ACLS course questions and answers

Questions

Last updated: July 30, 2024

• I am in the process of helping to open an outpatient cardiology practice in the state of Florida. The office is in a medical office building on a hospital campus. We plan to perform exercise stress tests in the office but will not perform any procedures that will require medication administration. Would a defibrillator and AED be sufficient in the office or would a crash cart be necessary? I can find the list of required medication for a crash cart from the FL Dept of Health, but would endotracheal tubes be necessary or would bag valve masks and oxygen with nasal cannulas be sufficient? The MD and NP are ACLS certified, but have not intubated an actual patient in many years

  You would need a crash cart with meds. As long as you have the equipment to manage an airway to your skill level you are fine.

• I saw many references in your asked questions section to “patients must not be more than 3 minutes from the nearest AED/defibrillator.” I am trying to assist in writing a policy for our organization, and I would like to inquire as to whether or not that is a recommendation from ACLS.net or if there is another source where this information is coming from that I can use as part of our risk assessment process

  It is recommended that a patient within a hospital be defibrillated within 3 minutes.

• I believe securing the airway of the patient who is unconscious and is out of the hospital. If the person is breathing spontaneously is it right not to intubate him in the field

  According to our medical experts, intubation is not indicated in the post-cardiac arrest scenario unless the patient is unable to breathe spontaneously. This patient would have an intact gag reflex and therefore would be at risk of aspiration. Intubation is not indicated in this scenario and would not meet the requirements for most EMS intubation protocol.

• Please confirm the dosing for narcan intranasal spray - is it 4mg or 0.4mg?

  “In recent years as the opioid crisis has grown Narcan has become available in IntraNasal spray in single dose applicators (4 mg). Most kits come with two doses so that it can be repeated once. There has been a big push to train all first responders and laypersons in their use.”

• We received a call from a customer of a small neurology practice that will now be doing research and is in need of a crash cart. She would like to know what are the requirements of a crash cart?

  “This information is available on our website. Crash Cart Supply & Equipment Checklist”

• I found a mistake when I read the flashcard of Acute Coronary Syndromes Algorithm. I believed that provide O2 to pt with COPD as SpO2 < 09%; not > 90%

  It should read less than 90%.

• I have a question of clarification on one of the test questions. I cannot find any information in the study packet re: securing the Tube Tamper device. Your thoughts on what page it is found on?

  I don’t have the pagination to be able to give her page numbers. You could try and search tube tamer though!

• A patient changes his heart rate from 64/min to 240/min. His Blood pressure drops from 120/60 to 50/p. The blood pressure has dropped because

  Stroke volume has decreased. Because of the increased heart rate there is less time for the left ventricle to fill during diastole and therefore less blood to pump (preload) with each contraction, resulting in hypotension.

• We are a provider agency “CUA” with Philadelphia DHS. There is a child who is currently in a specialized medical foster care home and is being reunited. The reason for the placement is because the mother was not properly taking care of his special needs. In order for the court to consider reunification, the mother needs to be trained on managing his Trachea Intubation. I want to know if you provide such training. If so, how would it be presented?

  Unfortunately, none of our courses cover trachea intubation. You can go to a children’s hospital for patient education.

• Can you please provide a reference for this statement on the website? Do I need ACLS if I have PALS?

  PALS emphasizes resuscitation in children less than 8 years or pre-puberty. The approach to resuscitation is vastly different between adults and children. One small example: adults have primary ischemic arrests (usually ventricular fibrillation) Infants and children rarely do. They arrest secondary to another cause such as hypoxia or hypovolemia. The list of differences is indeed a large one.

• If the patient has sign of ROSC after CPR and disappeared again, and so 1. How many times will continue CPR ?? 2. Coming ROSC and going !! 3. My question not how long each cycle, It’s about how many CPR cycles?

  There is no set time on restarting CPR. Once advanced life support is available, the interventions for the Hs and Ts will be considered. Each case is different, the team must consider the down time, and how long CPR has been in progress, the history of the patient, and events leading to cardiac arrest, and signs of return of circulation before making the decision to stop resuscitation attempts.

• My co-worker and I were discussing code situations with vented patients. I have always taken the patient off the vent and began bagging. I was taught this was the standard. He asked why and I really couldn’t explain (besides we can provide a more controlled rate/ PEEP). After trying to research more on this topic, I found very little information. If someone could explain the rationale a little better I would extremely appreciate it

  The AHA recommendation is that the patient comes off. Read more here.

• Hello, we are a Dermatology clinic who hosts clinical trials. The clinical trials require us to have a crash cart but do not give specific requirements for what should be in the crash cart. I found the recommendations on your website, but I’m wondering if there is a recommendation specific to clinics. Typically, we wouldn’t perform an intubation or give rescue medications other than epinephrine. Do you have a recommendation for clinics?

  There are no recommendations specific to clinics. Our generic recommendations would work as they would exceed, in all probability, State requirements. Those requirements are written by each State’s DOH.

• In your ACLS course, do you have a part about anaphylactic shock and the management associated in a non-hospital setting? For personal information, is your ALCS course exclusively online?

  Anaphylactic shock and the management associated in a non-hospital setting are not covered in our ACLS course. Our ACLS course is completed entirely online.

• Unlicensed health care workers… are they allowed to perform all of the duties of an ACLS course as long as they took an ACLS in-person course? Also, why do they sometimes give patients that suffered a heart attack morphine? Is that one of the drugs used in ACLS?

  1.Unlicensed healthcare workers can perform the BLS portion taught in ACLS such as compressions and use of AED. For medication administration, it is required that you work under the scope of your license. Nurses and doctors, for example, can administer medication. CNAs cannot give medications, even if they have taken the course.

  2.Morphine is one of the recommended interventions for chest pain. It is very efficient in helping relieve chest pain during a heart attack. The use of the mnemonic MONA helps remember the chest pain interventions: morphine, oxygen, nitroglycerin, and aspirin.

• I am a nuclear medicine technologist and have a question. We perform Nuclear Medicine stress tests on our patients daily. Both myself and the cardiac stress tech are ACLS certified. If a patient has a cardiac event or full-on code, are we legally allowed to push medications the NP or PA orders? They are in the room with us while doing the exam and watching the EKG machine intently. We have a code team in place from our ER, but it may take a few minutes for them to arrive. Nuclear Technologists administer radioactive tracers and Lexi scan under our license. Would epinephrine or other ACLS drugs be approved to administer as well?

  The answer depends on the policies of your institution. Some cardiac catheterization laboratories allow technologists to give medications, while others forbid it. Those decisions are made on an institutional basis.

• Can you tell me what age ACLS treats down to? I’ve heard multiple numbers, from 14 y/o, 16 y/o, to 18 and above. Our GI lab had a 16 y/o scheduled for sedation. Our policy states that providers must be PALS certified for pediatrics and ACLS for adults. The GI lab only has ACLS certification and was wondering if ACLS covers 16-year-olds. Can you clarify?

  AHA treats children at puberty (armpit hair in boys, breast development in girls) as adults. If age is known, it is age 14 for a child and up to 1 year for an infant.

• The cardiac arrest algorithm has 3 to 5 minutes between each medication (epi/amiodarone). Can amiodarone be given after the shock (possibly 2 minutes after Epi is given), or does it need to wait for 3 to 5 minutes?

  It can be given two minutes after the Epi and the defibrillation that follows.

• I work at an acute care rehabilitation hospital. We do not always have physicians present at the time of a code. Our policies state that an ACLS-trained person can follow the ACLS algorithm to treat a coding patient. Our question is, if the supervisor is the only person trained in ACLS, are they the person that has to push the epi and other medications within the algorithm? Because technically anyone not trained in ACLS should be receiving the order from a physician before they push the medications, is that correct?

  ACLS does not certify anyone to run a code. That is a facility policy. That said, any nurse has within their scope of practice the ability to administer acute care medications. However, a nurse generally requires an order to do so (standing written orders, verbal, or written order).

• What is the recommended depth for chest compressions?

  1/3 of the chest or 2 inches is the compression depth. 2.5 inches is the maximum.

• Is there a difference in CPR for hypothermia?

  There is no difference in response to hypothermia.

• Is procainamide required in a crash cart?

  The medications in a crash cart are the decision of individual facilities or regulatory agencies, not AHA.

• Please define “passive” ventilation

  Passive ventilation is practiced by EMS. A nonrebreather with 100% oxygen is placed while doing high-performance compressions. The theory is that the patient is ventilated passively. In the 2019 recommendations, this did not hold up to science, so it is being removed although it remains an EMS practice.

• What is the expected response time for cardiac arrest teams and for the use of an AED outside of critical care areas?

  For arrest team response, it is under 5 minutes. For use of an AED outside critical care, it is under 3 minutes.

• What is PETCO₂?

  It is pulmonary end-tidal CO₂.

• What is the recommended time to give tPA for ischemic stroke?

  tPA is recommended to be administered within 3 hours of symptom onset, or up to 4.5 hours of symptoms for some indications. Refer to the tPA administration guide.

• What is Adenosine given for?

  Adenosine is used to treat regular narrow complex tachycardias and, in some cases, to differentiate regular wide complex tachycardias. The initial dose is 6 mg, followed by 12 mg if needed.

• What is the dose for administering dopamine infusion for blood pressure management?

  5-20 mcg/kg/min to achieve a systolic blood pressure greater than 90 or MAP greater than 65.

• Why is the respiratory ventilation rate in pulseless patients different than patients with a pulse?

  The metabolic rate in cardiac arrest is greatly decreased (30% cardiac output at most), so oxygen needs are much lower. This is the concept behind “hands-only CPR” for laypersons.

• Do I need ACLS if I have PALS?

  PALS emphasizes resuscitation in children less than 8 years or pre-puberty. The approach to resuscitation is vastly different between adults and children. One small example: adults have primary ischemic arrests (usually ventricular fibrillation), while infants and children rarely do. They arrest secondary to another cause such as hypoxia or hypovolemia. The list of differences is indeed a large one.

• PALS or ACLS for shorter individuals? In adults of small stature, should ACLS or PALS be used?

  Pediatrics ends at puberty. Medications that are always weight-dosed would be adjusted by the smaller bodyweight, for example, dopamine at 2–10 mcg/kg/min. For the most part, adult doses apply to smaller adults.

• Can ACLS meds be administered without a doctor in the hospital?

  It depends upon the standing orders within your hospital.

• What happens if PALS algorithms are not followed?

  PALS certification is simply a recognition of completion of a continuing education course. The AHA offers treatment recommendations based on current science. However, it is up to the licensed provider to practice medicine according to what they determine to be best for their practice. There is no administration that enforces adherence to PALS algorithms.

• What age range is covered under PALS?

  Pediatric care is defined as ending at puberty. However, pediatric hospitals may use the definition of the “end of the 18th year.” PALS is aimed at infants (under one) and children (up to puberty or age 8). After that, adult CPR protocols apply.

• Is ACLS required for giving ACLS medications?

  There is no requirement that anyone must be ACLS certified. Most regulatory agencies, however, require training in resuscitation for anyone administering or monitoring patients receiving anesthesia or sedation. Many facilities use ACLS or PALS to meet this requirement, but it is not mandatory.

• I’m an EMT. Are my certifications still good if I move?

  ACLS and PALS certifications are valid worldwide. However, EMT certification may not be. You will need to complete whatever is required by your new state.

• What is the treatment for PEA?

  PEA should not be treated with defibrillation (AED). The treatment for PEA is to find the cause (usually hypovolemia or hypoxia) and address it.

• Can pVT evolve to PEA?

  Yes, PEA can result from ventricular fibrillation or ventricular tachycardia. However, the treatment for PEA remains the same: CPR, epinephrine, and addressing reversible causes.

• NIHSS prior to CT Scan without contrast?

  Yes. The NIHSS stroke scale needs to be completed before presenting the patient to the neurologist. However, the CT is the number one priority, and nothing but life threats should delay it.

• What do you mean by “do not delay the CT Scan”?

  It means if the CT scanner is available, perform the scan as soon as possible. You want the CT done early to make a diagnosis.

• Is a crash cart required for each treatment location?

  Yes, each room where procedures are performed needs a crash cart. Having one crash cart at a satellite office will not be sufficient.

• Is atropine recommended for second-degree type two & 3rd-degree AV block?

  Atropine remains the first-line drug for acute symptomatic bradycardia. However, it is not recommended in Mobitz II or 3rd-degree heart block if it’s likely to be a bundle of His or more distal conduction system block.

• How do you perform synchronized cardioversion?

  The monitor must be set for synchronization, using the R wave to time the shock. After cardioversion, immediately turn off synchronization mode to switch to defibrillation mode if needed. The defibrillation dose is generally double that of synchronized cardioversion. Check your manufacturer’s guidelines, but typically it’s between 150 joules and 200 joules for the first defibrillation.

• Is aspirin recommended for a STEMI?

  Yes, aspirin remains an important adjunct therapy to any reperfusion strategy used in infarction as well as the treatment of unstable angina for infarction prevention.

• How do you measure ST elevation or depression?

  1 mm is the threshold for clinical significance. The ST segment begins at the end of the QRS complex and ends at the start of the T wave. Any deviation of 1 mm (one small square) above or below baseline is considered significant.

• Is there a standard protocol required to be followed after giving an ACLS drug to a patient? Is there a specific length of time for patient monitoring required or a requirement for hospital transfer from a stand-alone surgery center?

  The responsibility of the organization is to determine if it can provide the level of care required by the patient. If the organization has a cardiac or intensive care unit that can provide ongoing care, then it is appropriate to keep the patient. Otherwise, the organization must find an accepting facility that can provide the required care. In your example, if a patient needs a pacemaker and your facility cannot provide it, they must be transferred to a facility that can.

• Looking for information on how the brain and sympathetic nervous system would be affected by ICD Shocks. I had an ICD storm and received 8 shocks in 3.5 minutes, then another 4 shocks a few days later. I spent a month in the hospital and though I’m doing OK now, I still have lingering issues 11 months later. Any information?

  We cannot provide medical advice. Please consult a specialist or your healthcare provider for more details regarding your condition.

• I am looking for updated information sheets, preferably from around 2020: Adult Cardiac Arrest Algorithm, Post-Cardiac Arrest Care Algorithm, Bradycardia Algorithm, Adult Tachycardia with a Pulse Algorithm, Adult Coronary Syndromes Algorithm, Adult Suspected Stroke Algorithm

  All the updated algorithms can be found on our site. You can view them here.

• I work in a small hospital in Northern California. We have a Zoll defibrillator that consistently fails its automated self-check with the error message that the electrode is not connected. The manual checks pass without issue, but I’m concerned. Am I wrong to be concerned?

  You are right to remain concerned. I would recommend asking the Zoll representative to explain why the unit is failing its self-checks and to ensure that it is fully operational. You could also document these issues as there could be liability concerns if the unit fails during patient use.

• One of my questions is marked as incorrect. I believe the answer is correct, as epinephrine shows improvement in survival to admission

  We are in the process of updating our exam. The data for lidocaine recently changed, and our exam will be updated accordingly.

• Where can the ACLS algorithms be found in your ACLS course?

  You can find them on our ACLS algorithms page.

• I’m having trouble finding how fast to initiate a beta blockade after admission in the literature. Also, when is it appropriate to give sodium bicarbonate during refractory VF?

  Sodium bicarbonate is no longer mentioned in resuscitation guidelines as of 2010. Beta-blockers should be initiated after stabilization, typically post-reperfusion therapy. Nitroglycerin is not administered during hypotension and should be avoided in cases of right ventricular infarction or when taking erectile dysfunction medications.

• Is there a standard (basic protocol/algorithm) for heart transplants and advanced cardiac life support (ACLS) related to the denervated heart?

  The AHA does not specifically address heart transplant patients. In post-transplant settings, bradycardia may be treated with beta-agonists like epinephrine or Isuprel. Pacing is also an option, either transvenous or transcutaneous, depending on the situation. Most bradycardias in this population are rare and may be due to parasympathetic denervation.

• This question is regarding the ethics of resuscitation. The last two paragraphs are confusing. “To clarify, prognostication of neurological outcome is recommended at least 72 hours after body temperature returns to normal in TTM-treated patients or 72 hours post-cardiac arrest in non-TTM-treated patients unless non-survivable conditions are present?”

  That is correct. If there are no non-survivable conditions (such as brain herniation), you should wait 72 hours after the return to normal body temperature in TTM-treated patients or 72 hours post-cardiac arrest in non-TTM-treated patients to make any neurological prognostications.

• I’m having a hard time finding how fast you should initiate a beta blockade after admission in the literature. Also, during refractory VF, when is it appropriate to give sodium bicarbonate?

  Sodium bicarbonate was eliminated from resuscitation guidelines in 2010. Beta-blockers should be initiated post-stabilization and after reperfusion therapy. Defibrillator pads should be placed on the chest with the heart between the pads.

• What is the standard protocol for ACLS in heart transplant patients?

  The AHA does not provide specific guidelines for heart transplant patients. In general, bradycardia in these patients is rare, but it can be managed with epinephrine or Isuprel. Pacing can also be used if needed. Immediate post-op bradycardia is often caused by sympathetic denervation or myocardial damage from biopsy.

• Does my ACLS certification remain valid if I move to a new state or country?

  ACLS and PALS certifications are recognized globally. However, your EMT certification may require additional requirements in a new state or country.

• What is the treatment for pulseless electrical activity (PEA)?

  PEA is not treated with defibrillation. The treatment involves identifying and correcting the underlying cause (commonly hypovolemia or hypoxia) while performing CPR and administering epinephrine.

• Can pVT evolve to PEA?

  Yes, pulseless ventricular tachycardia (pVT) can evolve into PEA after defibrillation. The treatment for PEA remains CPR, epinephrine, and addressing reversible causes.

• When should NIHSS be performed in a stroke patient?

  The NIHSS stroke scale should be completed before presenting the patient to a neurologist. The CT scan, however, is the priority and should not be delayed unless there are life-threatening conditions. If the CT shows a bleed, the treatment approach changes.

• What is meant by “do not delay the CT scan”?

  This means that if the CT scanner is available, the scan should be performed immediately, and other tests (such as an ECG) can be completed afterward. The CT scan is the top priority for diagnosing a stroke.

• Is a crash cart required for each treatment location in a medical facility?

  Yes, each location where procedures are performed should have its own crash cart. Sharing a crash cart between multiple locations could delay treatment in an emergency.

• Is atropine recommended for second-degree type II and third-degree heart blocks?

  Atropine remains the first-line drug for symptomatic bradycardia. However, it is not reliable in Mobitz II or third-degree heart block, and pacing or drugs like dopamine and epinephrine should be considered.

• How do you perform synchronized cardioversion?

  Synchronized cardioversion uses the R wave of the QRS complex to time the shock delivery. The defibrillator must be set to synchronization mode, and the energy levels are typically half of the defibrillation dose.

• Is aspirin recommended for a STEMI?

  Yes, aspirin is recommended for all patients with suspected STEMI as part of the reperfusion strategy, as well as for unstable angina.

• How do you measure ST elevation or depression on an ECG?

  ST elevation or depression of 1 mm or more is clinically significant. The ST segment begins at the end of the QRS complex and ends at the beginning of the T wave.

• Is there a protocol for patient monitoring after administering ACLS drugs in an outpatient setting?

  The organization is responsible for ensuring that it can provide appropriate care. If higher-level care is needed or a procedure is not available on-site, the patient should be transferred to an appropriate facility.

• How would multiple ICD shocks in a short period affect the brain and sympathetic nervous system?

  We cannot provide medical advice on this matter. Please consult your healthcare provider for more specific information regarding your situation.

• Where can I find updated information on ACLS algorithms?

  Updated ACLS algorithms can be found on our ACLS algorithms page.

• I am concerned about the self-check failure of our Zoll defibrillator. Should I be worried?

  Yes, if the device is consistently failing its automated self-checks, you should follow up with the manufacturer and ensure it is safe to use. It’s important to document these issues as well.

• One of my exam questions was marked incorrect, but I believe the answer is correct

  We are in the process of updating our exam. The guidelines and recommendations for some drugs, such as lidocaine, have recently changed.

• Is sodium bicarbonate still used in resuscitation for refractory VF?

  Sodium bicarbonate was removed from the resuscitation guidelines in 2010 and is no longer used for this purpose.

• What is the protocol for treating a heart transplant patient experiencing bradycardia?

  Treatment can include epinephrine or Isuprel for severe bradycardia. Pacing (transvenous or transcutaneous) may also be necessary in some cases. The most common cause of bradycardia in transplant patients is parasympathetic denervation.

• Can you tell me what age ACLS treats down to? I’ve heard multiple numbers, from 14 y/o, 16 y/o, to 18 and above. Our GI lab had a 16 y/o scheduled for sedation. Our policy states that providers must be PALS certified for pediatrics and ACLS for adults. The GI lab only has ACLS certification and was wondering if ACLS covers 16-year-olds. Can you clarify?

  AHA treats children at puberty (armpit hair in boys, breast development in girls) as adults. If age is known, it is age 14 for a child and up to 1 year for an infant.

• Is procainamide required in a crash cart?

  The medications in a crash cart are the decision of individual facilities or regulatory agencies, not AHA.

• I used to be a RN and taught ACLS at the last hospital I worked at. I have since surrendered my license and have considered taking up teaching ACLS as a new career. My question is: Do I have to have a medical license in order to teach the class, or just as I did before with BLS certification along with ACLS certification for teaching?

  You do not have to have a license, however, you must be functioning in an environment that utilizes the skills taught in ACLS.

• How long does ACLS certification last?

  The certification period lasts for 2 years.

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