ACLS Case Study Examples

The following case study examples were created by ACLS certified medical providers who have had first-hand experience in utilizing ACLS & BLS principles. We will continue to provide additional case studies for those who are seeking their ACLS certification or for those who are just interested in broadening their knowledge of life support techniques.

Advanced Cardiac Life Support: Unconscious Patient in the Hospital

Upon arriving in Mr. Jones' hospital room to administer his daily medications, you notice Mr. Jones' is not responding to your announcement when entering. You immediately go to his side and attempt to elicit a response, however, Mr. Jones is unresponsive and is not breathing. You attempt to find a pulse but there is none. After calling for help, what should you do next?

In order to successfully utilize Advanced Cardiac Life Support (ACLS), Basic Life Support (BLS) principles must be mastered. BLS consists of C-A-B; circulation, airway and breathing. When a patient is found unresponsive, not breathing and without a pulse, the first responder should begin chest compressions immediately. Chest compressions are performed by applying both hands on the patient's sternum at the level of the nipples and pressing hard, compressing the chest 2 inches. Chest compressions should be performed at a rapid rate, at least 100 per minute but allowing the chest to completely recoil after each compression. After 30 compressions, the first responder should give 2 rescue breaths to the patient.

While performing chest compressions, other medical staff arrive in the room to help. A team leader is selected and roles are assigned among all staff. A crash cart arrives and Mr. Jones is attached to a cardiac monitor. CPR is paused and the rhythm on the monitor is assessed. The rhythm is interpreted as ventricular fibrillation and Mr. Jones still does not have a pulse. What should be done next?

Mr. Jones is in ventricular fibrillation, a rhythm in which the heart is beating erratically and unable to circulate blood successfully. At this point, defibrillation would be the next appropriate step. The probability of an individual recovering successfully after sudden cardiac arrest is greatly improved when defibrillation is initiated immediately, if indicated. There should be no delay between defibrillation when the defibrillator arrives, and while applying the pads, CPR should be continued. In this scenario, defibrillation should be at 120-200 joules (J) and 360 J, for a biphasic and monophasic defibrillator, respectively. After defibrillation, CPR should be resumed immediately.

A shock is delivered to Mr. Jones and CPR is resumed. Epinephrine is administered to the patient and after two minutes of CPR, the cardiac rhythm is analyzed. The patient has no pulse and the cardiac monitor displays asystole. What would be the next appropriate list?

The patient is now in asystole, which means his heart is not pumping any blood. Asystole is a non-shockable rhythm and the defibrillator should not be used. When the heart is in asystole, CPR should be resumed and the appropriate medications administered. In this case, the patient would likely be given a second dose of epinephrine, three to five minutes after the first dose. Vasopressin could also be used in place of epinephrine.

CPR is continued, the team leader asks the medical team to begin to think about possible reversible causes of the patient's sudden cardiac arrest. What are the common etiologies for sudden cardiac arrest?

Although it is often difficult to consider causes in a high stress environment and while performing ACLS, there are several etiologies that can possibly be reversed and help the patient resume a normal cardiac rhythm. When thinking of these etiologies a helpful way to remember is 5 the H's and 5 T's, which are as follows:

Hypovolemia
Hypoxia
Hypothermia
Hypokalemia/Hyperkalemia
Hydrogen ion (acidosis)
Tamponade (cardiac)
Tension pneumothorax
Toxins
Thrombosis, pulmonary
Thrombosis, cardiac

While CPR is still being performed, an endotracheal tube is placed. The team begins mechanical ventilation and the patient's oxygen saturation increases. When CPR is paused after two minutes to evaluate the cardiac rhythm, the monitor reveals a sinus rhythm of 62 beats per minute. What steps should be taken next?

In this case example, hypoxia may have been the cause of the patient's arrest as the patient regained a normal cardiac rhythm after hypoxia was reversed by endotracheal intubation. Now that the patient is in this state, the ACLS algorithm for post-resuscitative care should be followed with expert consultation and close monitoring.

Final Notes: When sudden cardiac arrest occurs, the initiation of CPR is critical for the patient's chance of survival. The American Heart Association repeatedly emphasizes "push hard, push fast" when referring to the depth and rate of chest compressions during CPR. Additionally, unnecessary pauses in CPR should be avoided at all costs. For example, CPR should continue while the defibrillator pads are being applied and until full charge is obtained. Effective CPR and a comprehensive understanding of the ACLS principles, are the patient's greatest chance of survival.

Advanced Cardiac Life Support: A Person is Found Down, What do you Do?

As a paramedic, you are called to the scene at a local beach park. Bystanders state they found a man floating facedown in the ocean. When he was pulled out of the water, he was not breathing and had no pulse. Bystanders began CPR and when you arrive, CPR is being continued. The patient is loaded into the ambulance and connected to a cardiac monitor. The cardiac monitor displays atrial flutter. The patient has a pulse but continues to be unresponsive. What is the appropriate next step?

This patient suffered from sudden cardiac arrest (SCA) while in the ocean and was found without a pulse and unresponsive by bystanders. It is estimated that 326,000 people will suffer from SCA outside of a hospital every year in the United States. Unfortunately, only about one third of these individuals will receive CPR prior to the medical team arriving. However, when CPR is performed for SCA victims, it can double or even triple their chances of survival, thus emphasizing the importance of learning CPR. In this scenario, the patient likely was originally in ventricular fibrillation and his rhythm is now atrial flutter. Atrial flutter is a cardiac rhythm where the atria of the heart beat erratically, as the patient has a pulse, the heart is still able to pump some blood throughout the body. At this time, since the patient continues to be unresponsive, an advanced airway (e.g. endotracheal tube, laryngeal mask airway) should be considered and efforts be made to stabilize the patient.

The paramedics place an endotracheal and the placement is confirmed by auscultating bilateral breath sounds and exhaled CO2. Vital signs are taken and the patient's blood pressure is 72/36 mmHg, heart rate 143 beats per minute and irregular, oxygen saturation 98% and respiratory rate of 12 (controlled by mechanical ventilation). The cardiac monitor continues to show atrial flutter. What additional measures should be taken now?

The patient is in unstable atrial flutter. Indicators that a patient is unstable include chest pain, hypotension, altered mental status and signs of shock. In this example, the patient continues to be unresponsive (e.g. altered mental status) and also is hypotensive with a blood pressure of 72/36 mmgHg. At this point, steps should be taken to further stabilize the patient and the ACLS algorithm should be followed, in this case the algorithm of Tachycardia with Pulses applies.

The paramedics give the patient intravenous fluids and the blood pressure remains low, the patient is still in atrial flutter. What type of tachycardia is atrial flutter classified as?

One of the key aspects of ACLS is being able to identify cardiac rhythms. Atrial flutter is recognized by its classical saw-tooth pattern. The classification of tachycardia is based on the width of the QRS complex of the ECG.

- A wide QRS complex is considered to be ≥.12 seconds, which is then classified into a regular or irregular rhythm, examples include ventricular tachycardia and torsades de pointes.

-Conversely, a narrow complex tachycardia has a QRS complex of ≤.12 seconds, examples include atrial fibrillation and supraventricular tachycardia.

Atrial flutter is a narrow complex, irregular tachycardia, thus, following the algorithm, attempts should be made to control the heart rate by using beta-blockers or diltiazem. In this scenario, it is imperative for the best efforts be made to stabilize the patient but upon arrival to the hospital, expert consultation, such as with a cardiologist, should be sought.

The patient is given a beta-blocker and his blood pressure is now 122/73 mgHg. He is now awake but unable to talk because of the intubation. He is taken to the local hospital and then transferred to the intensive care unit. What are the important steps that should be taken now that the patient is stable?

The patient is considered stable when he has regained normal vital signs and has consciousness (unless sedated for medical reasons). The ACLS algorithms consider this as return of spontaneous circulation (ROSC). At this time the patient should be closely monitored and will require expert consultation. A full set of vital signs (blood pressure, oxygen saturation, pulse, waveform capnography) should be obtained. Several lab studies and an electrocardiogram (ECG) will be performed as well. Additionally, when ROSC is achieved, the patient should be considered for coronary reperfusion therapy or induced hypothermia.

Final Notes: Sudden cardiac arrest occurs relatively frequently in the United States and almost 90% of arrests happen in the patient's home. However, less than 8% of outside the hospital arrests will survive. Mastering the techniques of basic and advanced cardiac life support will prepare you to increase the chance of survival for patients and possibly your loved ones.

NEW 2020 AHA Guidelines

National Critical Care Institute is proud to offer health and medical practitioners with accelerated exams and an online training course that are based on the new 2020 AHA guidelines. The current ACLS provider manual which the American Heart Association now offers is dramatically updated with new techniques, terms and clinical recommendations. Our 100% online training course is an ideal way to prepare for either the ACLS certification or recertification exams as it is comprised of 20 pages that are derived after these new 2020 AHA guidelines. Additionally, each of our ACLS certification exams have been carefully updated to cover crucial new terminology and techniques based on the new 2020 American Heart Association guidelines. Enroll today in our online training course or ACLS exams to ensure you are certified with these new requirements.

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