AHA ACLS Skills Checkoff

The ACLS Skills Checkoff is the second part of a blended learning course that includes an online portion and an in-person portion.

Before attending this class, students much first purchase and complete the HeartCode ACLS Online Blending learning course for $173 at https://elearning.heart.org/course/1601.

 This online course is a self-directed, comprehensive eLearning program that uses adaptive learning technology to allow learners to acquire and demonstrate Advanced Cardiac Life Support skills using a personalized learning path that adapts in real time to a learner’s performance. The program is designed for healthcare professionals who need Advanced Cardiac Life Support training for their clinical duties. HeartCode® ACLS Online consists of a cognitive portion that is completed online. A separate psychomotor skill practice and testing session with an AHA Instructor is a required portion of  the certification process to earn a valid AHA ACLS Provider E-Card that is valid for two years. When the online course is complete, the learner will take a survey and then be able to access the completion certificate. This certificate needs to be emailed or printed and taken to the in-person Skills Session.

The Advanced Cardiac Life Support (ACLS) Skills Session (HeartCode Parts 2 and 3) is the in-person hands on practice and testing portion done after completing the American Heart Association ACLS HeartCode Part 1 Online Course. It's also known as an ACLS Assessment, ACLS Psychomotor Skills Assessment, or ACLS Skills Check.

 During the session, students practice and test their skills with an instructor in an in-person setting.

 The session typically includes:

Reviewing guidelines: Students review current ACLS guidelines with the instructor.

Practicing skills: Students practice skills in sequence in an "in-hospital" adult BLS scenario. These skills may include chest compressions, pocket-mask ventilations, bag-mask ventilations, and use of an AED (external automated defibrillator).

Testing on scenarios: Students test their skills on adult BLS, ventilation, and megacode scenarios. Megacodes are life-threatening cardiopulmonary scenarios that test students' understanding of ACLS concepts and mechanics. These scenarios may cover CPR, airway interventions, and cardiac arrhythmias.

On successful completion of both the online and in person parts of the course students are emailed an AHA ACLS Provider E-Card that is valid for two years. E-Cards are issued on the same day after the in person portion.

The American Heart Association’s Advanced Cardiac Life Support (ACLS) (also called Advanced Cardiovascular Life Support) is a specialized certification course and set of guidelines designed for healthcare professionals who manage serious cardiovascular emergencies, such as cardiac arrest, arrhythmias, stroke, and acute coronary syndromes. cpr.heart.org+2international.heart.org+2

Here’s a breakdown of what ACLS is, what it covers, who it’s for, and how the course works:

What is ACLS?

  • ACLS is an advanced set of protocols and algorithms that builds on Basic Life Support (BLS) skills (such as chest compressions, use of an AED, airway management) and adds additional diagnostic and therapeutic tools (e.g. ECG / cardiac rhythm interpretation, advanced airway techniques, IV/IO drug administration) in the care of cardiovascular emergencies. cpr.heart.org+2Wikipedia+2
  • It’s intended to enhance survival and neurological outcomes in patients with life-threatening cardiac conditions by applying a structured, evidence-based approach. international.heart.org+2Wikipedia+2
  • The ACLS algorithms address multiple components, including:
    1. High-quality CPR (continuous compressions, minimizing interruptions)
    2. Early defibrillation / electrical therapy
    3. Airway management and ventilation
    4. Recognition and treatment of arrhythmias (bradycardia, tachycardia, pulseless rhythms)
    5. Use of medications (epinephrine, amiodarone, etc.)
    6. Post-cardiac arrest care
    7. Team dynamics, communication, and leadership in resuscitation settings international.heart.org+2cpr.heart.org+2

Who is it for?

ACLS is intended for healthcare professionals who may need to direct or participate in managing advanced cardiac emergencies. This includes:

  • Physicians, nurses, and paramedics
  • Personnel in emergency response, intensive/critical care, emergency medicine, and related units
  • Any provider whose job or credentialing requires an ACLS course (hospital privileging, certification boards, etc.) international.heart.org+1

There is also an “ACLS for Experienced Providers” track tailored for learners who already have strong familiarity with ECG interpretation, ACLS pharmacology, and resuscitation leadership. cpr.heart.org

Course Format & Requirements

  • ACLS courses are offered in various formats: traditional instructor-led classroom sessions, blended learning (online didactic modules + hands-on skills sessions), or hybrid approaches like HeartCode ACLS which allow flexibility in the online component followed by a skills check in person. shopcpr.heart.org+2cpr.heart.org+2
  • Trainees must perform hands-on skills (simulated or real equipment) and pass both skill testing (megacode / scenario practice) and written (cognitive) assessments. international.heart.org+1
  • Upon successful completion, participants receive a Provider Course Completion Card, which is generally valid for 2 years. international.heart.org+1
  • After the expiration, recertification is required by retaking an ACLS course or an equivalent refresher.

  • This course teaches the importance of preventing cardiac arrest, high-performance teams, continuous high-quality CPR, systems of care, recognition and intervention of cardiopulmonary arrest, post-cardiac arrest care, acute dysrhythmias, stroke, and acute coronary syndromes (ACS)

    • Updated to reflect new science in the 2025 American Heart Association Guidelines for CPR & ECC, as well as the Update to the ASA Ischemic Stroke Guidelines
    • This course is designed for healthcare professionals who direct or manage cardiopulmonary arrest or other cardiovascular emergencies; personnel in emergency response, emergency medicine, intensive care, and critical care units; physicians, nurses, and paramedics; and others who need an ACLS course completion card for job or other requirements
    • This manual includes the systematic approach to a cardiopulmonary emergency, effective team communication, and the ACLS cases and algorithms.

    Key Components of ACLS

    1. High-Quality CPR

    • Deliver chest compressions at a depth of at least 2 inches (5 cm) and a rate of 100–120 per minute.
    • Ensure full chest recoil between compressions.
    • Minimize interruptions in compressions.
    • Rotate compressors every 2 minutes to prevent fatigue.
    • Avoid excessive ventilation; provide just enough to see chest rise.

    2. Airway Management

    • Begin with basic airway techniques, such as using a bag-mask device.
    • Consider advanced airway placement (e.g., endotracheal intubation) if necessary.
    • Monitor end-tidal CO₂ to assess the effectiveness of CPR and ventilation.

    3. Cardiac Arrest Algorithms

    • Shockable Rhythms (Ventricular Fibrillation/Pulseless Ventricular Tachycardia):
      • Immediate defibrillation.
      • Administer epinephrine 1 mg IV/IO every 3–5 minutes.
      • Consider antiarrhythmic drugs like amiodarone or lidocaine if arrhythmia persists.
    • Non-Shockable Rhythms (Asystole/Pulseless Electrical Activity):
      • Continue high-quality CPR.
      • Administer epinephrine 1 mg IV/IO every 3–5 minutes.
      • Identify and treat reversible causes (e.g., hypoxia, hypovolemia, acidosis).

    4. Post-Cardiac Arrest Care

    • Optimize oxygenation and ventilation.
    • Maintain blood pressure and perfusion.
    • Consider targeted temperature management (32–36°C) to improve neurological outcomes.
    • Evaluate for coronary reperfusion if indicated.5. Team Dynamics and Communication
    • Assign clear roles during resuscitation efforts.
    • Use closed-loop communication to confirm tasks.
    • Conduct regular debriefings to improve future performance.
     

     

    • Epinephrine: Continues to be recommended for cardiac arrest; high-dose epinephrine is not advised for routine use.
    • Antiarrhythmics: Amiodarone or lidocaine may be considered for ventricular fibrillation/pulseless ventricular tachycardia unresponsive to defibrillation.
    • Extracorporeal CPR (ECPR): May be considered in settings with available resources for patients with refractory cardiac arrest.

    For comprehensive information and training resources, visit the AHA's official ACLS page: cpr.heart.org.

    Course content: After completing the course, students should be able to:

    • Define systems of care
    • Apply the BLS, Primary, and Secondary Assessments sequence for a systematic evaluation of adult patients
    • Discuss how the use of a rapid response team (RRT) or medical emergency team (MET) may improve patient outcomes
    • Discuss how the use of a rapid response team (RRT) or medical emergency team (MET) may improve patient outcomes
    • Discuss early recognition and management of ACS, including appropriate disposition
    • Discuss early recognition and management of stroke, including appropriate disposition
    • Recognize bradycardias and tachycardias that may result in cardiac arrest or complicate resuscitation outcome
    • Perform early management of bradycardias and tachycardias that may result in cardiac arrest or complicate resuscitation outcome
    • Model effective communication as a member or leader of a high-performance team
    • Recognize the impact of team dynamics on overall team performance
    • Recognize respiratory arrest
    • Perform early management of respiratory arrest
    • Recognize cardiac arrest
    • Perform prompt, high-quality BLS including prioritizing early chest compressions and integrating early automated external defibrillator (AED) use
    • Perform early management of cardiac arrest until termination of resuscitation or transfer of care, including immediate post–cardiac arrest care
    • Evaluate resuscitative efforts during a cardiac arrest through continuous assessment of CPR quality, monitoring the patient’s physiologic response, and delivering real-time feedback to the team

     At the end of this class students will lead the team in a respiratory case scenario and a megacode scenario as well as a 50 question open book test.

     

    New 2025 Guidelines for ACLS

    Foreign-Body Airway Obstruction: Adults, Children and Infants
    New 2025: For adults with severe foreign-body airway obstruction (FBAO), repeated
    cycles of back blows followed by 5 abdominal thrusts should be performed until the
    object is expelled or the person becomes unresponsive.

    AED Pad Placement
    Anterolateral (High right, low left) or Anteroposterior (AP) Placement - 2 options
    1). Center of the chest and center of the back
    2) Place one on the upper left chest above the nipple and the other on the left side of
    the back near the spine. 

    It is reasonable to adjust the position of a patient's bra instead of removing it when
    placing pads.

    Rigid cervical collars are no longer recommended for neck or spinal injuries as the can make it more difficult to maintain a patent airway. Mouth-to-nose ventilation may be necessary if ventilation through the person’s mouth is impossible because of trauma, positioning, or difficulty obtaining a seal.

    A case series suggests that mouth-to-nose ventilation in adults is feasible, safe, and effective. After identifying an adult in cardiac arrest, a lone responder should activate the emergency response system first, then immediately begin CPR. In adult cardiac arrest, rescuers should perform chest compressions with the patient’s torso at approximately the level of the rescuer’s knees.

    CPR for adult cardiac arrest patients with obesity should be provided by using the same techniques as for the average weight patient.

    Higher first-shock energy settings (≥200 J) are preferable to lower settings for cardioversion of atrial fibrillation and atrial flutter. Updated termination of resuscitation (TOR) guidelines emphasize rule application based on emergency medical services (EMS) scope of practice (basic life support [BLS], ALS, or universal TOR rule [UTOR]), and that end-tidal carbon dioxide (ETCO2) should not be used in isolation to end resuscitative efforts.

    Administration of intra-arrest medications via an in-place endotracheal tube) have been removed.

    Use of point of care ultrasonography (POCUS) by experienced professionals during cardiac arrest may be considered to diagnose reversible causes if it can be done without interrupting resuscitative efforts (ie, CPR). Polymorphic ventricular tachycardia is always unstable and should be treated immediately with defibrillation, because delays in shock delivery worsen outcomes.

    Intravenous (IV) access remains the first-line choice for drug administration during cardiac arrest; however, intraosseous (IO) access is a reasonable alternative if IV access is not feasible or delayed.

    Post Cardiac Arrest Care - Maintain MAP >65 and target SPO2 90%-98%. Maintain 100% FIO2 until reliable SPO2 can be measured.

    Unstable Tachycardia is now defined as SBP below 80 and should be synchronized cardioverted.

    Stable Tachycardia Cardiovert / Adenosine 6 mg, 12 mg then start a Procainamide OR
    Amiodarone drip.
    (For synchronized cardioversion of atrial flutter in adults, an initial energy setting of
    200 J may be reasonable and incremented in the event of shock failure, depending
    on the biphasic defibrillator used.)
    Review New Adult and Pediatric Ventricular Assist Device Algorithm
    Therapeutic Hypothermia has been extended to a minimum of 36 hours.
    Adults and Children with Life Threatening Asthma Exacerbations refractory to
    standard therapy may benefit from EMCO.
    Hyperthermia: Adults and children with life-threatening hyperthermia from
    environmental causes, cocaine poisoning, or sympathomimetic poisoning should be
    rapidly cooled, ideally at a rate of at least 0.15 °C/min (0.27 °F/min). This is best
    achieved with immersion in ice water.
    It is recommended that health care professionals first attempt establishing IV access
    for drug administration in adult patients in cardiac arrest. Intraosseous (IO) access is
    reasonable if initial attempts at IV access are unsuccessful or not feasible for adult
    patients in cardiac arrest.
    This concludes the NEW 20250 Changes for ACLS


    When Performing CPR
    Always begin with chest compressions, not breaths. Give 30 compressions and 2
    breaths.
    5 cycles of 30 compressions and 2 breaths = 2 minutes.
    Check for a pulse every 2 minutes, and switch providers every 2 minutes so that the
    person giving compressions does not get too tired. High quality compressions must
    be given.
    For adults, compress at least 2 inches or 5 cm. Do not compress more than 2.4 inches
    or 6 CM. Always let the chest completely recoil between compressions. Provide 100 to
    120 compressions per minute.
    Don't spend more than 5 - 10 seconds assessing the patient, and checking for a pulse,
    or switching compressors. 

    If you are unsure if they have a pulse, begin chest compressions. Keep interruptions
    in chest compressions to 10 seconds or less.


    WAVEFORM CAPNOGRAPHY
    Waveform capnography is written as PETCO2 (Partial End Tidal Carbon Dioxide)
    Waveform capnography is used to measure CPR quality and determine ROSC (Return
    of Spontaneous Circulation).
    Think of ROSC as "Return of Life". If CPR is being done, and the patient's heart starts
    beating again on it's own, the patient has achieved ROCS, or return of life.
    Waveform capnography is the MOST reliable indicator of ETT placement. If the
    person doing the intubation happens to get the ETT into the esophagus vs the
    trachea, there would be no waveform capnography reading.
    A PETCO2 of less than 10 indicates ineffective chest compressions. Treatment should
    focus on improving the quality of chest compressions. A PETCO2 greater than 10
    indicates effective chest compressions . Normal PETCO2 is 35-40mmHg.
    Don't get the waveform capnography confused with the colormetric device. A
    colormetric device only changes color and indicates the detection of CO2 in the tube.

     

    RESCUE BREATHING
    When providing breaths, if doing compressions give 30 compressions and 2 breaths.
    Each breath should be given over 1 second, and only until you see the chest rise.
    Giving a bigger breath will only fill the stomach with air which will crush the
    diaphragm, chest, lungs, and crush the heart making it difficult to resuscitate your
    patient and decreasing cardiac output.
    If your patient has a pulse and simply cannot breath, provide rescue breaths at a rate
    of 1 breath every 6 seconds. This gives you 10 breaths/min
    If your patient is intubated (has an advanced airway), provide 1 breath every 6 seconds
    = 10/min. When an advanced airway is in place, compressions should not be paused
    to give breaths.
    If your patient has agonal gasps, this is NOT normal breathing and is a sign of cardiac
    arrest. Start CPR.


    GUIDELINES FOR SYNCHRONIZED CARDIOVERSION AND DEFIBRILLATION
    The only difference between defibrillation and cardioversion is: One is synchronized,
    and one is not.
    Synchronized cardioversion is a LOW ENERGY SHOCK that uses a sensor to deliver
    electricity that is synchronized with the peak of the QRS complex (the highest point
    of the R-wave).
    If the patient has a pulse, you must push the synchronize button on your defibrillator,
    before you deliver the shock. This will ensure that the shock lands on the R-wave of
    the heart beat.
    If you do not synchronize the shock on someone with a pulse, the shock could hit the
    heartbeat on the T-wave and cause the patient to go into ventricular fibrillation. This
    will be bad. Very, very bad.
    So just remember, you can’t synchronize dead. If the patient has a pulse, you must
    synchronize the shock. 

    HOW MANY JOULES DO YOU USE?
    Start with 200 Joules
    If the initial shock fails, always increase the dose in a stepwise fashion.


    THERAPEUTIC HYPOTHERMIA
    Used only when your patient remains unresponsive following cardiac arrest,
    especially those who presented with an initial rhythm of v-fib.
    These patients are cooled to 32-34 degrees celsius for at least-36 hours.
    If your patient wakes up and follow commands, do not start hypothermia protocol.
    Therapeutic Hypothermia can be combined with PCI (Percutaneous Coronary
    Intervention) or "heart cath" or "angiogram". Therapeutic hypothermia can be started
    after return of ROSC and then can be continued in the Catheterization Lab.


    CHEST PAIN
    Any patient having chest pain should have an EKG first. You must know if they are
    having a STEMI.
    STEMI (ST segment elevation) must go to the cath lab for an angiogram or they will
    die. The heart muscle is not perfusing. Just remember, if the ST segment is elevated
    and pointing toward heaven, your patient is GOING TO HEAVEN without immediate
    intervention.
    NSTEMI (ST depression) usually are able to go home on blood thinners. Having a
    depressed ST is not as life threatening as "going to heaven".
    The only exception to the EKG first, is a patient where the chest pain is caused by
    their increased heart rate.
    If they are in an unstable tachycardia WITH A PULSE, synchronized cardioversion
    should be the first treatment.
    So, if an ambulance is bringing you a STEMI patient, and your facility does not have
    the capabilities to do a heart cath, or angiogram, these patients need to be diverted
    to a specialty cardiac hospital even if it’s an hour away. If you accept the patient, you
    then have to get admit orders, have consents signed, do the whole medication
    reconciliation, then get transfer orders, find an accepting doctor and transfer the
    patient anyway.
    Door to balloon inflation time should be 90 minutes or less. The patient would be
    better off getting closer to a hospital that specializes in handling an acute heart
    attack, or M.I. (Myocardial Infarction or "heart muscle damage/death", and has a
    catheterization lab. 

    Suspected Stroke


    Assess Facial droop, arm drift, slurred speech and get the time the symptoms first
    started. This is super important! Get the time.
    Some facilities call this a "FAST" or Cincinnati Stroke Scale If the CT scan is negative
    and there is no sign of hemorrhage, Fibrinolytics should be started as soon as
    possible.
    The THIRD thing you need to do is get that CT SCAN. The CT scan should be done
    within 25 minutes of the patients arrival in the ED. You need to know if they are
    having an ischemic stroke or a hemorrhagic stroke. If they are bleeding, they will not
    get the fibrinolytics. Once the CT is done, there is no sign of bleeding and no
    contraindications, administer the fibrinolytics as soon as possible.
    The American Heart Association defines PEA as sinus rhythm without a pulse. During
    a CODE situation, you should check a pulse EVERY 2 MINUTES. If the monitor shows
    sinus rhythm or sinus bradycardia and there is no pulse, your patient is dead !
    Continue chest compressions and administer 1 mg of Epinephrine. Reassess the
    rhythm and the pulse EVERY 2 MINUTES and follow the cardiac arrest algorithm.
    Atropine is the first line treatment for any bradycardia regardless of the type, if
    Atropine is ineffective a dopamine drip should be started at 2-20 mcg/kg/min. A good
    place to start is at 5mcg/kg/min. Titrate to desired heart rate. If the heart rate does not
    increase, increase the dopamine drip rate. If the heart rate is too fast, decrease the
    dopamine drip rate. Run the dopamine until external pacing begins. 

    HOW TO PERFORM EXTERNAL PACING


    STEP 1: Turn on defibrillator and set to PACER mode.
    STEP 2: Place defib pads on your patient AND the 3 leads: red, white and black.
    STEP 3: Get a doctor's order to pre-medicate your patient. Pacing is VERY PAINFUL !
    STEP 4: Begin pacing. PRESS THE START BUTTON ! Your pacer should have default
    settings of a heart rate between 60-70 and a millivolt setting anywhere between 5
    and 30.
    STEP 5: If your patient's heart rate does not increase, increase the millivolts by 5 every
    couple of heart beats until your patient is 100% paced. 

    NOTE: You must have defib pads AND the 3 leads connected to your patient. BOTH of
    these must be connected to the defibrillator. The 3 leads (red, white and black) sense
    what your patient's heart rate is. So if your patient's heart rate is 40 and your pacer is
    set to a heart rate of 60, the pacer will shock them 20 times per minute for a total of
    60/bpm. If your patient's heart rate gets up to 61 nothing will happen. If their heart
    rate drops to 59 they get shocked once per minute. If it drops to 58 they get shocked
    twice per minute and so on. Without the red, white and black lead, your pacemaker
    will not know what to do. (If you can remember: White on the right, and smoke
    above the fire")
    Provide a fluid bolus of 1-2 liters if the patient remains hypotensive after ROSC.
    If you are going to induce therapeutic hypothermia, use COLD saline for the bolus.
    The minimum systolic BP to achieve is 90mmHg.
    Providing quality chest compressions immediately before a defibrillation attempt
    and giving drugs during compressions will improve successful conversion of V-Fib
    and the return of ROSC.
    The American Heart Association says that it is acceptable to stop resuscitation efforts
    if the patient has not had a pulse for 15 consecutive minutes. Except in special cases
    of drowning or hypothermia.
    Always be aware of safety hazards. Don’t ever cut adult pads in half or shock a
    patient if there is oxygen blowing across their chest. The oxygen combined with the
    electric spark could cause a small explosion or ball of fire that injures everyone in the
    room.
    Always provide chest compressions while the defibrillator is charging. The time it
    takes to analyze is several seconds, you want to make the hands-off period of time as
    short as possible. Some defibrillators can take up to 45 seconds to charge.
    Always make sure you have a 6 second rhythm strip if you are going to be counting
    the QRSs by 10 to get your heart rate. If you have a 12 second strip and do this you are
    likely to end up with a heart rate of 80 when it’s actually only 40. The treatment is
    significantly different.

    WHAT'S THE DIFFERENCE BETWEEN DEFIBRILLATING AND CARDIOVERSION?
    There are 2 types of shocks. One is synchronized and one is not.
    A synchronized shock is called cardioversion. A blind shock is defibrillation.
    If I blindly charge the defibrillator and shock them, if the shock happens to land on
    the last part of the heartbeat called the "T-wave" this will change their rhythm to
    V-Fib. This would be bad !
    But if I "Synchronize" the shock by pushing the "synch" button on the defibrillator, a
    small dot or line will appear above every "R-wave" (which is the tallest portion of the
    heartbeat). Then when I push the shock button, the machine will automatically
    synchronize the shock so that it lands on the "R" wave
    Now, do you see how you can't synchronize dead? You can't synchronize a shock to
    land on a particular part of a heartbeat if there is no heartbeat.
    MORE AWESOME TIPS:
    Always allow the chest to completely recoil when doing compressions. Say there was
    a small fire, and you had a water bottle full of water. Would it make sense to squeeze
    tiny amounts out really really fast? Or, would it make more sense to give the bottle a
    good squeeze and force out as much water as you can at one time, and repeat?
    When you compress the chest, it squeezes a small amount of blood out. By letting
    the chest completely recoil with each compression, more blood is squeezed out with
    every compression.
    The only rhythm you will ever shock is V-Fib and pulseless V-Tach (Because you can't
    synchronize DEAD)
    The biggest misconception people have is that when you shock someone, you jump
    start the heart just like you would jump start a car. This is not true. When the heart is
    in Ventricular Fibrillation or Pulseless
    Ventricular Tachycardia the heart is quivering. The heart is getting told to contract
    too fast, from too many different cells that it can't possibly keep up and just begins to
    vibrate. For example: My computer gets a virus. The first thing I want to do is pull the
    cord from the wall and stop the virus. I don't want to start opening other programs
    and get them running too. The same goes for V-Fib and Pulseless V-Tach.
    13
    The shock stops the heart completely, giving it a chance to start over and hopefully
    produce a normal organized rhythm. So if defibrillating actually stops the heart, do
    you see why shocking someone in asystole doesn't make any sense? Why shock
    someone to stop the heart, when their heart is already stopped.
    So remember V-Fib = DEFIB.

    For every heart rhythm 

    Pulse or not - no pulse, start CPR

    If they have a pulse, is it too fast or too slow

    Is it Vfib or Pulseless Vtach - they need a shock