Advanced Cardiac Life Support

Pre-Test
ACLS PRE-TEST

2015 AHA Guidelines

 Rhythm Identification:
Agonal/Asystole:

Artificial Pace Maker:

Atrial Fibrillation:

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Atrial Flutter:

Monomorphic
Ventricular
Tachycardia:

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Normal Sinus Rhythm:

Polymorphic Ventricular
Tachycardia:

Second-Degree
atrioventricular block
(Mobitz 1 block
Wenckebach)

Second-Degree
atrioventricular block
(Mobitz 2 block)

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Sinus Bradycardia:

Sinus Tachycardia:

Supraventricular
Tachycardia:

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 Third-Degree
atrioventricular
Block:

Torsades de Pointes:

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Ventricular Fibrillation:

PHARMACOLOGY/ PRACTICAL :

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1. A 35-year-old woman presents with a chief complaint of palpitations. She has no
chest discomfort, shortness of breath, or light-headedness. Her blood pressure is
120/78 mm Hg. Which intervention is indicated first? SVT
a. Vagal maneuvers

2. A 45-year-old woman with a history of palpitations develops light-headedness and

palpitations. She has received adenosine 6 mg IV for the rhythm shown here,
without conversion of the rhythm. She is now extremely apprehensive. Her blood
pressure is 128/70 mm Hg. What is the next appropriate intervention? SVT
a. Administer adenosine 12 mg IV

3. A 57-year-old woman has palpitations, chest discomfort, and tachycardia. The

monitor shows a regular wide-complex QRS at a rate of 180/min. She becomes
diaphoretic, and her blood pressure is 80/60 mm Hg. Which action do you take
next?
a. Perform electrical cardioversion

4. A 62-year-old man suddenly experienced difficulty speaking and left-sided

weakness. He meets initial criteria for fibrinolytic therapy, and a CT scan of the
brain is ordered. Which best describes the guidelines for antiplatelet and
fibrinolytic therapy?
a. Hold aspirin for at least 24 hours if rtPA is administered
5. After initiation of CPR and 1 shock for ventricular fibrillation, this rhythm is
present on the next rhythm check. A second shock is given, and chest
compressions are resumed immediately. An IV is in place, and no drugs have been
given. Bag-mask ventilations are producing visible chest rise. What is your next
intervention? V fib
a. Give epinephrine 1 mg IV/IO

6. How often should you switch chest compressors to avoid fatigue?

a. About every 2 minutes

7. In which situation does bradycardia require treatment?

a. Hypotension

8. A monitored patient in the ICU developed a sudden onset of narrow-complex

tachycardia at a rate of 220/min. The patient's blood pressure is 128/58 mm Hg, the
PETCO2 is 38 mm Hg, and the pulse oximetry reading is 98%. There is vascular
access in the left arm, and the patient has not been given any vasoactive drugs. A
12-lead ECG confirms a supraventricular tachycardia with no evidence of ischemia
or infarction. The heart rate has not responded to vagal maneuvers. What is your
next action?
a. Administer adenosine 6 mg IV push

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9. A patient has sinus bradycardia with a heart rate of 36/min. Atropine has been
administered to a total dose of 3 mg. A transcutaneous pacemaker has failed to
capture. The patient is confused, and her blood pressure is 88/56 mm Hg. Which
therapy is now indicated?
a. Epinephrine 2 to 10 mcg/min

10. A patient is in cardiac arrest. Ventricular fibrillation has been refractory to an

initial shock. If no pathway for medication administration is in place, which
method is preferred?
a. IV or IO

11. A patient is in cardiac arrest. Ventricular fibrillation has been refractory to a

second shock. Which drug should be administered first?
a. Epinephrine 1 mg IV/IO

12. A patient is in pulseless ventricular tachycardia. Two shocks and 1 dose of

epinephrine have been given. Which drug should be given next?
a. Amiodarone 300 mg

13. A patient is in refractory ventricular fibrillation. High-quality CPR is in progress.

One dose of epinephrine was given after the second shock. An antiarrhythmic drug
was given immediately after the third shock. You are the team leader. Which
medication do you order next?
a. Epinephrine 1 mg

14. A patient's 12-lead ECG is transmitted by the paramedics and shows a STEMI.
When the patient arrives in the emergency department, the rhythm shown here is
seen on the cardiac monitor. The patient has resolution of moderate (5/10) chest
pain after 3 doses of sublingual nitroglycerin. Blood pressure is 104/70 mm Hg.
Which intervention is most important in reducing this patient's in-hospital and
30-day mortality rate? ST Elevation
a. Reperfusion therapy

15. A patient was in refractory ventricular fibrillation. A third shock has just been
administered. Your team looks to you for instructions. What is your next action?
a. Resume high-quality chest compressions

16. A patient with sinus bradycardia and a heart rate of 42/min has diaphoresis and a
blood pressure of 80/60 mm Hg. What is the initial dose of atropine?
a. 1 mg

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17. A patient with STEMI has ongoing chest discomfort. Heparin 4000 units IV bolus
and a heparin infusion of 1000 units per hour are being administered. The patient
did not take aspirin because he has a history of gastritis, which was treated 5 years
ago. What is your next action?
a. Give aspirin 160 to 325 mg to chew

18. What action minimizes the risk of air entering the victim's stomach during bag-
mask ventilation?
a. Ventilating until you see the chest rise

19. What is the indication for the use of magnesium in cardiac arrest?
a. Pulseless ventricular tachycardia-associated torsades de pointes

20. What is the maximum interval for pausing chest compressions?

a. 10 seconds

21. What is the recommended compression rate for high-quality CPR?

a. 100 to 120 compressions per minute

22. What is the recommended depth of chest compressions for an adult victim?
a. At least 2 inches

23. Which action is likely to cause air to enter the victim's stomach (gastric inflation)
during bag-mask ventilation?
a. Ventilating too quickly

24. Which action should you take immediately after providing an AED shock?
a. Resume chest compressions

25. Which intervention is most appropriate for the treatment of a patient in asystole?
a. Epinephrine

26. You are caring for a 66-year-old man with a history of a large intracerebral
hemorrhage 2 months ago. He is being evaluated for another acute stroke. The CT
scan is negative for hemorrhage. The patient is receiving oxygen via nasal cannula
at 2 L/min, and an IV has been established. His blood pressure is 180/100 mm Hg.
Which drug do you anticipate giving to this patient?
a. Aspirin

27. You are providing bag-mask ventilations to a patient in respiratory arrest. How
often should you provide ventilations?
a. About every 5-6 seconds

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28. You are the code team leader and arrive to find a patient with CPR in progress. On
the next rhythm check, you see the rhythm shown here. Team members tell you
that the patient was well but reported chest discomfort and then collapsed. She
has no pulse or respirations. Bag-mask ventilations are producing visible chest rise,
and IO access has been established. Which intervention would be your next
action? PEA
a. Epinephrine 1 mg

29. You arrive on the scene to find CPR in progress. Nursing staff report the patient
was recovering from a pulmonary embolism and suddenly collapsed. Two shocks
have been delivered, and an IV has been initiated. What do you administer now?
Vfib
a. Epinephrine 1 mg IV

30. You arrive on the scene with the code team. High-quality CPR is in progress. An
AED has previously advised "no shock indicated." A rhythm check now finds
asystole. After resuming high-quality compressions, which action do you take
next?
a. Establish IV or IO access

31. Your patient is a 56-year-old woman with a history of type 2 diabetes who reports
feeling dizzy. She is pale and diaphoretic. Her blood pressure is 80/60 mm Hg. The
cardiac monitor documents the rhythm shown here. She is receiving oxygen at 4
L/min by nasal cannula, and an IV has been established. What do you administer
next? (sinus brady)
a. Atropine 0.5 mg IV

32. Your patient is not responsive and is not breathing. You can palpate a carotid
pulse. Which action do you take next?
a. Start rescue breathing

33. A patient has a rapid irregular wide-complex tachycardia. The ventricular rate is
138/min. He is asymptomatic, with a blood pressure of 110/70 Hg. He has a hx of
angina. What action is recommended next?
a. Seeking expert consultation.

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34. A 35-year old women has palpitations, Light-headiness & regular narrow complex
tachycardia, vagal maneuvers are ineffective. What’s next?
a. Adenosine 6 mg

NOTES FROM THE INITIAL COURSE:

● Always Check for a pulse.

● Squeeze bag Q 5-10 seconds = 10 vent/ minute

o Once airway is in place
● Tidal Volume: 500-600 ml = ½ adult bag squeeze

● Rescue breaths once Q 5-6 seconds

Advanced Cardiac Life Support Review 10/27/2020

Airway Management:
● Bag-Mask Ventilation.

● Respiratory arrest

● Waveform capnography

● If patient has a pulse but is not breathing:

o Ventilate once Q 5-6 Seconds
o After 2 minutes, check the pulse.
● Excessive ventilation:
o Causes gastric insufflation.
o Increases intrathoracic pressure.

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 o Decreases venous return and cardiac output.
o Lowers survival.
● Cardiac Arrest Patients:
o Tidal volume: 500-600 mL
o Half a bag squeeze.
● Airway Adjuncts:
o Oropharyngeal airway (OPA)
o Nasopharyngeal Airway (NPA)
● OPA:
o Pt’s who are unconscious
o Pt’s who have no gag reflex.
● NPA:
o Pt’s who are conscious semiconscious, or unconscious.
o Pt’s with or without a gag reflex.
● Basic Airway Skills:
o Airway Adjuncts
o Oropharyngeal Airway
● See OPA/ NPA measurements and how to do so.

● Indications for an Advanced Airway:

o Difficult bag-mask ventilation.
o Airway compromise
o Need to isolate airway.
● Advantages of Advanced Airway Devices:

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 o Isolating the airway
o Reducing the risk of aspiration and gastric insufflation.
o Ventilate once Q 6 seconds
o Endotracheal tube placement may interrupt compressions
for longer than 10 seconds.
o Supraglottic airways can be inserted without interrupting
compressions.
● Laryngeal Mask Airway:
o Supraglottic device
o Inserted without visualizing glottis.
o Inserted without interrupting chest compressions.
● Laryngeal Tube, Esophageal-Tracheal Tube:
o Supraglottic device
o Inserted without interrupting chest compressions.
o Inserted without visualizing the glottis.
● Ventilation Delivered to incorrect Lumen:
o Prevents adequate oxygenation and ventilation.
o Results in severe hypoxia.
● Incorrect Delivery to the Esophagus:
o Produces gastric insufflation.
o Complicates Ventilation.
o Complications:
▪ Trauma to oropharynx

▪ Incorrect placement in esophagus or right bronchus.

▪ Interruptions in compressions and ventillations.

o Benefits of OPA/ NPA:
▪ Keeps airway patent.

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 ▪ Allows suctioning of airway

▪ Delivers high concentrations of oxygen.

▪ Provides route for drugs

▪ Protects airway from aspiration.

● Key Uses for Waveform Capnography:

o Placement & Monitoring of an advanced airway.
o Management of ventilation support.
o Effectiveness of chest compressions.
o ROSC
● If the PETCO2 Readings are Low During Resuscitation:
o Minimize interruptions.
o Compress at least 2-Inches
o Compress at a rate of 100-120 BPM.
o Allow complete chest recoil.
o Avoid excessive ventilation.
Acute Ischemic Stroke:

● 87 % of all strokes in the US are ischemic.

● Stroke algorithm

● Stroke chain of survival.

● 8-D’s of Stroke Care.

● Chain:
o Rapid Recognition and Reaction to stroke warning signs.
o Rapid EMS dispatch.
o Rapid EMS system transport and prearrival notification to
the receiving hospital.

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 o Rapid diagnosis and treatment in the hospital.
● 8- D’s of Stroke:
o Detection
o Dispatch
o Delivery
o Door
o Data
o Decision
o Drug/Device
o Disposition
● Rule Out:
o Other causes such as hypoglycemia or seizure.
● Facial Droop, Arm Drift, Abnormal Speech.

● If 1 or more indicators from the Cincinnati Prehospital Stroke

Scale is abnormal, Probability of a stroke is 72%.
● Patients with an oxygen saturation value less than 94% and those
with unknown oxygen saturation values should be given
supplementary oxygen.
● ED Assessment:
o Assessment should occur within 10-minutes after arrival in
ED.
o A-B-C:
▪ Airway

▪ Breathing

▪ Circulation
o Lab tests:
▪ Blood Glucose

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 ▪ Serum Electrolytes

▪ CBC

▪ Coagulation Studies
o CT Scan:
▪ Should be evaluated within 45-Minutes after patients
arrival.
● Contraindications of RTPA therapy:
o Brain Hemorrhage
o Prior stroke
o Abnormal blood vessels in the brain
o Recent bleeding
o History of clotting problems
o Recent surgery or accidents.
● RTPA:
o May improve neurologic recovery by at least 30%
o Best clinical benefit achieved when treated within 3-hours
of symptom onset.
● Endovascular Therapy:
o Intra-arterial RTPA
o Mechanical clot disruption/ retrieval.
o Pt’s must meet inclusion criteria.
o May be given up to 6-hours from symptom onset, but
better outcomes with shorter times.
● For optimal Recovery:
o Control Blood glucose levels
o Manage temperature
o Manage Blood pressure

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 Acute Coronary Syndromes:
● NSTE-ACS:
o Non-ST-Segment elevation acute coronary syndromes.
● STEMI:
o ST-Segment Elevation myocardial Infarction.
● 50% of all deaths from ACS occur outside of the hospital.

● Step-1:
o Recognize the warning signs of cardiac ischemia
o Contact EMS:
o Advise Patient to chew 160-325 mg of non-enteric coated
aspirin.
o Don’t give the asa if:
▪ There’s a true aspirin allergy.

▪ Active or recent GI bleeding.

● Step-2:
o Assessment, care, and hospital preparation.
o Priorities:
▪ Obtain 12-lead ECG, Symptom management, and
transport.
o Symptom Management:
▪ Provide Oxygen if oxygen saturation is below 90%

▪ Administer aspirin 160-325 mg

▪ Administer 1 dose of nitroglycerin Q 3-5 minutes, For

a total of 2-doses.
o Contraindication for Nitroglycerin:

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 ▪ Severe Bradycardia

▪ Tachycardia

▪ Hypotension

▪ Phosphodiesterase inhibitors within the past 24-48

hours (often used for erectile dysfunction)
● Right Ventricular Infarction:
o Often present as inferior wall STEMI’s
o Confirm with right-sided 12-lead ECG
o If present, 1-tes contraindicated
o If only suspected, use nitrates with extreme caution.
● Step-3:
o Reperfusion goals
o 120 minutes from the first medical contact percutaneous
coronary intervention (PCI)
o 30-minutes from ED-arrival: Fibrinolytics
● ED- Assessment:
o Check Vital Signs
o Obtain medical history
o Review fibrinolytic checklist
o Obtain blood studies
o Obtain portable X-ray
● Adjunctive Treatments:
o Unfractionated or low-molecular weight heparin.
o Bivalirudin
o P2Y12 Inhibitors
o IV Nitroglycerin
o Beta-Blockers
o Glycoprotein llb/lla inihibitors.

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 o PCI- 120 minutes from first medical contact or 90 m inutes
from ED arrival.
High Quality BLS:

● Compress at least 2- inches in depth, if can’t reach consider using

a step stool.
● Compress at a rate of 100-120 BPM

● Allow complete chest recoil between compressions

● Minimize interruptions to 10-seconds or less.

● Avoid Excessive ventilation.

● Switch compressors Q 2- minutes

● Use audio and visual feedback devices.

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