Questions and answers - ACLS | ACLS Training Center

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). 4 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.”

“There was an additional number 4 that needed to be removed. It has been fixed in ACLS course

It should read as follows: 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

We can reference the content for ACLS and PALS, so use the provider manuals are reference. Each organization and unit determines what is required for their certifications. For the most part, if there is any care provided for children, either PALS or ENPC is required.

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. https://pubmed.ncbi.nlm.nih.gov/35926586/#:~:text=If%20any%20patient%20who%20is,and%20should%20be%20ventilated%20manually.

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.

1. a question about … 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.
   2. I also wanted to know why they sometimes give patients, that suffered a heart attack morphine. Is that one of the drugs that is used in ACLS? “

2. 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.
3. Morphine is one of the recommended interventions for chest pain. It is very efficient to help the chest pain during a heart attack. The use of the pneumonic MONA is a way to remember the chest pain interventions: morphine, oxygen, nitroglycerin, and aspirin.

I am a nuclear medicine technologist and have a question I am hoping you can answer.We perform Nuclear Medicine stress tests on our patients daily. Both myself, and the cardiac stress tech are ACLS certified. The question I have is if a patient has a cardiac event or full-on code; are we legally allowed to push medications the NP or PA order? They are in the room with us while doing 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 Technologist administer radioactive tracers and Lexi scan under our license. Would epinephrine or other ACLS drugs be approved to administer as well?

The answer is dependent upon the policies of your institution. Some cardiac catheterization laboratories utilize technologists to give medications and others forbid it. Those decisions are made on an institutional basis.

Can tell me what age ACLS treats down to? I have heard multiple numbers, from 14 y/o, 16 y/o, to 18 and above. This question recently came up from our GI lab which 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. With that said, any nurse has within their scope of practice the administration of acute care medications. However, I believe that a nurse 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 and so 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 is under 5 minutes. For use of an AED outside critical care 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 symptoms onset, or up to 4.5 hours of symptom for some indications. Refer to tPA administration guide.

What is Adenosine given for?

Adenosine is the treatment for 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) therefore oxygen needs are much lower. It is this concept that “hands-only CPR” for lay persons is based.

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.

PALS or ACLS for shorter individuals?

In adults of small stature, should ACLS or PALS be used? In other words, is weight-based dosing appropriate for small adults (i.e., 20 kg)?

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. The whole dose would use adult doses. This would include medications like epinephrine 1 mg or Amiodarone 300 mg during the arrest.

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 simply puts forth “treatment recommendations” based on current science. It is always up to the licensed provider to practice medicine according to what he/she determines to be best for his/her practice. There is no “administration” on any subject that tells physicians how to practice medicine. They carry their own liability and peer review process.

What age range is covered under PALS?

Pediatric is defined as ending at puberty. However, it is acceptable for pediatric tertiary hospitals to use the definition of “end of the 18th year” and most do. PALS is aimed at the infant (under one) and child age groups (puberty or 8). After that age adult CPR is applicable and given body weights (averages) adult doses begin to safely apply.

Is ACLS required for giving ACLS medications?

There is no requirement anywhere that says anyone must be ACLS certified. Most regulatory agencies do however require training in resuscitation for anyone administering or monitoring patients receiving anesthesia or sedation. Most facilities utilize ACLS or PALS to fulfill this need, but it is not a requirement.

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

If you are talking about ACLS and PALS, yes they are good worldwide. If you are talking about your EMT certification, no, you will need to complete whatever your new state requires.

What is the treatment for PEA?

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

Can pVT evolve to PEA?

Yes, PEA can be the result of defibrillator VF or VT but the treatment for PEA remains the same in this scenario. CPR, epinephrine, and searching for a reversible cause.

NIHSS prior to CT Scan without contrast

Yes. The NIHSS stroke scale needs to be completed prior to presenting the patient to the neurologist; however, the CT is the number one priority and nothing but life threats should delay it. The main reason is logic. If the CT is positive for head bleed, the entire process changes. You are no longer against a clock for thrombolysis. Once the CT is done, the rest of the checklist for rTpa can be completed. If the CT is positive for bleeding, then the checklist is completely unnecessary.

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

No, what it means is if the CT scanner is available, do it and do the ECG after the CT. You want the CT done as early as possible so that a diagnosis can be made.

Is a crash cart required for each treatment location?

Yes, each room that you are doing procedures in would need a crash cart. You should have a crash cart in every exam room. Having one crash cart at one satellite office will not help you to save someone at the other two offices. For example, if you keep one crash cart in each office and you just so happen to have two people suddenly crash on you that same day (very unlikely, but very possible) and on the first person you used the medication that you also needed on the second person, your crash cart is no longer ready to go and fully equipped after its use from the first patient crash!

Is atropine recommended for second degree type two & 3rd degree?

The bradycardia algorithm recommendation remains “in the absence of immediately reversible causes, atropine remains the first-line drug for acute symptomatic bradycardia. If atropine is ineffective transcutaneous pacing may be employed. Dopamine and epinephrine may be successful as an alternative to transcutaneous pacing.” There is a side note to “not rely on atropine in Mobitz II or 3rd degree heart block if you know it is likely to be an intranodal tissue block such as the bundle of his or more distal conduction system. However, in an acute event, it is unlikely that this diagnosis can be easily made and therefore atropine remains first-line. (C) 2016 American Heart Association. ISBN 978-1-61669-400-5 First printing March 2016. Page 124–125

How do you perform synchronized cardioversion?

A monitor set for synchronization must have an organized rhythm to “sync” to. It uses the R wave to time the delivery of the shock. The monitor must be turned off the synchronization mode immediately and turned to defibrillation or it will not discharge at all. The defibrillation dose in general doubles that of synchronized cardioversion. Check your manufacturer’s guidelines, but most are 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 indication. The ST segment does not start at the T wave though, it ends (ST) at the T wave and begins at the end of the QRS, thus labeled ST. Any deviation above or below by 1mm (one small square) is clinically 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 the requirement for hospital transfer from a stand-alone surgery center? For example, if we were to give atropine secondary to bradycardia and the heart rate recovers back within normal range is that patient then required to be transferred to the hospital for continued patient monitoring because they received atropine?

The responsibility an organization has when caring for a patient is that they need to determine if they can provide the level of care the patient requires. If the organization had a cardiac unit or intensive care unit that can provide ongoing care for the condition then it is appropriate to keep the patient, but if there is a potential of requiring higher level care or procedures that can’t do, the organization is responsible for finding an accepting facility that can provide that care. The patient also needs to be stable enough to endure the transport, this also poses the question on what level of care is required for transport for the likelihood that the patient decompensates in route. Each organization needs to have policies or guidelines on how to make those decisions, with the input of the patient of course. In your example, if expert consult deems that the patient will ultimately need a pacemaker but your hospital doesn’t do that procedure, the patient would have to go to where they do. Risks and benefits are discussed and a plan is made.

Looking for information or point me in the right direction on how the brain and sympathetic nervous system would be affected by ICD Shocks. I had an ICD Storm or VT storm and received 8 shocks in 3.5 minutes and another 4 a few days later, spent a month in the hospital. Though I’m doing OK now, I still have lingering issues 11 months later. I’ve had lots of mental help and I’m stable now but feel something inside me is damaged. I can’t seem to find any info on what happened to me looking for help

We can not give out medical advice.

I am looking for the following updated information sheets… preferably newer than 2015 so around 2020 would work. Adult cardiac arrest algorithm chart sheet Managing post cardiac arrest care: the post cardiac arrest care algorithm Managing bradycardia: the bradycardia algorithm adult tachycardia with a pulse algorithm adult coronary syndromes algorithm adult suspected stroke algorithm

Our site has all the updated algorithms. You can have a look at them here.

I work in a very small hospital in Northern California. I just found your website and am impressed with the information. We are in the process of making sure that we have current ACLS protocols and medications on our cart.
My question for this morning is that we have a Zoll defibrillator and cardiac monitor with what looks like all the bells and whistles. I have voiced concerns that our machine is consistently failing its automated self-check. It reads that the Electrode is not connected everything else reads OK. On manual checks where we charge the system at 30 j it passes without hesitation. We are checking the unit with it plugged into power, as I have been told that is the correct way. They had a representative from, Zoll come out and check the unit and was told that it fails because we are overcharging the unit? The uptake is that the unit is good to go. But the log, still shows failure on the autocheck and not the manual check that the RN does. So I remain skeptical that our unit is 100 percent electrically healthy, am I wrong to remain concerned?

I would have the representative show me how the unit will “pass” its self-check if not “overcharged”. I have never heard that phrase. I would be concerned if the “failed” documentation if the unit failed with a patient. Liability issue I would think.

One of my questions is marked as incorrect. I believe this is the correct answer as epinephrine DOES show improvement in survival to admission

I checked in with our medical experts and they were in the process of updating our exam. This particular question is one that was being revised. The lidocaine data recently changed and our exam is scheduled to be updated.

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

ACLS algorithms page.

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? I also can’t find any contraindications for why nitroglycerin is given other than hypotension. Where exactly should defibrillator pads be placed as the literature given isn’t supporting the question

EMS (or anyone) no longer intubates until Return of Spontaneous Circulation. Sodium Bicarbonate is not mentioned because it was eliminated from resuscitation guidelines in 2010. Nitroglycerin is NOT given in hypotension, in fact hypotension is a contraindication (and always has been) to the administration of Nitroglycerin. It is also not indicated in inferior wall MI with RV involvement. It is also contraindicated when taking medications for erectile dysfunction. Defibrillator pads can be placed anywhere that the heart is between the pads.

My name is Greg Bell, I’m and heart transplant coordinator in Louisville, KY. I’m looking for a standard of care or basic protocol for ACLS in heart transplant patients. Is there a standard (basic protocol/algorithm) for heart transplants & advanced cardiac life support r/t the denervated heart?

AHA does not deal with specialty practices. As a cath lab person of many years, in a cardiac transplant center, we utilized Beta such as Epinephrine or even Isuprel bolus for severe Bradycardia, although I have to be honest I can only think of once or twice it was an issue. Both transvenous (in the lab or the unit) or transcutaneous (on the floor) pacing would also benefit the patient. The most common cause of bradycardia is parasympathetic and so with that removed, it is actually quite rare. Immediately post op it can be due to sympathetic denervation or damage from biopsy. In this period bradycardia can and is managed with myocardial pacing wires. I hope this is helpful.

This question is regarding section 1 Ethics of Resuscitation. The last 2 paragraphs are confusing. “To clarify, prognostication of neurological outcome is recommended at least 72 hours after body temp returns to normal in TTM treated patients or 72 hours post cardiac arrest in non-TTM treated patients unless obviously non-survivable conditions are present?”

That is correct. If a patient who does not have non survivable conditions such as brain herniation etc. one should wait until 72 hours following return to normal body temperature. If TTM was not utilized, then decisions regarding status or withdrawal should be made 72 hours following the initial cardiac arrest.

RE: ACLS course study materials. Please define the following: rosc, ecmo, fem-fem, petco, timi, met

• ROSC: Return of spontaneous circulation
• ECMO: Extracorporeal membrane oxygenation (a form of bypass)
• FEM-FEM: Utilizes the femoral arterial and femoral vein percutaneously to assist with blood flow (partial bypass)
• PETCO₂: Measures the partial C0₂ pressure in the arteries. (Capnography)
• TIMI: As flow measurement standard
• MET: Medical emergency team who responds to floor from a critical care unit for patients with deteriorating status prior to arrest

I do not see a study material section about the EKG rhythms that the AHA requires: the specific recognition, the discerning characteristics, etc. I did notice perfunctory mentions of rhythms with an occasional EKG strip but no real study guide to the rhythm material. This was an important part of the ACLS AHA program and test. Am I missing something?

The interpretation of rhythms and their recognition are considered a prerequisite requirement for attendance in American Heart Association advanced cardiac life support courses and are not taught during the renewal or provider courses. We do have a separate monitor technician program that teaches these skills, but they are not included in the ACLS course as we model our course after the standardized requirements.

I am a RN working as a resuscitation coordinator in a hospital. I am worried your drug list is missing some drugs that are necessary in managing some of the reversible causes of cardiac arrest as and also drugs necessary for incubation. I wonder if it would be wise to include them on our crash trolley

I would need to know which drugs she is referring to before I can answer the question.

We are looking at updating our Crash Carts and came across the list you all have on your site. We have tried to locate that information in other locations. Is this just the recommended list you all think is sufficient or did it come from another source?

The list is a foundation for a basic crash cart. A crash cart has to be designed to meet the needs of your facility. There is no “required or complete” list.

Hello. My name is Bola, and I want to make an enquiry for my wife. my wife is a nurse who is interested in migrating to Canada to work. She is interested in doing a proper ACLS course, having already done one in Nigeria. I want to find out if your organisation gives recognised cerificates with a seal or stamp that will be recognised by the canadian immigration service, as she will be submitting it to the canadian government as part of her points in the point based system

I have no idea anything about immigration or medicine in Canada.

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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