Thank you for SureFire CPR! This At - Enrollware SureFire CPR... · Thank you for choosing SureFire CPR! This study guide is an outline to help you prepare ... and the signs of poor

Thank you for choosing SureFire CPR! This study guide is an outline to help you prepare for your upcoming ACLS course. Even though there is a lot of information in this guide, it is important to have your textbook to help you review the material over the next 2 years to keep your skills sharp. Because the course covers a lot of material in a short amount of time, there is some required pre‐course material. In the course you will be expected to evaluate and identify different cardiac emergencies. At the completion of the course, you will act as the team leader to diagnose and treat a variety of cardiac rhythms. Please pay special attention to the BLS review, as it is the foundation for ACLS. Here is what you need to do before you come to class.

1. Read through this study guide (paying particular attention to anything marked with a “*”) 2. Go to http://www.skillstat.com/Flash/ECGSim531.html and play the 6 Second ECG Game to

practice up on your ECG skills 3. Go to this website: American Heart Association Prestudy Material and enter the password:

acls15 . Once logged‐in,

Watch the CPR/AED Overview Video

Take the Precourse Self‐Assessment & score 70% or better (This is an AHA requirement)

Print out your results and bring them to class! (This is an AHA requirement)

We look forward to having you in class. If you need anything at all, please don’t hesitate to call us. Remember we also have PALS, BLS, PEARS, EKG, and NRP for your training needs as well. Thanks again! Take care,

Zack Zarrilli CEO/President SureFire CPR (888) 277‐3143 www.SureFireCPR.com

Study Guide Page 2 © SureFire CPR 2016

ACLS Assessment Quality ACLS can only be built upon a foundation of solid BLS skills. There are 2 levels of ACLS care: the BLS survey and

the ACLS survey.

The BLS Survey is used if the patient appears to be unconscious. The ACLS Survey is used if the patient is conscious.

BLS Survey:

A. Check responsiveness

a. If unresponsive, shout for any nearby help

B. Check Circulation & Breathing

a. Check the carotid pulse while simultaneously looking for chest rise

b. Assess pulse and breathing for 5‐10 seconds

c. Remember, agonal gasps or “guppy” breathing is not effective breathing and should be treated the

same as absent breathing. Agonal gasps are frequently an indication of cardiac arrest.**

b. If pulse is present but patient is not breathing: assist ventilations

c. If no pulse and no breathing: Start CPR

C. Defibrillation

a. Early defibrillation is a key aspect of the BLS survey

b. Once the AED arrives, turn it on, apply the pads, and defibrillate if indicated by the AED. Don’t forget to

state “Clear!” or “Do not touch the patient!” and ensure no one is touching the patient prior to defibrillating.

ACLS Survey:

A. Airway

a. Make sure the airway is adequate and protected

b. Use adjuncts if needed

c. Insert advanced airways

B. Breathing

a. Provide Oxygen

b. Confirm placement of Endotracheal Tube

c. Monitor waveform capnography

d. Avoid excessive ventilation

C. Circulation

a. Establish IV/IO access

b. Treat the heart rate and rhythm

c. Monitor CPR quality

d. Provide defibrillation or cardioversion if necessary

e. Take vital signs (BP, etc.)

D. Differential Diagnosis and Disability

a. Determine the reason for the problem


b. H’s and T’s (Seen later in this guide)

c. Mental Status

d. Glasgow Coma Scale

The Heart

Here is a quick review of the anatomy of the heart before we get into our ECG rhythms. First, blood enters the atria of the heart and an electrical impulse is sent out from the SA node. This electrical impulse travels through the atria causing them to contract. When the atria contract, it registers on the EKG as a P wave. Next, the electrical impulse travels to the AV node which sends out an electrical impulse that travels through the Bundle of His, bundle branches, and into the Purkinje fibers of the ventricles. This causes ventricular contraction which registers on the EKG as the QRS complex. Finally, the ventricles rest and repolarize, which is shown on the EKG as a T wave. (In case you were wondering, the atria repolarize also, but the electrical impulse is so miniscule, you can’t see it on the EKG) Narrow QRS complexes originate in the atria (near the AV node) and wide QRS complexes originate in in the ventricles (below the Bundle of His).

ECG Breakdown

Anatomy of the Heart


ECG Review and Cardiac Algorithms

Pulseless Rhythms:

1. Ventricular Fibrillation

2. Ventricular Tachycardia

3. Pulseless Electrical Activity

4. Asystole

Ventricular Fibrillation

Coarse VF

Fine VF

Description: Ventricular Fibrillation (also known as V‐Fib or VF) is the most common rhythm to occur immediately after cardiac arrest. The ventricles quiver and are unable to pump blood to the rest of the body. Survival chances diminish rapidly while in ventricular fibrillation and immediate defibrillation is essential. There are two types of V‐Fib: Coarse and Fine. Coarse VF is more easily corrected with defibrillation than fine VF. Fine VF is more likely seen in a patient with a prolonged cardiac arrest. Both types of ventricular fibrillation are treated with defibrillation.


Ventricular Tachycardia (No Pulse)

Description: Ventricular Tachycardia (also known as V‐Tach or VT) occurs when the ventricular focus takes over control

of the heart and fires at a tachycardic rate. The QRS complex is wide because it originates in the ventricles. This rhythm

is treated identically as V‐Fib when there are no pulses.

Treatment for Ventricular Fibrillation and Pulseless V‐Tach:

1. Defibrillate 2. Perform CPR for 2 minutes 3. Quickly check a rhythm and a pulse 4. If another shock is needed, clear the patient and defibrillate again 5. Repeat this sequence until the rhythm is not shockable

Medication Sequence (Performed Simultaneously with CPR and Defibrillation):

1. Epinephrine 1mg 1:10,000 IV/IO every 3 to 5 minutes a. The antecubital vein is the recommended first location to attempt an IV during a cardiac arrest

2. For refractory (persistent) VF: a. Amiodarone 300mg IV/IO (Initial dose)** b. Amiodarone 150mg IV/IO (second and final dose if VF/Pulseless VT persist)

3. All medications given during cardiac arrest should be administered via rapid IV/IO

Asystole

Description: Asystole is when there is no detectable activity on the ECG. It may follow many rhythms, including VF, PEA,

or 3rd Degree Heart Block. Always ensure that all leads are attached to the patient.


Pulseless Electrical Activity (PEA)

Description: Pulseless Electrical Activity (PEA) occurs when the heart is not beating and the patient has no pulse, but

there is still an electrical impulse creating some kind of rhythm on the ECG monitor. For example: Sinus rhythm without

a pulse = PEA**

For all patients without a pulse, CPR is the priority.

Treatment for Asystole and PEA: 1. CPR 2. Epinephrine 1mg of 1:10,000 IV/IO every 3‐5 minutes 3. Consider H’s and T’s to find the root of the problem.

Consider H’s and T’s (Differential Diagnosis)

Hypovolemia (most common cause)

Hypoxia

Hydrogen ion (acidosis)

Hypo/hyperkalemia

Hypoglycemia

Toxins

Tamponade, cardiac

Tension pneumothorax

Thrombosis, coronary

Thrombosis, pulmonary

Bradycardic Rhythms:

Sinus Bradycardia 1st Degree AV Block 2nd Degree Block (Type I) 2nd Degree Block (Type II) 3rd Degree Block


Sinus Bradycardia

Description: Sinus bradycardia occurs when the SA node fires at a rate that is too slow for the person’s age. For adults,

this is less than 60 beats per minute. Many athletes have a resting heart rate of less than 60, so it is important to only

treat patients that are symptomatic (fatigue, dizziness, hypotension, altered mental status, etc.)

1st Degree AV Block

Description: In a first‐degree AV block, everything is normal except for a prolonged PR interval. The interval is longer

than .20 seconds (or 5 small boxes on the ECG strip). This conduction delay in the AV node rarely causes any problems.

2nd Degree Block (Type I ‐ Wenckebach)

Description: Second Degree, Type I block occurs at the AV node. The PR interval gets progressively longer until it drops

the QRS complex. You can see 2 dropped QRS complexes on the strip above.

2nd Degree Block (Type II ‐ Mobitz)


Description: Second Degree, Type II block occurs below the AV node. The P waves are regular, but QRS complexes are

dropped. The electrical impulses fail to pass through the AV node which results in atrial contractions that are not

followed by ventricular contractions. This rhythm is more serious than the 2nd Degree Type I, and pacing is usually

recommended.

3rd Degree Block

Description: 3rd Degree, or Complete Heart Block is characterized by no communication between the SA and AV nodes. P

waves and QRS complexes will be completely independent of each other. The ventricles will generate their own

electrical signal through an accessory pacemaker in the lower chambers. The location of this “Escape Pacemaker” will

determine if the QRS complexes are wide or narrow (Junctional = Narrow QRS, Ventricular = Wide QRS).

Treatment (if symptomatic):

1. Oxygen (if hypoxemic)

2. Atropine .5mg (Repeated every 3‐5 minutes to a max dose of 3mg)**

a. Though atropine is recommended for symptomatic bradycardia, it will probably not work in high

degree heart blocks (2nd Degree Type II or 3rd Degree)

3. Prepare for Transcutaneous Pacing (TCP) if needed, especially if in a high degree heart block.

4. If, at any point, airway or breathing become compromised, treat patient with simple airway maneuvers and

ventilation.**

As an alternative to TCP, chronotropic drug infusions are also available:

Dopamine IV infusion (2‐20 mcg/kg/min)**

Epinephrine IV infusion (2‐10 mcg/min)

For patients in respiratory failure with rapidly dropping heart rates, assisting with ventilation and simple airway

maneuvers are the highest priority.**

Tachycardic Rhythms: Sinus Tachycardia

Supraventricular Tachycardia

Monomorphic Ventricular Tachycardia

Polymorphic Ventricular Tachycardia

Torsades de Pointes


Sinus Tachycardia

Description: Sinus tachycardia occurs when the SA node fires at a rate that is too fast for the person’s age. For adults,

this is generally between 101 and 150 beats per minute. In sinus tach, all of the normal components of an ECG are

present (P waves, QRS complexes, and T waves). Sinus tachycardia usually starts and stops gradually and is the result of

pain or another cause that can be identified (fever, exercise, etc.)

Supraventricular Tachycardia

Description: Supraventricular tachycardia, or SVT is a category of rhythms that have indistinguishable P waves due to a

rate greater than 150 bpm. The P waves typically run into the preceding T waves. These rhythms have narrow QRS

complexes because the impulses are generated above the ventricles (Supra = above). Specific SVT rhythms include: Atrial

Tachycardia, Junctional Tachycardia, and occasionally Atrial Flutter, Atrial Fibrillation, and Sinus Tachycardia.

Stable Treatment:

1. Vagal Maneuvers**

2. Adenosine 6mg rapid IVP**

3. Adenosine 12 mg rapid IVP (2nd dose)**

4. Consider Beta Blockers or Calcium Channel Blockers, especially if SVT is irregular.

Unstable Treatment:

1. Sedate patient if possible

2. Prepare for immediate Cardioversion.**

a. Consider 6mg Adenosine only if IV has already been established, medication is prepared,

and the signs of poor perfusion are just barely starting to appear.


Monomorphic Ventricular Tachycardia (with pulses)

Description: In monomorphic V‐Tach the QRS complexes are the same size and shape.

Stable Treatment:

1. Seek expert consultation

2. Consider Adenosine 6mg rapid IVP

3. Consider Adenosine 12 mg rapid IVP (2nd dose)

4. Consider Amiodarone Infusion of 150mg over 10 minutes

Unstable Treatment:

1. Sedate patient if possible

2. Prepare for immediate Cardioversion. **

If No Pulse:

1. Defibrillate and begin CPR

Polymorphic Ventricular Tachycardia (with pulses)

Description: In polymorphic V‐Tach the QRS complexes are different sizes and shapes.

Treatment:

1. Polymorphic VT is treated the same as VF – Defibrillate and begin CPR


Torsades de Pointes

Description: In Torsades de Pointes the QRS complexes are different sizes and shapes in a twisting pattern. This

rhythm can be caused by low magnesium, low potassium, or as an adverse effect of certain medications that prolong the

QT interval. Magnesium is the preferred treatment.

Electrical Therapy Basics There are three types of electrical therapy: Defibrillation, Cardioversion, and Transcutaneous Pacing. Here is a

quick review on how to do all three:

How to Defibrillate

1. When the AED or defibrillator arrives, turn it on

2. Place the pads on the patient’s chest according to the AED instructions or your protocols

3. Allow the AED to analyze the rhythm (or analyze it yourself on a manual defibrillator)

4. Prepare to shock by selecting the correct number of Joules

5. Press Charge – Announce “Charging”

a. Continuing compressions while charging helps minimize interruptions in chest compressions

while performing CPR.**

6. Clear the patient! Make sure no one is touching the patient or bed

7. Press the shock button

8. Immediately resume CPR following the shock

AED Reminders:

If the AED does not promptly analyze the rhythm, begin chest compressions.

Oxygen should not be blowing over a patient’s chest during a shock (for safety)**

High quality compressions immediately before and after defibrillation increase the chance of conversion

from VF**

If the patient is lying on snow or a small puddle, you do not have to move the patient as the water/snow is underneath the patient and not in the direct path of the electrical arc.**

If patient is in a large puddle or body of water, the patient must be moved

If the patient has water on their chest it must be wiped clear


How to Perform Synchronized Cardioversion 1. Consider sedation

2. Turn on defibrillator

3. Place electrodes on patient according to manufacturer’s instructions

4. Press “SYNC” button

5. Look for markers on R waves indicating “Sync” mode

6. Select appropriate energy setting

7. Press Charge – Announce “Charging”

8. Clear the patient – make sure everyone is clear and there is no oxygen on the patient

9. Press the shock button

10. Analyze the rhythm again, if no conversion, increase the joules and repeat.

Recommended Initial Cardioversion Dosages:

Narrow regular: 50‐100 J Biphasic

Narrow Irregular: 120‐200 J Biphasic** / 200 J Monophasic

Wide regular: 100 J Biphasic

Wide irregular: Defibrillation dose (do not sync)

How to Perform Transcutaneous Pacing

1. Consider sedation

2. Place electrodes on patient according to manufacturer’s instructions

3. Turn on Pacer

4. Set the pacing rate

5. Slowly increase mA (Milliamps) until capture is achieved with corresponding pulses.

a. Capture is characterized by a wide QRS complex with a tall, broad T wave. Pulses will

correspond to the monitor.

Below is a picture of what you should be looking for with successful transcutaneous pacing:


Airway Basics Adjuncts

Nasopharyngeal airway (NP)

Used in semi‐conscious patients

Measured from the tragus of the ear to the corner of the nose

Contraindicated in head injuries

Oropharyngeal airway (OP)

Used in unconscious patients with no gag reflex

Measured from the corner of the mouth to the angle of the jaw**

Advanced Airways

Endotracheal Tube

The ideal airway for most patients

When suctioning an ET tube, suction during withdrawal for no longer than 10 seconds.**

When using ties that secure the ET tube around a person’s neck (Tube Tamer) make sure the tie

does not obstruct venous return from the brain.**

Continuous waveform capnography is the most reliable method of confirming and monitoring ET

tube placement.

Laryngeal Mask Airway (LMA)

Used by providers not familiar with ET tube intubation

During CPR, once an advanced airway is in place, compressions and breaths are asynchronous.

100 compressions per minute – Do not stop compressions for the breaths!

Ventilate once every 6 seconds (which equals 10 breaths per minute)

Oxygen Delivery

If delivered through a non‐rebreather mask or bag valve mask (BVM), O2 should be set at 10‐15LPM.

Adult rescue breathing should be at a rate of 1 breath every 5‐6 seconds

Capnography and pulse oximetry should be used when available

Post cardiac arrest oxygenation should be kept between 94‐99%.**

Always be aware of excessive ventilations as they can lead to increased pressure in the chest and a

subsequent decrease in cardiac output.**

Waveform Capnography (PETCO2)

Continuous waveform capnography is the most reliable indicator of proper ET tube placement.**

Capnography measures the PETCO2 (Partial Pressure of End‐Tidal CO2).

Normal capnography (PETCO2) ranges are from 35‐40mmHg

Quantitative capnography allows for monitoring of CPR quality.**

PETCO2 readings of less than 10mmHg indicate that chest compressions may not be effective.**

Endotracheal (ET) Tube

NP Airway

0P Airway

A rapid rise in PETCO2 can be the first

indication of the return of spontaneous

circulation (ROSC)


Stroke Signs and symptoms of a stroke:

Sudden weakness or numbness of the face, extremities, or on one side of the body

Loss of speech or difficulty speaking

Loss of vision, especially in one eye

Sudden severe headache

Difficulty standing or walking with any of the symptoms above

Treatment:

Support ABCs

Evaluate using the Cincinnati Pre‐Hospital Stroke Scale**

o Facial Droop

o Arm Drift

o Slurred speech “You can’t teach an old dog new tricks”

Check blood sugar

Establish stroke onset time

Transport to the nearest Stroke Receiving Center

Upon arrival to the emergency department, the head CT scan is the priority.**

Stroke patients must be transported to the appropriate stroke receiving center with CT capabilities. The CT scan will be

used to see if the stroke is possibly being caused by an intracranial hemorrhage. If there are no signs of hemorrhage,

fibrinolytic therapy will be started as soon as possible.**

Acute Coronary Syndromes (ACS)

ACS can be divided into 3 groups:

1. Unstable Angina

2. ST segment elevation MI (STEMI)

3. Non‐ST‐segment elevation MI (NSTEMI)

Signs and symptoms of ACS:

Chest pain that radiates to the jaw or down the left arm

o These classic signs are typically subtler in women

and diabetic patients

When in doubt, always perform a 12‐lead ECG**


Treatment of ACS:

Support ABCs

If patient is unconscious and not breathing normally, begin CPR and prepare to defibrillate

If stable:

o 12‐Lead ECG**

o Oxygen

o Aspirin – 160‐325mg (if not already given by EMS)**

o Nitroglycerin – 3 doses SL (if BP is good, there is no sign of a right ventricular infarction, no marked

tachy‐ or brady‐dysrhythmias, and there has been no Viagra, etc. in the past 24‐48 hours)

o Morphine – 2mg increments if nitroglycerin does not relieve chest pain

o Labs

o Chest x‐ray

The rapid response team (RRT) or medical emergency team’s (MET) primary purpose is identifying and treating

early clinical deterioration.** Call the MET team as soon as possible!

Post Resuscitation Care

After return of spontaneous circulation (ROSC), patients can display a wide variety of responses. Some may become

awake and alert, while others remain comatose. After we achieve return of spontaneous circulation (ROSC) it is

important to continue to provide cardio‐respiratory support through the ABCD’s.

Airway

o Optimizing ventilation and oxygenation is the first priority for patients who achieve ROSC.**

Breathing

o Look for a PETCO2 range of 35‐40mmHg on the waveform capnography.**

Circulation

o For hypotensive patients who achieve ROSC, a 1‐2 L bolus of IV fluid is recommended.**

o The minimum systolic blood pressure one should attempt to achieve in a hypotensive ROSC patient is

90mmHg.

o If the patient remains hypotensive despite fluid bolus, an Epinephrine drip at 0.1‐0.5 mcg/kg/min can be

used to treat the hypotension.**

o Differential Diagnosis (12 lead, H’s, and T’s)

A healthy brain is the primary goal of CPR and it has been shown that therapeutic hypothermia, 32‐36° Celsius,** for at

least 24 hours may be beneficial for patients who remain comatose after ROSC. This may also be considered in children

and infants. Therapeutic hypothermia is not indicated when the patient is responding to verbal commands.**


Code Termination

If Asystole has been persistent for 25 minutes or more despite medication and high quality CPR, consider terminating

resuscitation after consulting medical control.** In cases with obvious signs of death (rigor mortis** etc.) it is

appropriate to withhold resuscitative efforts.

Megacode Cases

At the end of the course you will lead a resuscitation team to provide care for a patient with cardiac complications.

There will be multiple rhythm changes during the scenario, so please study the algorithms in this study guide and in your

student manual to help you prepare. The 6 roles of your team members will be: Team Leader, Airway, Medications, BLS,

Monitor/Defibrillator, and Recorder. The Megacode cases will be conducted in a low stress environment to help you

implement the skills that you will learn in the course.

BLS for the Healthcare Provider Review The Basic Steps of BLS / CPR

1. Check the Scene for Safety As Soon As You See A Potential Victim 2. Check responsiveness

a. Tap the Person and Shout, “Are You OK?” b. If unresponsive, shout for any nearby help

3. Check Circulation & Breathing

a. Check the carotid pulse while simultaneously looking for chest rise

b. Assess pulse and breathing for 5‐10 seconds

c. Remember, agonal breaths or “guppy” breathing is not effective breathing and should be treated like

respiratory arrest.

4. Activate Emergency Response and Get the AED

a. If patient is unresponsive or a pulse/breathing is absent, activate emergency response and send someone

to get an AED, then…

b. If pulse is present but patient is not breathing: assist ventilations

c. If no pulse and no breathing: Start CPR

5. Defibrillation

a. Early defibrillation is a key aspect of the BLS survey

b. Once the AED arrives, turn it on, apply the pads, and defibrillate if indicated by the AED. Don’t forget to

state “Clear!” or “Do not touch the patient!” and ensure no one is touching the patient prior to defibrillating 6. Continue CPR until:

a. An AED Arrives b. Paramedics or Rapid Response Team Take Over, or c. The Victim Starts to Move

CPR should be performed on victims that have no pulse and no normal breathing within 10 seconds.**


A common but fatal mistake in cardiac arrest management is prolonged interruptions in chest compressions.** Interruptions in chest compressions should be 10 seconds or less.**

If there is no suspected neck injury, the best way to open the airway is with a head‐tilt, chin‐lift.**

For Children and Infants, CPR should be started if there is no normal breathing, signs of poor perfusion, and a pulse of less than 60 beats per minute

Hand Placement for Adult CPR

2 Hands on the lower half of the breastbone**

Hand Placement for Infant CPR

1 Rescuer ‐ 2 Fingers on the Center of the Chest

2 Rescuers – Encircling Thumbs Technique** What if they have a pulse, but aren’t breathing effectively?

You will start rescue breathing

Your breaths should last 1 second and make the victim’s chest rise** o Adults (1 Breath every 5‐6 Seconds)** o Children (1 Breath every 3‐5 Seconds if the pulse is >60)

12‐20 breaths per minute** o Bag Mask devices are not recommended for 1 rescuer CPR.**

AED Review

The first thing to do when an AED becomes available is to turn it on.**

As soon as an AED is available, it should be used.**

If the AED does not immediately analyze the rhythm, resume compressions **

After a shock from the AED, immediately resume compressions.**

Adult pads may be used on pediatric patients if pediatric pads are not available.

Pulse Check Locations

Children – Carotid Artery

Infants – Brachial Artery** Compression Rate

100‐120 compressions per minute (The beat to the song Stayin’ Alive is at 100 beats per minute!)

Every 2 minutes or 5 cycles of CPR it is important to switch compressors** Compression Depth

Adults – At least 2”

Children and Infants – At least 1/3rd the depth of the chest**

High quality chest compressions = allowing complete chest recoil**

2 Finger Infant CPR Hand Placement

2 Rescuer Encircling Thumbs Technique


Compression to Ventilation Ratio

Adults – 30 Compressions : 2 Breaths**

Children and Infants (1 Rescuer) – 30 Compressions : 2 Breaths

Children and Infants (2 Rescuers) – 15 Compressions : 2 Breaths**

After an Advanced Airway (Endotracheal Tube or Combitube) is placed the ratio changes

Compressions are Continuous at 100 per minute**

Breaths are 1 every 6 seconds (10 ventilations per minute)** Choking

The best way to relieve severe choking in a responsive infant is with cycles of 5 back slaps followed by 5 chest thrusts.**

For conscious adult victims, encourage the person to cough until they can no longer breathe. At this point, ask for consent to help and perform abdominal thrusts (Heimlich Maneuver) until the object is expelled or the person goes unconscious.

If a victim of foreign‐body airway obstruction becomes unconscious, send someone to get help and then start CPR, beginning with compressions.**

What to Expect

1. Please come 10‐15 minutes early to class to check in so that we can start on time.

2. Wear comfortable clothing, if you have long hair we recommend you bring a hair tie for the CPR portion of class.

3. Feel free to bring food and drinks to class. We have a refrigerator and microwave for you to use if you need

them. (We also have snacks and drinks for you in case you get hungry.)

4. We like to keep our classes small so that you have the best learning environment possible.

5. We promise to do whatever we can to make your experience fun, stress free, and educational.

Thank you again for taking our course and for your dedication to helping save lives. We look forward to seeing you in

class and hope this study guide helps you prepare. If you have any suggestions on how we can make this guide or your

course better, please let us know!

Documents

Thank you for SureFire CPR! This At - Enrollware SureFire CPR... · Thank you for choosing SureFire CPR! This study guide is an outline to help you prepare ... and the signs of poor