ACLS

Question 1

Cardiac Arrest Algorithm (shockable)

Answer 1

1. Start CPR [+give oxygen and attach monitor/defibrillator]
2. Determine if rhythm is shockable
3. If VF/pVT -> shock as soon as defibrillator is available
4. CPR for 2 minutes [+IV/IO access]
5. Conduct a rhythm check (and a pulse check).
6. If VF/pVT -> shock
7. Resume CPR for 2 minutes. Once IV/IO access is available and AFTER the second shock, give epinephrine every 3-5 minutes. [Consider advanced airway, capnography]
8. Conduct a rhythm check (and a pulse check).
9. If VF/pVT -> shock
10. CPR for 2 minutes; give amiodarone (or lidocaine if not available). [Treat reversible causes]
11. Return to step 5 until ROSC is achieved -> post-cardiac arrest care album

Question 2

What rhythms are shockable?

Answer 2

VF and pVT

Question 3

How does epinephrine work during

Answer 3

Beta-adrenergic effects - vasoconstriction to increase cerebral and coronary blood flow by increasing MAP and aortic diastolic pressure

Question 4

Why is amiodarone used?

Answer 4

Shown to improve ROSC and hospital admission with refractory VF/pVT

Question 5

Overall effect of amidoarone?

Answer 5

Lowers defibrillation threshold, making defib more effective; slows the heart

Blocks Na channels at rapid pacing frequencies (class I effect) and exerts a non-competitive anti-sympathetic action (class I effect), as well as lengthening of the cardiac action potential (class III effect)

Question 6

How does lidocaine work?

Answer 6

Depresses the automaticity of Purkinje fibers, raising the stimulation threshold in the ventricular muscle fibers (decreases likelihood of fibrillation)

Blocks permeability of the neuronal membrane to Na, which results in inhibition of depolarization and the blockade of conduction

Question 7

What rhythms are not shockable?

Answer 7

Asystole or pulseless electrical activity

Question 8

Cardiac Arrest Algorithm (non-shockable)

Answer 8

1. Start CPR [+give oxygen and attach monitor/defibrillator]
2. Determine if rhythm is shockable
3. If asystole/PEA -> continue CPR for 2 minutes [+IV/IO access +epinephrine every 3-5 minutes + consider advanced airway/capnography]
4. If ever shockable -> other algorithm; if not, continue CPR for 2 minutes and treat reversible causes
5. If ROSC -> post-cardiac arrest care algorithm

Question 9

Bradycardia Algorithm

Answer 9

1. Assess appropriateness for clinical condition - HR typically <50/min if bradyarrhythmia (and symptomatic)
2. Identify and treat underlying cause; maintain patent airway; assist breathing as necessary, give oxygen if hypoxemic, cardiac monitor to identify rhythm; monitor blood pressure and oximetry; IV access; 12-lead EKG if available (do not delay therapy)
3. Hypotension? Acute AMS? Signs of shock? Ischemic chest discomfort? Acute heart failure?
4. If adequate perfusion -> monitor and observe.
5. If inadequate perfusion -> administer atropine.
6. If atropine is ineffective, prepare for transcutaneous pacing or dopamine infusion or epinephrine infusion
7. If not efficacious, expert consultation, prepare for transvenous pacing, treat contributing causes

Sequence is determined by severity; may need to implement multiple interventions simultaneously

Question 10

How does atropine work?

Answer 10

Anticholinergic; treats certain types of bradycardia.

-Blocks action of vagus nerve (increases HR)

Question 11

What is TCP?

Answer 11

Uses electrodes on the patient’s chest to deliver electrical impulses and override the normal pacemaker

Question 12

How does dopamine work?

Answer 12

Stimulates the beta-1 receptors, resulting in improved contractility, increased SA node rate, and enhanced impulse conduction in the heart.

Question 13

Tachycardia algorithm?

Answer 13

If pulses are present, determine whether stable or unstable.

1. Assess appropriateness for clinical condition; HR typically 150+
2. If tachycardic + pulse present -> identify and treat underlying cause; maintain patent airway; assist breathing as necessary; oxygen if hypoxemic; cardiac monitor to identify rhythm, monitor BP and oximetry
3. Unstable if rate related cardiovascular compromise - hypotension, acutely AMS, signs of shock, ischemic chest discomfort, heart failure
4. Synchronized cardioversion; establish IV access beforehand if time permits. Consider sedation. Do not delay for this. If regular narrow complex, consider adenosine.
5. If stable, evaluate the QRS complex (wide or narrow - 0.12s) and rhythm (irregular or regular)?
6. If monomorphic wide-complex - expert consultation (treatment has the potential for harm), obtain IV access and 12-lead EKG, consider ADENOSINE ONLY IF REGULAR AND MONOMORPHIC; consider antiarrhythmic infusion
7. If narrow-complex and regular - attempt vagal maneuvers; if unsuccessful, give adenosine. If successful, monitor for recurrence. If recurrence, give adenosine again or other AV nodal-blocking agents such as the non-dihydropyridine calcium channel blockers or beta-blockers. Expert consultation if recurrent.

Question 14

What does synchronized cardioversion do?

Answer 14

Delivers a shock synchronized with a peak of the QRS complex, the highest point of the R wave; avoids the delivery of shock during repolarization (can precipitate VF)

Question 15

How does adenosine work?

Answer 15

Slows conduction through the AV node and terminates ~90% of re-entrant tachyarrhythmias within 2 minutes

Does not terminate atrial flutter/fibrillation, but will slow AV conduction, allowing identification of these waves

Question 16

If the rhythm converts with adenosine, it is most likely ___.

Answer 16

Re-entrant SVT.

Question 17

When is adenosine contraindicated?

Answer 17

Unstable, irregular, or polymorphic wide-complex tachycardias because it may cause degeneration to VF

Question 18

Immediate Post-Cardiac Arrest Care Algorithm?

Answer 18

1. ROSC
2. Ensure adequate airway and support breathing - maintain O2 94+% (use lowest O2 concentration); consider advanced airway and waveform capnography; do not hyperventilation
3. Treat hypotension when SBP<90 (IV/IO bolus, vasopressor infusion, consider treatable causes)
4. 12-lead EKG to identify STEMI or high suspicion of AMI
5. If STEMI or high suspicion of AMI - coronary reperfusion
6. If no STEMI, examine ability to follow commands.
7. If no, consider initiating targeted temperature management protocols.
8. Otherwise, transfer to ICU for advanced critical care

Question 19

IO access points?

Answer 19

Proximal tibia
Humeral head
Medial malleolus
Sternum

Question 20

Contraindications to IO access?

Answer 20

Fracture and crush injuries near the access site
Conditions with fragile bones
Previous attempts in the same bone
If infection is present in the overlying tissues

Question 21

List the 6 team roles in ACLS.

Answer 21

1. Compressor
2. AED/Monitor/Defibrillator
3. Airway
4. Team Leader
5. IV/IO/Medications
6. Timer/Recorder

Question 22

Doses of the 2 medications given in the arrest algorithm?

Answer 22

Epinephrine - 1 mg every 3-5 minutes

Amiodarone - 300 mg bolus (first dose) 150 mg (second dose)

Question 23

Shock energy for defibrillation - biphasic vs. monophasic?

Answer 23

Biphasic - manufacturer recommendation; if unknown, use maximum available. Second and subsequent doses should be equivalent, and higher doses may be considered

Monophasic - 360J

Question 24

If PETCO2 is below ___mmHg, attempt to improve CPR quality.

Answer 24

10

Question 25

List reversible causes of arrest.

Answer 25

``` Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypo/hyperkalemia Hypothermia Tension pneumothorax Tamponade, cardiac Toxins Thrombosis, pulmonary Thrombosis, coronary ```

Question 26

Indicators of ROSC

Answer 26

Pulse and BP Abrupt sustained increase in PETCO2 (typically 40+ mmHg) Spontaneous arterial pressure waves with intra-arterial monitoring

Question 27

When ROSC is achieved, how should the patient be ventilated and oxygenated?

Answer 27

Start at 10 breaths/min and titrate to target PETCO2 for 35-40 mmHg When feasible, titrate FiO2 to minimum necessary to achieve SPO2 94+%

Question 28

When ROSC is achieved what IV bolus should be given?

Answer 28

1-2 L NS or LR

Question 29

When ROSC is achieved, what epinephrine IV infusion should be started?

Answer 29

0.1-0.5 mcg/kg per minute In a 70kg adult -> 7-35 mcg/minute

Question 30

When ROSC is achieved, what dopamine IV infusion should be started?

Answer 30

5-10 mcg/kg/minute

Question 31

When ROSC is achieved, what norepinephrine IV infusion should be started?

Answer 31

0.1-0.5 mcg/kg/minute (7-35 mcg/minute in 70 kg adult)

Question 32

In bradycardia algorithm, what is the atropine dose?

Answer 32

First dose: 0.5 mg bolus Repeat every 3-5 minutes Maximum: 3 mg

Question 33

In bradycardia algorithm, what is the dopamine IV infusion rate?

Answer 33

2-20 mcg/kg/minute; titrate to patient response, taper slowly

Question 34

In bradycardia algorithm, what is the epinephrine IV infusion rate?

Answer 34

2-10 mcg/minute infusion, titrate to patient response

Question 35

Synchronized cardioversion initial recommended doses in tachycardia algorithm?

Answer 35

Narrow regular: 50-100 J Narrow irregular: 120-200 J biphasic or 200 J monophasic Wide regular: 100 J Wide irregular: defibrillation dose (not synchronized)

Question 36

Adenosine dose in tachycardia algorithm?

Answer 36

First dose: 6 mg rapid IV push followed with NS flush | Second dose: 12 mg if required

Question 37

Options for antiarrhythmic infusions for stable wide-QRS tachycardia?

Answer 37

1. Procainamide IV dose 2. Amiodarone IV dose 3. Sotalol IV dose

Question 38

Procainamide dose for stable wide-QRS tachycardia?

Answer 38

20-50 mg/min until arrhythmia suppressed, hypotension ensues, QRS duration increases >50%, or maximum dose 17 mg/kg given. Maintenance infusion: 1-4 mg/min. Avoid if prolonged QT or CHF.

Question 39

Amiodarone dose for stable wide-QRS tachycardia?

Answer 39

First dose: 150 mg over 10 minutes. Repeat as needed if VT recurs. Follow by maintenance infusion of 1 mg/min for first 6 hours.

Question 40

Sotalol dose for stable wide-QRS tachycardia?

Answer 40

100 mg (1.5 mg/kg) over 5 minutes. Avoid if prolonged QT

Question 41

Steps in post-cardiac arrest care?

Answer 41

1. Targeted temperature management 2. Hemodynamic and ventilation optimization 3. Immediate coronary reperfusion w/PCI for eligible patients 4. Glycemic control 5. Neurologic care and prognostication

Question 42

Targeted temperature management?

Answer 42

Administer to comatose (ie, lacking meaningful response to verbal commands) adult patients w/ROSC - select and maintain a constant temperature between 32 and 36 C for at least 24 hours

Question 43

Hemodynamic and ventilation optimization?

Answer 43

Titrate inspired O2 during post-arrest to the lowest level required to achieve an arterial O2 of 94+% when feasible (helps avoid O2 toxicity) Avoid excessive ventilation by starting ventilation rates at 10/minute - normocarbia (PETCO2 of 30-40 mmHg or PaCO2 of 35-45) [helps avoid adverse hemodynamic effects of increased intrathoracic pressures, potential decreases in cerebral blood flow with lowered CO2) - Higher PaCO2 may be permissible in those with acute lung injury or higher airway pressures - Mild hypocapnia might be useful as a temperature measure when treating cerebral edema - Note that when temperature is below normal, lab values for PaCO2 might be higher than actual values Titrate fluids and vasoactive/inotropic agents as needed to optimize BP, CO, and systemic perfusion

Question 44

Immediate coronary reperfusion w/PCI for eligible patients?

Answer 44

If coronary artery occlusion is suspected, transport the patient to a facility capable of PCI

Question 45

Glycemic control?

Answer 45

Do not attempt to alter glucose concentration within a lower range due to risk of hypoglycemia; no specific range per AHA

Question 46

Neurologic care and prognostication?

Answer 46

Reliable early prognostication of neurologic outcome is essential; in patients treated with TTM, delay until at least 72 hours after return of normothermia. For those not treated with TTM, the earliest time is 72 hours after cardiac arrest and potentially longer if the residual effect of sedation or paralysis confounds the clinical exam

Question 47

Define high quality CPR.

Answer 47

1. Push hard (at least 2" or 5cm) and fast (100-120/min) + allow complete chest recoil 2. Minimize interruptions in compressions 3. Avoid excessive ventilation 4. Rotate compressor Q2 minutes or sooner if fatigued 5. If no advanced airway, 30:2 compression:ventilation ratio 6. Use quantitative waveform capnography - if PETCO2 <10, attempt to improve quality 7. Intra-arterial pressure - if diastolic phase pressure <20, attempt to improve quality

Question 48

Shock energy for defibrillation in arrest?

Answer 48

Biphasic: manufacturer recommendation (eg, initial dose of 120-200 J); if unknown, use maximum available. Second and subsequent doses should be equivalent and higher doses may be considered. Monophasic: 360 J (same dose for subsequent shocks)

Question 49

Epinephrine dose and frequency?

Answer 49

1 mg IV/IO Q3-5 minutes

Question 50

Amiodarone dose and frequency?

Answer 50

300 mg IV/IO bolus - first dose | 150 mg IV/IO bolus - second dose

Question 51

Clues to ROSC?

Answer 51

1. Pulse and BP 2. Abrupt sustained increase in PETCO2 [typically 40+] 3. Spontaneous arterial pressure waves with intra-artierla monitoring

Question 52

What is the role of vasopressin in the arrest pathway?

Answer 52

None - removed, as it offers no advantage as a substitute to epinephrine

Question 53

Lidocaine dose if amio is not available?

Answer 53

1-1.5 mg/kg IV/IO first dose | 0.75 mg/kg IV/IO at 5-10 minute intervals to a maximum dose of 3 mg/kg

Question 54

What medication should be considered for torsades de pointes associated w/a long QT interval? What is another indication for this medication?

Answer 54

Magnesium sulfate Patients with known or suspected low serum magnesium such as patients w/alcoholism or other conditions associated with malnutrition or hypomagnesemia

Question 55

How does mag sulfate work?

Answer 55

Na/K pump agonist Suppresses atrial L and T-type calcium channels and ventricular after depolarization Remember that this prevents recurrent or treats persistent VT associated with torsades de pointes

Question 56

Dose of mag sulfate?

Answer 56

Loading dose of 1-2 g IV/IO diluted in 10 mL (D5W or NS), given as IV/IO bolus, typically over 5-20 minutes

Question 57

Treatment of VF/pVT in hypothermia?

Answer 57

Engage in active rewarming If moderate hypothermia (30-34 C), give medications spaced at longer intervals and provide active core rewarming in addition to CPR and defibrillation

Question 58

How should medications be delivered if via peripheral IV?

Answer 58

Takes 1-2 minutes to reach the central circulation Give via bolus injection unless otherwise specified Follow w/a 20 mL bolus of IV fluid Elevate the extremity for about 10-20 seconds to facilitate delivery of the drug to the central circulation

Question 59

Dose of naloxone to give if suspecting opioid-associated arrest?

Answer 59

2 mg IN or 0.4 mg IM; may repeat after 4 minutes

Question 60

PEA encompasses a heterogenous group of rhythms that are organized or semiorganized but lack a palpable pulse and include...

Answer 60

1. Idioventricular rhythms 2. Ventricular escape rhythms 3. Post-defibrillation idioventricular rhythms 4. Sinus rhythm 5. Other

Question 61

Describe what happens in PEA.

Answer 61

Typically, there is weak contractile function insufficient to produce a pulse or effective CO; most common initial condition after a successful defibrillation. PEA also includes other conditions where the heart is empty due to inadequate preload (hypovolemia or decrease venous return)

Question 62

IV/IO access takes priority over advanced airway management in PEA/asystole except in what situations?

Answer 62

BMV is ineffective | Arrest is 2/2 hypoxia

Question 63

You need to confirm that a flat line on the monitor is true asystole and not what other 2 possible conditions?

Answer 63

Not another rhythm (eg, fine VF) masquerading as a flat line Not the result of an operator error (confirm that leads are not loose and are indeed connected, that the power is on, and that the signal gain is sufficiently high)

Question 64

Reasons to stop resuscitative efforts?

Answer 64

- Rigor mortis - Indicators of DNAR status - Threat to safety of providers

Question 65

How can asystole be used as an end point?

Answer 65

Often represents the final rhythm; prolonged efforts are unnecessary or futile. Consider stopping if ETCO2 is <10 after 20 minutes of CPR