Thank you for choosing SureFire CPR!

This study guide is an outline to help you prepare for your

upcoming ACLS course. Even though there is a lot of information in this guide, it is important to have
your textbook to help you review the material over the next 2 years to keep your skills sharp.
Because the course covers a lot of material in a short amount of time, there is required prestudy
material.
In the course you will be expected to evaluate and identify different cardiac emergencies. At the
completion of the course, you will act as the team leader to diagnose and treat a variety of cardiac
rhythms. Please pay special attention to the BLS review, as it is the foundation for ACLS.
Here is what you need to do before you come to class.
1. Read through this study guide (paying particular attention to anything marked with a *)
2. Go to http://www.skillstat.com/Flash/ECGSim531.html and play the 6 Second ECG Game to
practice up on your EKG skills
3. Go to this website: American Heart Association Prestudy Material and enter the password:
compression
4. Watch the ACLS Science Overview Video
5. Watch the CPR/AED Overview Video
6. Watch the Intraosseous Video
7. Watch the ACS Video
8. Watch the Stroke Video
9. Take the Precourse Self-Assessment
10. Print out your results and bring them to class!
We look forward to having you in class. If you need anything at all, please dont hesitate to call us.
Remember we also have PALS, BLS, PEARS, EKG, and NRP for your training needs as well. Thanks
again!
Take care,
Zack Zarrilli
CEO/President
SureFire CPR
(888) 277-3143
www.SureFireCPR.com

ACLS Assessment
Quality ACLS can only be built upon a foundation of solid BLS skills. There are 2 levels of ACLS care: the BLS survey and
the ACLS survey.
The BLS Survey is used if the patient appears to be unconscious. The ACLS Survey is used if the patient is conscious.

BLS Survey:
A. Check the scene for safety hazards. A safety threat to providers is an indication to stop or withhold resuscitative
efforts**
B. Check responsiveness and breathing
C. Activate the emergency response system and get an AED
D. Circulation
a. Check the carotid pulse for at least 5, but no more than 10 seconds**
b. If no pulse, start CPR
i. Hard, fast compressions. AT LEAST 100 compressions per minute**
ii. High quality compressions will produce a small amount of blood flow to and through the
heart**
iii. Minimize interruptions in compressions to less than 10 seconds**
iv. Switch compression providers every 2 minutes or 5 cycles**
c. If a pulse is present, start rescue breathing
i. 1 breath every 5-6 seconds**
ii. Do not routinely use crichoid pressure**
E. Defibrillation**
a. If no pulse, check for a shockable rhythm as soon as the AED arrives

ACLS Survey:
A. Airway
a. Make sure the airway is adequate and
protected
b. Use adjuncts if needed
c. Insert advanced airways
B. Breathing
a. Provide Oxygen
b. Confirm placement of Endotracheal
Tube
c. Monitor waveform capnography
d. Avoid excessive ventilation
C. Circulation

a.
b.
c.
d.

Establish IV/IO access

Treat the heart rate and rhythm
Monitor CPR quality
Provide defibrillation or Cardioversion if
necessary
e. Take vital signs (BP, etc.)
D. Differential Diagnosis and Disability
a. Determine the reason for the problem
b. Hs and Ts (Seen later in this guide)
c. Mental Status
d. Glasgow Coma Scale

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The Heart
Here is a quick review of the anatomy of the heart before we get into our ECG rhythms.
First, blood enters the atria of the heart and an electrical impulse is sent out from the SA node. This electrical impulse
travels through the atria causing them to contract. When the atria contract, it registers on the EKG as a P wave.
Next, the electrical impulse travels to the AV node which sends out an electrical impulse that travels through the Bundle
of His, bundle branches, and into the Purkinje fibers of the ventricles. This causes ventricular contraction which registers
on the EKG as the QRS complex.
Finally, the ventricles rest and repolarize, which is shown on the EKG as a T wave. (In case you were wondering, the atria
repolarize also, but the electrical impulse is so miniscule, you cant see it on the EKG)
Narrow QRS complexes originate in the atria (near the AV node) and wide QRS complexes originate in in the ventricles
(below the Bundle of His).

Anatomy of the Heart

ECG Breakdown

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ECG Review and Cardiac Algorithms

Pulseless Rhythms:
1. Ventricular Fibrillation
2. Ventricular Tachycardia

3. Pulseless Electrical Activity

4. Asystole
Ventricular Fibrillation

Coarse VF

Fine VF
Description: Ventricular Fibrillation (also known as V-Fib or VF) is the most common rhythm to occur immediately after
cardiac arrest. The ventricles quiver and are unable to pump blood to the rest of the body. Survival chances diminish
rapidly while in ventricular fibrillation and immediate defibrillation is essential.
There are two types of V-Fib: Coarse and Fine. Coarse VF is more easily corrected with defibrillation than fine VF. Fine
VF is more likely seen in a patient with a prolonged cardiac arrest.
Both types of ventricular fibrillation are treated with defibrillation.

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Ventricular Tachycardia (No Pulse)

Description: Ventricular Tachycardia (also known as V-Tach or VT) occurs when the ventricular focus takes over control
of the heart and fires at a tachycardic rate. The QRS complex is wide because it originates in the ventricles. This rhythm
is treated identically as V-Fib when there are no pulses.

Treatment for Ventricular Fibrillation and Pulseless V-Tach:

1.
2.
3.
4.
5.

Defibrillate
Perform CPR for 2 minutes
Quickly check a rhythm and a pulse
If another shock is needed, clear the patient and defibrillate again
Repeat this sequence until the rhythm is not shockable

Medication Sequence (Performed Simultaneously with CPR and Defibrillation):

1. Epinephrine 1mg 1:10,000 IV/IO every 3 to 5 minutes
a. Vasopressin 40 U may be substituted for the first or second dose of Epi
b. A peripheral IV is the preferred method of access for Epi administration during a cardiac arrest**
2. For refractory (persistent) VF:
a. Amiodarone 300mg IV/IO (Initial dose)**
b. Amiodarone 150mg IV/IO (second and final dose if VF/Pulseless VT persist)
3. All medications given during cardiac arrest should be administered via rapid IV/IO**

Asystole

Description: Asystole is when there is no detectable activity on the ECG. It may follow many rhythms, including VF, PEA,
or 3rd Degree Heart Block. Always ensure that all leads are attached to the patient.

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Pulseless Electrical Activity (PEA)

Description: Pulseless Electrical Activity (PEA) occurs when the heart is beating and has a rhythm, but the patient does
not have a pulse. For example: Sinus rhythm without a pulse = PEA**
For all patients without a pulse, CPR is the priority.

Treatment for Asystole and PEA:

1. CPR
2. Epinephrine 1mg of 1:10,000 IV/IO every 3-5 minutes
3. Consider Hs and Ts to find the root of the problem.

Consider Hs and Ts (Differential Diagnosis)

Hypovolemia (most common cause)

Hypoxia
Hydrogen ion (acidosis)
Hypo/hyperkalemia
Hypoglycemia

Bradycardic Rhythms:
Sinus Bradycardia
1st Degree AV Block
2nd Degree Block (Type I)

Toxins
Tamponade, cardiac
Tension pneumothorax
Thrombosis, coronary
Thrombosis, pulmonary

2nd Degree Block (Type II)

3rd Degree Block

Sinus Bradycardia

Description: Sinus bradycardia occurs when the SA node fires at a rate that is too slow for the persons age. For adults,
this is less than 60 beats per minute. Many athletes have a resting heart rate of less than 60, so it is important to only
treat patients that are symptomatic (fatigue, dizziness, hypotension, altered mental status, etc.)

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1st Degree AV Block

Description: In a first-degree AV block, everything is normal except for a prolonged PR interval. The interval is longer
than .20 seconds (or 5 small boxes on the ECG strip). This conduction delay in the AV node rarely causes any problems.

2nd Degree Block (Type I - Wenckebach)

Description: Second Degree, Type I block occurs at the AV node. The PR interval gets progressively longer until it drops
the QRS complex. You can see 2 dropped QRS complexes on the strip above.

2nd Degree Block (Type II - Mobitz)

Description: Second Degree, Type II block occurs below the AV node. The P waves are regular, but QRS complexes are
dropped. The electrical impulses fail to pass through the AV node which results in atrial contractions that are not
followed by ventricular contractions. This rhythm is more serious than the 2nd Degree Type I, and pacing is usually
recommended.

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3rd Degree Block

Description: 3rd Degree, or Complete Heart Block is characterized by no communication between the SA and AV nodes. P
waves and QRS complexes will be completely independent of each other. The ventricles will generate their own
electrical signal through an accessory pacemaker in the lower chambers. The location of this Escape Pacemaker will
determine if the QRS complexes are wide or narrow (Junctional = Narrow QRS, Ventricular = Wide QRS).

Treatment (if symptomatic):

1. Oxygen
2. Atropine .5mg (Repeated every 3-5 minutes to a max dose of 3mg)**
a. Though atropine is now recommended for symptomatic bradycardia, it will probably not work in
high degree heart blocks (2nd Degree Type II or 3rd Degree)
b. In truly symptomatic patients, Atropine is first line treatment,** even before Oxygen!
3. Prepare for Transcutaneous Pacing (TCP) if needed
4. If, at any point, airway or breathing become compromised, treat patient with simple airway maneuvers and
ventilation.**
As an alternative to TCP, chronotropic drug infusions are also available:
Dopamine IV infusion (2-10 mcg/kg/min)**
Epinephrine IV infusion (2-10 mcg/min)
For patients in respiratory failure with rapidly dropping heart rates, assisting with ventilation and simple airway
maneuvers are the highest priority.**

Tachycardic Rhythms:

Sinus Tachycardia
Supraventricular Tachycardia
Monomorphic Ventricular Tachycardia

Polymorphic Ventricular Tachycardia

Torsades de Pointes

Sinus Tachycardia

Description: Sinus tachycardia occurs when the SA node fires at a rate that is too fast for the persons age. For adults,
this is generally between 101 and 150 beats per minute. In sinus tach, all of the normal components of an ECG are
present (P waves, QRS complexes, and T waves). Sinus tachycardia usually starts and stops gradually and is the result of
pain or another cause that can be identified (fever, exercise, etc.)

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Supraventricular Tachycardia

Description: Supraventricular tachycardia, or SVT is a category of rhythms that have indistinguishable P waves due to a
rate greater than 150 bpm. The P waves typically run into the preceding T waves. These rhythms have narrow QRS
complexes because the impulses are generated above the ventricles (Supra = above). Specific SVT rhythms include: Atrial
Tachycardia, Junctional Tachycardia, and occasionally Atrial Flutter, Atrial Fibrillation, and Sinus Tachycardia.

Stable Treatment:
1. Vagal Maneuvers**
2. Adenosine 6mg rapid IVP**
3. Adenosine 12 mg rapid IVP (2nd dose)**

Unstable Treatment:
1. Sedate patient if possible
2. Prepare for immediate Cardioversion.**
a. Consider 6mg Adenosine if time
For Irregular SVT consider Beta Blockers and Calcium Channel blockers

Monomorphic Ventricular Tachycardia (with pulses)

Description: In monomorphic V-Tach the QRS complexes are the same size and shape.

Stable Treatment:
1.
2.
3.
4.

Seek expert consultation

Adenosine 6mg rapid IVP
Adenosine 12 mg rapid IVP (2nd dose)
Consider Amiodarone Infusion of 150mg over 10 minutes

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Unstable Treatment:
1. Sedate patient if possible
2. Prepare for immediate Cardioversion. **

If No Pulse:
1. Defibrillate and begin CPR

Polymorphic Ventricular Tachycardia (with pulses)

Description: In polymorphic V-Tach the QRS complexes are different sizes and shapes.

Treatment:
1. Polymorphic VT is treated the same as VF Defibrillate and begin CPR

Torsades de Pointes

Description: In Torsades de Pointes the QRS complexes are different sizes and shapes in a twisting pattern. This

rhythm can be caused by low potassium or quinidine toxicity. Magnesium is the preferred treatment.

Electrical Therapy Basics

There are three types of electrical therapy: Defibrillation, Cardioversion, and Transcutaneous Pacing. Here is a
quick review on how to do all three.

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How to Defibrillate
1.
2.
3.
4.
5.

When the AED or defibrillator arrives, turn it on

Place the pads on the patients chest according to the AED instructions or your protocols
Allow the AED to analyze the rhythm (or analyze it yourself on a manual defibrillator)
Prepare to shock by selecting the correct amount of Joules
Press Charge Announce Charging
a. Continuing compressions while charging helps minimize interruptions in chest compressions
while performing CPR.**
6. Clear the patient! Make sure no one is touching the patient or bed
7. Press the shock button
8. Immediately resume CPR following the shock

AED Reminders:

If the AED does not promptly analyze the rhythm, begin chest compressions.**
Oxygen should not be blowing over a patients chest during a shock (for safety)**
The advantage of hands-free defibrillation pads is that they allow for more rapid defibrillation**
High quality compressions immediately after defibrillation increase the chance of conversion from VF**

How to Perform Synchronized Cardioversion

1.
2.
3.
4.
5.
6.
7.
8.
9.

Consider sedation
Turn on defibrillator
Place electrodes on patient according to manufacturers instructions
Press SYNC button
Look for markers on R waves indicating Sync mode
Select appropriate energy setting
Press Charge Announce Charging
Clear the patient make sure everyone is clear and there is no oxygen on the patient
Press the shock button
a. This could take a second while the machine determines the correct shock timing
10. Analyze the rhythm again, if no conversion, increase the joules and repeat.

Recommended Initial Cardioversion Dosages:

Narrow regular: 50-100 J Biphasic

Narrow Irregular: 120-200 J Biphasic / 200 J Monophasic
Wide regular: 100 J Biphasic
Wide irregular: Defibrillation dose (do not sync)

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How to Perform Transcutaneous Pacing

1.
2.
3.
4.
5.

Consider sedation
Place electrodes on patient according to manufacturers instructions
Turn on Pacer
Set the pacing rate
Slowly increase mA (Milliamps) until capture is achieved with corresponding pulses.
a. Capture is characterized by a wide QRS complex with a tall, broad T wave. Pulses will
correspond to the monitor.

Below is a picture of what you should be looking for with successful transcutaneous pacing:

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Airway Basics
Adjuncts

Nasopharyngeal airway (NP)

Used in semi-conscious patients
NP Airway
Measured from the tragus of the ear to the corner of the nose
Contraindicated in head injuries

Oropharyngeal airway (OP)
Used in unconscious patients with no gag reflex
Measured from the corner of the mouth to the angle of the jaw**
Advanced Airways
0P Airway

Endotracheal Tube
The ideal airway for most patients
When suctioning an ET tube, suction during withdrawal for no longer than 10 seconds.**
When using ties that secure the ET tube around a persons neck (Tube Tamer) make sure the tie
does not obstruct venous return from the brain.**
Continuous waveform capnography is the most reliable method of confirming and monitoring ET
tube placement.**

Laryngeal Mask Airway (LMA)
Used by providers not familiar with ET tube intubation

Once an advanced airway is in place, compressions and breaths are asynchronous.
100 compressions per minute Do not stop compressions for the breaths!
8-10 Breaths per minute (1 every 6-8 seconds)**
Endotracheal (ET) Tube
Oxygen Delivery
If delivered through a non-rebreather mask or bag valve mask (BVM), O2 should be set at 10-15LPM.
Adult rescue breathing should be at a rate of 1 breath every 5-6 seconds
Capnography and pulse oximetry should be used when available
Post cardiac arrest oxygenation should be kept between 94-99%.**
Beware of administering high concentrations of Oxygen in post-ROSC patients due to potential oxygen
toxicity and reperfusion injury.**
Waveform Capnography (PETCO2)
Continuous waveform capnography is the most reliable indicator of proper ET tube placement.**
Capnography in intubated patients provides information about the resuscitative efforts
Normal capnography ranges are from 35-40mmHg
Quantitative capnography allows for monitoring of CPR quality.**
Readings of less than 10mmHg indicate that chest compressions may not be effective.**

A rapid rise in PETCO2 can be the first

indication of the return of spontaneous
circulation (ROSC)

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Stroke
Signs and symptoms of a stroke:

Sudden weakness or numbness of the face, extremities, or on one side of the body
Loss of speech or difficulty speaking
Loss of vision, especially in one eye
Sudden severe headache
Difficulty standing or walking with any of the symptoms above

Treatment:

Support ABCs
Evaluate using the Cincinnati Pre-Hospital Stroke Scale**
o Facial Droop
o Arm Drift
o Slurred speech You cant teach an old dog new tricks
Check blood sugar
Establish stroke onset time
Transport to the nearest Stroke Receiving Center
Upon arrival to the emergency department, the head CT scan is the priority.**

Stroke patients must be transported to the appropriate stroke receiving center with CT capabilities. If a hospitals CT is
down, divert to the next closest hospital with CT capabilities.**

Acute Coronary Syndromes (ACS)

ACS can be divided into 3 groups:
1. Unstable Angina
2. ST segment elevation MI (STEMI)
3. Non-ST-segment elevation MI (NSTEMI)

Signs and symptoms of ACS:

Chest pain that radiates to the jaw or down the left arm
o These classic signs are typically more subtle in women
and diabetic patients
When in doubt, always perform a 12-lead ECG**

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Treatment of ACS:

Support ABCs
If patient is unconscious and not breathing normally, begin CPR and prepare to defibrillate
If stable:
o 12-Lead ECG**
o Oxygen
o Aspirin 160-325mg (if not already given by EMS)**
o Nitroglycerin 3 doses SL (if systolic BP is >90mmHg and there has been no Viagra, etc. in the past 72
hours, no indication of right-sided-infarct, no marked tachy or brady arrhythmia)
o Morphine 2mg increments if nitroglycerin does not relieve chest pain
o Labs
o Chest x-ray

The rapid response team (RRT) or medical emergency teams (MET) primary purpose is identifying and treating
early clinical deterioration.** Call the MET team as soon as possible!

BLS for the Healthcare Provider Review

The Basic Steps of BLS / CPR
1. Check the Scene for Safety As Soon As You See A Potential Victim**
2. Tap the Person and Shout, Are You OK?
3. If No Response, Have Someone:
a. Call 911 or a Code
b. Get an AED
c. Come Back
4. Look for Normal Breathing
5. If No Normal Breathing, Check the Carotid Pulse (Brachial for Infants) for 10 Seconds or Less**
6. If No Pulse or you are unsure whether they have a pulse start chest compressions**
7. Continue until:
a. An AED Arrives
b. Paramedics or Rapid Response Team Take Over, or
c. The Victim Starts to Move
CPR should be performed on victims that have no pulse and no normal breathing within 10 seconds.**
A common but fatal mistake in cardiac arrest management is prolonged interruptions in chest compressions.**
Interruptions in chest compressions should be 10 seconds or less.**
If there is no suspected neck injury, the best way to open the airway is with a head-tilt, chin-lift.**
For Children and Infants, CPR should be started if there is no normal breathing, signs of poor perfusion, and a pulse of
less than 60 beats per minute

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Hand Placement for Adult CPR

2 Hands on the lower half of the breastbone**

Hand Placement for Infant CPR

1 Rescuer - 2 Fingers on the Center of the Chest

2 Rescuers Encircling Thumbs Technique**

2 Finger Infant CPR Hand Placement

What if they have a pulse, but arent breathing effectively?

You will start rescue breathing
Your breaths should last 1 second and make the victims chest rise**
o Adults (1 Breath every 5-6 Seconds)**
o Children (1 Breath every 3-5 Seconds if the pulse is >60)

12-20 breaths per minute**
o Bag Mask devices are not recommended for 1 rescuer CPR.**
2 Rescuer Encircling Thumbs Technique**
AED Review
The first thing to do when an AED becomes available is to turn it on.**
As soon as an AED is available, it should be used.**
If the AED does not immediately analyze the rhythm, resume compressions **
After a shock from the AED, immediately resume compressions.**
Hands-free pads allow for more rapid defibrillation**
Adult pads may be used on pediatric patients if pediatric pads are not
available.**

Pulse Check Locations

Children Carotid Artery
Infants Brachial Artery**
Compression Rate
At least 100 per minute** (The same beat as the song Stayin Alive)
Every 2 minutes or 5 cycles of CPR it is important to switch compressors**
Compression Depth
Adults At least 2
Children and Infants At least 1/3rd the depth of the chest**
High quality chest compressions = allowing complete chest recoil**
Compression to Ventilation Ratio
Adults 30 Compressions : 2 Breaths**
Children and Infants (1 Rescuer) 30 Compressions : 2 Breaths
Children and Infants (2 Rescuers) 15 Compressions : 2 Breaths**
After an Advanced Airway (Endotracheal Tube or Combitube) is placed the ratio changes

Compressions are Continuous at 100 per minute**

Breaths are 1 every 6-8 seconds (8-10 ventilations per minute)**

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Choking
The best way to relieve severe choking in a responsive infant is with cycles of 5 back slaps followed by 5 chest
thrusts.**
For conscious adult victims, encourage the person to cough until they can no longer breathe. At this point, ask
for consent to help and perform abdominal thrusts (Heimlich Maneuver) until the object is expelled or the
person goes unconscious.
If a victim of foreign-body airway obstruction becomes unconscious, send someone to get help and then start
CPR, beginning with compressions.**

Post Resuscitation Care

After return of spontaneous circulation (ROSC), patients can display a wide variety of responses. Some may become
awake and alert, while others remain comatose. After we achieve return of spontaneous circulation (ROSC) it is
important to continue to provide cardio-respiratory support through the ABCDs.
Airway
o Optimizing ventilation and oxygenation is the first priority for patients who achieve ROSC.**
Breathing
o Look for a PETCO2 range of 35-40mmHg on the waveform capnography.**
Circulation
o For hypotensive patients who achieve ROSC, a 1-2 L bolus of IV fluid is recommended.**
o The minimum systolic blood pressure one should attempt to achieve in a hypotensive ROSC patient is
90mmHg.**
Differential Diagnosis (12 lead, Hs, and Ts)
A healthy brain is the primary goal of CPR and it has been shown that therapeutic hypothermia, 32-34 degrees Celsius,**
for 12-24 hours may be beneficial for patients who remain comatose after ROSC. This may also be considered in children
and infants. Therapeutic hypothermia is not indicated when the patient is responding to verbal commands.**
If possible, all out-of-hospital cardiac arrest victims who gain ROSC in the field should be transported to a PCI-capable
facility,** such as a cardiac receiving hospital, or a facility with a cardiac catheterization laboratory.

Code Termination
If Asystole has been persistent for 25 minutes or more despite medication and high quality CPR, consider terminating
resuscitation after consulting medical control.** In cases with obvious signs of death (rigor mortis** etc.) it is
appropriate to withhold resuscitative efforts.

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Megacode Cases
At the end of the course you will lead a resuscitation team to provide care for a patient with cardiac complications.
There will be multiple rhythm changes during the scenario, so please study the algorithms in this study guide and in your
student manual to help you prepare. The 6 roles of your team members will be: Team Leader, Airway, Medications, BLS,
Monitor/Defibrillator, and Recorder. The Megacode cases will be conducted in a low stress environment to help you
implement the skills that you will learn in the course.

What to Expect
1. Please come 10-15 minutes early to class to check in so that we can start on time.
2. Wear comfortable clothing, if you have long hair we recommend you bring a hair tie for the CPR portion of class.
3. Feel free to bring food and drinks to class. We have a refrigerator and microwave for you to use if you need
them. (We also have snacks and drinks for you in case you get hungry.)
4. We like to keep our classes small so that you have the best learning environment possible.
5. We promise to do whatever we can to make your experience fun, stress free, and educational.

Thank you again for taking our course and for your dedication to helping save lives. We look forward to seeing you in
class and hope this study guide helps you prepare. If you have any suggestions on how we can make this guide or your
course better, please let us know!

** Starred material relates to test questions.

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