ACLS — Advanced Cardiovascular Life Support — All Questions
22 questions
A patient has a heart rate of 38 with hypotension and altered mental status. What is the first-line drug?
- a.Adenosine
- b.Atropine✓
- c.Amiodarone
- d.Metoprolol
Atropine has been shown effective for symptomatic bradycardia in observational studies and is the first drug used; the other options are tachycardia or rate-slowing drugs.
A patient with wide-complex tachycardia has a pulse but is hypotensive and confused. The appropriate treatment is:
- a.Unsynchronized defibrillation
- b.Synchronized cardioversion✓
- c.Adenosine only, then observe
- d.No treatment; continue to observe
An unstable tachycardia WITH a pulse (hypotension, altered mental status, ischemic chest pain, or signs of shock) is treated with immediate synchronized cardioversion. Synchronization times the shock to the R wave to avoid delivering energy during the vulnerable T-wave period, which could induce VF. Unsynchronized defibrillation is reserved for pulseless VT/VF.
Atropine has failed to improve a patient's symptomatic bradycardia. Appropriate next steps include:
- a.Pacing or an epinephrine drip✓
- b.Defibrillate the patient
- c.Adenosine 6 mg rapid IV push
- d.Synchronized cardioversion
If atropine is ineffective, the 2025 Guidelines call transcutaneous pacing or agents that raise heart rate and blood pressure (such as epinephrine or dopamine) reasonable; the choice depends on experience and resources.
A patient has a heart rate of 38, blood pressure 76/40 and confusion. What is the first-line drug?
- a.Atropine✓
- b.Amiodarone
- c.Adenosine
- d.Diltiazem
Atropine has been shown effective for symptomatic bradycardia in observational studies; the other drugs treat tachycardias.
Atropine fails in unstable bradycardia. What is a reasonable next step?
- a.Adenosine
- b.Synchronized cardioversion
- c.Verapamil
- d.Transcutaneous pacing✓
If atropine is ineffective, transcutaneous pacing or agents that raise heart rate and blood pressure, such as epinephrine or dopamine, are reasonable alternatives.
What must be confirmed after starting transcutaneous pacing?
- a.The rate is over 150
- b.The patient is asleep
- c.Only pacer spikes on the monitor
- d.Mechanical capture with a pulse✓
The Guidelines highlight difficulty achieving and maintaining both electrical and mechanical capture, so perfusion must be confirmed, not just the monitor pattern.
A conscious patient needs transcutaneous pacing. What should the team anticipate?
- a.Permanent pacemaker in the ED
- b.Pain; sedation may be needed✓
- c.Immediate need for intubation
- d.No discomfort at all
Transcutaneous pacing is often painful in conscious patients and tolerance may require sedation; it bridges to transvenous pacing or definitive treatment.
An asymptomatic athlete has a heart rate of 44. What is appropriate?
- a.Transcutaneous pacing
- b.No treatment for the rate✓
- c.Atropine to raise the rate
- d.Epinephrine infusion
Bradycardia can be a normal finding in healthy adults and athletes; treatment is for symptomatic or unstable bradycardia.
A patient in stable, regular narrow-complex tachycardia fails a modified Valsalva. What is next?
- a.Adenosine✓
- b.Atropine
- c.Epinephrine
- d.Defibrillation
Adenosine has very high conversion rates for AV nodal and AV reentrant tachycardias and is used after vagal maneuvers fail in stable patients.
What energy should start synchronized cardioversion for unstable atrial fibrillation in 2025?
- a.10 J
- b.50 J
- c.200 J✓
- d.25 J
The 2025 Guidelines replaced the incremental low-energy approach with a recommendation to begin at 200 J for atrial fibrillation and flutter.
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A patient with wide-complex tachycardia has a systolic pressure of 74 mm Hg and is confused. What is indicated?
- a.Immediate synchronized cardioversion✓
- b.Atropine IV
- c.Verapamil IV
- d.Observation and fluids only
If the patient is unstable because of the WCT, such as systolic pressure below 80 mm Hg or altered mentation, immediate synchronized cardioversion is warranted.
Why is verapamil dangerous for a wide-complex tachycardia of ventricular origin?
- a.It is too slow to work
- b.It causes torsades only in children
- c.It speeds the ventricular rate to 300
- d.It can cause shock and arrest✓
Verapamil will not terminate a WCT of ventricular origin and may cause profound hypotension leading to shock and cardiac arrest.
A patient with pre-excited atrial fibrillation (WPW) is rapidly conducting. Which drug class should be avoided?
- a.IV fluids
- b.AV nodal blockers✓
- c.Oxygen
- d.Sedatives before cardioversion
AV nodal blockers such as digoxin, calcium channel antagonists, β-blockers or IV amiodarone may cause VF in pre-excited AF; cardioversion is recommended.
Which rate-control drug should be avoided in rapid AF with decompensated systolic heart failure?
- a.Amiodarone
- b.Diltiazem✓
- c.Oxygen
- d.Furosemide
Nondihydropyridine calcium channel blockers such as diltiazem may further decompensate patients with LV systolic dysfunction and heart failure; amiodarone is an alternative.
Sustained polymorphic VT with a pulse develops. What is the treatment?
- a.Oral β-blocker
- b.Adenosine and observation
- c.Immediate defibrillation✓
- d.Synchronized cardioversion at 50 J
The 2025 Guidelines recommend that all adults with sustained polymorphic VT receive immediate defibrillation, since it is always unstable.
What does the modified Valsalva maneuver achieve compared with the standard maneuver?
- a.No difference at all
- b.Conversion of VF
- c.Guaranteed conversion
- d.Up to about 50%✓
Standard Valsalva ends 20 to 30% of narrow-complex tachycardias, and modified techniques improve termination to up to 50%.
Why is carotid massage used with caution?
- a.It can trigger stroke✓
- b.It lowers blood sugar
- c.It is painful for children
- d.It always causes VF
When performing carotid massage, caution is advised because it can precipitate a stroke in patients with carotid atherosclerosis.
A patient in stable monomorphic VT receives an antiarrhythmic. What should be immediately available?
- a.A pacemaker magnet
- b.A cooling blanket
- c.Oral potassium
- d.A defibrillator✓
When antiarrhythmics are given for WCT, immediate defibrillator availability is encouraged because each drug may convert the rhythm to a faster, unstable form.
In symptomatic bradycardia with shock and no IV access, what may be started immediately?
- a.Oral atropine
- b.IM adenosine
- c.Transcutaneous pacing✓
- d.Cardioversion
For severe symptomatic bradycardia causing shock without IV or IO access, immediate transcutaneous pacing while access is pursued may be undertaken.
Which is an example of a reversible cause of bradycardia listed in the Guidelines?
- a.A high fever from a cold
- b.Hypoxemia✓
- c.Hyperthermia from exercise
- d.Normal sleep
Causes of symptomatic bradycardia include myocardial ischemia, hypoxemia, hypothyroidism, infection, electrolyte abnormalities, and medications or toxins.
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In patients with coronary artery disease, what total atropine dose does the FDA-approved label restrict to?
- a.10 mg to 12 mg
- b.No limit
- c.0.1 mg
- d.2 mg to 3 mg✓
The label restricts total atropine to 2 mg to 3 mg (maximum 0.03–0.04 mg/kg) in coronary artery disease to avoid atropine-induced tachycardia raising oxygen demand.
A patient has symptomatic bradycardia and a history of recent heart transplant. What alternatives exist if atropine does not help?
- a.Cardioversion
- b.Pacing or an epinephrine or dopamine infusion✓
- c.Diltiazem
- d.Adenosine
If atropine is ineffective, transcutaneous pacing or agents such as epinephrine or dopamine are reasonable, chosen by experience and resources.