ACLS PROVIDER Course Study Guide/Pre-Test - · PDF fileHeartland CPR, llc Page 1 of 26 2/2/17...

Heartland CPR, llc of 26 2/2/17

ACLS PROVIDER Course Study Guide/Pre-Test

*PLEASE COMPLETE AND BRING THIS DOCUMENT WITH YOU TO CLASS*

Heartland CPR, llc 8101 NW 10th St, Suite #C3 Oklahoma City, OK 73127

405-603-6666 [email protected]

www.HeartlandCPR.com

*source: American Heart Association ACLS Provider Manual supplementary material http://ahainstructornetwork.americanheart.org/idc/groups/ahaecc-public/@wcm/@ecc/documents/downloadable/ucm_479382.pdf


PR interval: Measures from the beginning of the P wave to the beginning of the Q wave

Normal: 0.12 - 0.20 sec QRS complex: Measures from the beginning of the Q wave to the end of the S wave

Normal: <0.12 sec QT interval: Measures from the beginning of the Q wave to the end of the T wave

Normal: Needs to be corrected for heart rate – usually 0.44 to 0.32 sec (heart rate of 60 – 100 bpm for both men and women)

Intrinsic Rates: SA Node 60 – 100 AV Node 40 – 60 PF 15 – 40


Method for estimating heart rate To estimate heart rate, memorize the rate intervals: 300, 150, 100, 75, 60, 50, 40, and 30. This method estimates heart rate. Although there are other methods and tools available, this method does not require a 3-second or 6-second strip and it can be used easily at the bedside.

1. Pick a complex that falls on a heavy line 2. Estimate the rate by counting heavy boxes 3. Using 300, 150, 100, 75, 60, 50, 40, 30

Other heart rate measurements that can be used:

• Count the number of QRS complexes (R waves) on a 6-second strip and multiply by 10 • Divide 300 by the number of large boxes between 2 consecutive QRS complexes (R waves) • Divide 1500 by the number of tiny boxes between 2 consecutive QRS complexes (R waves)

For atrial rate measurements, use the methods indicated above with P waves substituted for QRS complexes (R waves). Normal atrial rate: 60 – 100 Normal ventricular rate: 60 – 100


1. Atrial rate: Regular; P to P is regular, 60 – 100 bpm Ventricular rate: Regular; R to R is regular, 60 – 100 bpm P waves: P wave before every QRS complex QRS: Unchanged unless aberrant conduction due to premature beat or increased rate Intervals: PR: 0.12 - 0.20 sec

QRS: <0.12 sec

Regular or irregular: ________________________________________________________________ P waves present: __________________________________________________________________ Atrial rate: ________________________________________________________________________ Ventricular rate: ___________________________________________________________________ PR interval: _______________________________________________________________________ QRS interval: _____________________________________________________________________ Notes:


2. Atrial rate: Regular; P to P is regular, <60 bpm Ventricular rate: Regular; R to R is regular, <60 bpm P waves: P wave before every QRS complex QRS: Unchanged unless aberrant conduction due to premature beat or increased rate Intervals: PR: 0.12 - 0.20 sec

QRS: <0.12 sec



3. Atrial rate: Regular; P to P is regular, >100 bpm Ventricular rate: Regular; R to R is regular, >100 bpm P waves: P wave before every QRS complex QRS: Unchanged unless aberrant conduction due to premature beat or increased rate Intervals: PR: 0.12 - 0.20 sec

QRS: <0.12 sec



4. Atrial rate: Regular; P to P is regular if P waves can be identified, 150 – 250 bpm Ventricular rate: Regular; R to R intervals are regular, 150 - 250 bpm P waves: Difficult to detect or hidden because of the fast heart rate QRS: Unchanged unless aberrant conduction due to premature beat or increased rate Intervals: PR: not measureable

QRS: <0.12 sec



5. Atrial rate: No P to P interval (no P waves, fibrillation “f” waves only), rate can’t be measured Ventricular rate: R to R intervals are irregular, rate is variable – irregularly irregular P waves: Small f waves create a wavy baseline QRS: Unchanged unless aberrant conduction due to premature beat or increased rate Intervals: PR: not measureable

QRS: <0.12 sec



6. Atrial rate: Regular; F to F is regular (no P waves - “F” or flutter waves), 250 – 400 bpm Ventricular rate: R to R intervals are regular or irregular based on fixed or variable block,

60 – 150 bpm (usually 2:1 AV block) P waves: Absent; more F’s than QRS’s; Flutter waves have sawtooth appearance QRS: Unchanged unless aberrant conduction due to premature beat or increased rate Intervals: PR: not measureable

QRS: <0.12 sec



7. Atrial rate: Regular; P to P is regular, 60 – 100 bpm Ventricular rate: Regular; R to R is regular, 60 – 100 bpm P waves: P wave before every QRS complex QRS: Unchanged unless aberrant conduction due to premature beat or increased rate Intervals: PR: >0.20 sec

QRS: <0.12 sec



8. Atrial rate: Regular; P to P is regular, 60 – 100 bpm Ventricular rate: R to R intervals decrease progressively; until QRS is dropped, rate is variable P waves: More P waves than QRS complexes QRS: Unchanged unless aberrant conduction due to premature beat or increased rate,

but dropped in a cyclic pattern Intervals: PR: increase with each beat

QRS: <0.12 sec



9. Atrial rate: Regular; P to P is regular, rate is variable Ventricular rate: Regular; until QRS is blocked, rate is less than atrial rate P waves: More P waves than QRS complexes QRS: Unchanged unless aberrant conduction due to premature beat or increased rate Intervals: PR: 0.12 – 0.20 sec where they can be measured

QRS: variable



10. Atrial rate: Regular; P to P is regular (if underlying rhythm sinus), 60 – 100 bpm, can be variable (eg atrial fibrillation) Ventricular rate: Regular; R to R is regular, <60 bpm

(40 – 60 bpm if junctional, 15 – 40 if ventricular) P waves: More P waves than QRS complexes (complete A-V dissociation) QRS: Unchanged unless aberrant conduction due to premature beat or increased rate Intervals: PR: increases with each beat

QRS: variable, but usually >0.12 sec



11. Atrial rate: Absent Ventricular rate: Absent P waves: Absent QRS: Absent Intervals: PR: absent

QRS: absent



12. Atrial rate: Obscured Ventricular rate: Irregular and chaotic; 250 – 350 bpm P waves: Obscured QRS: Variable, wide and bizarre, not identical Intervals: PR: absent

QRS: >0.12 sec



13. Atrial rate: Obscured (see discussion below) Ventricular rate: Regular; R to R intervals are regular, >150 bpm P waves: Obscured (see discussion below) QRS: Wide and bizarre, unchanged unless aberrant conduction due to premature beat

or increased rate Intervals: PR: absent*

QRS: >0.12 sec *Learn More-Advanced ECG. The rhythm strip here emphasizes the regular wide complex tachycardia (WCT) aspect of VT. In most patients a WCT will be ventricular tachycardia, especially with older age and history of cardiac disease or acute chest discomfort. In these settings, presume and treat as VTG. With advanced rhythm training, you will learn that WCTs may be abnormally conducted supraventricular rhythms and “look like” VT. Careful examination of a rhythm strip attempts to identify atrioventricular dissociation (not shown here). The atria in VT continue to contract in most instances, and the atrial and ventricular impulses are dissociated. This leads to the “footprints” identifying VT on rhythm strips. These are (1) AV dissociation observed as P waves “marching” through the wide complexes and occasional fusion or Dressler’s beats. Fusion beats occur when the atrial contraction by chance conducts part of the QRS complex. This also is an indication of independent atrial depolarization and AV dissociation.



14. Atrial rate: Absent Ventricular rate: Absent P waves: Absent QRS: Absent Intervals: PR: absent

QRS: absent



15. A patient is in respiratory arrest with a pulse. The patient should be ventilated

a. Twice every 5 – 6 seconds (10 – 12 times/min) b. Once every 5 – 6 seconds (10 – 12 times/min) c. Twice every 10 seconds d. Once every 8 seconds

16. The dose for Dopamine IV infusion in post-arrest care is

a. 5 – 10 mgs/kgs b. 1 – 20 mcg/kg per minute c. 5 – 25 mcg/kgs d. 5 – 10 mcg/kg per minute

17. In regular Monomorphic Tachycardia, the initial dose for Adenocard is

a. 12 mg b. 6 mg c. 6 mg, 12 mg d. 6 mg/ 12 mg, 12 mg

18. In a patient with wide unstable Tachycardia with a pulse, the dose of Amiodarone is

a. 150 mg infused over 10 minutes b. 300 mgs IV c. 150 mg IV d. 300 mg infused over 10 minutes

19. In post-Cardiac Arrest care, optimal PETCO2 readings are

a. 35 – 40 mm Hg b. 40 – 45 mm Hg c. 45 – 50 mm Hg d. >50 mm Hg

20. What is the appropriate compression rate for an adult during cardiac arrest?

a. 60-80 compressions/minute b. 80-100 compressions/minute c. 100-110 compressions/minute d. 100-120 compressions/minute


21. Procainamide IV dose infusion for stable wide-QRS Tachycardia is:

a. 150 mg over 10 min b. 2 – 20 mcg/kg/min c. 25 mg/min d. 20 – 50 mg/min

22. What is the most reliable method of confirming and monitory correct endotracheal tube placement?

a. visual confirmation b. condensation in the ET tube c. continuous waveform capnography d. auscultation of lung fields

23. Bradycardia requires treatment when

a. chest pain or shortness of breath is present b. the heart rate is less than 60/min with or without symptoms c. the patient’s 12-lead ECG shows an MI d. the blood pressure is less than 100 mm Hg systolic with or without symptoms

24. 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. The next action is to

a. perform immediate synchronized cardioversion b. obtain a 12-lead ECG c. establish IV access d. give Amiodarone 300 mg IV push

25. A 62-year-old man suddenly experienced difficulty speaking and left-sided weakness. He was

brought to the emergency department. He meets initial criteria for fibrinolytic therapy, and a CT scan of the brain is ordered. What are the guidelines for antiplatelet and fibrinolytic therapy?

a. administer Heparin if CT scan is negative for hemorrhage b. give Aspirin 160 mg and Clopidogrel 75 mg orally c. do not give Aspirin for at least 24 hours d. administer Aspirin 160 – 325 mg chewed immediately


26. During treatment of a patient with chest pain, the patient becomes unresponsive. After calling for help and determining that the patient is not breathing, you are unsure whether the patient has a pulse. What is your next action?

a. leave and get an AED b. deliver two quick breaths c. begin chest compressions d. continue to check for a pulse

27. Initiation of fibrinolytic therapy in appropriate patients should occur

a. within 30 minutes of hospital arrival and <3 hours from symptom onset b. within 2 hours of hospital arrival and <3 hours from symptom onset c. within 1.5 hours of hospital arrival and < 6 hours from symptom onset d. within 1 hour of hospital arrival and <3 hours from symptom onset

28. A patient with possible acute coronary syndrome has ongoing chest discomfort unresponsive to 3 sublingual nitroglycerin tablets. There are no contraindications, and 4 mg or Morphine Sulfate was administered. Shortly afterward, blood pressure falls to 88/60 mm Hs, and the patient has increased chest discomfort. You should

a. give normal Saline 250 – 500 mL fluid bolus b. start Dopamine at 2 mcg/kg/min and titrate to a systolic blood pressure reading of 100

mm Hg c. give sublingual nitroglycerin 0.4 mg d. give an additional 2 mg of Morphine Sulfate

29. When inducing Hypothermia, how much 4’ C fluid should be administered?

a. 250 – 500 cc normal Saline b. 1 – 2 L normal Saline c. 500 cc – 1 L normal Saline d. 1 L normal Saline

30. In a patient with no pulse, the dose for Magnesium Sulfate is

a. 1 – 2 mgs IV/IO b. 1 – 2 mcg/kg IV/IO c. 1 – 2 grams IV/IO d. 1 – 2 grams endotracheal tube

31. The advanced airway rule means

a. chest compressions are not interrupted and given at a rate of 100/min b. no advanced airway is utilized c. medications can be administered via endotracheal tube d. chest compressions continue at a ratio of 30:2


32. 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. 0.5 mg b. 1 mg c. 3 mg d. 0.1 mg

33. A patient is in cardiac arrest. Ventricular fibrillation has been refractory to an initial shock.

What is the recommended route for drug administration during CPR?

a. endotracheal b. external jugular vein c. femoral vein d. peripheral IV

34. 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, your next action is to

a. gain IV or IO access b. call the patient and discontinue code c. attempt endotracheal intubation with minimal interruptions in CPR d. place an esophageal-tracheal tube or laryngeal mask airway

35. 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 100/60 mm Hg. Which of the following is now indicated?

a. give normal saline bolus 250 – 500 mL b. start Epinephrine 2 – 10 mcg/min c. give additional 1 mg Atropine d. start Dopamine 10 – 20 mcg/kg per minute

36. A patient is in cardiac arrest. Ventricular Fibrillation has been refractory to a second shock. Of

the following, which drug and dose should be administered first by the IV/IO route?

a. Atropine 1 mg b. Sodium bicarbonate 50 mEq c. Vasopressin 20 units d. Epinephrine 1 mg


37. A patient is in Refractory Ventricular Fibrillation and has received multiple appropriate defibrillation shocks, Epinephrine 1 mg IV twice, and an initial dose of 300 mg Amiodarone IV. The patient is intubated. A second dose of Amiodarone is now called for. The recommended second dose of Amiodarone is

a. 150 mg IV push b. 1 mg/kg IV push c. 300 mg IV push d. an infusion of 1 – 2 mg/min

38. A patient is in pulseless Ventricular Tachycardia. Two shocks and one dose of Epinephrine have been given. Which is the next drug/dose to anticipate to administer?

a. Lidocaine 0.5 mg/kg b. Epinephrine 3 mg c. Vasopressin 40 units d. Amiodarone 300 mg

39. A patient is in Refractory Ventricular Fibrillation. High-quality CPR is in progress, and shocks have been given. One dose of Epinephrine was given after the second shock. An antiarrhythmic drug was given immediately after the third shock. What drug should the team

a. escalating dose of Epinephrine 3 mg b. repeat the antiarrhythmic drug c. Sodium Bicarbonate 50 mEq d. second dose of Epinephrine 1 mg

40. Which of the following statements about the use of Magnesium in Cardiac Arrest is most

accurate?

a. Magnesium is indicated for shock –refractory Monomorphic VT b. Magnesium is indicated for VF refractory to shock and Amiodarone or Lidocaine c. Magnesium is contraindicated for VT associated with a normal QT interval d. Magnesium is indicated for VF/pulseless VT associated with Torsades de pointes

41. A patient is in Cardiac Arrest. High-quality chest compressions are being given. The patient is

intubated and an IV has been started. The rhythm is Asystole. Which is the first drug/dose to administer?

a. Epinephrine 3 mg via endotracheal route b. Atropine 0.5 mg IV or IO c. Atropine 1 mg IV or IO d. Epinephrine 1 mg


42. A patient with possible ST-segment elevation MI has ongoing chest discomfort. Which of the following would be a contraindication to the administration of nitrates?

a. left Ventricular Infarct with Bilateral Rales b. use of Phosphodiesterase inhibitor within 12 hours c. blood pressure greater than 180 mm Hg d. heart rate 90/min

43. A 35-year-old woman has palpitations, light-headedness, and a stable Tachycardia. The monitor shows a regular narrow-complex QRS at a rate of 180min. Vagal maneuvers have not been effective in terminating the rhythm. An IV has been established. What drug should be administered IV?

a. Lidocaine 1 mg/kg b. Adenosine 6 mg c. Atropine 0.5 mg d. Epinephrine 2 – 10 mcg/kg per minute

44.

The patient suddenly becomes unconscious and has a weak carotid pulse. Cardiac monitoring, supplementary oxygen, and an IV have been initiated. The code card with all drugs and a transcutaneous pacer are immediately available. Next you would:

a. begin transcutaneous pacing b. give Atropine 0.5 mg IV c. initiate Dopamine at 10 – 20 mcg/kg per minute and titrate to patient response d. initiate Epinephrine at 2 – 10 mcg/kg per minute


45.

A 35-year-old woman presents to the ER Department with a chief complaint of palpitations. She has no chest discomfort, shortness of breath, or light-headedness. Which of the following is indicated first?

a. give Adenosine 12 mg IV slow push over 1 – 2 minutes b. give Adenosine 3 mg IV bolus c. perform vagal maneuvers d. give Metoprolol 5 mg IV and repeat if necessary

46.

You are monitoring a patient with chest discomfort who suddenly becomes unresponsive. You observe the above rhythm on the cardiac monitor. A defibrillator is present. What is your first action?

a. establish an IV and give Epinephrine 1 mg b. intubate the patient and give Epinephrine 2 – 4 mg via the endotracheal tube c. begin CPR with chest compressions for 2 minutes/5 cycles of compressions/ventilations d. give a single shock


47.

Following initiation of CPR and 1 shock for VF, 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 order?

a. prepare to give Amiodarone 300 mg IV b. administer 3 stacked shocks at 200 J c. prepare to give Epinephrine 1 mg IV d. perform endotracheal intubation; administer 100% oxygen

48.

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 above without conversion of the rhythm. She is now extremely apprehensive. Blood pressure is 108/70 mm Hg What is the next appropriate intervention?

a. perform immediate unsynchronized cardioversion b. sedate and perform synchronized cardioversion c. perform vagal maneuvers and repeat Adenosine 6 mg IV d. repeat Adenosine 12 mg IV


49.

A patient presents with the above rhythm and reports and irregular heartbeat. She has no other symptoms. Her medical history is significant for a Myocardial Infarction 7 years ago. Blood pressure is 110/70 mm Hg. What would you do at this time?

a. administer Nitroglycerin 0.4 mg sublingual or spray b. perform emergency synchronized cardioversion c. administer Lidocaine 1 mg/kg IV d. continue monitoring and seek expert consultation

50.

This patient was admitted to the general medical ward with a history of alcoholism. A code is in progress, and he has recurrent episodes of this rhythm. You review his chart. Notes about the 12-lead ECG say that his baseline QT interval is high normal to slightly prolonged. He has received two doses of Epinephrine 1 mg and one dose of Amiodarone 300 mg IV so far. What would you order for his next medication?

a. repeat Amiodarone 300 mg IV b. repeat Amiodarone 150 mg IV c. give Magnesium Sulfate 1 – 2 grams IV diluted in 10 mL D5W over 5 – 20 minutes d. give Lidocaine 1 – 1.5 mg IV and start infusion 2 mg/min

ACLS PROVIDER Course Study Guide/Pre-Test - · PDF fileHeartland CPR, llc Page 1 of 26 2/2/17...

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