ACLS Practice Quiz

Test your knowledge with our free ACLS Practice Test provided below in order to prepare you
for our official online exam. The practice test consists of 10 multiple-choice questions that are
derived from the ACLS provider handbook and adhere to the latest ILCOR and ECC guidelines.

1. What does the BLS Survey want you to assess which of the following?*

o Airway, Breathing, Circulation, Defibrillation

o Responsiveness, Activate EMS and get AED, Circulation, Defibrillation

o Airway, Blood Pressure, CPR, Differential Diagnosis

o Circulation, Breathing, Cardiac Assessment, Drugs

“Airway, Breathing, Circulation…” was the BLS survey prior to the last ILCOR
guideline revision in 2010 and has been replaced. Responsiveness, Activate EMS and get
AED, Circulation, and Defibrillation is the correct sequence in the ILCOR 2020
guidelines. Blood Pressure is not part of the BLS survey. Cardiac assessment and drugs
are not part of the BLS survey.

 2. What amount of time should ACLS providers minimize interruptions during chest
compressions?*

o 10 seconds

o 20 seconds

o 30 seconds

o 60 seconds

In the 2020 guidelines, it's emphasized that limiting interruptions to chest compressions
to 10 seconds or less. When chest compressions are interrupted perfusion to the heart and
brain rapidly drops, increasing the chance of damage due to lack of oxygen. Keeping the
 heart well-perfused increases the likelihood of return of spontaneous circulation, as well
as the effectiveness of defibrillation.

 3. The ACLS Survey includes assessing which of the following?*

o Airway, Breathing, Chest Compressions, Deformity

o Airway, Breathing, Circulation, Defibrillation

o Airway, Blood Pressure, CPR, Differential Diagnosis

o Airway, Breathing, Circulation, Differential Diagnosis

While deformity may provide clues to traumatic injury, deformity is not part of the ACLS
survey. While defibrillation is an important intervention, it is covered under “Circulation”
and is not the “D” represented in the ACLS survey. While blood pressure is an important
vital sign, it is a component of “Circulation”. In the ACLS survey the “B” stands for
“Breathing”. The ACLS survey is Airway, Breathing, Circulation, and Differential
Diagnosis.

 4. Which of the following is NOT an element of effective resuscitation team dynamics?*

o Closed-loop communication

o Clear roles and responsibilities

o Multiple leaders of the team

o Knowing one's limitations

Closed loop communication is present when team members repeat instructions back to
the team leader confirming that the instruction was heard and understood as intended.
This is an element of effective resuscitation team dynamics. Clear roles and
responsibilities allow each team member to perform tasks and be accountable for them.
Overlap and omission are both eliminated with clear roles and responsibilities of team
members and therefore are essential to effective resuscitation team dynamics. Multiple
team leaders create overlap and conflict and will reduce the effectiveness of a
resuscitation team. Knowing one’s limitations is important to effective resuscitation team
dynamics to allow roles and responsibilities to be assigned to team members proficient in
them.
 5. How can hyperventilation be detrimental?*

o Increase intrathoracic pressure

o Decrease venous return to the heart

o Diminish cardiac output

o All of the above

Hyperventilation increases intrathoracic pressure during diastole which decreases venous

return to the heart. This decreases preload which diminishes cardiac output.

 6. Which item is NOT a basic airway skill?*

o Head tilt-chin-lift maneuver

o Jaw-thrust maneuver without head extension

o Bag-mask ventilation

o Placement of laryngeal mask airway (LMA)

 7. What is the suction catheter that provides the most competent suctioning of the thick
particulate matter and oropharynx?*

o Pediatric soft flexible catheter

o Rigid catheter (Yankauer)

o Laryngeal tube

o None of the above

 8. What item is NOT an example of Advanced Airways?*

o Nasopharyngeal airway (NPA)

o Esophageal-tracheal tube (combitube)

 o Laryngeal mask airway (LMA)

o Endotracheal tube (ET tube)

 9. The compression-to-ventilation ratio during CPR for an adult prior to placement of an
advanced airway is:*

o 30:1

o 30:2

o 15:1

o 20:2
 10. What reason is NOT valid during the critical early defibrillation for individuals
experiencing sudden cardiac arrest?*

o A common initial rhythm in out-of-hospital witnessed sudden cardiac arrest is

ventricular fibrillation (VF).

o The most effective treatment for VF is electrical defibrillation.

o The probability of successful defibrillation decreases quickly over time.

o Individuals in asystole respond well to late defibrillation.

Ventricular Tachycardia
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1. What are initial steps in management?

 ABC’s
 Adenosine
 Consult cardiology
 Cardiovert

The patient is unstable and ABC’s should be addressed immediately, including airway and breathing
assessment, establishing IV, and monitor. Additionally, at this time, the etiology of the hypotension and
hypo perfusion is unknown so adenosine, cardiology consult and cardioversion can’t be considered at
this point.

2. What is the initial treatment?

 Amiodarone
 Defibrillation

 Cardioversion
 All of the above

For unstable wide complex tachycardia, i.e. with signs of poor perfusion, synchronized cardioversion is
the initial choice of management. While Amiodarone may be considered with stable or unstable
ventricular tachycardia, the initial management of unstable would be cardioversion, to hopefully convert
back to sinus rhythm.

3. The answer is:

 20J via synchronized cardioversion

 80J via synchronized cardioversion

 100J via synchronized cardioversion

 20J via unsynchronized defibrillation

The initial J/kg for cardioversion is 0.5 - 1J/kg. For patients with a pulse, it is imperative the defibrillator
be turned to the SYNCHRONIZED mode to avoid delivering electricity to the heart during cardiac
repolarization (or during the T wave). Delivering electricity during this time (during the T wave), can
precipitate ventricular fibrillation. With synchronized cardioversion, the machine senses the native QRS
complex and attempts to deliver electricity during the peak of the QRS (or depolarization of the
ventricle).
4. What is the next step in management?

 Administration of epinephrine
 Defibrillation
 Amiodarone
 Cardioversion

The patient is in pulseless ventricular tachycardia and like ventricular fibrillation, deliverance of rapid
defibrillation can be life-saving. Initiate CPR until the machine is ready to defibrillate. Make sure
everyone is “clear” prior to delivering shock.

5. Which of the following correctly describes the appropriate medication and dosing to be administered
in pulseless ventricular tachycardia?

 6mg adenosine, consider 150mg amiodarone during subsequent round of CPR

 1mg epinephrine, consider 150mg amiodarone during subsequent round of CPR

 1mg epinephrine, consider 300mg amiodarone during subsequent round of CPR

 1mg atropine, consider epinephrine during subsequent round of CPR

For ventricular fibrillation or pulseless ventricular tachycardia, the mainstay of treatment is rapid
defibrillation with administration of effective CPR. During this time, you can administer epinephrine,
1mg, and consider giving Amiodarone 300mg. The initial dose of amiodarone in a pulseless/coding
patient is 300mg, followed by 150mg if additional doses are required. For a patient that is stable
ventricular tachycardia (has a pulse, is not hypo perfused), the initial dose of amiodarone is 150mg bolus
over 10 minutes.

ACLS Megacode 2: Bradycardia

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Score: 5
Percentage: 71%
1. What type of arrhythmia is this patient experiencing?

 First-degree AV block
 Second-degree, Mobitz type I AV block

 Second-degree, Mobitz type II AV block

 Third degree AV block

Mobitz type I second degree AV block is defined by progressive PR interval prolongation followed by a
non-conducted P-wave. In contrast, in type II second degree block the PR interval remains unchanged
before a P-wave fails to conduct. Mobitz type I second degree AV block can occur due to a variety of
both pathologic and iatrogenic factors. Common pathologies include acute or chronic ischemia,
infiltrative myocardial diseases, myocarditis, and hyperkalemia. Physician induced causes include AV
blocking medications (beta-blockers, calcium channel blockers), catheter ablations, or valve transplants.

2. Given the patient’s elevated respiratory rate and an SaO2 of 90%, what is an initial appropriate step in
management?

 Initiate CPAP
 Initiate BiPAP
 2L of O2 via nasal cannula

 Endotracheal intubation

While not acutely in any respiratory distress, hypoxemia is a common cause of symptomatic bradycardia
and initiation of 2L of O2 via nasal cannula is an appropriate initial measure for patients with an SaO2
<94%. Providers should ensure ongoing monitoring of respiratory status in individuals with symptomatic
bradycardia, as they are at risk for developing pulmonary edema.

3. What medication can be given as initial therapy in this patient?

 0.5 mg bolus IV atropine

 5 mg bolus IV atropine
 0.5 mg bolus norepinephrine
 5 mg bolus norepinephrine
This patient has symptomatic bradycardia, including signs of inadequate tissue perfusion manifesting as
new onset dizziness, hypotension, and confusion. Other signs and symptoms of poor tissue perfusion
can include shock, persistent ischemic chest pain, and pulmonary edema. ACLS guidelines recommend
intervention when symptoms are likely attributable to bradycardia. Atropine is a good initial treatment
for symptomatic bradycardia, as long as there is no evidence for 2nd degree Mobitz type II or 3rd degree
heart block. Atropine works at the AV node, and is unlikely to be effective if blockages in conduction are
at or below the Bundle of His. It will also be ineffective in transplanted hearts, due to a lack of vagal
innervation.

4. While other interventions are prepared, at what dose and frequency can Atropine be delivered after
the initial dose?

 1.0 mg IV every 1-2 minutes

 1.0 mg IV every 3-5 minutes
 0.5 mg IV every 1-2 minutes

 0.5 mg IV every 3-5 minutes

Atropine can be repeated every 3 to 5 minutes at 0.5 mg, up to a total dose of 3 mg. Further
interventions should not be delayed for the administration of atropine.

5. The next best step is?

 Defibrillation

 Transcutaneous cardiac pacing

 Extracorporeal membrane oxygenation
 Synchronized cardioversion

Transcutaneous pacing should be initiated as soon as possible in bradycardic patients who are unstable,
severely symptomatic or demonstrate no response to atropine. It is non-invasive and can be performed
at the bedside. Given that the treatment can be uncomfortable, light analgesia and sedation should be
used if readily available. Unresponsiveness to atropine is not an indication for transcutaneous pacing. If
patient is stable and bradycardia, then they can be monitored. Stability of the patient dictates whether
they should be paced.

6. If transcutaneous pacing is unavailable or ineffective, which medication can be used as an alternative

next best step?
  Epinephrine infusion at 2-10 μg/min
 Norepinephrine infusion at 2-10 μg/min
 Vasopressin infusion at 2-10 μg/min
 Dobutamine infusion at 2-10 μg/min

If transcutaneous pacing is unavailable or ineffective, an epinephrine infusion can be initiated in

symptomatic bradycardic patients unresponsive to atropine. Alternatively, ACLS guidelines recommend
dopamine infusion at 2-10 μg/min – which can be either added to epinephrine or given alone. Doses for
each medication should be titrated to patient response, with continuous assessment of intravascular
volume and support as needed.

7. The next step is?

 Prepare for cardiac catheterization

 Prepare for transvenous pacing

 Continue transcutaneous pacing
 Placement of patient on heart transplant list

Patients in which transcutaneous pacing and chronotropic agents do not resolve their symptoms should
be prepared for transvenous pacing. Expert consultation should be made for further management and
evaluation for the need of permanent pacemaker placement.

ACLS Megacode 3: Ventricular Fibrillation

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1. What is the next best step?

  Intubate the patient
 Check a pulse

 Defibrillate
 Start CPR

New ACLS guidelines emphasize “CAB” circulation, airway, breathing. As such, identification of the
rhythm is imperative with regards to next steps in ACLS algorithm. An unstable patient with Vtach and a
pulse should be cardioverted. Vtach without a pulse should be defibrillated.

2. What are the appropriate Joules for monophasic and biphasic defibrillators?

 120 J for mono, 360 J for biphasic

 360 J for mono, 360 J for biphasic

 360 J for mono, 200 J for biphasic

 100 J for mono, 50 J for biphasic

Monophasic defibrillators deliver electricity in 1 vector whereas biphasic defibrillators deliver

electricity in 2 vectors.

It is possible to start at a lower J for biphasic defibrillator and increase with each shock. It is
important to know what resources you have available at your hospital or clinic. AEDs can be
either but more commonly are biphasic

3. What is the next step?

 Continue CPR, administer epinephrine

 Cardiovert
 Cease efforts
 Get an EKG

According to pulses Vtach algorithms, Cardioversion is reserved for unstable tachycardias. It is

inappropriate to cease efforts after such a short time in arrest. Do not pause CPR for superfluous testing
such as getting labs or a formal 12 lead EKG

4. What medication, other than epinephrine, can be administered next?

  Amiodarone
 Atropine
 Adenosine
 Atenolol

Dose at 300mg IV push during codes scenario.

5. What is your next step?

 Check a pulse
 Defibrillate
 Cardiovert

 Administer Amiodarone

The rhythm is ventricular tachycardia and is classified as stable, unstable, or pulseless, based on the
clinical scenario. If the patient is in pulseless vtach, early defibrillation is key, but patients with a pulse
should not be defibrillated.

6. What do you do next?

 Epinephrine
 Cardiovert
 CPR

 Defibrillate

This rhythm is vfib which is not compatible with life and is not a perfusing rhythm. The patient will not
have a pulse and should be immediately defibrillated as soon as possible. In a scenario where this is
recognized, CPR should ensue until defibrillation can occur. In this particular scenario, as patient has had
multiple rounds of CPR etc, defibrillator should be prepared and no time wasted prior to delivering
electricity.

ACLS Megacode 4: Supraventricular

Tachycardia
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1. What is the best management strategy?

 IV fluids

 Carotid massage or valsalva maneuvers

 Beta-blockers
 Calcium channel blockers

The initial rhythm is consistent with supraventricular tachycardia. The initial management in a
stable/well-perfused patient is to attempt vagal maneuvers. Appropriate vagal maneuvers include
carotid massage, valsalva, ice water application (less practical but possibly helpful in the field). Recent
studies confirm the following maneuvers followed by lifting of the legs is 40% more successful at
conversion to normal sinus.

2. What medication can be administered for therapeutic and/or diagnostic purposes?

 Adenosine

 Amiodarone
 Amitriptyline
 Atenolol

6mg followed by 12mg if patient does not convert back to normal sinus rhythm.

3. What is your next step in management?

 Administer beta blockers

 Administer calcium channel blockers

 Re-assess vitals
  Transfuse

This is sinus tachycardia. The treatment for sinus tachycardia is identifying the underlying cause. Her
tachycardia may be from any number of causes such as dehydration, anemia, anxiety, pain, etc. It is
important to not “treat a number” but rather to treat the patient. She may require tachycardia to
augment her cardiac output and blunting that response with medication may harm the patient.

4. What is your next step in management?

 Administer calcium channel blocker

 Defibrillate
 Cardiovert

 Carotid massage

This patient appears to be more unstable at this time and less perfused as she is symptomatic with light-
headedness and quite hypotensive. While you can attempt carotid massage while you are preparing the
cardioversion, the best and most appropriate management step is to cardiovert the patient.
Defibrillation in this scenario would not be appropriate as patient has a pulse. Calcium channel blockers
would not be appropriate as the patient is unstable and medications can further decrease the blood
pressure.

5. What Joules should be used for cardioversion?

 360 J
 220 J

 200 J
 150 J

Cardioversion treats arrhythmias. It looks similar to a defibrillation and is done using an AED. The main
difference between the two is that cardioversion is synchronized, meaning it’s aligned to the current
heartbeat. The electoral discharge is used to convert an abnormal heart rate to normal sinus rhythm in
people with certain types of abnormal heartbeats (arrhythmia).

ACLS Megacode 5: Stroke

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1. What bedside test is imperative to evaluate for easily reversible cause of symptoms?

 Blood pressure
 Reflexes

 Visual acuity
 Blood sugar

2. Which of the following are absolute contraindications for administration of TPA?

 Stroke in the last 3 months

 Symptom onset within the last 3 hours

 Platelet count less than 150,000

 Minor, resolving symptoms

Absolute contraindications to TPA include:

 Intracranial hemorrhage on CT
 SAH
 Neurosurgery, stroke, or head trauma in the last 3 months
 Uncontrolled hypertension: >/=. 185/110
 History of intracranial hemorrhage, AVM, or neoplasm
 Active internal bleeding
 Platelet count <100,000 or INR > 1.7 or use of anticoagulation
 Hypoglycemia (blood sugar <50)
 Large stroke: NIH >.
 Multi lobar stroke on CT

3. The expectation of time to evaluation, time to CT scan, time to CT read, and time to diagnosis in an
acute ischemic stroke is?
  25 minutes to assess, 45 minutes to CT scan, 60 minutes to CT read, 70 minutes to diagnosis

 10 minutes to assess, 25 minutes to CT scan, 45 minutes to CT read, 60 minutes to diagnosis

 15 minutes to assess, 25 minutes to CT scan, 60 minutes to CT read, 80 minutes to diagnosis
 10 minutes to assess, 30 minutes to CT scan, 45 minutes to CT read, 90 minutes to diagnosis

ACLS Megacode 6: Syncope/Pulseless

Electrical Activity
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1. What are the appropriate next steps in management?

 Initiate CPR
 Check blood sugar
 Defibrillate
 Give atropine

The identified rhythm and clinical scenario is PEA (pulseless electrical activity). CPR should be initiated
while considering possible causes of the arrest.

2. What medication can be administered for further management?

 Amiodarone
 Atropine
 Epinephrine
 Vasopressin
Epinephrine is essentially the only medication indicated in PEA arrest. Amiodarone is useful in
vfib/pulsesless vtach but does not have proven role in PEA arrest. Vasopressin was previously indicated
if multiple epinephrine doses were unsuccessful. However, most recent updated guidelines call only for
epinephrine for PEA arrest.

3. Which of the following are considered possible causes of PEA arrest?

 Tamponade, Trauma, Tension pneumothorax

 Hypocalemia, Hypernatremia, Hyperthermia
 Hypervolemia, Alkalosis, Hypokalemia
 Thalassemia, Teratoma, Tuberculosis

When evaluating someone in arrest, it is important to consider the “Hs and Ts” during resuscitation as
therapies for these causes can treat the arrest. Hs:Hypoxia, Hyperkalemia, Hydrogen ion, (acidosis)
Hypothermia, Hypovolemia, Ts: Thrombus - MI or PE, Toxins, Tamponade, Trauma, Tension
pneumothorax

4. What are the next appropriate steps in management?

 Defibrillate, prepare to intubate

 Cardiovert, prepare to intubate
 Intubate and continue CPR
 Intubate and give amiodarone

The patient has ventricular tachycardia with a pulse. Defbrillating someone with a pulse is life
threatening. Defibrillation delivers electricity immediately whereas during cardioversion, avoids the
vulnerable portion of repolarization and safely delivers a shock to convert to normal sinus.

5. What is the next step?

 Cardiovert
 Defibrillate

 Epinephrine
 Amiodarone

Once the rhythm is identified as vfib or pulses vtach, it is imperative to defibrillate as soon as possible to
increase chances of survival.
 ACLS Megacode 7: STEMI
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1. What are the best diagnostic / therapeutic first steps?

 IV, chest xray, sl NTG, Arterial blood gas

 IV, CT scan chest , heparin
 IV, SL ntg , IV beta blocker
 Give 4 (81mg) Aspirin tablets, 12 lead ekg, IV, oxygen

Aspirin reduces mortality and morbidity in ACS patients. 12 lead EKG should be performed with 10
minutes of arrival to ED/casualty. IV will facilitate rapid administration of fluids and medications.

2. Interpret the ekg and choose the best therapies:

 Acute inferior STEMI, SL ntg, morphine and beta blocker

 Acute anterior STEMI, Aspirin, contact Cardiology for Lytic therapy or emergent cardiac
angiography and intervention.

 NSTEMI, aspirin, statin, beta blocker and cardiology consult

 Non-diagnostic EKG, admit for observation and stress test.

ST elevation in leads V1-V4 with reciprocal ST depression in inferior (II,III,AVF). Aspirin, beta blocker if
hypertensive, statin Cardiology consult, immediate consideration for thrombolysis or primary
percutaneous coronary intervention (PCI).

3. What should be done urgently?

  Anterior STEMI, IV diuretics, SL NTG, IV beta blocker, lytic therapy
 NSTEMI, aspirin, Beta blocker and heparin

 Inferior STEMI, aspirin, IV fluid bolus, cardiology consult

 Inferior STEMI, aspirin, iv diuretics, beta blocker , morphine and cardiology consult

ST elevation in leads II,III,AVF, V5,V6 ST depression V1-V4. Avoid nitrates and beta blockers in inferior
STEMI because of RV infarction and potential to cause cardiogenic shock.

4. What are the next appropriate steps in management?

 Defibrillate, prepare to intubate

 Cardiovert, prepare to intubate

 Intubate and continue CPR
 Intubate and give amiodarone

The patient has ventricular tachycardia with a pulse. Defbrillating someone with a pulse is life
threatening. Defibrillation delivers electricity immediately whereas during cardioversion, avoids the
vulnerable portion of repolarization and safely delivers a shock to convert to normal sinus.

5. What is the next step?

 Cardiovert
 Defibrillate
 Epinephrine

 Amiodarone

Once the rhythm is identified as vfib or pulses vtach, it is imperative to defibrillate as soon as possible to
increase chances of survival.

SVT is a broad term for a number of tachyarrhythmias

that originate above the ventricular electrical conduction system
(Purkinje fibers).
Classic Paroxysmal SVT has a narrow QRS complex & has a
very regular rhythm. Inverted P waves are sometimes seen after
the QRS complex. These are called retrograde p waves.

The heart fills during diastole, and diastole is normally 2/3 the
cardiac cycle. A rapid heart rate will significantly reduce the time
which the ventricles have to fill. The reduced filling time results in
a smaller amount of blood ejected from the heart during systole.
The end result is a drop in cardiac output & hypotension.

With the drop in cardiac output, a patient may experience the

following symptoms. These symptoms occur more frequently with
a heart rate >150 beats per minute:
 Shortness of air (S)
 Palpitation feeling in chest (S)
 Ongoing chest pain (U)
 Dizziness (S)
 Rapid breathing (S)
 Loss of consciousness (U)
 Numbness of body parts (S)

The pathway of choice for SVT in the tachycardia algorithm is

based on whether the patient is stable or unstable. The symptoms
listed above that would indicate the patient is unstable are noted
with the letter (U). Stable but serious symptoms are indicated with
the letter (S).
 Unstable patients with SVT and a pulse are always treated with
synchronized cardioversion. The appropriate voltage for
cardioverting SVT is 50-100 J. This is what AHA recommends
and also SVT converts quite readily with 50-100 J.

Below is a short video which will help you quickly

identify supraventricular tachycardia on a monitor.
Please allow several seconds for the video to load. (4.37 mb)

Click for next Rhythm Review: Atrial Flutter

Questions Asked On This Page

1.

1. Q: What are vagal maneuvers?

A: A vagal maneuver is a technique by which you attempt to

increase intrathoracic pressure which stimulates the vagus nerve.
This can result in slowed conduction of electrical impulses through
the AV node of the heart. The following methods can be used.

1. Cough Method: Have a patient cough forcefully. This is a

simple form of vagal maneuver. A cough stimulates an
increase in intrathoracic pressure which will stimulate the
vagus nerve. This can result in slowed conduction of electrical
impulses through the AV node of the heart.
 2. Straw Method: Have the patient blow forcefully through a straw
for 3-5 seconds.
3. Bear down Method: Have the patient bear down and strain.
Kind of like how a person might strain when having a bowel
movement.
4. Syringe Plunger Method: First, show the patient how easy it is
to move the plunger by pulling it back and forth in within the
syringe. Now instruct the patient place their mouth over the exit
end of the syringe and attempt to blow the plunger out of the
syringe. Have them blow for 3-5 seconds.
5. Abdominal Pressure Method: Press into the patient’s abdomen
while they contract and resist pressing into their abdomen.
6. Ice Method: Quote from a healthcare provider: “We had a kid
(approximately 12 yrs old) present to our ER in SVT, instead of
using drugs and vagal maneuvers we dunked his face in a
bucket of ice twice, and it immediately & effectively brought the
heart rate down. We observed him for a period of time, and the
kid was fine. Worked wonders! Young army doctor’s idea!”

2. Q: I can’t distinguish the sinus tachycardia example from

the three re-entry SVT examples on the pre-test no
matter how long I stare at the strips…they look identical
to me. Help please, and thanks.

A: On the Pretest at the AHA website, Look at each

image carefully. Don’t try to over-observe. Just look at
each one and notice how many QRS complexes there
are.
There are almost double the amount of QRS complexes
in all of the SVT when compared to the Sinus
Tachycardia. This is the easiest way to tell SVT from
Sinus tachycardia. Also, P-waves are only clear in the
sinus tachycardia. Most of the time with SVT you will not
be able to see the p-waves. SVT rate will usually be
greater than 150 and Sinus tachycardia will be less than
150.
 1. Q: Let me get this straight. Svt is a heart rate greater than
150 with conduction at or above the av node?

A: That is correct.
Atrial flutter is an abnormal heart rhythm that technically falls
under the category of supra-ventricular tachycardias. Atrial flutter
is typically not a stable rhythm and will frequently degenerate into
atrial fibrillation.

Atrial Flutter will usually present with atrial rates between

240-350 beats per minute. These rapid atrial rates are caused by
electrical activity that moves in a self-perpetuating loop within the
atria.

The impact and symptoms of atrial flutter depend upon the

ventricular rate of the patient (i.e. cardiac output). Usually, with
atrial flutter, not all of the atrial impulses will be conducted to the
ventricles, and the more atrial impulses that are conducted, the
greater the negative effect.
Symptoms
Symptoms of atrial flutter are similar to those of atrial fibrillation
and may include the following:
 palpitations, chest pain or discomfort
 shortness of air
 lightheadedness or dizziness
 nausea
 nervousness and feelings of impending doom
 symptoms of heart failure such as activity intolerance and swelling of the
legs occur with prolonged fast flutter)

Complications
As with its symptoms, atrial flutter shares the same complications
as atrial fibrillation. These complications are usually due to
ineffective atrial contractions and rapid ventricular rates.
Ineffective atrial contractions can lead to thrombus formation in
the atria and rapid ventricular rates can cause decompensation
and heart failure.

Prevent complications from atrial flutter with early cardioversion.

Treatment
For the purposes of ACLS, atrial flutter is treated the same as
atrial fibrillation. When atrial flutter produces hemodynamic
instability and serious signs and symptoms, it is treated using
ACLS protocol.

For the patient with unstable tachycardia due to this

tachyarrhythmia (atrial flutter), immediate cardioversion is
recommended. Drugs are not used to
manage unstable tachycardia.
Cardioversion
Atrial flutter is considerably more sensitive to electrical direct-
current cardioversion than atrial fibrillation, and usually requires a
lower energy shock. 20-50J is commonly enough to revert to
sinus rhythm.

AHA recommends an initial shock dose 0f 50-100 J for

cardioverting unstable atrial flutter.

atrial fibrillation
The most common cardiac arrhythmia, atrial fibrillation, occurs
when the normal electrical impulses that are generated by the SA
node are overwhelmed by disorganized electrical impulses in the
atria.

These disorganized impulses cause the muscles of the upper

chambers of the heart to quiver (fibrillate) and this leads to the
conduction of irregular impulses to the ventricles.

For ACLS, atrial fibrillation becomes a problem when the

fibrillation produces a rapid heart rate which reduces cardiac
output and causes symptoms or an unstable condition.

When atrial fibrillation occurs with a (RVR) rapid ventricular rate

(rate > 100 beats/min), this is called a tachyarrhythmia. This
tachyarrhythmia may or may not produce symptoms. Significant
symptoms that occur are due to a reduction in cardiac output.
The following is a list of the most common symptoms.
 palpitations or chest discomfort
 shortness of air and possibly respiratory distress
 hypotension, light-headedness and possibly loss of consciousness
 peripheral edema, jugular vein distention, and possibly pulmonary edema

For the purpose of ACLS, it is important to be able to recognize

atrial fibrillation when the patient is symptomatic. On an ECG
monitor, there are two major characteristics that will help you
identify atrial fibrillation.
1. No p-waves before the QRS on the ECG. This is because there are no
coordinated atrial contractions.
2. The heart rate will be irregular. Irregular impulses that the ventricles
are receiving cause the irregular heart rate.

When the heart rate is extremely rapid, it may be difficult to

determine if the rate is irregular, and the absence of p-waves will
be the best indicator of atrial fibrillation.
ACLS Treatments:
For the purposes of ACLS atrial fibrillation is treated when the
arrhythmia/tachyarrhythmia produces hemodynamic instability
and serious signs and symptoms.

For the patient with unstable tachycardia due to a

tachyarrhythmia, immediate cardioversion is recommended.
Drugs are not used to manage unstable tachycardia. The
appropriate voltage for cardioverting unstable atrial fibrillation is
120-200 J.

Cardioversion of stable atrial fibrillation should be performed with

caution if the arrhythmia is more than 48 hours old and no
anticoagulant therapy has been initiated due to the risk of emboli
that can cause MI and stroke.

There are several other tachycardia rhythms that can be seen

with both stable and unstable tachycardia. These rhythms
include monomorphic ventricular
tachycardia and polymorphic ventricular tachycardia both of
which are wide-complex tachycardias.

Wide complex tachycardias are defined as a QRS of ≥ 0.12

second. Expert consultation should be considered with these
rhythms.

These wide-complex tachycardias are the most common forms of

tachycardia that will deteriorate to ventricular fibrillation.
Monomorphic Ventricular Tachycardia

With monomorphic VT all of the QRS waves will be symmetrical.

Each ventricular impulse is being generated from the same place
in the ventricles thus all of the QRS waves look the same.
Treatment of monomorphic VT is dependent upon whether the
patient is stable or unstable. Expert consultation is always
advised, and if unstable, the ACLS tachycardia algorithm should be
followed.

Polymorphic Ventricular Tachycardia

With polymorphic ventricular tachycardia, the QRS waves will not

be symmetrical. This is because each ventricular impulse can be
generated from a different location. On the rhythm strip, the QRS
might be somewhat taller or wider.

One commonly seen type of polymorphic ventricular tachycardia

is torsades de pointes. Torsades and other polymorphic VT are
advanced rhythms which require additional expertise and expert
consultation is advised.
If polymorphic VT is stable the ACLS tachycardia algorithm should
be used to treat the patient. Unstable polymorphic ventricular
tachycardia is treated with unsynchronized shocks
(defibrillation). Defibrillation is used because synchronization
is not possible.

These wide complex tachycardias tend to originate in the

ventricles rather than like a normal rhythm which originates in the
atria.

Top Questions Asked On This Page

1.

1. Q: What are the doses for synchronized cardioversion?

A: Here are the cardioversion voltage doses:

 Narrow regular: 50-100 J

 Narrow irregular: 120-200 J biphasic or 200 J monophasic
 Wide regular: 100 J
 Wide irregular: defibrillation dose (not synchronized)”

All of this information is covered on the tachycardia

algorithm page.

1.

1. Q: Is it necessary to memorize the doses listed above?

A: It is necessary to understand the concepts and be

familiar with the shock dosages.
The repetition that is built into the website is designed to
 help you become very familiar with all of the concepts
and use them in emergencies.

1. Q: What sort of a pulse would you be feeling with a

polymorphic VT?

A: You may feel a weak pulse or a strong pulse depending

on how long the polymorphic VT has been going on. One
thing is for sure….You won’t be feeling a pulse for very long
if this rhythm continues.