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Study Guide Sheet on Advanced Cardiovascular Life Support (ACLS)
Typology: Lecture notes
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This study guide is an outline of content that will be taught in the American Heart Associa on ACLS (Advanced Cardiac Life Support) Course. It is intended to summarize important content, but since all ACLS content cannot possibly be absorbed in a class given every two years, it is expected that the student study ahead of me.
This guide does not replace the Advanced Cardiac Life Support Provider Manual and is only intended as a guide to help you study for your class, but even more so , as a refresher in-between cer fica on classes.
We hope you find value in this study guide.
Good luck! Heart Savers Training, LLC
The BLS Survey C - A - B
Assessment Techniques & Ac,ons
1 Check Responsiveness • Tap and shout, “Are you alright?”
2
Ac,vate the Emergency Response System Get the AED
3 CPR
4 Defibrilla,on
Assess
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Airway Management in Respiratory Arrest – Advanced airway equipment includes the ET tube, laryngeal mask airway or Air-Q, and the esophageal tracheal tube. If it is within your scope of prac ce, you may use advanced airway equipment in the course as treatment when appropriate and available.
The OPA is used in pa ents who are at risk for developing airway obstruc on from the tongue or from relaxed upper airway muscle. This J-shaped device liFs the tongue away from the posterior wall of the pharynx.
The OPA is used in unconscious pa ents without a gag reflex if procedures to open the airway fail to provide and maintain a clear, unobstructed airway. An OPA should not be used in a conscious or semiconscious pa ent because it may s mulate gagging and vomi ng. The key assessment is to check whether the pa ent has an intact cough and gag reflex. If so, do not use an OPA.
The NPA is used as an alterna ve to an OPA in pa ents who need a basic airway management adjunct. The NPA is a soF rubber or plas c uncuffed tube that provides a conduit for airflow between the nares and the pharynx.
Unlike oral airway, NPAs may be used in conscious or semiconscious pa ents (pa ents with an intact cough and/or gag reflex). The NPA is indicated when inser on of an OPA is technically difficult or dangerous. Also, do not use a NPA in a pa ent with a possible head injury [basal skull fracture.]
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Place the OPA against the side of the face. When the p of the OPA is at the corner of the mouth, the flange is at the angle of the mandible. A properly sized and inserted OPA results in proper alignment with the gloMc opening.
If bag-mask ven la on is adequate, providers may defer inser on of an advanced airway. Establishing an IV or IO takes priority over ET Tube placement.
Suc oning is an essen al component of maintaining a pa ent’s airway. Providers should suc on the airway immediately if there are copious secre ons, blood, or vomit.
Suc oning a9empts should not exceed 10 seconds. To avoid hypoxemia, precede and follow suc oning a9empts with a short period of administra on of 100% oxygen.
Monitor pa ent’s heart rate, pulse oxygen satura on, and clinical appearance during suc oning. If bradycardia develops, oxygen satura on drops, or clinical appearance deteriorates, interrupt suc oning at once. Administer high flow oxygen un l the heart rate returns to normal and the clinical condi on improves. Assist ven la on as needed.
Airway Device Ven,la,ons During Cardiac Arrest
Ven,la,ons During Respiratory Arrest
Bag-Mask (30:2) 2 ven la ons aFer every 30 compressions
Any Advanced Airway 1 ven,la,on every 6 seconds (10 breaths per minute)
1 ven,la,on every 5 to 6 seconds (10-12 breaths per minute)
Cricoid Pressure is not recommended during ven,la,ons [when ven,la,ng the pa,ent]. To prevent gastric disten,on, ven,late only un,l you see chest rise (approx. 1 second for each breath)
However, cricoid pressure can s,ll be used to help visualize the vocal cords but only when ini,ally intuba,ng the pa,ent.
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peak of the QRS complex
defibrilla on.
The first thing you do with an AED is Turn it on.
Be sure oxygen is not flowing across the pa ents’ chest when delivering a shock
The pause in chest compressions to check the rhythm should not exceed 10 seconds
o Unstable SVT (50 to 100 Joules -biphasic)
o Unstable Atrial Flu9er (50 to 100 Joules -biphasic)
o Unstable Atrial Fibrilla on (120 to 200 Joules -biphasic)
o Unstable regular monomorphic tachycardia with pulse (100 Joules -biphasic)
For a pa ent whose ECG shows:
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Priori,es for vascular access are:
The ACLS provider Course presents only basic knowledge focusing on early treatment and the priority of rapid reperfusion, relief of ischemic pain, and treatment of early life-threatening complica ons. Reperfusion may involve the use of fibrinoly c therapy or coronary angiography with PCI (i.e., balloon angioplasty / sten ng).
If the pa ent has signs/symptoms sugges ve of Ischemia or Infarc on
Assessment, care and hospital prepara on:
NOTE: Relief of pain with nitroglycerin is neither specific nor a useful diagnos c tool to determine the e ology of symptoms in ED pa ents with chest pain or discomfort.
GI e ologies as well as other causes of chest discomfort can “respond” to nitroglycerin administra on. Therefore, the response to nitrate therapy is not diagnos c of ACS.
When Appropriate
Historically in ACLS, providers have administered drugs via either the IV or endotracheal route. Endotracheal absorp on of drugs is poor and op mal drug dosing is not known. For this reason, peripheral IV access is preferred and if not available then use the Intraosseous (IO) route.
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Cardiac Rhythms - 12 &15 Leads
“It has been stated: “every second that passes that a cardiac cath lab is not ac vated, 500 heart cells die.” [Bob Page, Mul -Lead Medics, pg. 3].
Therefore, as a healthcare provider, in order to give excellent pa ent care, it is essen al that we understand and are able to recognize cardiac rhythms. To know the differences between non-threatening and lethal arrhythmias, and most of all, how to treat them. (Picture purchased from Shu9erstock)
Everyone with chest pain or any cardiac dysrhythmia needs to have a 12-Lead ECG done, as well as a 15-Lead ECG. The 12-lead ECG uses 10 electrodes: one on each limb and six on the chest. Limb leads should be placed on the arms and legs, and never on the chest. The Precordial leads are placed in specified posi ons on the chest. Three of those same leads are moved to check the posterior por on of the heart in performing
This sec on is in no way a thorough treatment of cardiac rhythms, but simply an overview and review. We encourage you to constantly study and increase your knowledge and understanding of cardiac rhythms.
materials and/or email us at heartsaverstraining@gmail.com for addi onal resources that we recommend. You may also choose to further your prac cal understanding by registering for one of our EKG Rhythms / 12 & 15-Lead Classes.
Let’s begin...
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Sinoatrial [SA] Node Rhythms
difference:
(Normal) Sinus Rhythm
Normal Sinus Rhythm occurs when the SA node is firing at a rate that is considered ‘normal’ for a person’s age The rate is generally 60 to 100 bmp. The key to normal sinus rhythm is that all components of a normal ECG are present: P waves, [normal PR intervals], narrow QRS complex, and T waves. There is usually no treatment required for this rhythm. The term is sometimes considered a misnomer and its use is
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All the rhythms found in this ACLS Study Guide have been recorded in Lead II
Sinus Tachycardia
Sinus tachycardia occurs when the SA node is firing at a rate that is faster than normal for a person’s age The rate is generally 101 to 150 bmp. The key to sinus tachycardia is that all components of a normal ECG are present: P wave, QRS complex, and T wave. Sinus tachycardia generally starts and stops gradually. Causes can be numerous, such as: pain, fever, fluid and/or blood loss [hypovolemia and/or dehydra on], beta blocker withdrawal, CHF, hypoxemia, caffeine, alcohol withdrawal, a recent MI, or anxiety/agita on are some of the causes that that can be iden fied and treated.
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Sinoatrial [SA] Node Rhythms
Atrioventricular [AV] Blocks These blocks fall into three categories: First Degree, Second Degree Types I & II [two types], and Third Degree
First Degree Block
First-degree atrioventricular block (AV block), or PR prolonga,on, is a disease of the electrical conduc on system of the heart in which the PR interval is lengthened beyond 0.20 seconds [or five (5) small squares on the ECG]. In first-degree AV block, the impulse conduc ng from the atria to the ventricles, through the atrioventricular node (AV node), is delayed and travels slower than normal. First Degree Block can be caused by medica ons such as: Digoxin, Calcium Channel Blockers, and Beta Blockers.
Second Degree Block - Mobitz / Type I [Wenckebach]
Second Degree AV Block Type 1 is a disease of the AV node. This heart block is characterized by progressive prolonga,on of the PR interval on the electrocardiogram (ECG) on consecu ve beats followed by a blocked P wave (i.e., a 'dropped' QRS complex). AFer the dropped QRS complex, the PR interval resets and the cycle repeats itself. This par cular rhythm can be caused by medica ons such as: Digoxin, Calcium Channel Blockers, and Beta Blockers. Cardiac ischemia found in the Right Coronary Artery can also cause this rhythm.
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Normal, longer, longer, ‘drop’… then you have Wenckebach
If the R is far from P, then you have a First Degree
Third-degree atrioventricular block (AV block), also known as complete heart block, is a serious medical condi on in which the impulse generated in the sinoatrial node (SA node) in the atrium of the heart does not propagate to the ventricles.
Because the impulse is blocked, there is an accessory pacemaker in the lower chambers that will typically ac vate the ventricles. This is known as an escape rhythm. Since this accessory pacemaker also ac vates independently of the impulse generated at the SA node, this is a very dangerous block because two independent “rhythms” can be noted on the ECG. This rhythm is oFen associated with cardiac ischemia involving the LeF Coronary Arteries
You will find that the P waves and QRS complexes are regular, but not associated with each other. The P waves [usually 60 to 100 bpm] will march out regularly throughout the rhythm. The QRS complexes [usually 30 to 40 bpm] will also be regular and march out. They just don’t associate.
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If Ps and Qs don’t agree, then you have a Third Degree
Pulseless Electrical Ac,vity (PEA)
Pulseless Electrical Ac vity (PEA) occurs when the heart has an electrical beat but without the heart mechanically pumping. It can be any organized rhythm, but the pa ent does not have a pulse. Start or con nue CPR immediately.
Iden fica on of the underlying causes is essen al. Use your H’s & T’s to try and correct the problems.
Asystole
Asystole is a cardiac arrest rhythm in which there is no discernible electrical ac vity on the ECG monitor and the pa ent does not have a pulse. Asystole is some mes referred to as a “flat line.” To confirm Asystole you should:
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PEA / Asystole
Cardiac Arrest Rhythms
Pulseless Ventricular Tachycardia
Monomorphic:
Ventricular Tachycardia (VT) can present itself with or without a pulse. When VT is present and the vic m has no pulse , the treatment is the same as VF. Pulseless VT can rapidly deteriorate to VF
Electrical defibrilla on in high dose shocks for VF/PVT will give the best chance for conver ng the pa ent out of pulseless VT. In fact, as with VF, the earlier defibrilla on occurs, the higher the survival rate.
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Note: Vasopressin has been removed from the 2015 AHA Guidelines for VF and Pulseless VT. The AHA states that Vasopressin offers no advantage as a subs,tute for Epinephrine in cardiac arrest
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Bradycardic Rhythms
The Key Clinical Ques,ons to ask are, Is the Bradycardia causing the pa,ent’s symptoms or Is there some illness perhaps causing the Bradycardia
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