Please define "passive" ventilation.

Passive ventilation is practiced by EMS. A non rebreather 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 remains an EMS practice.

On page 3 regarding defibrillation (Section 1: Advanced cardiac life support): statement at top of page says, "The in-hospital goal is defibrillation within 5 minutes." HOWEVER, at the bottom of the same page: "Recommendation: AED provides for defillation under 3 minutes." Is the recommendation "within 5 minutes," or "under 3 minutes?"

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

In Section 1 of ACLS, is it PETCO2 that is being referred to, or is it carbon monoxide? (CO). I think it is pulmonary end tidal CO2, but wanted to make sure.

It is pulmonary end tidal CO2

Is this the most current up to date Algorithm on the ACLS Suspected Stroke Algorithm page. I note there is no mention of the 3–4.5 hour window.

Yes, it is. It is scheduled to be updated in October of 2020. The time window is discussed in the course as an indication to enter the algorithm.

Adenosine doses not discussed for narrow complex tachycardia. 12mg followed by 6mg? Or have I overlooked? Adenosine has a big role in ACLS and I was surprised it was barely mentioned in the text portion of your website. It’s covered more on the algorithms but I think it deserves more attention in the text.

The dose for Adenosine is 6mg followed by 12mg. The only role that Adenosine plays is in the treatment of REGULAR narrow complex tachycardia and in limited cases to differentiate regular wide complex. There are no medications that play a big role as even in cardiac arrest, no medication has increased the likelihood of neuro intact survival. Medications have been shown only to increase return of spontaneous circulation to admission NOT to discharge.

As nursing students, we should learn the ACLS protocols thoroughly, according to the guidelines of the American Heart Association. Unfortunately, we found some disagreements about the dosage of dopamine in ROSC protocol, and in Bradycardia protocol: The Bradycardia protocol writes 2–10mcg/kg The problem is that at the ROSC protocol wrote in some versions 5–10mcg/kg, and in other versions we saw - 2–10mcg/kg also, as Bradycardia' protocol. We would like to know what is the most correct dosages at both of the protocols?

They are both correct. One is used to increase heart rate and one is used to maintain NP following arrest.

How does 200 compressions equal 3 cycles?

The “rates” recommended by AHA have never represented the “number of compressions in a minute”. They recommend the speed at which compressions are delivered.

Ventillation rate in pulseless patients vs patients with a pulse

Why is the ventilation rate different with a pulseless individual versus an individual with a pulse? What is pathophysiology?

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?

I am presently setting up a training for some surgeons at a private clinic that provides surgical procedures to adults and one of my guys told me that he has the PALS certification and does not understand why he should need to be recertified with ACLS. Can you explain the difference in the two trainings and confirm if this particular doctor would need ACLS certification as well.

PALS empasizes 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 hypovolmeia. The list of difference 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 body weight, for example, Dopamine at 2–10ugms/kg/min. Whole dose would use adult doses. This would include medications like Epinephrine 1mg or Amiodarone 300mg during arrest.

Word choice in course: Beta-blocker versus propranolol

In your material you state that Propranolol should not be used with Cocaine overdose. It would be clearer to state that any Beta Blocker should not be used. The way it is phrased, some might interpret that other B-Blockers could be used.

The statement about propranolol is directly from AHA ECC guidelines and we state that we follow those guidelines so we should. I recognize that in many cases everyday practice differs as each and every practitioner has the right and even expectation to Practice and so there are many deviations. AHA simply writes recommendations based on their interpretation of current science.

Asystole: ACLS protocol with no doctor present

Just for clarification I am ACLS provider my ACLS still valid till November 2019 and I am working in ICU as RN if the patient asystol and there's no Doctor available can I give the medication as ACLS protocol without Dr order

No you cannot. It depends upon the standing riders within your hospital. Any hospital can write standing protocols for nurses on any subject.

PALS algorithm not followed

If I have a complaint about doctor who holds a PALS card but didn’t follow the recommendation guidelines. Who do I contact with/in pals administration.

PALS certification is simply recognition of completion of a continuing education course. The AHA simply puts forth “treatment recommendations” based upon 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. "​.

Information on Acute Coronary Syndromes Algorithm

Is there a mistake on your PDF? Under the top O2 box, it reads "O2 sat > 90% with COPD," indicating you would apply O2 if the SpO2 was over 90%.

Oxygen is withheld in the absence of shortness of breath unless oxygen saturation is less than 90% in patients with COPD. In absence of air hunger for others it is 94–99%. A recent change directs that supplemental oxygen be withheld in the absence of air hunger and the suspected presence of ischemia (acute coronary syndrome or CVA) until oxygen saturation falls to 90% as well. This is not reflected in the algorithm as it is a recent update to science guidelines.

What is the age range covered by PALS?

Age range covered under PALS

Can you assist me with the age group that is covered under PALS ? I have a hospital indicating that PALS is up to age 18 - when online and everything I am reading is indicating Puberty or ages 12ish /...

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.

ACLS for giving ACLS meds requirement: Fact or fiction?

I work as 1 out of 6 sole RNs in a Urgent Care. All the RNs, except for a few who reapplied, were replaced with MAs a few years ago. RNs were required to have BLS,ACLS,TNCC and ENPC (PALS included in ENPC). The Urgent care clinics have the usual crash carts and we do have many MIs,SVTs and PSVTs present to the clinics. 911 is called, but IVs are started (by the RN or provider) and treatment is begun. My ACLS is up for renewal soon, unfortunately I am on leave, so money is extremely tight. I emailed my manager for the company to assist in paying for this, but was informed “ACLS is not a part of my job description, so we will not pay for the class." The manager is non medical, so it's difficult to get “medical related” questions answered. MY QUESTION IS: Shouldn’t a RN be required to have ACLS to give ACLS meds and be able to provide ACLS measures with the Provider? Why even have a crash cart with ACLS meds?

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.

Tachycardia with Pulse Algorithm

In your Tachycardia with Pulse Algorithm, it's written "Second dose 12mg if required". Following the AHA recommendations, we have the option to give also a third 12mg dose. God bless you!

I just re-read four resources from AHA and none recommend a third dose of Adenosine. They are all limited to a single 6mg dose followed by a single 12mg dose. This was permitted in 2010 guidelines though.

Medications and supplies for non ACLS certified RNs in a cardiology office

Hi. I am a RN working in a cardiology office. Was wondering what medications I should keep on hand? And what supplies? Not all of the RNs in the office are acls certified and it is not a requirement to work here.

That would depend upon what you are Doing in the office. If you are doing just clinical that’s up to you. If you are doing stress or stress echo then it is different

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

Hi, I had a question. I am a registered EMT in Nebraska, and want to move to South Carolina. Do I need to complete my courses and certification again, or do I just sign new paperwork and pay a fee? Thank you for your help and time. Brittany H.

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

Stopcocks

I am working on an education update sheet for my nurses. I work on a Pediatric Cardiac floor. Adenosine is given from time to time. I was researching to find the best technique. I found a photo from the PALS Provider Manual of 2002 in an article from Pediatric Emergency Care 2007, titled Emergency Department Management of the Pediatric Patient with Supraventricular Tachycardia. I have attached the photo. We have always only used one stopcock and wanted to know the rationale for the use of 2 stopcocks. Perhaps an updated technique has been demonstrated to be more effective. Can you provide me with any further information. We are just looking to find the best technique.Thank you. Regina, H. Riley Heart Center, IU Health.

A single stopcock works fine. They are using a manifold that by design has input for multiple infusions. As long as you have immediate flush following fast bolus you are fine.

QUESTION #1 of 3: PEA and pulseless VT/VF

For the cardiac arrest algorithm pVT/VF, I am wonder that will PEA happened follow by a pulseless VT/VF after AED? JUDY's REPLY.....

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.

QUESTION #2 of 3: PEA and pulseless VT/VF

Thanks for your support.... But my meaning is that “Will pVT/VF and PEA exit on the same scenario”? Such as a patient developed pVT, AED was given and later he/she developed PEA, will this happen?

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.

Questions 3 of 3: PEA and pulseless VT/VF

Could I ask one more question that: “how frequent will this situation happen?

There is no way to tell. It depends on what is going on with the patient, the condition of their myocardium and underlying illness.

NIHSS Prior to CT Scan without contrast

How important the NIHSS is prior to CT scan without contrast? Can it be done immediately after the CT scan by an ED doctor (in the table while the machine is processing the images/Neurology is getting the first impression)? Will the NIHSS score prior to CT change anything regarding the patient treatment/decision?

Yes. The NIHSS stroke scale needs to be complete 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 bleed, then the checklist is completely unnecessary. I hope this helps with your question.

My name is Hugo Arsenio and I'm a Staff Nurse in a Stroke Center. Regarding the Adult suspected stroke algorithm (https://www.acls.net/acls-suspected-stroke-algorithm.htm) I need clarification regarding the time ECG should be preformed. On Step 4 of the algorithm you mention that "Obtain a 12-lead ECG and assess for arrhythmias." followed by "Do not delay the CT scan to obtain the ECG..." What do you mean by "do not delay the CT Scan." If every action from Step 4 is done except the ECG and CT team is ready to receive the patient, should I do an ECG as long as it doesn't exceed the set 25minutes goal from Door to CT or should I delay the ECG until after the CT Scan is done?

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 diagnosis can be made.

Tachycardia and adenosine dosage

On your website under managing stable tachycardia, you state, " give adenosine 6 mg rapid IV push. If patient does not convert, give adenosine 12 mg rapid IV push. May repeat 12 mg dose of adenosine once". This is incorrect. According to AHA Guidelines you are to give adenosine 6 mg IV push, if patient does not convert, give adenosine 12 mg rapid IV push for a total of 2 doses.

Most facility protocols permit three doses of adenosine as does the AHA. adenosine is ATP which is what your body creates for energy. It remains in your system for seconds. It is impossible to overdose on adenosine. It is used in large doses in cath labs for vasospastic coronaries, it is used for sluggish distal flow. If you read the AHA guidelines for practice you will find that the dosage of Adenosine is very widespread depending upon application. The only reason the recommendation is two-three doses is because the efficacy of adenosine in rhythms that involve the AV node is close to 100% if given correctly. If it has not worked after a couple doses the assumption is that the rhythm is bypassing the AV node or it is being given improperly.

Previous (2010) algorithm guidelines

Hello, can you provide me with algorithm information regarding the use of the algorithm for acute coronary syndromes prior to the revised algorithm that was revised with respect to the latest 2016 AHA guidelines for CPR and ECC?

The prior algorithm is dated 2010. I am sure that it maybe able to be found online, but because the treatment recommendations are outdated, we can no longer distribute it.

ACLS course questions

At my company, we selected a group of estheticians to perform a microblading service (semi-permanent tattoos for eyebrows) and had them all complete the Bloodborne Pathogens online course through your site. Some of them have mentioned that at some point when they completed or during their course there was a note about how the bloodborne pathogen test related to the hepatitis B shot. I want to know if this is something that you recommend individuals who need the bloodborne pathogen certification should also have the shot and if so, if you believe that in most places the employer is the one who pays for the hepatitis B shot.

Everyone is recommended to have the Hepatitis B series unless contraindicated by a medical condition. It has been part of the infant vaccinations for years. Employers who have blood exposure usually pay for the series as the protection relates to their job. Tattoo artists have regular blood exposure and should definitely be vaccinated.

ACLS course questions

I cannot understand the section on ethics and resuscitation. I need help understanding what is being taught, seems to be contradictory. Also, and aside. On the last exam that I failed I answered a question about who one would withhold CPR on. I answered a 22 year old suicide, and got it wrong. A suicide is dead- that is the definition of suicide. One does not resuscitate a dead person ,it is taught. An attempted suicide is sti'll alive when you engage him. What do you think of my argument. If I am correct, then I would pass the exam.

You are correct, that question is confusing. We are talking about CPR so all of the patients are assumed to be cardiac arrest, but I guess assumption can be confusing. As far as "not understanding the chapter in ethics" that is a pretty broad statement. If he has specific questions regarding the AHA recommendations and opinion regarding ethics in resuscitation I would be glad to answer them, but it is difficult to review the entire chapter in the answer to a question.

ACLS course questions

On the study material, Section 5, under "Priorities of Care", the 6th one down, - Quantitative waveform capnography If PETCO Is all that is supposed to be there. is there any wording or definition missing? (If PETCO?) what else should be there?

PETCO < 10 mmHg compressions are inadequate and need to be addressed.

ACLS exam questions

Thanks for offering this service. However, I had issues with some of the exam questions. First, one question asked for the preferred drug administration route among peripheral IV, central venous catheter, interosseus and endotracheal. I selected "central venous catheter", which apparently was incorrect. In a code situation, if you have a working patent central venous line, I seriously doubt anyone would choose a peripheral line, interosseus or endotracheal over a central line for pushing emergency drugs. *Second, there was a question about a "tube tamer" (circumferential tie). This "tube tamer" was never mentioned in the ACLS course review material. Third, there was a question about how to choose the appropriate size of a King Airway. This information was also omitted from the course material. Otherwise, I thought the online review material was appropriate for the certifications that I pursued. I have forwarded your website to my credentialing officer, for anyone looking for a quick & convenient way to get ACLS/BLS/PALS certified.

AHA writes it's recommendations geared toward EDs and EMS. It is not assumed that a central line is in place. Obviously if that is the case you are correct. However, given time required for placement in MOST areas of practice, AHA recommends the use of peripheral access.

The use of a circumferential tie to keep ET tubes in place is discussed under intubation. The worry is that compression of bilateral carotid arteries or occlusion of venous return can occur if they are placed tight and therefore are not recommended.

King airways are sized by patient height and are listed in the packaging for the airway.

Adenosine push and telemetry

I work on a med-surgical unit with very limited telemetry. The topic of being able to push adenosine on the telemetry side has come up. Any information that supports either in favor or not in favor of giving adenosine is ok to give in this type of environment would be greatly appreciated.

Adenosine – requires cardiac monitoring as a diagnosis of regular narrow complex tachycardia (indication for adenosine) or wide complex stable tachycardia with unknown origins. Adenosine is very safe. It is ATP, which is what the human body produces for energy. It is impossible to overdose a patient on adenosine as it disappears within seconds of administration. There are non black box warnings for this medication. It is a standard ACLS medication. Common reactions include flushing, SOB, chest pain, nausea, headache and lightheadedness but all resolve within the seconds that the drug remains in the system. It is common for the patient to have pause as adenosine will stop AV Nodal conduction but this too self resolves within seconds. With that said, smaller (non-tertiary) hospitals are sometimes very cautious about what medications they permit to be given outside of the ICU. However, adenosine is approved for use in EMS (ambulances) and is regularly administered by nurses in emergency departments, catheterization laboratories and just about every other unit in most hospitals. Hope this helps with your question.

Proper Number of Leads to Use

Can use just 5 leads on a 12-lead machine and get the same results. That is my understanding.

If it has a monitoring screen, then yes. If it is designed for "static" EKGs, then no.

Cardiologist Certifications

I am checking with my manager to see what certifications are needed for cardiologist doctors for the USA. (FYI, just moved from Canada and not going back to Canada).

There is no national legislation regarding credentialing for cardiologists in the United States. The only regulations relate to medicare/medicaid payment. On the state level, each state has its own physician licensure requirements. Generally this requires completing AMA-accredited continuing education (which our courses have) and practicing in a medical group. Persons doing surgery will also require ACLS as every state has a law about that. I am not aware of any state that has additional requirements for cardiologists other than baseline physician requirements.

PETCO Meaning

What is PETCO?

PETCO. Partial (pressure) end tidal C02. It is what is measured utilizing capnography.

Why do waves on ECG strips go down instead of up?

I'm noticing when I look at the ECG strips some of the waves from the heartbeats go down instead of going up on the paper. Why is this?

Crash Carts for Multiple Locations

I am in charge of OSHA at our office and was wondering, since we have 3 satellite offices, do we need a crash cart at every office? What are the basics that we would need?

Do you do procedures in each location and have more than one procedure room per location? If so, then 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!

Atropine for Mobitz II & 3rd Degree

I was told not to give Atropine to a patient in MOBITZ II or 3rd degree and to go straight to transcutaneous pacing. Could you please verify this?

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 infranodal 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

Synchronized Cardioversion for Pulseless

If I have a patient that I have synchronized cardioverting due to vtach, then the patient goes pulseless, will the monitor continue to synchronize shock the rhythm? I know you would immediately defibrillate if it's witnessed, but what if you sync cardiovert and the patient goes pulseless? Will it continue to shock at the joules and rate you've set? Or will it not recognize it? Any advice?

A monitor set for synchronization must have an organized rhythm to “synch” 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 is general double that of synchronized cardioversion. Check your manufacturer’s guidelines, but most are between 150 joules and 200 joules for the first defibrillation. Hope this helps to clear up any questions.

ASA in STEMI

Can you confirm no role for ASA in STEMI any more or ACS?

No this is not the case. The absence of Aspirin in the treatment section for STEMI and unstable angina is an oversight. It has been corrected in the new course (2016 Guidelines). Aspirin remains an important adjunct therapy to any reperfusion strategy used in infarction as well as the treatment of unstable angina for infarction prevention.

Emergent CABG

I work on cruise ships. Here on board we only have available as inhibitor of P2Y12ADP clopidogrel. In many occasions in the setting of a high risk ACS and in the middle of the sea we prescribe it; we are aware that this potentially delays treatment in case the patient requires open heart surgery when disembarked on next available port, since the medication can not be reversed. I am considering inquiring about this with my supervisors to try to persuade them to let us have available ticagrelor, since is the only P2Y12ADP inhibitor that can be reversed with a platelet transfusion in case an urgent open heart surgery is required due to trivascular disease. Would you support this as a valid reason to ask for ticagrelor to be made available on cruiseships? On the other hand, I am about to renew my BLS and ACLS in a yearly conference we have in September in Miami, but my PALS will expire next year... I will contact you then to request information about locations and dates available.

Emergent CABG is extremely rare. Most often if an acute event is occurring the patient will be treated with PCI to open the culprit vessel and other vessels will be addressed with CABG at a later date electively. No medication precludes PCI, so it is not an issue.

ST Segment Elevated or Depressed?

I know that the ST segment is normal when it is at the isoelectric line level which occurs right after the T wave. Now, what is the criteria to label such an ST segment elevated or depressed? How many mm above or below? And what if it starts below the isoelectric line level and crosses the isoelectric line to end up above? What about if it starts elevated and then crosses the isoelectric line to end up below?
Gilbert - writing from Tiffin, Iowa

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. We are going to make a clinician out of you yet!

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