Post-ACLS Megacode Study

Post-ACLS Megacode

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Terms in this set (55)

SCENARIO 1: You witness a middle-aged, obese Move the man out of the way of pedestrian traffic on the escalator
male pedestrian collapse on an escalator in an
airport. He is clutching his chest and slumps over
on the person behind him. The bystander places
him on the floor at the end of the down-moving
escalator track. As a first responder certified in
ACLS, which of the following is your first course
of action?

1: You have moved the man to a seating area near send someone to get AED
the bottom of the escalator. The man is gasping
for breath but does not appear to be effectively
breathing. You yell at him "Are you alright?" but he
does not respond. What is your next action?

1: After sending for EMS and waiting for an AED to check for a pulse

arrive, you continue to attend to the man. The

man is unresponsive and he is now only gasping. The rescuer must determine if this is respiratory failure alone or cardiac arrest.
What is your next action? Checking for a pulse follows sending people for help.

Give one breath every 5-6 s

1: You find a definite pulse on his carotid artery. It

is fast, but clearly present. What is your next The man has a pulse, so he needs rescue breathing, not chest compressions.
action? One ventilation every 5-6 seconds is appropriate in an adult without an
advanced airway in place.

check for a pulse

1: The AED device has not yet arrived. You have

been delivering breaths for two minutes, spaced
you must determine if the victim's situation has deteriorated. Respiratory arrest
5-6 seconds apart. He is not breathing
may lead to cardiac arrest. Pulse checks should be done every two minutes in
spontaneously. What is your next action?
respiratory arrest.

1: You pause rescue breathing to check for a begin CPR

pulse. You cannot feel a definite pulse after 10 Since there is no pulse, the man is now in cardiac arrest. He needs CPR,
seconds of trying. What is your next action? including chest compressions.
Post-ACLS Megacode
1: You start high-quality CPR at a rate of 100-120 Rip the pads off the man's chest and apply new pads in the same locations
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compressions per minute. The AED arrives
moments later. You open the man's shirt to find a Chest hair can interfere with electrical contact through the AED pads. The
copious amount of thick hair covering his chest adhesive on the pads can act as a rapid depilatory (i.e. it rips the chest hair out).
and he is damp with sweat. The AED cannot get a New pads can then be used on the bare skin.
good signal through the pads because of the hair,
even though you have pressed them down very
hard. What is your next action?

1: With hair removed and new pads placed, the resume CPR ASAP

AED gets a good signal from the patient. It

reports that there is a shockable rhythm. You clear Regardless of patient response, resume high-quality CPR immediately and
everyone from the patient, announce the shock, continue for two minutes. Even if a pulse returns, it may not be adequate to
and then deliver one shock. What is your next pump blood for a few minutes. A pulse check at this point is irrelevant. An AED
action? automatically controls the level of energy delivered.

check for a pulse

1: After two minutes of CPR, what is your next

action? It is important to determine if the man has regained spontaneous circulation.
This can be done with a pulse check.

Continue to monitor pulse, breathing, and rhythm until EMS arrives

1: The man has a strong, regular pulse. He is not

responsive, but appears to be breathing. You feel
CPR can stop at this point, as the man has had a return of spontaneous
air movement through his mouth. What is your
circulation (ROSC). He should be monitored very closely until EMS arrives. It is
next action?
unwise to remove the AED pads in case his condition deteriorates.

SCENARIO 2: You are called to a patient's hospital acute ischemic stroke

room by family members. According to the family,

the 63-year-old patient was awaiting discharge Facial droop, pronator arm drift, and slurred speech are strong indicators of
for a diabetes mellitus-related complication when acute stroke. You cannot know for sure at this point if the stroke is ischemic or
she suddenly started to slur her speech. This hemorrhagic, but ischemic strokes are more than 4 times more common than
started about 10 minutes ago. You examine the hemorrhagic strokes are.
woman and ask her to smile. One side of her face
does not lift symmetrically with the other. You
then ask her to close her eyes and hold both arms
in front of her, palms up. She cannot lift one arm.
She is in no acute pain. What is most likely
occurring in this patient?

2: You believe the woman is having an acute finger stick blood glucose

stroke and it is likely ischemic. You assess airway,

breathing, and circulation. She is breathing
normally with mild tachycardia (105 bpm) and
good oxygen saturation (96% on room air). What
diagnostic test should be done that can be
performed at the bedside?
Blood glucose abnormalities can mimic the signs of stroke. A "fingerstick"
measurement is a fast and easy way to rule out an abnormal blood glucose
level. This should not delay preparations for a head CT, however. The head CT
will need to be performed in the radiology department, however, not by
fluoroscopy.
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2: Which of the following diagnostic test/study
should be ordered emergently for this patient and
is the most important for determining further
treatment?
2: The patient is immediately moved to radiology
for a CT scan. A qualified physician states that the
head CT shows no sign of bleeding (hemorrhage).
There is radiological evidence to suggest early
ischemic stroke. The patient's symptoms have not
resolved. True or false: the patient should be
evaluated for fibrinolytic therapy?
2: The hospital's stroke team has been called to
radiology and the patient is being assessed for
fibrinolytic therapy. Which of the following would
NOT disqualify the patient from receiving this
treatment?
2: The patient is diagnosed with an ischemic
stroke by the stroke team. She meets all inclusion
criteria and has no exclusion criteria. She is given
fibrinolytic therapy (tPA) intravenously. Assuming
proper protocol was followed, we know that this
drug was given within what time of symptom
onset?
2: You are in the room with her two hours after tPA
treatment. She complains of a terrible headache
and then becomes unresponsive. The patient has
no history of epilepsy, but begins to convulse. Her
eyes are pointed toward the left side of her face.
You suspect which of the following?
SCENARIO 3: You are called by a nursing student
because a patient's heart rate is 44 beats per
minute. You will respond immediately, but which
of the following facts about the patient would
make you feel the most encouraged?
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CT scan of brain
A CT scan of the brain without contrast should be obtained as quickly as
possible. The goal is to determine if there is blood visible in the brain
parenchyma (indicates hemorrhage).
true
Evidence points to an ischemic stroke in evolution. Fibrinolytic therapy may
help, but the patient must be screened to determine if tPA is appropriate in this
case.
pt had heart attack 4 yrs ago
A heart attack is only a relative contraindication to tPA if it occurred within the
previous three months. The other conditions listed are absolute
contraindications.
4.5 hrs
We know the time that symptoms began, but the question does not list when
tPA was administered. We do know, however, that the maximum duration
between symptom onset and IV tPA is 4.5 hours, so if the providers followed
proper protocols, the drug must have been given within this window.
acute hemorrhagic stroke
Blood is irritating to brain tissue and can cause abnormal electrical activity,
leading to seizures. One of the risks of tPA is that the ischemic stroke may
undergo hemorrhagic conversion. That said, hemorrhagic conversion of
ischemic stroke can occur with or without tPA treatment. Acute hemorrhagic
stroke is the most likely result in this case.
he runs 3 marathons a year
A heart rate of 44 beats per minute could be physiologically appropriate in an
elite athlete. When evaluating bradycardia it is important to consider the heart
rate along with the overall clinical picture.
Post-ACLS Megacode
3: When you enter the room, you find the patient Symptomatic bradycardia with poor perfusion
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is an elderly gentleman and presumably not an

elite athlete. He is lying on his back and said that Slow heart rate, dizziness, pre-syncope argue strongly for a diagnosis of
he has felt funny for about an hour. He reports symptomatic bradycardia.
some dizziness and some mild chest pain. He
almost fell while going to the bathroom. The
nursing student adds that he has high blood
pressure and is on a beta-blocker. What do you
suspect is happening to this patient?

give supplemental O2

3: You measure the patient's blood pressure and

find him to be hypotensive. His blood pressure is
85/55. The nursing student adds that his normal
pressure is approximately 140/90. Pulse oximetry
reveals an oxygen saturation of 91%. What is the
next action?
Supplemental oxygen should be given to people with symptomatic bradycardia
to keep blood oxygen levels between 94 and 99%. There is no clear evidence
of stroke. An AED is for use in the community—manual defibrillators would be
used in a hospital setting. Transcutaneous pacing may be considered, but it
would not be the next action, since it will require additional time and testing
(supplemental oxygen is readily available).

3: You apply supplemental oxygen via nasal atropine 0.5 mg bolus IV once

cannula and send someone to retrieve a 12-lead

ECG. In the meantime, you decide to treat the An IV bolus of atropine at a dosage of 0.5 mg is the appropriate drug and
symptomatic bradycardia with poor perfusion. dosage for initial management of symptomatic bradycardia.
What treatment will you choose first?

3: Another staff member is applying the ECG atropine 0.5 mg bolus IV once

leads, but it has been about 3 minutes since the

first dose of atropine was given. The patient's Additional doses of atropine may be given, but there is no dose escalation or
heart rate initially increased to 60 bpm but now is reduction across administrations. In other words, give 0.5 mg IV each time up to
at 50 bpm. You decide to administer another dose a maximum of 3 mg cumulatively.
of atropine. What dose will you give?

switch to ACS pathway

3: You obtain a 12-lead ECG and there is ST-

segment elevation in leads II, III, and aVF. What is
This ECG is consistent with acute coronary syndrome. Bradycardia should be
your next action?
managed within the context of the ACS algorithm.

Give 325 mg aspirin orally, asking him to chew it

3: You confirm that the patient has no known drug

AND Notify staff for immediate reperfusion therapy

allergies. Since you now suspect a myocardial

AND Draw blood for various labs (cardiac enzymes, electrolytes, coagulation
infarction, what is your next action?
panel)

SCENARIO 4: You are called to the patient's Check blood pressure

bedside because she is experiencing the + Check mental status

sensation of fluttering in her chest. You perform + Check for signs of heart failure
an initial assessment and find that the 22-year-old
woman is communicative and in no acute distress.
The rhythm monitor on the defibrillator reveals a
regular, narrow complex heart rate of 150 beats
per minute. Your initial evaluation should include
which of the following?
Post-ACLS Megacode
4: She denies chest pain or shortness of breath.
Her lungs are clear to auscultation, has no jugular
venous distention and no edema. A 12-lead ECG
confirms a regular, narrow-complex
tachyarrhythmia. Her blood pressure is 130/85
mmHg. What is your next action?
4: The vagal maneuver did not lower the patient's
heart rate. What is your next action?
4: The adenosine did not lower the patient's heart
rate. What is your next action?
4: The patient is visibly anxious and now states
that she is having chest pain. She describes the
pain as a pressure in her chest. When asked about
her pain, she appeared confused. Her systolic
blood pressure is now 100/70. What is your next
action?
4: You determine that the woman's tachycardia is
causing rate-related symptoms and decide to
provide cardioversion. The rhythm is still narrow
and regular. After administering light sedation,
you provide an initial dose of energy from the
defibrillation through externally placed pads.
What dose of energy should you initially deliver?
4: You deliver the energy and the patient
immediately loses consciousness. You cannot find
a pulse after trying for ten seconds. The heart
monitor still shows a tachyarrhythmia. What is your
next action?
4: You administer a defibrillation dose (200 J
biphasic) to the patient. What is your next action?
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CAROTID MASSAGE
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A vagal maneuver such as carotid massage should be tried first in a person with
stable tachycardia
adenosine 6mg IV bolus once
The first dosage of IV adenosine for supraventricular tachycardia is 6 mg. Never
massage both carotid arteries simultaneously.
adenosine 12mg IV bolus once
If adenosine 6 mg fails to convert the patient's supraventricular tachycardia to a
sinus rhythm, the subsequent dosage of IV adenosine should be increased to 12
mg.
cardioversion
This tachyarrhythmia is now causing cardiovascular instability. It is appropriate to
move to cardioversion as therapy.
50-100 joules synchronized
The first energy level to apply to treat SVT is 50-100 Joules. This should be
synchronized to the person's cardiac cycle. A defibrillation or unsynchronized
shock is not appropriate.
defibrillate
The patient has pulseless ventricular tachycardia or ventricular fibrillation. Thus,
the first and best intervention is to provide a defibrillation or unsynchronized
shock.
start CPR
Provide chest compressions as part of CPR immediately after providing a shock.
This should continue for two minutes without interruption.
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Post-ACLS Megacode
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4: After two minutes of CPR, the patient still has
no pulse and the rhythm is now ventricular
fibrillation. What is your next action?
4: You administer the second defibrillation and
resume high-quality CPR. You also administer
which of the following?
5: You are on a ride along in an EMS vehicle. A
person has been pulled from an icy river after
being submerged for at least ten minutes.
Someone attaches a heart monitor which shows
organized waveforms and a very slow heart rate
(roughly 10 beats per minute). The airway has
been suctioned and is clear. No pulse or
breathing is detected. Which of the following do
you suspect?
5: Which of the following is your first management
action?
5: While you are providing high-quality CPR,
others have established IV access and have
passed an advanced airway. What is your next
action?
5: Given the patient's history, which probable
cause of PEA should be treated immediately?
5: The heart monitor is still in place, but is no
longer registering a rhythm. What has happened?
5: What is the major difference between the initial
management of PEA and asystole?
deliver 2nd defibrillation at the same dose
For biphasic energy, 200 J is already the maximum dosage level. Subsequent
shocks should be delivered at this same energy. It is too soon to abort the
resuscitation in this woman (and probably too soon for any patient). She is a
young and otherwise healthy woman who has a relatively high likelihood of
regaining spontaneous circulation.
epi 1mg IV bolus
Epinephrine 1 mg is the treatment of choice for adult cardiac arrest. In the
pulseless ventricular tachycardia/ventricular fibrillation algorithm, now is the
proper time to administer it.
PEA
A person is said to have pulseless electrical activity (PEA) if they are
unresponsive and have no palpable pulse, yet have organized cardiac electrical
activity on ECG. It is more appropriate to treat this person for pulseless
electrical activity than bradycardia because of the absence of a palpable pulse.
start CPR
CPR with immediate chest compressions is the first action. Epinephrine through
a peripheral IV is worthless without some sort of circulation, such as that
obtained through chest compressions.
continue CPR while others give epinephrine
Chest compressions should continue without interruption. Make use of team
members when they are available. Outcomes are better when teams work
together during resuscitations.
treat hypoxia and hypothermia at the same time
pt is in asystole
they are managed the same way; initially, no major differences
Asystole and PEA share a single ALCS algorithm. For resuscitation purposes,
they are essentially the same diagnostic entity, and they are treated the same
way.
Post-ACLS Megacode
5: You have conducted three cycles of CPR and attempt defibrillation
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administered epinephrine. There is still no pulse.

Body temperature is 31°C. You see that the rhythm The heart is now displaying sings of ventricular fibrillation. It is appropriate to try
strip now shows low amplitude ventricular defibrillation since ventricular fibrillation is a "shockable" rhythm. Resuscitation
fibrillation. Which of the following is the next best efforts should not be stopped until the victim has regained normal body
action? temperature through rewarming.

5: You administer a defibrillation dose (200 J Administer atropine 0.5 mg bolus IV once

biphasic) to the patient and continue CPR. After

two minutes, you check the pulse and rhythm. The Given the presence of a palpable pulse, the best management is to follow the
patient returns to sinus bradycardia (30-bpm) and symptomatic bradycardia algorithm. Thus, atropine 0.5 mg IV bolus is indicated.
there is a faint, but definite pulse present. Blood
pressure is 80/30 mm Hg. He is still unconscious.
What is your next action?

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second degree heart block type 1

6: You happen to notice that a patient on the

There is progressive prolongation of the PR interval followed by a "dropped"
telemetry unit has an abnormal rhythm. You reach
QRS complex. This indicates second degree heart block, Mobitz type I. This is
the patient's bedside to find the 40-year-old man
also called the Wenckebach phenomenon.
apparently sleeping. There is no indication in his
medical record that he has had an arrhythmia. His
rhythm strip showed the following:

perform focused history and PE

6: you wake the man up, but he seems

disoriented. Which of the following should you do
Most people are often disoriented when they wake up in a hospital. You should
first?
gather more information before taking action.

6: The patient becomes more alert as he wakes symptomatic bradycardia

up, but his blood pressure is 85/55 and his heart

rate is 48 beats per minute. He states that he feels
very uneasy and dizzy and is having trouble
breathing. Auscultation reveals crackles at the
base of the lungs. What is your assessment at this
point?
Hypotension, difficulty breathing, and pulmonary edema suggest that
bradycardia is symptomatic. The rhythm strip does not show evidence of
infarction; however, you should obtain a 12-lead ECG.

6: While you were assessing the patient, other administer atropine

team members have applied supplemental

oxygen via nasal cannula and made sure that IV It may be possible to prevent additional cardiovascular symptoms from
access was patent (open and flushed). Another bradycardia by treating it with atropine. Atropine is indicated as an early
person is starting to apply the ECG leads. What is treatment for symptomatic bradycardia. Other assessments and interventions
your next action? are also useful, though of a lower priority.
Post-ACLS Megacode 0.5 mg IV push
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6: You decide to administer atropine for
symptomatic bradycardia. What dose do you
The correct dose of atropine for symptomatic bradycardia is 0.5 mg. It should
give?
be given as a bolus injection or "IV push."

6: You administer the atropine and monitor the begin CPR

patient's response. Other team members are

starting a second large bore IV. After ten seconds
of checking the carotid artery, you cannot find a
pulse but the rhythm monitor shows a very slow
(25 bpm) bradycardia. What is your next course of
action?
Despite the electrical activity on the monitor, there is no palpable pulse. This
indicates the patient has entered pulseless electrical activity (PEA). Therefore,
the immediate intervention is cardiopulmonary resuscitation (CPR), beginning
with chest compressions.

6: A "code blue" has been sent out and the six NO

people in the room quickly assemble into a team.

You start high-quality CPR at a rate of 100 to 120 You are in position as the team member in charge of chest compressions (the
compressions per minute. According to AHA "compressor"). The team leader oversees the entire resuscitation but is not
recommendations, are you in the correct position physically involved in the interventions (i.e. drug infusions, ventilation, chest
to be the team leader? compression, etc.)

PEA

6: While you are performing CPR, another person

brings a defibrillator and attaches the pads. The This rhythm strip confirms your suspicion of pulseless electrical activity. The
following rhythm is present:
term symptomatic bradycardia is less useful in this context because there is no
palpable pulse.
There is no pulse after a 10 second check. Which
of the following best describes this patient's
condition?

administer 1mg epi push

This patient should be treated for cardiac arrest, specifically with epinephrine.
6: Assuming that CPR is continuing, how do you
Amiodarone is recommended in pulseless ventricular tachycardia and
first manage pulseless electrical activity?
ventricular fibrillation after epinephrine and unsynchronized cardioversion
(shock). Non-synchronized cardioversion has no place in cardiac arrest.
Atropine in asystole/PEA is unlikely to positively influence outcomes.

Pt presents with SVT but is awake and talking

vagal maneuvers

What is the best first step in managing this This patient is stable and most likely has supraventricular tachycardia, a common
patient's tachycardia?
form of tachycardia typically caused by a reentry circuit in the conduction
1) Synchronized cardioversion
system. This condition most commonly presents with a narrow QRS, however the
2) Procainamide infusion at 60 mg/min until QRS interval can be >120 ms in cases associated with aberrant conduction or a
arrhythmia is suppressed
fixed bundle branch block. Vagal maneuvers such as Valsalva or carotid sinus
3) Vagal maneuvers
massage block conduction at the AV node, disrupting the reentry system,
4) Sedation and Intubation making them an appropriate initial intervention in these patients. .
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pt is still not better. What is the next best step in 6mg IV adenosine rapid push followed by NS flush

management?

1) 6 mg rapid IV push of Adenosine, followed by SVT that is refractive to vagal maneuvers should be treated with adenosine.
NS flush
Adenosine has an extremely short half-life of less than 10 seconds. It should be
2) 12 mg rapid IV push of Adenosine, followed by administered via rapid injection into a large proximal vein, followed by a normal
NS flush
saline flush of 20 mL and extremity elevation. Patients should be on continuous
3) IV infusion of 6 mg Adenosine over 1 hour
EKG monitoring during administration.
4) IV infusion of 12 mg Adenosine over 1 hour

Increase dose to 12 mg rapid IV push of Adenosine

still not responsive to initial adenosine bolus.

As seen here, it's essential that patients are warned of the significant albeit
The next step is?
transient side effects prior to adenosine injection, which include flushing , chest
1) Repeat rapid IV push of 6 mg
pain and difficulty breathing. If the initial 6 mg dose is ineffective, it is
2) Increase dose to 12 mg rapid IV push of appropriate to give a 2nd and even 3rd dose of adenosine at 12 mg. If
Adenosine
adenosine continues to fail in converting SVT after the 2nd and 3rd attempt, you
3) Immediate defibrillation
should consider other etiologies such as A-Flutter or non-reentrant SVT. It's
4) Retry vagal maneuvers important to remember that larger doses (18 mg) may be needed in patients
who consume very large amounts of caffeine or take theophylline, as these
decrease the effectiveness of adenosine.

patient now develops wide monomorphic VT but Immediately perform synchronized cardioversion at 100J

has palpable pulse. The next step is?

1) Start a beta-blocker
This patient has become acutely unstable, with conversion of his rhythm to a
2) Immediately perform defibrillation at 200J
ventricular tachycardia (VT). Patients with regular, wide complex monomorphic
3) Give third dose of 12 mg rapid IV push of VT and a palpable pulse should be immediately treated with 100J synchronized
Adenosine
cardioversion.
4) Immediately perform synchronized
cardioversion at 100J