygen demand. ET route is discouraged, but if used2-2.5mg diluted in 10ml NaCl.

LIDOCAINE

Class: Indicated for: IV/IO Bolus Dosage:Antiarrhythmic V-Fib/Pulseless V-Tach 1-1.5 mg/kg

Stable V-Tach

Infusion dosage:1-4mg/min (30-50g/kg/min)

Comments:May repeat at 0.5-0.75mg/kg every 5-10 minutes to maximum dose 3mg/kg. Prophylactic usein AMI is contraindicated. Use with caution in presence of impaired liver. Discontinue infusion if signs oftoxicity develop.

MAGNESIUM SULFATE

Class: Indicated for: IV Dosage:Electrolyte Cardiac arrest if torsades or 1-2g in 10ml D5W over 20 minutes

Hypomagnesemia

Comments:Occasional fall in blood pressure with rapid administration. Use with caution in renal patients.

MORPHINE SULFATE:

Class: Indicated for: IV Bolus Dosage:Opiate Chest pain 2-4mg every 5-30 minutesAnalgesic Pulmonary edema

Comments:Administer slowly and titrate to effect. May cause respiratory depression be prepared tosupport ventilations. May cause hypotension. Naloxone is reversal agent.

NALOXONE

Class: Indicated for: IV/IO Bolus Dosage:Opiate Antagonist Narcotic overdose 0.4-2mg

Comments:If needed, can administer up to 10mg in 10 minutes. Monitor for recurrent respiratorydepression. May cause opiate withdrawal. ET route discouraged, but can be used if IV/IO access notavailable.


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VASOPRESSIN

Class: Indicated for: IV/IO Bolus Dosage:Hormone V-Fib/V-Tach 40 U IV/IO

PEA, Asystole

Comments:Only given on time. May cause cardiac ischemia and angina. May replace first or second dose ofEpi. Not recommended for responsive patients with coronary artery disease.

VERAPAMIL

Class: Indicated for: IV Bolus Dosage:Calcium Channel Blocker A-Fib/A-Flutter 2.5-5mg over 2-5 minutes

PSVT

Comments:Alternative drug after Adenosine to terminate PSVT with adequate blood pressure andpreserved LV function. Can cause peripheral vasodilation and hypotension. Use with extreme caution inpatients receiving oral -blockers.


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ELECTRICAL THERAPY

Defibrillation

Fibrillation is a disorganized rhythm that, if present in the ventricles, is life threartening. A

defibrillatory shock uses electrical current to terminate all electrical activity of the irregularly beating

heart. The hope is that following defibrillation, the heart will resume beating in a coordinated

fashion. Early delivery of electrical therapy, combined with immediate CPR following the arrest, is

critical to survival from sudden cardiac arrest.

Cardioversion

Synchronized cardioversion is a treatment option for V-Tach with a pulse, SVT, and unstable atrial

fibrillation or flutter. The shock is delivered in coordination with the QRS complex of the heart in

hopes of returning to a normal sinus rhythm. The standard sequence of energy levels for

synchronized cardioversion are as follows: 100J, 200J, 300J, & 360J monophasic energy dose (or

clinically equivalent biphasic energy dose). If the patient receiving the electrical therapy is conscious,

consider sedation prior to cardioversion.

Pacing

External cardiac pacing, or transcutaneous pacing, stimulates heart activity with an electrical impulsedelivered across the chest wall. It is a recommended therapy for symptomatic and hemodymanically

compromised bradycardias. If the patient receiving the therapy is conscious, consider sedation. The

general guideline for pacer settings is starting from zero, turn the milliamps up until capture is

achieved, then set the rate at 20 beats per minute above the monitored heart rate, with a minimum

rate of 50 bpm.


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Normal Sinus RhythmNormal Sinus Rhythm

Also known NSR orRSR)

Rhythm Regular

Rate 60 - 100

P waves Normal in configuration and

direction; one P wave precedes

each QRS complex

PRI Normal (0.12 - 0.20 seconds)

QRS Normal (0.10 seconds or less)

Sinus TachycardiaSinus Tachycardia((Jim never has a second cup at homeJim never has a second cup at home))

Rhythm Regular

Rate 100 - 160

P waves Normal in configuration and

direction; one P wave precedes

each QRS complex



Sinus Bradycardia

inus Bradycardia

Rhythm Regular

Rate 40 - 60

P waves Normal in configuration and directi on;

one P wave precedes each QRS



Premature Atrial Contraction (PAC)Premature Atrial Contraction (PAC)

Rhythm Underlying rhythm usually regular, irregular with

pause

Rate Rate of the underlying rhythm

P waves P wave is premature and abnormal in size,shape or direction. Abnormal P wave is often

found in the T wave distorting it's contour.

PRI Normal or prolonged (>0.20 seconds) usually

differs from underlying rhythm



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Rhythm (Regularly)

Irregular

Rate Normal (60-100) or slow (less than

60)

P waves Normal in configuration and directi on;

one P wave precedes each QRS



Sinus ArrhythmiaSinus Arrhythmia Supraventricular Tachycardia

Rhythm Regular

Rate 150 - 250

P waves Hidden in preceding T wave.

PRI Not measurable


Paroxysmal Supraventricular Tachycardia (PSVT)Paroxysmal Supraventricular Tachycardia (PSVT)

Rhythm Regular

Rate 150 - 250

P waves Abnormal (often pointed); usually hidden in preceding T

wave.

PRI Not measurable


ATRIAL FIBRILLATION


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ATRIAL FLUTTER

Junctional Escape Rhythm

unctional Escape Rhythm

Rhythm Regular

Rate 40-60

P waves Inverted in Lead II and will occur immediately before

the QRS, immediately after the QRS, or hidden within

the QRS.

PRI Short 0.10 seconds or less)


Premature Junctional ContractionPremature Junctional Contraction

Rhythm Underlying rhythm usually regular,

irregular with PJC

Rate Rate of the underlying rhythm

P waves P wave associated with PJC will be inverted in Lead IIand will occur immediately before the QRS, immediatelyafter the QRS, or hidden within the QRS.



Accelerated Junctional Rhythm

Rhythm Regular

Rate 60-100

P waves Inverted in Lead II and will occurimmediately before the QRS, immediately

after the QRS, or hidden within the QRS.




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Junctional Tachycardia

Rhythm Regular

Rate > 100 bpm

P waves Inverted in Lead II and will occur immediately before,

after, or hidden within the QRS.

PRI Short (0.10 seconds or less)


Introducing the Funny Looking Beat

(Is that a PVC?)The 2 types and

several flavors of

Premature

Ventricular

Contraction

Ventricular Tachycardia

Rhythm Usually regular

Rate 100 (usually 140 to 250)

P waves SA node usually still beats; P wave is usually hidden in the

QRS

PRI Not measurable

QRS Wide (0.12 seconds or greater)

Ventricular Fibrillation

There are no discernible QRS complexes.QRS

There is no PRI.PRI

There are no discernible P Waves.P Waves

Cannot be determined since there are no discernible waves or complexes.Rate

Irregular. The baseline is totally chaotic.Rhythm


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ASYSTOLE

PRI

.20 Sec

.

First-Degree AV Block

Rhythm Regular

Rate Heart rate is that of underlyingrhythm usually sinus) both atrial

and ventricular rates will be the

same.

P waves Sinus; one P wave precedes each

QRS complex

PRI Prolonged (> 0.20 seconds);

remains constant


? ?

Second-Degree AV Block Type I

Mobitz I or Wenckebach)

Rhythm Atrial: Regular Ventricular: Irregular

Rate Heart rate is that of underlying rhythm usually

sinus) both atrial and ventricular rates will be

the same.

P waves Sinus; one P wave precedes each QRS

complexPRI PR varies. PR progressively lengthens until a P

wave occurs without a QRS. A pause follows

the dropped QRS.


SecondSecond--Degree AV Block Type IIDegree AV Block Type II

Rhythm Atrial: Regular

Ventricular: Will be regular unless AV conduction

varies

Rate Atrial: Rate of underlying rhythm

Ventricular: Rate will depend on AV conduction. Less

than the atrial rate.

P waves Sinus; two or three P waves (sometimes more) beforeeach QRS

PRI May be normal or prolonged; remains constant

QRS Normal (if block located in bundle of His)

Wide (if blocked located in bundle branches)


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Summary of BLS ABCD Maneuvers for Infants, Children, and Adults (Newborn Informa

MANEUVERAdult

Lay Rescuer: 8 YearsHCP: Adolescent and older

ChildLay Rescuer: 1 to 8 Years

HCP: 1 Year to Adolescen

AIRWAY Head Tilt-Chin Lift (HCP: suspected trauma

BREATHING(INITIAL)

2 Breaths at 1 Second/Breath 2 Effective Br

HCP: Rescue breathing without chest compressions10 to 12 Breaths/Minute

(approximate)(1 Breath Every 5-6 Seconds)

12 to 20 Breat(1 Breath

HCP: Rescue breaths for CPR with advanced airway8 to 10 Breaths/Minute (approxim

(1 Breath Every 6-8 Seconds

Foreign Body Airway Obstruction (FBAO) Abdominal Thrusts

Circulation HCP: Pulse check ( 10 seconds) Carotid

Compression Landmarks Lower Half of Sternum

Compression Method:- Push Hard and Fast

- Allow Complete Recoil

Heel of One Hand;Other Hand On Top

Heel of One Hand, orAs For Adults

Compression Depth 1 to 2 Inches Approximately 1/3

Compression Rate Approximately 100 Compressions/

Compression-Ventilation Ratio 30:2 (One or Two Rescuer)30

HCP

Defibrillation AED

Use Adult PadsDo Not Use Child Pads

USE AED AS SOON ASPOSSIBLE

Use AED After 5 Cycles of CP(out of hospital).

Use Pediatric System for Child 8 years if available.

HCP: For sudden collapse (outhospital) or in-hospital arrest, u

AED as soon as possible.

NOTE: Maneuvers Used By Only Healthcare Providers Are Indicated By HCP.


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ACLS PROVIDER MANUAL STUDENT CD FAQ

1. I cannot access the ACLS Precourse Self-Assessment Test.

- Internet Explorer must be open before the CD is inserted. Remove the CD from the tray; closeall other applications, then insert the CD

- If you have a pop-up blocker, remove the CD from the tray, re-insert the CD while holding downthe Ctrl key so Macromedia Flash can run.OR you can go to My Computer > Right Click On the CD-ROM drive > Explore> Double Click onPC_Start or MAC_Start

- Make sure you are using Internet Explorer 6.0 or higher (Not AOL, FireFox, Mozilla orNetscape)

- Check to make sure Active X Controls are enabled by going to Internet Explorer> Tools>Internet Options> Security Tab> Custom Level> Active X Controls and Plug-ins> Enable

- Check to make sure Allow Active Content CDs to run on my Computer is checked by going toTools>Internet Options> Advanced Tab> Security

- Download Adobe Flash Player and Adobe Reader from www.adobe.comif you do not have italready installed on your computer. Restart the computer after you have installed the AdobeFlash Player

2. I cannot play the CD more than two, three, four times- Delete Temp Files Internet Explorer > Tools > Internet Options > General > Delete Files. Click

on OK- Close other programs running in the background- Restart the Computer

3. I cannot open ACLS Core Drugs or any other PDF files on the CD- Make sure you have Adobe installed on your computer, otherwise download Adobe Acrobat

Reader from www.adobe.com.-

4. I can't hear any sound. What do I do?- Make sure the speakers are turned on and the volume is turned up- Check the Volume and Mute settings on your computer. Make sure Mute is not checked, and

adjust Volume as needed.There are multiple ways to check these settings:

Click on the speaker icon in your system tray. Adjust Volume if needed and make sure

Mute is not checked.Go to Start > Settings > Control Panel>Sounds and Audio Devices>Volume. Make sure

Mute is not checked. Then go to Advanced. Adjust Volume if needed and make sureMute is not checked.

Go to Start > Programs > Accessories > Entertainment > Volume Control.- Make sure the volume on the video clip is turned up. The Volume Control button is located at

the bottom of the screen on the left.


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ACLS CourseCPR/AED Testing ChecklistAdult 1-Rescuer CPR and AED Test

Name: ______________________________________________ Date of Test: _____________________

Skill

StepCritical Performance Steps

Adult/Child CPR

With AED

if done correctly

1 Checks unresponsiveness

2 Tells someone to call 911 and get an AED

3 Opens airway using head tiltchin lift

4Checks breathing

Minimum 5 seconds; maximum 10 seconds

5 Gives 2 breaths (1 second each)

6Checks carotid pulse

Minimum 5 seconds; maximum 10 seconds

7 Bares victims chest and locates CPR hand position

8Delivers first cycle of compressions at correct rate

Acceptable 23 compressions

STOP THE TEST

Test ResultsIndicate Pass or Needs

Remediation:P NR

2006 American Heart Association


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Skills Station Competency Checklist

Management of Respiratory Arrest

if done

correctly

BLS Primary Survey and Interventions

Establishes unresponsiveness

Activates EMS and gets AED

or

Directs 2ndrescuer to activate the emergency response system and get the

AED

Opens the airway (head tiltchin lift or, if trauma is suspected, jaw thrust

without head extension)

Checks for breathing (look, listen, and feel; at least 5 seconds but not more

than 10 seconds)

If breathing is absent or inadequate, gives 2 breaths (1 second per breath) that

cause the chest to rise

Checks carotid pulse. Notes that pulse is present. Does not initiate chest com-

pressions or attach AED.

Performs rescue breaths at the correct rate of 1 breath every 5 to 6 seconds

(10 to 12 breaths/min)

ACLS Secondary Survey Case Skills

Inserts oropharyngeal and nasopharyngeal airway (student should demonstrate both)

Performs correct bag-mask ventilation

Administers oxygen

Reassesses pulse about every 2 minutes

Critical Actions

Performs Primary ABCDs

Properly inserts OPA or NPA

Can ventilate with bag-mask

Gives proper ventilationrate and volume

Rechecks pulse and other sign of circulation. Does not initiate chest compressions.



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Learning Station Competency Checklist

VF/Pulseless VT

VF/VT

PULSELESS ARREST BLS Algorithm: Call for help, give CPR Give oxygenwhen available Attach monitor/defibrillator when available

No

Asystole/PEA

Check rhythmShockable rhythm?

NoCheck rhythmShockable rhythm?


Give 5 cycles of CPR*

Resume CPR immediately for 5 cyclesWhen IV/IO available, give vasopressor Epinephrine1 mg IV/IO

Repeat every 3 to 5 min or

May give 1 dose of vasopressin 40 U IV/IO toreplace first or second dose of epinephrine

Consider atropine 1 mg IV/IO for asystole or slow PEA rate

Repeat every 3 to 5 min (up to 3 doses)


Give 5 cycles

of CPR*

10

9

1

2

3

4

5

6

7

8


11

If asystole, go to Box 10 If electrical activity, check

pulse. If no pulse, go toBox 10

If pulse present, beginpostresuscitation care

12

13

Go to

Box 4

Shockable Not Shockable

Shockable

Shockable

Shockable

Not

Shockable

During CPR

Push hard and fast (100/min)

Ensure full chest recoil

Minimize interruptions in chestcompressions

One cycle of CPR: 30 compressionsthen 2 breaths; 5 cycles 2 min

Avoid hyperventilation

Secure airway and confirm placement

*After an advanced airway is placed,rescuers no longer deliver cyclesof CPR. Give continous chest com-pressions without pauses for breaths.Give 8 to 10 breaths/minute. Checkrhythm every 2 minutes

Rotate compressors every

2 minutes with rhythm checks Search for and treat possible

contributing factors: Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypo-/hyperkalemia Hypoglycemia Hypothermia Toxins Tamponade, cardiac Tension pneumothorax Thrombosis (coronary or pulmonary) Trauma

Give 1 shock Manual biphasic: device specific

(typically 120 to 200 J)Note: If unknown, use 200 J

AED: device specific Monophasic: 360 JResume CPR immediately

Continue CPR while defibrillator is chargingGive 1 shock Manual biphasic: device specific

(same as first shock or higher dose)Note: If unknown, use 200 J

AED: device specific Monophasic: 360 JResume CPR immediately after the shockWhen IV/IO available, give vasopressor during CPR

(before or after the shock) Epinephrine 1 mg IV/IO



Continue CPR while defibrillator is charging

Give 1 shock Manual biphasic: device specific(same as first shock or higher dose)Note: If unknown, use 200 J

AED: device specific Monophasic: 360 JResume CPR immediately after the shockConsiderantiarrhythmics; give during CPR(before or after the shock) amiodarone(300 mg IV/IO once, thenconsider additional 150 mg IV/IO once) orlidocaine(1 to 1.5 mg/kg first dose, then 0.5 to0.75 mg/kg IV/IO, maximum 3 doses or 3 mg/kg)

Consider magnesium,loading dose1 to 2 g IV/IO for torsades de pointes

After 5 cycles of CPR,* go to Box 5 above



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VF/VT

PULSELESS ARREST BLS Algorithm: Call for help, give CPR Give oxygenwhen available Attach monitor/defibrillator when available

No

Asystole/PEA


NoCheck rhythmShockable rhythm?



Resume CPR immediately for 5 cyclesWhen IV/IO available, give vasopressor Epinephrine1 mg IV/IO


May give 1 dose of vasopressin 40 U IV/IO to

replace first or second dose of epinephrine

Consider atropine 1 mg IV/IO for asystole or slow PEA rate

Repeat every 3 to 5 min (up to 3 doses)


Give 5 cycles

of CPR*

10

9

1

2

3

4

5

6

7

8


11

If asystole, go to Box 10 If electrical activity, check

pulse. If no pulse, go toBox 10

If pulse present, beginpostresuscitation care

12

13

Go to

Box 4

Shockable Not Shockable

Shockable

Shockable

Shockable

Not

Shockable

During CPR

Push hard and fast (100/min)

Ensure full chest recoil

Minimize interruptions in chestcompressions

One cycle of CPR: 30 compressionsthen 2 breaths; 5 cycles 2 min

Avoid hyperventilation

Secure airway and confirm placement

*After an advanced airway is placed,rescuers no longer deliver cyclesof CPR. Give continous chest com-pressions without pauses for breaths.Give 8 to 10 breaths/minute. Checkrhythm every 2 minutes

Rotate compressors every2 minutes with rhythm checks

Search for and treat possiblecontributing factors: Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypo-/hyperkalemia Hypoglycemia Hypothermia Toxins Tamponade, cardiac Tension pneumothorax Thrombosis (coronary or pulmonary) Trauma

Give 1 shock Manual biphasic: device specific

(typically 120 to 200 J)Note: If unknown, use 200 J

AED: device specific Monophasic: 360 JResume CPR immediately

Continue CPR while defibrillator is chargingGive 1 shock Manual biphasic: device specific

(same as first shock or higher dose)Note: If unknown, use 200 J

AED: device specific Monophasic: 360 JResume CPR immediately after the shockWhen IV/IO available, give vasopressor during CPR(before or after the shock)

Epinephrine 1 mg IV/IORepeat every 3 to 5 min or


Continue CPR while defibrillator is chargingGive 1 shock

Manual biphasic: device specific(same as first shock or higher dose)Note: If unknown, use 200 J

AED: device specific Monophasic: 360 JResume CPR immediately after the shockConsiderantiarrhythmics; give during CPR(before or after the shock) amiodarone(300 mg IV/IO once, then

consider additional 150 mg IV/IO once) orlidocaine(1 to 1.5 mg/kg first dose, then 0.5 to0.75 mg/kg IV/IO, maximum 3 doses or 3 mg/kg)

Consider magnesium,loading dose1 to 2 g IV/IO for torsades de pointes

After 5 cycles of CPR,* go to Box 5 above

Learning Station Competency ChecklistPEA/Asystole



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Prepare for transvenous pacing

Treat contributingcauses Consider expert consultation

Adequate

PerfusionObserve/Monitor

Maintain patent airway; assist breathingas needed

Give oxygen

Monitor ECG (identify rhythm), blood pressure, oximetry

Establish IV access

BRADYCARDIA

Heart rate


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E

CC

American Heart Association

Advanced CardiovascularLife Support

Written PrecourseSelf-Assessment

October 2006



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ACLS Provider CourseWritten Precourse Self-Assessment Answer Sheet

Name_________________________________ Date_____________________

Circle the correct answers.

Question Answer Question Answer

1. a b c d 16. a b c d

2. a b c d 17. a b c d

3. a b c d 18. a b c d

4. a b c d 19. a b c d

5. a b c d 20. a b c d

6. a b c d 21. a b c d

7. a b c d 22. a b c d

8. a b c d 23. a b c d

9. a b c d 24. a b c d

10. a b c d 25. a b c d

11. a b c d 26. a b c d

12. a b c d 27. a b c d13. a b c d 28. a b c d

14. a b c d 29. a b c d

15. a b c d 30. a b c d

Please fill in the correct rhythm for questions 31 40.

31. _____________________________

32. _____________________________

33. _____________________________

34. _____________________________

35. _____________________________

36. _____________________________

37. _____________________________

38. _____________________________

39. _____________________________

40. _____________________________


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ACLS Precourse Written Self-Assessment 3 2006 American Heart Association

5. A woman with a history of narrow-complex PSVT arrives in the ED. She is alert and orientedbut pale. HR is 165 bpm, and the ECG documents SVT. BP is 105/70 mm Hg. Supplementaloxygen is provided, and IV access has been established. Which of the follow ing drug -dosecombinations is the most appropriate initial treatment?

a. Adenosine 6 mg rapid IV pushb. Epinephrine 1 mg IV pushc. Synchronized cardioversion with 25 to 50 Jd. Atropine 1 mg IV push

6. Which of the following facts about identification of VF is true?

a. A peripheral pulse that is both weak and irregular indicates VFb. A sudden drop in blood pressure indicates VFc. Artifact signals displayed on the monitor can look like VFd. Turning the signal amplitude (gain) to zero can enhance the VF signal

7. Endotracheal intubation has just been attempted for a patient in respiratory arrest. During

bag-mask ventilation you hear stomach gurgling over the epigastrium but no breath sounds,and oxygen saturation (per pulse oximetry) stays very low. Which o f the following is the mostlikely explanation for these findings?

a. Intubation of the esophagusb. Intubation of the left main bronchusc. Intubation of the right main bronchusd. Bilateral tension pneumothorax

8. Which of these statements about IV administration of medications during attemptedresuscitation is true?

a. Give epinephrine via the intracardiac route if IV access is not obtained within 3 minutesb. Follow IV medications through peripheralveins with a fluid bolusc. Do not follow IV medications through centralveins with a fluid bolusd. Run normal saline mixed with sodium bicarbonate (100 mEq/L) during continuing CPR

9. A 60-year-old man (weight = 50 kg) with recurrent VF has converted from VF again to a wide-complex nonperfusing rhythm after administration of epinephrine 1 mg IV and a 3

rdshock.

Which of the following drug regimens is most appropr iate to give next?

a. Amiodarone 300 mg IV pushb. Lidocaine 150 mg IV pushc. Magnesium 3 g IV push, diluted in 10 mL of D5W

d. Procainamide 20 mg/min, up to a maximum dose of 17 mg/kg


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10. While treating a patient in persistent VF arrest after 2 shocks, you consider usingvasopressin. Which of the following guidelines for use of vasopressin is true?

a. Give vasopressin 40 U every 3 to 5 minutes

b. Give vasopressin for better vasoconstriction and -adrenergic stimulation than that provided byepinephrine

c. Give vasopressin as an alternative to a first or second dose of epinephrine in shock-refractoryVFd. Give vasopressin as the first-line pressor agent for clinical shock caused by hypovolemia

11. Which of the following causes of PEA is mostlikely to respond to immediate treatment?

a. Massive pulmonary embolismb. Hypovolemiac. Massive acute myocardial infarctiond. Myocardial rupture

12. Which of the following drug-dose combinations is recommended as the initial medication to

give a patient in asystole?

a. Epinephrine 3 mg IVb. Atropine 3 mg IVc. Epinephrine 1 mg IVd. Atropine 0.5 mg IV

13. A patient with a heart rate of 40 bpm is complaining of chest pain and is confused. Afteroxygen, what is the first drug you should administer to this patient while a transcutaneouspacer is brought to the room?

a. Atropine 0.5 mg

b. Epinephrine 1 mg IV pushc. Isoproterenol infusion 2 to 10 g/mind. Adenosine 6 mg rapid IV push

14. Which of the follow ing statements correctly describes the ventilations that should beprovided after endotracheal tube insertion, cuff inflation, and verification of tube posit ion?

a. Deliver 8 to 10 ventilations per minute with no pauses for chest compressionsb. Deliver ventilations as rapidly as possible as long as visible chest rise occurs with each breathc. Deliver ventilations with a tidal volume of 3 to 5 mL/kgd. Deliver ventilations using room air until COPD is ruled out


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15. A patient in the ED reports 30 minutes of severe, crush ing, substernal chest pain. BP is110/70 mm Hg, HR is 58 bpm, and the monitor shows regular sinus bradycardia. The patienthas received aspirin 325 mg PO, oxygen 4 L/min via nasal cannula, and 3 sublingualnitroglycerin tablets 5 minutes apart, but he continues to have severe pain. Which o f thefollowing agents should be given next?

a. Atropine 0.5 to 1 mg IVb. Furosemide 20 to 40 mg IVc. Lidocaine 1 to 1.5 mg/kgd. Morphine sulfate 2 to 4 mg IV

16. Which of the following agents are used frequently in the early management of acute cardiacischemia?

a. Lidocaine bolus followed by a continuous infusion of lidocaineb. Chewable aspirin, sublingual nitroglycerin, and IV morphinec. Bolus of amiodarone followed by an oral ACE inhibitord. Calcium channel blocker plus IV furosemide

17. A 50-year-old man who is profusely diaphoretic and hypertensive complains of crushingsubsternal chest pain and severe shortness of breath. He has a history of hypertension. Hechewed 2 baby aspirins at home and is now receiving oxygen. Which of the follow ingtreatment sequences is most appropriate at this time?

a. Morphine then nitroglycerin, but only if morphine fails to relieve the painb. Nitroglycerin then morphine, but only if ST elevation is >3 mmc. Nitroglycerin then morphine, but only if nitroglycerin fails to relieve the paind. Nitroglycerin only, because chronic hypertension contraindicates morphine

18. A 50-year-old man has a 3-mm ST elevation in leads V2to V4. Severe chest pain continues

despite administration of oxygen, aspirin, nitroglycerin SL 3, and morphine 4 mg IV. BP is170/110 mm Hg; HR is 120 bpm. Which of the following treatment combinations is mostappropriate for this patient at this time (assume no contraindications to any medication)?

a. Calcium channel blocker IV + heparin bolus IVb. ACE inhibitor IV + lidocaine infusionc. Magnesium sulfate IV + enoxaparin (Lovenox) SQd. Fibrinolytic + heparin bolus IV

19. A 70-year-old woman complains of a moderate headache and trouble walking. She has afacial droop, slurred speech, and difficu lty raising her right arm. She takes severalmedications for high blood pressure. Which of the following actions is most appropr iate to

take at this time?

a. Activate the emergency response system; tell the dispatcher you need assistance for a womanwho is displaying signs and symptoms of an acute subarachnoid hemorrhage

b. Activate the emergency response system; tell the dispatcher you need assistance for a womanwho is displaying signs and symptoms of a stroke

c. Activate the emergency response system; have the woman take aspirin 325 mg and then haveher lie down while both of you await the arrival of emergency personnel

d. Drive the woman to the nearby ED in your car


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20. Within 45 minutes of her arrival in the ED, which o f the following evaluation sequencesshould be performed for a 70-year-old woman with rapid onset of headache, garbled speech,and weakness of the right arm and leg?

a. History, physical and neurologic exams, noncontrasthead CT with radiologist interpretationb. History, physical and neurologic exams, noncontrasthead CT, start of fibrinolytic treatment if CT

scan is positive for strokec. History, physical and neurologic exams, lumbar puncture (LP), contrasthead CT if LP is

negative for bloodd. History, physical and neurologic exams, contrasthead CT, start fibrinolytic treatment when

improvement in neurologic signs is noted

21. Which of the following rhythms is a proper indication for transcutaneous cardiac pacing?

a. Sinus bradycardia with no symptomsb. Normal sinus rhythm with hypotension and shockc. Complete heart block with pulmonary edemad. Asystole that follows 6 or more defibrillation shocks

22. Which of the following causes of out-of-hospital asystole is most likely to respond totreatment?

a. Prolonged cardiac arrestb. Prolonged submersion in warm waterc. Drug overdosed. Blunt multisystem trauma

23. A 34-year-old woman with a history of mitral valve prolapse presents to the ED complainingof palp itations. Her vital signs are as follows: HR = 165 bpm, resp = 14 per minute, BP =

118/92 mm Hg, and O2sat = 98%. Her lungs sound clear, and she reports no shortness ofbreath or dyspnea on exertion. The ECG and monitor display a narrow-complex, regulartachycardia. Which of the following terms best describes her conditi on?

a. Stable tachycardiab. Unstable tachycardiac. Heart rate appropriate for clinical conditiond. Tachycardia secondary to poor cardiovascular function

24. A 75-year-old man presents to the ED with a 1-week history of lightheadedness, palpitations ,and mild exercise intolerance. The initial 12-lead ECG displays atrial fibrillation, whichcontinues to show on the monitor at an irregular HR of 120 to 150 bpm and a BP of

100/70 mm Hg. Which of the following therapies is the most appropriate next intervention?

a. Sedation, analgesia, then immediate cardioversionb. Lidocaine 1 to 1.5mg/kg IV bolusc. Amiodarone 300 mg IV bolusd. Seek expert consultation


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25. You prepare to cardiovert an unstable 48-year-old woman with tachycardia. Themonitor/defibrillator is in synchronization mode. The patient suddenly becomesunresponsive and pulseless as the rhythm changes to an irregular, chaotic, VF-like pattern.You charge to 200 J and press the SHOCK but ton, but the defibrillator fails to deliver a shock.Why?

a. The defibrillator/monitor battery failedb. The sync switch failedc. You cannot shock VF in sync moded. A monitor lead has lost contact, producing the pseudo-VF rhythm

26. Vasopressin can be recommended for which of the follow ing arrest rhythms?

a. VFb. Asystolec. PEAd. All of the above

27. Effective bag-mask ventilations are present in a patient in cardiac arrest. Now, 2 minutes afterepinephrine 1 mg IV is given, PEA cont inues at 30 bpm. Which o f the follow ing actions shouldbe done next?

a. Administer atropine 1 mg IVb. Initiate transcutaneous pacing at a rate of 60 bpm

c. Start a dopamine IV infusion at 15 to 20 g/kg per minuted. Give epinephrine (1 mL of 1:10 000 solution) IV bolus

28. The following patients were diagnosed with acute ischemic stroke. Which of these patientshas NO stated contraindication for IV fibrinolytic therapy?

a. A 65-year-old woman who lives alone and was found unresponsive by a neighborb. A 65-year-old man presenting approximately 4 hours after onset of symptomsc. A 65-year-old woman presenting 1 hour after onset of symptomsd. A 65-year-old man diagnosed with bleeding ulcers 1 week before onset of symptoms

29. A 25-year-old woman presents to the ED and says she is having another episode of PSVT. Hermedical history inc ludes an electrophysiolog ic stimulation study (EPS) that confirmed areentry tachycardia, no Wolff-Parkinson-White syndrome, and no preexcitation. HR is 180bpm. The patient reports palpitations and mild shortness o f breath. Vagal maneuvers withcarotid sinus massage have no effect on HR or rhythm. Which of the following is the mostappropriate next intervention?

a. DC cardioversionb. IV diltiazemc. IV propranolold. IV adenosine


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34.

Normal Sinus Rhythm Sinus Tachycardia Sinus Bradycardia Atr ial Fibri llation Atr ial Flutter

Reentry Supraventricular Tachycardia

Monomorphic Ventricular Tachycardia Polymorphic Ventricular Tachycardia Ventricular Fibrillation Second-Degree Atrioventricular Block Third-Degree Atrioventricular Block

35.

Normal Sinus Rhythm Sinus Tachycardia Sinus Bradycardia Atr ial Fibri llation Atr ial Flutter Reentry Supraventricular Tachycardia



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36.




37.




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38.




39.




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40.




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ACLS Written 2006 Precourse Self-AssessmentAnswer Key

1. The correct answer is d.See ACLS Provider Manual, pages 38 and 43.

2. The correct answer is b.See ACLS Provider Manual, page 53

3. The correct answer is c.See ACLS Provider Manual, page 45

4. The correct answer is c.See ACLS Provider Manual, page 37.

5. The correct answer is a.See ACLS Provider Manual, page 101.


7. The correct answer is a.See ACLS Student CD, pages 22-23


9. The correct answer is a.See ACLS Provider Manual, page 46.

10. The correct answer is c.

See ACLS Provider Manual, page 45.

11. The correct answer is b.See ACLS Provider Manual, page 58-59


13. The correct answer is a.See ACLS Provider Manual, page 83

14. The correct answ er is a.See ACLS Provider Manual, page 32

15. The correct answer is d.See ACLS Provider Manual page 72.See ACLS Student CD, ACLS Core Drugs



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17. The correct answer is c.See ACLS Provider Manual page 72.

18. The correct answer is d.See ACLS Provider Manual, page 76 and 78


20. The correct answ er is a.See ACLS Provider Manual, pages 106 and 112-113.



23. The correct answ er is a.See ACLS Provider Manual, page 98

24. The correct answer is d.See ACLS Provider Manual, pages 99

25. The correct answer is c.See ACLS Provider Manual, pages 93-95 and 99

26. The correct answer is d.See ACLS Provider Manual, pages 45. 48, 53 and 62

27. The correct answer is a.See ACLS Provider Manual, page 53

28. The correct answ er is c.See ACLS Provider Manual, page 115.

29. The correct answer is d.See ACLS Provider Manual, page 101

30. The correct answer is d.See ACLS Provider Manual, pages 83 and 86

31. Normal Sinus Rhythm

See ACLS Student CD Nonarrest Rhythms32. Second Degree Atrioventricu lar Block

See ACLS Student CD Nonarrest Rhythms

33. Sinus Bradycardia


34. Arial Flutter


35. Sinus Bradycardia



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36. Third Degree Atrioventricular Block


37. Atrial Fibrillation

See ACLS Student CD Nonarrest Rhythms38. Monomorphic Ventricular Tachycardia


39.Polymorphic Ventricular Tachycardia


40.Ventricular Fibrillation

See ACLS Student CD Core Arrest Rhythms

Documents

ACLS Guia Estudio 2006