Thank you for SureFire CPR! This At

Thank you for choosing SureFire CPR! This study guide is an outline to help you prepare for your upcoming ACLS course. Even though there is a lot of information in this guide, it is important to have your textbook to help you review the material over the next 2 years to keep your skills sharp.

Because the course covers a lot of material in a short amount of time, there is some required pre- course material.

In the course you will be expected to evaluate and identify different cardiac emergencies. At the completion of the course, you will act as the team leader to diagnose and treat a variety of cardiac rhythms. Please pay special attention to the BLS review, as it is the foundation for ACLS.

Here is what you need to do before you come to class.

1. Read through this study guide (paying particular attention to anything marked with a "*") 2. Go to and play the 6 Second ECG Game to

practice up on your ECG skills 3. Go to this website: American Heart Association Prestudy Material and enter the password:

acls15 . Once logged-in, Watch the CPR/AED Overview Video Take the Precourse Self-Assessment & score 70% or better (This is an AHA requirement) Print out your results and bring them to class! (This is an AHA requirement)

We look forward to having you in class. If you need anything at all, please don't hesitate to call us. Remember we also have PALS, BLS, PEARS, EKG, and NRP for your training needs as well. Thanks again!

Take care,

Zack Zarrilli CEO/President SureFire CPR (888) 277-3143

ACLS Assessment

Quality ACLS can only be built upon a foundation of solid BLS skills. There are 2 levels of ACLS care: the BLS survey and the ACLS survey.

The BLS Survey is used if the patient appears to be unconscious. The ACLS Survey is used if the patient is conscious.

BLS Survey:

A. Check responsiveness a. If unresponsive, shout for any nearby help

B. Check Circulation & Breathing a. Check the carotid pulse while simultaneously looking for chest rise b. Assess pulse and breathing for 5-10 seconds c. Remember, agonal gasps or "guppy" breathing is not effective breathing and should be treated the same as absent breathing. Agonal gasps are frequently an indication of cardiac arrest.** b. If pulse is present but patient is not breathing: assist ventilations c. If no pulse and no breathing: Start CPR

C. Defibrillation a. Early defibrillation is a key aspect of the BLS survey b. Once the AED arrives, turn it on, apply the pads, and defibrillate if indicated by the AED. Don't forget to state "Clear!" or "Do not touch the patient!" and ensure no one is touching the patient prior to defibrillating.

ACLS Survey:

A. Airway a. Make sure the airway is adequate and protected b. Use adjuncts if needed c. Insert advanced airways

B. Breathing a. Provide Oxygen b. Confirm placement of Endotracheal Tube c. Monitor waveform capnography d. Avoid excessive ventilation

C. Circulation a. Establish IV/IO access b. Treat the heart rate and rhythm c. Monitor CPR quality d. Provide defibrillation or cardioversion if necessary e. Take vital signs (BP, etc.)

D. Differential Diagnosis and Disability a. Determine the reason for the problem

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b. H's and T's (Seen later in this guide) c. Mental Status d. Glasgow Coma Scale

The Heart

Here is a quick review of the anatomy of the heart before we get into our ECG rhythms.

First, blood enters the atria of the heart and an electrical impulse is sent out from the SA node. This electrical impulse travels through the atria causing them to contract. When the atria contract, it registers on the EKG as a P wave.

Next, the electrical impulse travels to the AV node which sends out an electrical impulse that travels through the Bundle of His, bundle branches, and into the Purkinje fibers of the ventricles. This causes ventricular contraction which registers on the EKG as the QRS complex.

Finally, the ventricles rest and repolarize, which is shown on the EKG as a T wave. (In case you were wondering, the atria repolarize also, but the electrical impulse is so miniscule, you can't see it on the EKG)

Narrow QRS complexes originate in the atria (near the AV node) and wide QRS complexes originate in in the ventricles (below the Bundle of His).

Anatomy of the Heart

ECG Breakdown

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ECG Review and Cardiac Algorithms

Pulseless Rhythms: 1. Ventricular Fibrillation 2. Ventricular Tachycardia 3. Pulseless Electrical Activity 4. Asystole

Ventricular Fibrillation

Coarse VF

Fine VF Description: Ventricular Fibrillation (also known as V-Fib or VF) is the most common rhythm to occur immediately after cardiac arrest. The ventricles quiver and are unable to pump blood to the rest of the body. Survival chances diminish rapidly while in ventricular fibrillation and immediate defibrillation is essential. There are two types of V-Fib: Coarse and Fine. Coarse VF is more easily corrected with defibrillation than fine VF. Fine VF is more likely seen in a patient with a prolonged cardiac arrest. Both types of ventricular fibrillation are treated with defibrillation.

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Ventricular Tachycardia (No Pulse)

Description: Ventricular Tachycardia (also known as V-Tach or VT) occurs when the ventricular focus takes over control of the heart and fires at a tachycardic rate. The QRS complex is wide because it originates in the ventricles. This rhythm is treated identically as V-Fib when there are no pulses.

Treatment for Ventricular Fibrillation and Pulseless V-Tach:

1. Defibrillate 2. Perform CPR for 2 minutes 3. Quickly check a rhythm and a pulse 4. If another shock is needed, clear the patient and defibrillate again 5. Repeat this sequence until the rhythm is not shockable

Medication Sequence (Performed Simultaneously with CPR and Defibrillation):

1. Epinephrine 1mg 1:10,000 IV/IO every 3 to 5 minutes a. The antecubital vein is the recommended first location to attempt an IV during a cardiac arrest

2. For refractory (persistent) VF: a. Amiodarone 300mg IV/IO (Initial dose)** b. Amiodarone 150mg IV/IO (second and final dose if VF/Pulseless VT persist)

3. All medications given during cardiac arrest should be administered via rapid IV/IO

Asystole

Description: Asystole is when there is no detectable activity on the ECG. It may follow many rhythms, including VF, PEA, or 3rd Degree Heart Block. Always ensure that all leads are attached to the patient.

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Pulseless Electrical Activity (PEA)

Description: Pulseless Electrical Activity (PEA) occurs when the heart is not beating and the patient has no pulse, but there is still an electrical impulse creating some kind of rhythm on the ECG monitor. For example: Sinus rhythm without a pulse = PEA**

For all patients without a pulse, CPR is the priority.

Treatment for Asystole and PEA:

1. CPR 2. Epinephrine 1mg of 1:10,000 IV/IO every 3-5 minutes 3. Consider H's and T's to find the root of the problem.

Consider H's and T's (Differential Diagnosis)

Hypovolemia (most common cause) Hypoxia Hydrogen ion (acidosis) Hypo/hyperkalemia Hypoglycemia Toxins Tamponade, cardiac Tension pneumothorax Thrombosis, coronary Thrombosis, pulmonary

Bradycardic Rhythms: Sinus Bradycardia 1st Degree AV Block 2nd Degree Block (Type I) 2nd Degree Block (Type II) 3rd Degree Block

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Sinus Bradycardia

Description: Sinus bradycardia occurs when the SA node fires at a rate that is too slow for the person's age. For adults, this is less than 60 beats per minute. Many athletes have a resting heart rate of less than 60, so it is important to only treat patients that are symptomatic (fatigue, dizziness, hypotension, altered mental status, etc.)

1st Degree AV Block

Description: In a first-degree AV block, everything is normal except for a prolonged PR interval. The interval is longer than .20 seconds (or 5 small boxes on the ECG strip). This conduction delay in the AV node rarely causes any problems.

2nd Degree Block (Type I - Wenckebach)

Description: Second Degree, Type I block occurs at the AV node. The PR interval gets progressively longer until it drops the QRS complex. You can see 2 dropped QRS complexes on the strip above.

2nd Degree Block (Type II - Mobitz)

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Description: Second Degree, Type II block occurs below the AV node. The P waves are regular, but QRS complexes are dropped. The electrical impulses fail to pass through the AV node which results in atrial contractions that are not followed by ventricular contractions. This rhythm is more serious than the 2nd Degree Type I, and pacing is usually recommended.

3rd Degree Block

Description: 3rd Degree, or Complete Heart Block is characterized by no communication between the SA and AV nodes. P waves and QRS complexes will be completely independent of each other. The ventricles will generate their own electrical signal through an accessory pacemaker in the lower chambers. The location of this "Escape Pacemaker" will determine if the QRS complexes are wide or narrow (Junctional = Narrow QRS, Ventricular = Wide QRS).

Treatment (if symptomatic):

1. Oxygen (if hypoxemic) 2. Atropine .5mg (Repeated every 3-5 minutes to a max dose of 3mg)**

a. Though atropine is recommended for symptomatic bradycardia, it will probably not work in high degree heart blocks (2nd Degree Type II or 3rd Degree)

3. Prepare for Transcutaneous Pacing (TCP) if needed, especially if in a high degree heart block. 4. If, at any point, airway or breathing become compromised, treat patient with simple airway maneuvers and

ventilation.**

As an alternative to TCP, chronotropic drug infusions are also available: Dopamine IV infusion (2-20 mcg/kg/min)** Epinephrine IV infusion (2-10 mcg/min)

For patients in respiratory failure with rapidly dropping heart rates, assisting with ventilation and simple airway maneuvers are the highest priority.**

Tachycardic Rhythms:

Sinus Tachycardia Supraventricular Tachycardia Monomorphic Ventricular Tachycardia Polymorphic Ventricular Tachycardia Torsades de Pointes

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