Welcome to the ultimate ACLS (Advanced Cardiovascular Life Support) study guide brought to you by Heart Start CPR. Whether you’re preparing for your initial certification or renewing after two years, this guide is designed to support you every step of the way. ACLS can feel overwhelming, especially with the volume of information and critical thinking involved. But you don’t have to tackle it alone.
We’ve broken everything down into manageable sections, covering the key topics you’ll need to understand: from essential BLS (Basic Life Support) review to advanced cardiac algorithms, ECG rhythm recognition, pharmacology, and effective team-based resuscitation. Let’s get started on your journey toward ACLS certification success.
1. Introduction to ACLS
ACLS builds on the basics of BLS (Basic Life Support) and prepares healthcare providers to respond effectively to life-threatening cardiovascular emergencies. It focuses on treating cardiac arrest, stroke, acute coronary syndromes (ACS), and other critical conditions using advanced skills like ECG interpretation, IV medication administration, and airway management.
Anyone working in critical care, emergency medicine, anesthesia, or prehospital care needs ACLS certification. At Heart Start CPR, we train professionals to not only pass the test but to perform confidently when lives are on the line.
The ACLS Provider Course includes hands-on practice and real-world scenarios. It highlights the importance of high-quality CPR, working as a team, and making quick, informed decisions. The American Heart Association (AHA) updates ACLS guidelines every five years. Our training follows the latest 2020–2025 AHA guidelines, ensuring you’re learning the most current protocols.
2. Basic Life Support (BLS) Review
A strong foundation in BLS is essential before moving on to advanced ACLS skills. The Adult Chain of Survival highlights the key actions that significantly increase the chances of survival in cardiac emergencies:
- Early recognition and activation of emergency response
- High-quality CPR with effective chest compressions
- Rapid defibrillation when indicated
- Timely advanced life support interventions
- Coordinated post-cardiac arrest care
Chest compressions remain the core of high-quality CPR. Depth should reach at least 2 inches, with a rate of 100–120 compressions per minute, and full recoil between compressions to allow for proper heart filling. For patients who have a pulse but are not breathing, rescue breaths should be delivered every 6 seconds (10 breaths per minute).
An AED (Automated External Defibrillator) plays a critical role in early defibrillation. Familiarity with the full BLS algorithm ensures a seamless transition into advanced care. Heart Start CPR also offers BLS classes to help healthcare professionals build strong, confident skills at the foundational level.
3. ACLS Core Concepts
The ACLS Survey, structured as ABCD, provides a clear and organized way to assess and manage patients during resuscitation:
- Airway
- Breathing
- Circulation
- Differential Diagnosis
This approach ensures that life-threatening issues are addressed systematically and quickly. Differentiating the underlying cause of a cardiac arrest is a vital part of effective ACLS care. The H’s and T’s serve as a mental checklist for identifying and treating reversible causes:
- H’s: Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo-/Hyperkalemia, Hypothermia
- T’s: Tension pneumothorax, Tamponade, Toxins, Thrombosis (coronary/pulmonary), Trauma
Airway management includes basic tools like oropharyngeal (OPA) and nasopharyngeal (NPA) airways, as well as advanced options such as endotracheal tubes (ETT), laryngeal mask airways (LMA), and i-gel devices. Bag-valve-mask (BVM) ventilation is also essential for delivering effective breaths, and proper technique helps ensure adequate oxygenation.
For medication delivery, intravenous (IV) access is preferred. If IV access is not available, intraosseous (IO) access serves as a reliable alternative during emergencies
4. Pharmacology for ACLS
Medications play a vital role in managing cardiac arrest and other cardiovascular emergencies. Here are the key drugs and their recommended uses:
- Epinephrine: 1 mg IV/IO every 3–5 minutes during cardiac arrest; infusion of 2–10 mcg/min for bradycardia
- Amiodarone: 300 mg IV/IO for VF/pVT; second dose of 150 mg if needed
- Atropine: 1 mg IV every 3–5 minutes for bradycardia (maximum 3 mg total)
- Adenosine: 6 mg rapid IV push for stable SVT; may give 12 mg if no response
- Magnesium Sulfate: 1–2 g IV for torsades de pointes
- Dopamine: Infusion at 5–20 mcg/kg/min for bradycardia or hypotension
- Norepinephrine: Infusion at 0.1–0.5 mcg/kg/min for post-arrest hypotension
5. ACLS Algorithms (Updated Guidelines)
Various treatment algorithms guide the management of cardiovascular emergencies. Below are the key ACLS algorithms based on the latest AHA guidelines:
Cardiac Arrest
- Shockable Rhythms (VF/pVT): Defibrillation → CPR → Epinephrine 1 mg IV/IO every 3–5 minutes → Amiodarone 300 mg IV/IO bolus; second dose of 150 mg if needed.
- Non-Shockable Rhythms (Asystole/PEA): CPR → Epinephrine 1 mg IV/IO every 3–5 minutes → Identify and treat reversible causes.
Bradycardia with a Pulse
- Assess for symptoms.
- If symptomatic, administer Atropine 1 mg IV every 3–5 minutes (maximum 3 mg).
- If Atropine is ineffective, consider transcutaneous pacing or Dopamine infusion (5–20 mcg/kg/min) or Epinephrine infusion (2–10 mcg/min).
- Identify and treat underlying causes.
Tachycardia with a Pulse
- Assess stability:
- Stable: Consider vagal maneuvers; administer Adenosine (6 mg rapid IV push, followed by 12 mg if needed) or use antiarrhythmic drugs.
- Unstable: Synchronized cardioversion.
- Identify and treat underlying causes.
Acute Coronary Syndrome (ACS)
- Administer MONA: Morphine, Oxygen, Nitroglycerin, Aspirin.
- Obtain a 12-lead ECG.
- If STEMI is suspected, prepare for Percutaneous Coronary Intervention (PCI) or fibrinolytics.
Stroke
- Rapid identification using the Cincinnati Stroke Scale.
- Confirm with a CT scan.
- If within the treatment window, administer thrombolytics.
- Use the NIH Stroke Scale for severity scoring.
4. ECG Rhythm Recognition
ECG interpretation is the heart of ACLS. Here are the essentials:
- Normal Sinus Rhythm: Regular P waves, 60–100 bpm
- Bradycardia: Sinus or AV block rhythms <60 bpm
- Tachycardia: Narrow complex (SVT), wide complex (VT)
- VF: Chaotic, disorganized rhythm—no pulses
- pVT: Rapid wide QRS, no pulse—shock immediately
- Asystole: Flatline—do not shock
- PEA: Organized rhythm with no pulse—treat cause
Heart blocks:
- 1st degree: PR >0.20s
- 2nd degree Type I (Wenckebach): PR lengthens then drops
- 2nd degree Type II (Mobitz): PR constant with dropped QRS
- 3rd degree: Complete dissociation between P waves and QRS
6. ACLS Team Dynamics
A smooth code relies on strong teamwork and clear roles. Key elements include:
- Defined roles: Assign tasks like team leader, compressor, recorder, medication administrator, and airway tech.
- Closed-loop communication: Always repeat back orders to confirm understanding and avoid errors.
- Effective leadership: Stay calm, delegate tasks clearly, and keep the team focused and coordinated.
- Post-code debriefing: Discuss what worked well and what could be improved for future codes.
At Heart Start CPR, we focus on ACLS team dynamics and the resuscitation triangle roles to ensure everyone knows their part and works seamlessly together during resuscitation.
7. Case Scenarios and Practice Questions
Applying what you’ve learned to real-world cases helps cement your knowledge. We include interactive scenario walkthroughs with rationales, so you understand the “why” behind each step.
Here are some examples we go over in training:
- VF Arrest: Bystander CPR, AED used, EMS arrives—what next?
- Bradycardia with hypotension: What’s the first-line drug?
- ACS patient: Chest pain and ST elevation—what labs and drugs are priorities?
- Stroke alert: How to rapidly assess, triage, and prepare for tPA?
8. Special Considerations in Pediatric ACLS
ACLS isn’t just for adults—pediatric patients require specific considerations:
- Age-Based Dosing: Medication doses and defibrillation energy levels differ for children. Familiarize yourself with the pediatric drug doses and energy levels for shocks.
- Pediatric Assessment Triangle (PAT): Quickly assess the child’s appearance, work of breathing, and circulation to identify the severity of illness.
- Advanced Pediatric Airway Management: Pediatric airway anatomy differs from adults, and the proper selection of airway devices is critical.
- Special Resuscitation Protocols: The AHA provides specific algorithms for pediatric cardiac arrest, bradycardia, and tachycardia.
9. Test Preparation Tips
Preparing for the ACLS exam and Megacode can feel intense, but the right strategy makes it easier. The process includes a written test and a hands-on Megacode scenario. Here’s how to crush the ACLS exam and Megacode:
- Know the format: Expect a multiple-choice test and a Megacode where you’ll assess rhythms, make treatment decisions, and lead a team.
- Practice the flow: Recognize rhythms, know the interventions, and work on clear communication during team-based simulations.
- Stay calm and focused: Use your time wisely—read carefully, act decisively, and avoid second-guessing.
- Use study resources: Review with flashcards, algorithm posters, videos, and ACLS practice tests to lock in key concepts.
- Test yourself early: Take multiple practice exams to track your progress and identify weak areas.
Conclusion: Preparing for Success in ACLS
Through this guide, you’ve explored the essential ACLS concepts, algorithms, pharmacology, and team dynamics. With the right preparation and practice, you can ensure that you’re not just familiar with the guidelines, but are ready to apply them in high-pressure situations.
At Heart Start CPR, we prioritize hands-on learning and team-based practice, giving you the tools to feel confident in both your knowledge and actions. Stay focused, practice regularly, and remember that the more prepared you are, the better equipped you’ll be to manage real-life emergencies. By combining solid training with real-world application, you’ll be ready for any resuscitation scenario that comes your way.
If you’re preparing for the ACLS exam, good luck and make sure to prepare well. You’ve got this.
