ACLS

Question 1

Synchronized cardioversion

Answer 1

Initial Recommended Doses:

Narrow regular: 50-100J
Narrow irregular: 120-200J (200j monophasic)
Wide regular: 100J
Wide irregular: Defib dose (360 monophasic; 200,300,360 biphasic)

Question 2

Transcutaneous Pacing

Answer 2

Steps:

IV, O2, EKG
Place Pt supine
Confirm EKG (sympto, unstable brady)
Apply pads
Turn on pacer
Set H.R. 80
Start between 0-20mA
Increase by 10mA to capture
Verify pulse
Adjust H.R. to compensate for B.P.

Question 3

12 Lead Analysis (10 step method)

Answer 3

Rate/rhythm
Pathological Q waves
ST segment elevation 
ST segment depression
Changes in T wave morphology
LVH voltage criteria
QRS presentation
Reciprocal changes
STEMI Criteria
Interpretation

Question 4

Left Ventricular Hypertrophy (LVH)

Answer 4

Use the sum of the following…

Largest negative deflection in v1-v2
Largest positive deflection in v5-v6

If sum is 35 or more mm or mv suspect LVH

Question 5

Sgarbosa Criteria

Answer 5

Used for diagnosis of acute MI in the presence of LBBB

5 pts.- ST elevation 1mm or more concordant with QRS

3 pts.- ST depression of 1mm or more in v1-3

2 pts.- ST elevation of 5mm or more discordant with QRS

If total score is 3 or greater consider MI, with score of 2 being probable.

Question 6

Left Bundle Branch Block (LBBB)

Answer 6

A wide QRS as the result of supraventricular electrical activity.

Suspect BBB

If QRS is greater than 0.12 sec, read baseline backwards from v1 with first deflection indicating right or left branch; via turn signal.

**see sgarbosa Criteria to rule out MI

Question 7

Benign Early Repolarization

Answer 7

Predominantly seen in African-American male, under 40 with no long term health risk.

Look for “upwardly concave” ST segment elevation in leads v4-6 and relatively large T waves in respective leads.

Question 8

Ventricular Paced Rhythm

Answer 8

STEMI mimick resembling LBBB but presents with pacer spike.

Question 9

Pericarditis

Answer 9

Presents as diffuse, non-contiguous ST segment elevation

Described pain as sharp

Discomfort changed by movement, with relief upon leaning forward.

Question 10

STEMI mimics

Answer 10

Left Ventricular Hypertrophy LVH

LEFT Bundle Branch Block LBBB

Benign Early Repolarization BER

Pericarditis

Ventricular Paced Rhythm

Question 11

Defibrillation

Answer 11

Steps:

Confirm pulses arrest
Begin CPR
Apply pads
Charge 200J *(2-4J/kg pediatric dose)
Confirm EKG shockable Rhythm (v-fib/ pulseless v-tach)
Clear Pt
Administer shock
Resume 2 min CPR
Re-evaluate EKG

Question 12

Cardioversion

Answer 12

Indications: perfusing V-Tach, SVT, A-Fib w/ RVR >150, 2:1 A-Flutter

Steps:

Consider sedation (2-5mg versed)
Apply pads
Press sync
Confirm monitor synced with R wave
Charge:
SVT, 2:1 A-Flutter: 50J
V-Tach, A-Fib: 100J
**Pediatric: 0.5J/kg
Clear Pt
Press and hold shock button until countershock
Re-evaluate Pt

Question 13

12 Lead Regions

Answer 13

II, III, aVF: Inferior 
V1-V2: Septal
V3-V4: Anterior
V5-V6: Lateral (low)
I, aVL: Lateral (high)

Posterior: V1-V2-V3-V4* (V4 between shoulder blades)

Right Ventricular Involvement: V4r** (V4 moved to right side Pt)

Question 14

Parts of EKG

Answer 14

P wave: atrial depolarization

PR interval: distance in time between the beginning of the P wave and the beginning of the QRS. 0.12-0.20 sec

QRS: Ventricular depolarization. 0.04-0.12 sec

T wave: Ventricular Repolarization.

ST segment: baseline between QRS and T wave.

QT interval: total time of ventricular depolarization. 0.33-0.42 sec

Question 15

Refractory periods

Answer 15

Absolute refractory: the myocardium cannot accept any stimulus to initiate another depolarization. With one exception of R on T phenomenon

Relative refractory: a strong enough stimulus can initiate another depolarization.

Question 16

Q waves

Answer 16

Normally represent left to right depolarization of ventricular septum.

Typically seen in left side leads: I, aVL, V5, V6

Usually not seen in V1-3

Question 17

Pathological Q waves

Answer 17

> 40ms or 1mm wide
2mm deep
25% depth of QRS

Seen in leads V1-3
Usually indicate current or prior MI

Absence of Q wave in V5, V6 considered abnormal. May indicate LBBB

Question 18

Tachycardia with a pulse

Answer 18

Identify and treat underlying causes:
Maintain airway
O2 if less than 94%
Cardiac monitor and V/S

Persistent arrhythmia causing the following:
Hypotension 
Altered mental status
Shock
Ischemic chest pain
Acute heart failure

If yes:
Begin cardioversion
Consider adenosine if regular and narrow.

If no:
Wide QRS?