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Bradycardia Quiz #3

This practice test is part of a comprehensive ACLS training course. After completing the full course, you will participate in real codes with confidence, and you will ace the AHA ACLS provider course. Register HERE to take the full course.

This ACLS Quiz focuses on the bradycardia algorithm of the ACLS Protocol.
There are 10 questions to answer. Your quiz will be graded after completion.

(2015-2020 guidelines)

Comments

  1. Is atropine always considered first for symptomatic bradycardia even if a TCP is ready and even if
    Mobitz II or Complete block is present ? Love your course.

    Ken

    Reply

    • AHA recommends atropine as first line, but states “the administration of atropine should not delay TCP if poor perfusion is present.”
      Also, AHA states: “that the use of atropine should not be relied upon for Mobitz II and complete block.”

      For symptomatic Mobitz II or complete block with poor perfusion and TCP is ready go with TCP. I there is time as you prep for TCP give a dose of atropine and observe the response.

      Kind regards,
      Jeff

      Reply

  2. I have worked as an NP, now retired. Could someone explain the difference between SVT and atrial tachycardia. Are they the same? To me “supraventricular” implies above the ventricles, which would be the atria.

    Reply

    • Atrial tachycardia is a form of supraventricular tachycardia, originating within the atria but outside of the sinus node.

      SVT usually refers to AVNRT or AVRT.

      AVNRT occurs due to the presence of the slow and fast pathway in the AV Node. Repolarization does not occur simultaneously and a re-entry circuit can be created that allows for rapid depolarization of the ventricles.

      AVRT exists when an extra conduction circuit exists outside of the AV Node and an abnormal pathway exists that can allow a circuit to be created that allows excessively fast heart rates. This video explains AVNRT and AVRT succinctly. SVT Video

      Here is a good article about the specifics of Atrial Tachycardia.
      Kind regards,
      Jeff

      Reply

  3. I am wondering if there is a typo in the 2015 guidelines regarding TCP. While the book says to set mA 2 above capture dose, this doesn’t make any sense to me. Portable defibrillators that would be used for TCP have an mA adjustment that goes up by 10 mA increments. I don’t believe that it is even an option to adjust by 2 mA at a time (such small voltages would only apply to transvenous pacing). I am wondering if it should be 20 mA above capture.

    Reply

    • It is correct. The guidelines provide general guidance that may need to be adapted to the equipment that you have on hand. In your case, set the pacer to achieve capture and then go one “increment” up from that. The objective is to obtain full and consistent capture. Positioning and body fat disposition can cause the capture dose to fluctuate so it is wise to set the capture dose one increment higher. Whether that is 2 mA, 5 mA, or 10 mA, the objective is to get it slightly above the dose that causes capture.

      Kind regards,
      Jeff

      Reply

  4. Hi Jeff
    Great site, thanks. This is my second time using it for ACLS.
    Question 8: That PR interval doesn’t look normal to me. It is very short. Surely this is more likely to be a junctional rhythm?

    Reply

    • Thanks for the encouragement. I’m so glad that you have found the site helpful.

      In question 8, The main reason why this would be classified as sinus bradycardia is because there are P waves preceding all QRS complexes. There is a clear relationship between the P waves and QRS complexes.

      Typically with junctional bradycardia QRS complexes will be disassociated from the P waves because there is no communication between the atria and ventricles.

      Here is a basic definition for a junctional rhythm:
      -A junctional rhythm with a rate of 40-60 bpm.
      -QRS complexes are typically narrow (< 120 ms). -No relationship between the QRS complexes and any preceding atrial activity (e.g. P-waves, flutter waves, fibrillatory waves). Kind regards, Jeff

      Reply

    • Yes there is a logical reason. First, the cause of the bradycardia should be corrected. The cause of bradycardia in the presence of hypothermia is most likely hypothermia. Also, with severe hypothermia since the heart is unable to respond to the electrical stimulus pacing will not be helpful until the patient is warmed.

      Kind regards,
      Jeff

      Reply

  7. Jeff,
    I would just like to say that bradycardias have always been my weak point and your website has really helped me a lot with the how to correct them. Thank you so much

    Reply

  8. lots of excellent questions and scenarios. Very help full site.

    but I have a question on sequencing of meds in the scenarios.
    It seems I can’t predict when you would give epi vs vasopressin vs amiodarone. I know vaso can replace epi 1 or 2, and that amiodarone comes after epi. But it seems sometimes the first dose of epi/vaso is not given until the second round of CPR. In one scenario, the was an IV and monitor attached, the patient went into Vfib, was shocked, and CPR was started, but epic/vaso wasn’t given this first round, but waited until the second round. why would you wait? In another scenario 1st epi was given during CPR, then in the following round of CPR amiodarone wasn’t given, but waited until after the second epic was given. So can you clarify when each should be given. indeed, in my class we have been taught that epi should be in as soon as possible, and that amiodarone can also go in as soon as possible (assuming VF/VT), but that it may be better organizationally to alternate epi and amiodarone between cpr cycles

    Reply

    • I make every attempt to ensure that everything on the website sticks precisely to the 2010-2015 AHA guidelines at this time. The new guideline changes will take effect some time around March-April of this year. At this time the right branch of the cardiac arrest algorithm Vt/Vf calls for epinephrine to be give after the 2nd shock during CPR. Vasopressin can replace the first or 2nd dose of epinephrine. After the first epi/vaso administration, it is given every 3-5 minutes. The first dose of amiodarone is always given after the 3rd shock during CPR. The second dose of amiodarone can given given after the 4th shock as along as the first dose has been given time to circulate and take effect.

      In your last sentence you stated: ” in my class we have been taught that epi should be in as soon as possible, and that amiodarone can also go in as soon as possible (assuming VF/VT), but that it may be better organizationally to alternate epi and amiodarone between cpr cycles”

      The administrate on epinephrine as soon as possible for pulseless for Vt/Vf deviates from the AHA ACLS guidelines. Even with the new 2015-2020 guidelines which will be released some time around March-April 2016, Epinephrine is given as soon as possible only for the right branch of the cardiac arrest algorithm. For pVt/Vf, epinephrine is suggested to be given after the 2nd shock during CPR. By the way, vasopressin is being completely removed from the cardiac arrest algorithm (March-April 2016). I have never heard of amiodarone being recommended to be given as soon as possible and this deviates away from the recommendations of the AHA guidelines. Remember, the guidelines are just guidelines and individual facilities, EMS systems, ect. can develop their own protocols for their own use. The AHA just provides recommendations for best practice.

      For this website, I try not to deviate away from the strict guidelines to ensure that providers taking the AHA ACLS provider course are thoroughly prepared with the recommendations of the AHA.

      Kind regards,

      Jeff

      Reply

      • Is third degree displayed with a narrow QRS as opposed to 2nd II, I am having trouble distinguishing between these

      • 2nd degree block type II and third-degree block can both have a wide QRS complex.

        About 75% of cases of second-degree block type II will have a wide QRS complex because the conduction block is located distal to the Bundle of His, producing broad QRS complexes.

        One easy way to tell the difference between the two is that with second-degree block type II there will always be a P-wave before a QRS complex.

        With third-degree block, you will see some QRS complexes that have no regular P-wave.

        Kind regards,
        Jeff

  9. Hi Jeff, Regarding Question # 3. You referenced the 2010 AHA ACLS provider manual P.P. 113 stating that the demand rate begins at 60/min and adjust as needed. The 2010
    AHA Handbook of Emergency Cardiovascular Care pp #14 states: Set demand rate to
    approximately 80/min. Is it just a typo in the latter?

    Reply

    • I’m not sure why there is a difference. Within ACLS, 60/min has been the standard for quite some time. I would say it’s a typo. In my experience as a health care provider, we have started the demand rate to 60/min and titrated up or down as needed. Kind regards, Jeff

      Reply

  10. This is a messed up test item – “dose and frequency” applies to intermittent dosing, not infusions.
    Intermittent is 1mg every 3-5 minutes, so that is the best option given how this item is worded.

    Reply

    • 1 mg every 3-5 minutes is not used in the bradycardia algorithm. There is only one way that epinephrine is used in the bradycardia algorithm. It is only used as an infusion. I did not want to give this away by stating dose and infusion rate. This is why I stated it as dose and frequency. The question was not attempting to miss lead, but simply to keep from giving away part of the answer. It is easy for students to forget that in this algorithm, epinephrine is only used as an infusion for chemical pacing in place of electrical pacing.

      Kind regards,
      Jeff

      Reply

  11. Jeff,

    I am a nursing student and am greatful for this website! This will help me in many aspects when it comes to testing for critical care exams. The transcutaneous pacing is new information for me. Do you have a video about this or recommend a webiste. I know that it is performed by placing pads on top of the skin, but is there more to it? And how does TCP differ from a shock since they both stimulate the heart to contract?

    Reply

  12. As far as atropine goes, are we only giving one dose to see if it works and then moving on, or are we maxing it out at 3mg before we try another method?

    Also, would transcutaneous pacing occur at the same time as either dopamine or epinephrine, or is that another alternative to epi and dopamine?

    Thanks Jeff. I have my ACLS later on this week and I think this will be an invaluable tool.

    Reply

    • If you get a response from atropine and the heart rate improves, the heart rate may go down again as the atropine is metabolized. This would then require additional doses of atropine up to the 3mg max.
      As for the 2nd question, If you use TCP, you would not need the epi or dopamine drip for rate control. Epi or dopamine may be used to replace TCP and they have been found to be equally effective to TCP.
      Also, you may find that if TCP is not available, epi or dopamine may be available for use until TCP is ready.
      Hope this makes sense.
      Kind regards,
      Jeff

      Reply

  13. I love it…As soon as I seen service men at the head of this site I was sure it would be beneficial…Although they are navy and I am prior army!

    Reply

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