# question on ACLS algorithm: cardiac arrest

1. Hello, I was hoping someone could clarify something for me. I'm taking ACLS in a few weeks and am studying the algorithms. For cardiac arrest it says to give epinenephrine q 3-5 min. Let's say you give it, the rhythm is shock able and you continue CPR for 2 minutes. It then says give amiodarone. Here's my question: Since it is then almost time to readminister the epinephrine, do you give the 2 drugs back to back? Give amiodarone and then almost immediately epinephrine. Obviously I'm a newbie, as this is a very basic question. 1 more question. My experience thus far has only been in LTC. I haven't yet had to start an IV. I've only done it twice, almost a year and a half ago in the ED during clinical with the guidance of a nurse. Do you learn IV access in the class? I'll YouTube it, and go over the steps, but that's all I can do for now. Any advice is greatly appreciated. Thanks
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3. Follow the algorithm, does the algorithm say give both meds at the same time? Na.
It will make more sense when you take the class.

It depends on the rhythm the pt is in. A systole and PEA are only getting epi. Every 3-5 mins which is usually when your 5 cycles of CPR is over and you check rhythm.
AHA for acls are going to start with a Brady/Tachy, than vtach/vfib, than a systole/PEA and magically they always survive The rhythms I just listed will be either or.
4. As for iv's, no they don't teach you. You just do it over and over in real life. Practice makes perfect
5. I'm asking about the IV's because during acls you have to start an IV if one is not already in place. In the class, are they already placed, or am I going to look like an idiot trying to start an IV during a code. Anyway, no, it does not specifically say give at the same time, but with vf/vt, after you administer the epinephrine, you then determine if the rhythm is shock able, then you give CPR for 2 minutes. Then it does say administer amiodarone. By the time that is administered, it is very close to the time for the next dose of epinephrine. This also has led me to another question. In my drug book, it says epinephrine is to be administered over 1 minute except in ACLS cases where it can be administered more rapidly. Do you just push it over a few seconds? Same question for amiodarone. My drug book does not specify over how much time to push it in a code.
6. I think you are over thinking it. You won't actually have to start an IV; it's a mock. When you run your mega code you have a team - you will say you start compressions, you start an IV (if one is not in place in the scenario), you man the airbag, etc., then you run the show.
7. A. Yes, you are over thinking it. It will all make sense after the class. Right now it would probably be good to focus on the meds and doses and what rhythm they go with. Do the AHA practice test a bunch of times.

Look at the algorithm, again, it's not telling you to give 2 meds. If you're at the point you're giving amiodarone, it's not telling you to give another round of epi.
What helped me was, when you do a rhythm check (after 2 mins or 5 cycles of CPR) if you're seeing a different rhythm, in your brain, whatever you've done is null and you follow the guidelines for the rhythm you're seeing NOW

B. you don't actually start an IV, you say start IV. Apply 02, attach pads. It's all simulated on a CPR 'Dummy'.
8. And most instructors understand! If you need a minute to "think" just make sure someone is doing compressions!
9. Thanks everyone! That really helped relieve some anxiety.
10. Quote from Orion81
Hello, I was hoping someone could clarify something for me. I'm taking ACLS in a few weeks and am studying the algorithms. For cardiac arrest it says to give epinenephrine q 3-5 min. Let's say you give it, the rhythm is shock able and you continue CPR for 2 minutes. It then says give amiodarone. Here's my question: Since it is then almost time to readminister the epinephrine, do you give the 2 drugs back to back? Give amiodarone and then almost immediately epinephrine. Obviously I'm a newbie, as this is a very basic question. 1 more question. My experience thus far has only been in LTC. I haven't yet had to start an IV. I've only done it twice, almost a year and a half ago in the ED during clinical with the guidance of a nurse. Do you learn IV access in the class? I'll YouTube it, and go over the steps, but that's all I can do for now. Any advice is greatly appreciated. Thanks
I would just add that the intervention of choice during for ACLS for shockable rhythms (vfib, pulselss vtach) is defibrillation. When a code's beginning, BLS (compressions and ventilation) applies. Once a rhythm is identified, ACLS interventions begin. If the initial rhythm is vfib or pulseless vtach, defibrillation takes precedence over med. So you're clearing, shocking, immediately resuming compressions; all the while whomever you've designated for meds should be drawing up med. Once IV access is established (or already is) epi or vasopressin IVP during compressions because compressions help circulate med. CPR continues for 2 min at which time a pulse/rhythm check occurs (stop compressions). If asystole or PEA, resume CPR, and epi can be administered IVP if it's been 3 min since last dose. If rhythm is shockable (vfib or pulseless vtach), defibrillate. The team leader (usually physician) can choose vasopressin in place of 1st or 2nd epi. Amiodarone can be substituted for refractory vfib/pulseless vtach after at least first round of defib/pressor. You wouldn't administer amiodarone and a vasopressor together.
So basically during your mock code, you're going to be the team leader; you're assigning a specific responsibility to each member. 1: meds/IV 2: document 3: defib 4: airway 5: compressions. All you're doing is telling each person what you'd like for them to do based on the present situation. It's unnerving at first, but just review your algorithms and take your time. You'll be golden Good luck!
11. Quote from XmasShopperRN
I would just add that the intervention of choice during for ACLS for shockable rhythms (vfib, pulselss vtach) is defibrillation. When a code's beginning, BLS (compressions and ventilation) applies. Once a rhythm is identified, ACLS interventions begin. If the initial rhythm is vfib or pulseless vtach, defibrillation takes precedence over med. So you're clearing, shocking, immediately resuming compressions; all the while whomever you've designated for meds should be drawing up med. Once IV access is established (or already is) epi or vasopressin IVP during compressions because compressions help circulate med. CPR continues for 2 min at which time a pulse/rhythm check occurs (stop compressions). If asystole or PEA, resume CPR, and epi can be administered IVP if it's been 3 min since last dose. If rhythm is shockable (vfib or pulseless vtach), defibrillate. The team leader (usually physician) can choose vasopressin in place of 1st or 2nd epi. Amiodarone can be substituted for refractory vfib/pulseless vtach after at least first round of defib/pressor. You wouldn't administer amiodarone and a vasopressor together.So basically during your mock code, you're going to be the team leader; you're assigning a specific responsibility to each member. 1: meds/IV 2: document 3: defib 4: airway 5: compressions. All you're doing is telling each person what you'd like for them to do based on the present situation. It's unnerving at first, but just review your algorithms and take your time. You'll be golden Good luck!
Wow, thank you so much. That cleared it up for me completely. The way I was interpreting the algorithm for VF/VT was alternating epi and amiodarone after each shock because of the way the arrows go full circle starting over the whole cycle again (assuming shockable rhythm). But thank you for clearing that up for me because I just wasn't getting it.
12. Quote from Orion81
Wow, thank you so much. That cleared it up for me completely. The way I was interpreting the algorithm for VF/VT was alternating epi and amiodarone after each shock because of the way the arrows go full circle starting over the whole cycle again (assuming shockable rhythm). But thank you for clearing that up for me because I just wasn't getting it.
No worries, glad to help. The algorithms can be really confusing until you actually see ACLS in practice. The reason the algorithms go in a circle is because your next intervention depends on what's going on now. And it's not uncommon for a code to require several rounds of meds/defib before return of spontaneous circulation or code team is willing to call the code. I really enjoy ACLS and PALS (if you couldn't tell . Feel free to ask if you have anymore questions!
13. Shock, CPR, epi, shock, CPR, amiodarone, shock, CPR, epi, shock CPR, amiodarone, shock, CPR, epi, etc. reassess patient after 2 minutes CPR each time. In ACLS, drugs are pushed fast (as fast as you can get it in) followed by 20 cc saline flush. You do NOT need to demonstrate IV starting, just verbalize that you started it. Don't read into the questions on the exam, its straight forward. Also, the mega code is done in group now so you will not be alone. Good Luck!