Study Guide for

ACLS
EKG Rhythm Refresher
Remember how to count heart rate
Identify this rhythm
12 Lead of a Normal Sinus Rhythm
Identify this Rhythm
 How do you treat this rhythm?
{V-fib}
Cardiac Arrest Algorithm
Assign roles as needed
• Compressor (2), airway, IV and meds,
monitor/defib, recorder
Step 1?
Start CPR then attach monitor, defib pads, oxygen to
BVM
Step 2?
Is this rhythm shockable? What are the 2 shockable
rhythms?
V-fib and pulseless V-tach
What now?
Shock at 200 or 360
What do you do after you shock the 1st time?
You have just shocked for the first time,
what do you do next?
CPR for 2 minutes – ask medics what
they know. Ask recorder to time for 2
minutes until next rhythm check
What do you need to get done in those
2 minutes?
IV/IO, fluids, history, check CPR quality,
check for a pulse with compressions,
ensure patent airway with BVM
ventilations
2 min time called, now what?
Wait for 30 compressions to be done
and check pulse and rhythm for less
than 10 seconds – do you need to
shock?
Same rhythm appears on monitor, what do you do now?
• Resume CPR, charge defib, clear pt and shock
Now what can to do after the second shock?
• Resume CPR and Give?
• Epinephrine every 3 minutes (ask recorder to time q3min)
What are you determining?
• Causes of cardiac arrest. What are the Hs & Ts?
• Hypovolemia, Hypoxia, Hydrogen ion, Hyper/hypokalemia
• Tension pneumo, Cardiac Tamponade, Toxins, Trauma, Thrombi - PE, MI
2 minutes is called and you?
• Check pulse and rhythm, if unchanged you?
• Shock and resume CPR
What can you give now?
• Amiodarone 300 mg IVP
Torsades = Polymorphic VTach
Treat like V Tach
• after starting CPR and Shocking
• You will give Magnesium 1- 2 g
IVP
• Continue with efforts. Should
see it change into a
monomorphic rhythm
Identify these rhythms
 To decide, you may need to check a pulse
{Asystole and PEA}
Cardiac Arrest Algorithm:
Assign roles prn
Compressor (2), airway, IV and meds, monitor/defib, recorder
Step 1?
Start CPR then attach monitor, defib pads, oxygen to BVM, start IV
Step 2?
Determine if this a shockable rhythm
Step 3?
Give epinephrine q3min, consider advanced airway
Step 4+
Check pulse and rhythm q2min or until something changes
 Return of Spontaneous Circulation (ROSC)
Congratulations you just restarted someone’s heart. Now the work begins
Step 1 – Do they respond to verbal commands?
If Yes –
• Are they able to control airway, can you sit them up slightly to help.
• IV, O2, monitor, EKG, labs (expect these to be off following CPR), chest
xray (see what you may have damaged),
• Fix underlying problem so it does not happen again
 ROSC
If No – Pt does not respond to any commands
• ABCs, consider securing airway with endotracheal tube and ventilator
• Order Chest Xray
• Order Foley Catheter and NG Tube
• Labs – CBC, CMP, trop,
• Treat hypotension SBP <90
• IV/IO bolus, pressors, consider treatable causes
• Get an EKG, even if you had one from before. If MI, consider involving
interventional cardiologist for PCI
• Initiate Targeted Temperature Management (TTM) – start cooling patient to
a number between 32 – 36 C
• Start treating underlying cause you may know or found with labs
• ADMIT and transfer to ICU
Identify this rhythm
 Sinus Bradycardia with a pulse
HR is less than 50/min
Step 1?
• Identify and treat underlying problem.
• ABCs, monitor, BP, O2, IV, 12 lead
Symptomatic or Asymptomatic?
• What is cause the bradycardia?
• Hypotension, Altered mental status, Shock, MI,
Acute heart failure, etc
If NO – monitor, observe, do you need cardiac
consult?
If Yes – give?
Atropine
If atropine does not work you can –
Transcutaneous pace OR Dopamine OR Epi drip
Consider seeking Expert Consultation
Identify these rhythms
Sinus Tachycardia
Rate >100 but <150
Treat underlying cause
• Fever, Emotional, Hypoxia,
Hypovolemia, Trauma, Toxins,
etc
• IV, O2 if <95%, monitor, EKG,
labs, fluids
 SVT – Supraventricular Tachycardia
HR above 150
Tachycardia with a pulse algorithm:
Identify and Treat underlying cause
• ABCs, oxygen, monitor, pads, BP, O2, IV
Is tachyarrhythmia causing
• Hypotension, AMS, shock, chest discomfort,
acute heart failure
If yes – synchronized cardioversion
(fix NOW)
• Sedate w/versed or similar if time permits
Pads on, 50-100 J, push sync, hold shock until
charge delivered
 SVT
If NO – is it wide complex or narrow
• Narrow – you have time
• IV, 12 lead EKG
• Vagal Meneuvers
• Valsava, blow through straw, ice to face,
etc
• Adenosine (if regular) 6 mg, can
repeat once at 12mg
• Consider Beta Blocker or CCB
• Consider expert consultation
 SVT/Vtach with a pulse
If Wide complex Tachycardia with
a pulse: >0.12s
• IV, 12 lead EKG, consider
adenosine if regular and
monomorphic, consider
antiarrhythmic infusion (ami,
procainamide, lido)
• Consider expert consultation
If they go unstable at any time -
synchronized cardioversion
Pg 121 in ACLS book,
know them!
 Megacode Example
Case Scenario
You have a 57 y/o Male who came
into ER because he would get SOB
walking across the room, Dizzy
when standing, and wife made
him come.
History of HTN, hyperlipidemia,
T2DM.
Vitals: BP 80/50, HR 40, RR 20, O2
sat 93%, temp 97.1, glucose 126
mg/dL
 Megacode Example
What do you do first?
• IV, O2, Monitor, EKG
• Defib Pads
• Fluids – start treating underlying
causes
Stable or unstable?
• Give atropine, TCP, Dopamine?
 Megacode Example
You give Atropine and see this on
the monitor
What algorithm are you in now?
• Cardiac Arrest – V-fib
What do you do?
• Start CPR and Defibrillate
2 minutes gets called
• Recheck pulse and rhythm
• Same, resume CPR and shock
2 minutes gets called
• Recheck pulse and rhythm
 Megacode Example
Pt has no pulse – what rhythm is
this?
• PEA
What algorithm are you in?
• Asystole/PEA
What do you do?
• CPR, consider advanced airway
What do you give?
• Epinephrine 1 amp
 Megacode Example
2 minutes is called
• You check pulse and rhythm and
you see this
• You have a pulse that matches
What do you do next?
• ROSC protocols
• ABCs
• Do they respond to commands?
• TTM
• Intubate, Foley, NG tube
• Labs, Chest Xray, EKG
• Underlying
cause/diagnosis/treatment
EKG Shows STEMI – what now?
• Call interventional cardiologist and
transfer to cath lab for PCI