I finally graduated from medical school, after a long 4 years. Normally, when I graduate from school, I feel free. But in this case, I don’t feel any freer.
Why? Because of residency. It starts in one week and I do not feel ready at all.
One of the requirements for working in the hospital is to become certified in Advanced Cardiovascular Life Support (ACLS). In some cases, you gotta become certified in Pediatric Advanced Life Support (PALS) as well.
Let’s tackle one thing at a time. First up … ACLS.
Usually, a program will give you a book or an online course so you can learn it on your own. However, my residency is a bit unlike others when it came to preparing for the certification. I had to either borrow the American Heart Association’s provider’s manual from the library or find my own resources. No one gave me anything. Then on testing day, the residency will cram as many lessons as it can in half a day … prior to the exams.
Some of my fellow interns borrowed the aforementioned book. Some bought it. But being the rebel that I am, I carved my own path. I spent very little money (less than $3), kept the resource I used, and passed the ACLS exams with flying colors … on my very first try.
As I have said in the past, I am not a particularly bright boy. So if I can learn ACLS by myself in half a day and pass the exam with almost perfect scores (at the end, one of the instructors even asked me to teach the course), you can too.
Wanna know how I did it? Yes? Alright.
I basically used two main resources:
The first resource is a series of YouTube videos. They are high quality, concise, and best of all … free.
The second resource is an ACLS review book from Amazon. The e-book is extremely affordable and will cover whatever isn’t covered in the videos. (If you don’t have a Kindle device or a Kindle app, you can use the Kindle Cloud Reader. All you need to use the reader is an internet browser.)
Resource #1 – Videos
Not only will I embed the videos onto this page, I will also include the most important information you should learn from each video. Take 2 – 3 hours and go through the videos. Compare your notes to mine. And by the end, you will not only memorize the high-yield information … you will also understand it.
ACLS 1 – Introduction
– goal of ACLS:
- prevent cardiac arrest
- treat cardiac arrest
- manage post-cardiac arrest: during return of spontaneous circulation (ROSC)
ACLS 2 – Airway (Part 1)
– O2 in body = cardiac output * O2 content in blood
– increase O2 content in blood by ventilation (i.e. mouth to mouth resuscitation)
– in cardiac arrest, cardiac output = 0 (so focus on CPR)
- good chest compression: at least 100 / min, 2″ deep
ACLS 3 – Airway (Part 2)
– confirm placement of endotracheal tube clinically
- see chest wall rise
- listen to epigastrium (if hear whoosh of air, tube in wrong place)
- listen to bi-lateral chest (want air sounds)
– confirm placement of endotracheal tube mechanically
- gold standard: waveform capnography
– rate of ventilation: 6 – 10 breaths / minute
ACLS 4 – Cardiac Arrest (VF / VT – Part 1)
– triple 0: no pulse, no blood pressure, no respiratory rate
– step 1: call code (get help)
– step 2: CPR (most important!), O2 ventilation, monitor
– step 3: cycle of check rhythm (see VF or pulseless VT) –> defibrillate –> uninterrupted CPR for 2 minutes –> administer drug –> repeat cycle
- during first cycle: get IV / IO (intraosseous infusion) access
- during second cycle: administer epinephrine (1 mg q5min IV) or vasopressin (40 units IV) for vasopressors, and open airway (endotracheal tube or LMA)
- during third cycle: administer amiodarone 300 mg IV (anti-arrhythmia)
- during subsequent cycles: switch between epinephrine and amiodarone 150 mg IV
- after third cycle: consider 5H’s and 5T’s (reversible causes of cardiac arrest)
ACLS 5 – Cardiac Arrest (VF / VT – Part 2)
– good explanation of waveform capnography (starts at 6:50)
– if no amiodarone, use lidocaine 1 – 1.5 mg / kg
– good explanation of 5H’s and 5T’s (starts 11:30)
ACLS 6 – Cardiac Arrest (Asystole & PEA)
– pulseless arrests: VF, pulseless VT, asystole, PEA
– asystole: no electrical activity, no mechanical activity
- check second lead to confirm asystole (could be VF)
– PEA: yes electrical activity, no mechanical activity
– if not VF or pulseless VT –> no shock, no amiodarone (but continue rest of steps 1 – 3 shown in ACLS 4)
– stress good-quality CPR and early defibrillation when indicated (improves survival for hospital admission)
ACLS 7 – Bradycardia
– know algorithm
– dopamine: alpha and beta agonist
ACLS 8 – Tachycardia (Part 1)
– know algorithm
– < 150 bpm is sinus in origin and has non-cardiac causes
– synchronized cardioversion: shock on R wave (if shock on T –> refractory VF)
– use calcium-channel blockers (non-dihydropyridine): diltiazem, verapamil
ACLS 9 – Tachycardia (Part 2)
– re-entrant tachycardia = SVT
– AV nodal blockers (to control tachycardia): vagal maneuver, adenosine, beta blocker, calcium-channel blocker
ACLS 10 – Tachycardia (Part 3)
– wide complex tachycardia (electrical conduction not going through AV node): VT / VF, SVT with aberrancy (goes through AV node), pre-excited tachycardia (wolff-parkinson-white syndrome), torsades de pointes
– narrow (irregular) tachycardia: a-fib + RVR, MAT, sinus tachycardia + premature atrial contraction
ACLS 11 – Post-Resuscitation Care
– step 1: optimize bp (systolic blood pressure > 90 mmHg) – use IV, pressor
– step 2: optimize breathing (PaCO2 = 40 – 45)
– step 3: treat ACS – send to catheterization laboratory
– step 4: induce therapeutic hypothermia – put icepack on axilla or groin, or give chilled IV fluid
- prevent brain damage (cooling = depress neurologic demand)
- target: 32 – 34 C for 12 – 24 hrs (drop from 37 C)
- cooling blanket (maintenance)
- sedate with fentanyl drip (and will prevent shivering)
- prevent hypothalamus from warming body: give rectal tylenol
– missing steps: gets labs and 12-lead EKG
– candidate: pulse (ROSC), comatose, start within 30 minutes of pulse
Important tip! You should know the following drugs, when they are used, and their doses.
– epinephrine (VF / pulseless VT / PEA / asystole)
– amiodarone (VF / pulseless VT)
– adenosine (tachycardia)
– atropine (bradycardia)
Resource #2 – ACLS Review Book
After you have gone through the videos, go through the Advanced Cardiac Life Support (ACLS) Provider Handbook by Dr. Karl Disque.
The book covers the important things, without bogging you down with low-yield, nitpicking details. Unlike the official book, this one is a review book. Therefore, it should take you only a few hours to get through it. (Personally, it took me 4 hours to finish it from cover to cover.)
There are some things you should be aware of. A lot of the algorithms are very small in size. You may have to squint your eyes to read it. I also found an error. The dose for magnesium sulfate (for torsades de pointes) should have been 1 – 2 g IV, instead of 1 – 2 mg IV.
Nevertheless, these are minor faults. The book is still a great deal at $2.99, especially compared the official book at $44+.
How to Pass the ACLS Exams with Flying Colors
Go through the videos and the review book once. You will develop an understanding of ACLS. Pay attention during the live lessons. You will know what to focus on for the exam. Spend just a little effort follow my instructions and you should have no problem getting certified, even if you never seen the materials before in your life.
This article is part of the How to Survive Medical School series. Click on the link if you want more tips and hints about surviving academic hell.