Advanced Cardiac Life Support on the CCFP exam

Approach

• Heart & Stroke sets Canada's resuscitation guidelines. Its 2025 Canadian edition marks where Canada differs from the American text.
• Read each new edition when it appears. Know the changes, not only the course you took.
• Train as a team. Teamwork training and CPR feedback devices are both recommended for health professionals.
• Hospital code teams should be trained in advanced life support, with clear roles for each member.
• Debrief after codes, right away and again later. Each finds different problems to fix.

Approach

• Ventricular fibrillation or pulseless ventricular tachycardia: defibrillate at once. Early good CPR and a prompt shock matter most.
• In a shockable arrest, epinephrine comes only after the first shocks fail.
• Twisting (polymorphic) ventricular tachycardia gets an unsynchronized shock at defibrillation energy.
• A pulse, a wide regular rhythm, and the patient is unstable: synchronized cardioversion. Start at 100 J for monomorphic ventricular tachycardia.
• Stable, regular wide-complex tachycardia: try vagal manoeuvres or adenosine first. Cardiovert if drugs fail.

Approach

• Read P waves against QRS complexes before you treat. The table below sorts the blocks.
• Unstable slow rhythm: atropine 1 mg first. Next, dopamine at 5 to 20 µg/kg per minute.
• Slow rhythm still unstable after drugs: transvenous pacing is reasonable until the cause is fixed.
• Unstable narrow-complex tachycardia: synchronized cardioversion at 100 J.
• Unstable atrial fibrillation: synchronized cardioversion at 200 J or more with a biphasic device. Atrial flutter: start at 200 J.
• A child's supraventricular tachycardia that vagal manoeuvres, adenosine and cardioversion do not fix: get expert advice. Procainamide or amiodarone are options. IV sotalol is not available in Canada.

Approach

• High potassium with ECG changes: IV calcium protects the heart. Do not wait for the lab result.
• On digoxin, skip calcium. If digoxin toxicity is likely, give digoxin-specific antibody fragments.
• Antibody fragments treat life-threatening toxicity: severe ventricular rhythms, a slowing rhythm, or second- or third-degree block that atropine does not fix.
• Potassium above 5.5 mmol/L in an adult, or above 6 in a child, with fast-worsening toxicity also calls for them.
• Acute overdose, amount unknown: 20 vials. Chronic toxicity: 6 vials in an adult, 1 vial in a child of 20 kg or less. Do not wait for the level.
• In arrest from suspected high potassium, calcium is unproven. Never let it delay CPR, shocks or epinephrine.
• Cocaine with a temperature above 40 °C: cool fast. Ice-water immersion works best.

Approach

• Before an advanced airway: 30 compressions, then 2 breaths.
• Each breath should just make the chest rise. With an adult bag, that is about one third to one half of a squeeze.
• Breathing stopped but a pulse, or arrest with an advanced airway in: 1 breath every 6 seconds, 10 a minute.
• Head and neck trauma: try a jaw thrust and an airway adjunct. If the airway still will not open, use a head tilt–chin lift.
• Confirm a tube or supraglottic airway (a tube that sits above the vocal cords) with waveform capnography (a breath-by-breath CO2 trace).
• Suspected opioid overdose with no breathing: give naloxone.
• In a child, arrest usually follows failing breathing or shock. Fix oxygen and breathing early.

Approach

• Start CPR by default. Hold it for danger to the team, clear signs of irreversible death, or a directive that refuses it.
• A family's spoken request to withhold CPR can be ethical to accept in some settings.
• You need not give treatment with no realistic benefit, even when a substitute decision-maker asks. Lean on hospital policy or an ethics consult.
• Adult arrest outside hospital: the universal rule supports stopping when paramedics did not witness it, no shock was given, and circulation never returned.
• Do not stop on one number. In children, no end-tidal CO2 cutoff decides it alone.
• Weigh it all together: the rhythm, the length of the code, health before the arrest, and known wishes.

Approach

• Start advance care planning early. Revisit it often, and update it as health changes.
• Name a substitute decision-maker. Record the patient's values and wishes.
• Share the decision: explain the condition and the options, learn the goals and values, then recommend a plan that fits them.
• Write it down. A portable order for life-sustaining treatment carries wishes from one setting to the next.
• Do not start or continue life support that clashes with the patient's values. Do not offer burdensome care that does not match their goals.
• Feeding tubes and IV fluids rarely ease dry mouth or hunger in advanced illness with wasting.
• Advanced dementia: offer careful hand-feeding, not a feeding tube.

Approach

• Offer relatives the chance to be present. Being there can lower the risk of complicated grief.
• Give them one team member who stays with them and explains what is happening.
• Know your hospital's policy. It may list situations where presence is not possible.
• After the code, speak plainly in a quiet place. Offer to meet again.
• If the patient survives, check patient and caregivers for emotional distress before discharge. About a quarter have it. Treat it or refer.

Approach

• Base every dose and tube size on the child's weight. If you do not know it, estimate it with a standard tool, never from memory.
• Use a cognitive aid, such as a dosing chart. It can improve how the team performs.
• Nonshockable arrest in a child: give the first epinephrine as early as you can.
• Most child arrests follow failing breathing or shock, not a heart problem. Oxygen and breathing come first.
• Infant compressions: two thumbs around the chest, or the heel of one hand, at least one third of the chest depth.
• Keep pauses in compressions under 10 seconds.
• After circulation returns, keep systolic and mean pressures above the 10th percentile for age.