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ACLS Megacode Case 1: Sinus Bradycardia (Bradycardia ➔ VF/Pulseless VT ➔ Asystole ➔ ROSC)
Megacode Testing Checklist 1/2 Bradycardia ➔ VF/Pulseless VT ➔ Asystole ➔ ROSC Student Name: __________________________________________ Test Date: ___________________ ✓ if done correctly
Critical Performance Steps
Out-of-Hospital Scenario You are a paramedic and arrive on the scene to find a 57-year-old woman complaining of indigestion. She is cold, clammy, and diaphoretic. She tells you she is about to faint. EMS responders have obtained vital signs: HR 38/min, BP 70 mm Hg/palpable, RR 16/min, and O2 saturation 93%. No other assessment or management has been performed. Now you assume the role of team leader.
Case Development Initial Assessment
Bradycardia Algorithm
This woman may have an ACS. The case focus, however, is bradycardia. The team leader should begin to take a history and direct team members to start oxygen (if not initiated) and an IV and place monitor leads. Nitroglycerin at this point would be inappropriate in the absence of typical ischemictype discomfort and given the woman’s vital signs (severe bradycardia and hypotension—contraindicated). The student is presented with bradycardia and needs to follow the Bradycardia Algorithm. A critical action is noting that symptoms are due to bradycardia that requires management. Actions at this point should include at least an initial dose of atropine and preparation for TCP or use of chronotropic drugs (epinephrine or dopamine infusion).
12/22/10 5:25 PM
Cardiac Arrest Algorithm (VF/Pulseless VT)
The patient suddenly develops VF. The team leader will follow the Cardiac Arrest Algorithm. Now the student team leader will assign additional team functions and monitor for highquality CPR. The case should continue through safe defibrillation, administration of a vasopressor, and consideration of an antiarrhythmic drug.
Cardiac Arrest Algorithm (Asystole)
After a shock, the patient becomes asystolic. The student continues to monitor high-quality CPR and follows the asystole pathway of the Cardiac Arrest Algorithm.
Immediate Post–Cardiac Arrest Care Algorithm
The team continues high-quality chest compressions, the patient has ROSC, and the Immediate Post–Cardiac Arrest Care Algorithm is initiated.
Bradycardia Management Starts oxygen if needed, places monitor, starts IV Places monitor leads in proper position Recognizes symptomatic bradycardia Administers correct dose of atropine Prepares for second-line treatment
VF/Pulseless VT Management Recognizes VF Clears before ANALYZE and SHOCK Immediately resumes CPR after shocks Appropriate airway management Appropriate cycles of drug–rhythm check/shock–CPR Administers appropriate drug(s) and doses
Asystole Management Recognizes asystole Verbalizes potential reversible causes of asystole/PEA (H’s and T’s) Administers appropriate drug(s) and doses Immediately resumes CPR after rhythm checks
Post–Cardiac Arrest Care Identifies ROSC Ensures BP and 12-lead ECG are performed, O2 saturation is monitored, verbalizes need for endotracheal intubation and waveform capnography, and orders laboratory tests Considers therapeutic hypothermia
STOP TEST Test Results
© 2011 American Heart Association
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Team Leader Ensures high-quality CPR at all times Assigns team member roles Ensures that team members perform well
Circle P or NR to Indicate Pass or Needs Remediation:
Instructor signature affirms that skills tests were done according to AHA Guidelines. Save this sheet with course record.
P
NR
Instructor Signature: _______________________________ Print Instructor Name: ______________________________ Date: ________________
90-1011_ACLS_Part5_Appendix_A.indd 124
ACLS Megacode Case 2: Mobitz Type II AV Block (Bradycardia ➔ VF/Pulseless VT ➔ Asystole ➔ ROSC) In-Hospital Scenario You are evaluating a 57-year-old woman complaining of indigestion. She is brought immediately from triage (arrived by personal car) and placed in ED room 2. She is cold, clammy, and diaphoretic. She states that she feels as if she is about to faint. The triage nurse is working with you and has obtained vital signs: HR 38/min, BP 70 mm Hg/palpable, RR 16/min, and O2 saturation 91%.
Case Development Initial Assessment
Bradycardia Algorithm
This woman may have an ACS. The case focus, however, is bradycardia. The team leader should begin to take a history and direct team members to start oxygen (if not initiated) and gain IO access (not able to get an IV in) and place monitor leads. Nitroglycerin at this point would be inappropriate in the absence of typical ischemic-type discomfort and given the patient’s vital signs (severe bradycardia and hypotension— contraindicated). The student is presented with bradycardia and needs to follow the Bradycardia Algorithm. A critical action is noting that symptoms are due to bradycardia that requires management. Actions at this point should include at least an initial dose of atropine and preparation for TCP or use of chronotropic drugs (epinephrine or dopamine infusion).
Cardiac Arrest Algorithm (VF/Pulseless VT)
The patient suddenly develops VF. The team leader will follow the Cardiac Arrest Algorithm. Now the student team leader will assign additional team functions and monitor for highquality CPR. The case should continue through safe defibrillation, administration of a vasopressor, and consideration of an antiarrhythmic drug.
Cardiac Arrest Algorithm (Asystole)
After a shock, the patient becomes asystolic. The student continues to monitor high-quality CPR and follows the asystole pathway of the Cardiac Arrest Algorithm.
Immediate Post–Cardiac Arrest Care Algorithm
The team continues high-quality chest compressions, the patient has ROSC, and the Immediate Post–Cardiac Arrest Care Algorithm is initiated.
Megacode Testing Checklist 1/2 Bradycardia ➔ VF/Pulseless VT ➔ Asystole ➔ ROSC Student Name: __________________________________________ Test Date: ___________________ ✓ if done correctly
Critical Performance Steps Team Leader Ensures high-quality CPR at all times Assigns team member roles Ensures that team members perform well
Bradycardia Management Starts oxygen if needed, places monitor, starts IV Places monitor leads in proper position Recognizes symptomatic bradycardia Administers correct dose of atropine Prepares for second-line treatment
VF/Pulseless VT Management Recognizes VF Clears before ANALYZE and SHOCK Immediately resumes CPR after shocks Appropriate airway management Appropriate cycles of drug–rhythm check/shock–CPR Administers appropriate drug(s) and doses
Asystole Management Recognizes asystole Verbalizes potential reversible causes of asystole/PEA (H’s and T’s) Administers appropriate drug(s) and doses Immediately resumes CPR after rhythm checks
Post–Cardiac Arrest Care Identifies ROSC Ensures BP and 12-lead ECG are performed, O2 saturation is monitored, verbalizes need for endotracheal intubation and waveform capnography, and orders laboratory tests Considers therapeutic hypothermia
STOP TEST Test Results
Circle P or NR to Indicate Pass or Needs Remediation:
Instructor signature affirms that skills tests were done according to AHA Guidelines. Save this sheet with course record.
P
NR
Instructor Signature: _______________________________ Print Instructor Name: ______________________________ Date: ________________
1/22/11 11:21 AM
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ACLS Megacode Case 3: Tachycardia (VT)—Cardioversion (Tachycardia ➔ VF/Pulseless VT ➔ PEA ➔ ROSC) Out-of-Hospital Scenario You are a paramedic and arrive on the scene to find a 65-year-old man complaining of palpitations and chest discomfort. He is cold, clammy, and diaphoretic. He states that he feels as if he is about to faint. EMS responders have placed oxygen and obtained vital signs: HR 160/min, BP 70 mm Hg/palpable, RR 16/min, and O2 saturation 96%.
Case Development Initial Assessment
Tachycardia Algorithm
This man may have an ACS. The case focus, however, is initially a tachycardia. The student should begin to take a history, start an IV, and attach monitor electrodes or pads to the patient. Nitroglycerin at this point would be inappropriate and contraindicated because of hypotension. Aspirin may be given. The student is presented with tachycardia and needs to follow the Tachycardia Algorithm. A critical action is noting that symptoms are due to tachycardia that requires management. The monitor shows a wide-complex tachycardia: VT. The student should recognize that the patient is symptomatic and prepare for immediate cardioversion. Consideration of drug therapy should not delay cardioversion.
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12/22/10 5:25 PM
Cardiac Arrest Algorithm (VF/Pulseless VT)
The patient should suddenly develop VF. The student will follow the VF/pulseless VT pathway of the Cardiac Arrest Algorithm. Now the student team leader will assign team functions and monitor for high-quality CPR. The case should continue through safe defibrillation, administration of a vasopressor, and consideration of an antiarrhythmic drug.
Cardiac Arrest Algorithm (PEA)
The patient is now in PEA. The student continues to monitor high-quality CPR and follows the PEA pathway of the Cardiac Arrest Algorithm. Although the patient is likely in cardiogenic shock, the student should state a differential diagnosis of PEA.
Immediate Post–Cardiac Arrest Care Algorithm
The team continues high-quality chest compressions, the patient has ROSC, and the Immediate Post–Cardiac Arrest Care Algorithm is initiated.
Megacode Testing Checklist 3 Tachycardia ➔ VF/Pulseless VT ➔ PEA ➔ ROSC Student Name: __________________________________________ Test Date: ___________________ ✓ if done correctly
Critical Performance Steps Team Leader Ensures high-quality CPR at all times Assigns team member roles Ensures that team members perform well
Tachycardia Management Starts oxygen if needed, places monitor, starts IV Places monitor leads in proper position Recognizes unstable tachycardia Recognizes symptoms due to tachycardia Performs immediate synchronized cardioversion
VF/Pulseless VT Management Recognizes VF Clears before ANALYZE and SHOCK Immediately resumes CPR after shocks Appropriate airway management Appropriate cycles of drug–rhythm check/shock–CPR Administers appropriate drug(s) and doses
PEA Management Recognizes PEA Verbalizes potential reversible causes of PEA/asystole (H’s and T’s) Administers appropriate drug(s) and doses Immediately resumes CPR after rhythm and pulse checks
Post–Cardiac Arrest Care Identifies ROSC Ensures BP and 12-lead ECG are performed, O2 saturation is monitored, verbalizes need for endotracheal intubation and waveform capnography, and orders laboratory tests Considers therapeutic hypothermia
STOP TEST Test Results
Circle P or NR to Indicate Pass or Needs Remediation:
Instructor signature affirms that skills tests were done according to AHA Guidelines. Save this sheet with course record.
P
NR
Instructor Signature: _______________________________ Print Instructor Name: ______________________________ Date: ________________
90-1011_ACLS_Part5_Appendix_A.indd 126
ACLS Megacode Case 4: Tachycardia (SVT)—Drug Therapy (Tachycardia ➔ VF/Pulseless VT ➔ PEA ➔ ROSC) In-Hospital Scenario In the ED, you are evaluating a 65-year-old man complaining of palpitations. He is in no distress. He has a history of coronary artery disease and had a stent placed in the past. Otherwise, he is healthy, with no other medical problems. His vital signs are HR 170/min, BP 110/70 mm Hg, RR 16/min, and O2 saturation 95%.
Case Development Initial Assessment
Tachycardia Algorithm
This man has mild symptoms and is hemodynamically stable. The case focus, however, is initially a tachycardia. The student should begin to take a history, start an IV, and place a monitor. Nitroglycerin at this point would be inappropriate because of the rapid tachycardia. Aspirin may be given. The student is presented with tachycardia and needs to follow the Tachycardia Algorithm. A critical action is noting that the patient is asymptomatic except for palpitations and is hemodynamically stable. He does not require immediate cardioversion. Note or show that he has a regular narrowcomplex tachycardia. The team leader should follow the algorithm and indicate vagal maneuvers and initial therapy with adenosine.
Cardiac Arrest Algorithm (VF/Pulseless VT)
During this treatment, the patient suddenly develops VF. The student will follow the VF/pulseless VT pathway of the Cardiac Arrest Algorithm. Now the student team leader will assign team functions and monitor for high-quality CPR. The case should continue through safe defibrillation, administration of a vasopressor, and consideration of an antiarrhythmic drug.
Cardiac Arrest Algorithm (PEA)
After a shock, the patient is now in PEA. The student continues to monitor high-quality CPR and follow the PEA pathway of the Cardiac Arrest Algorithm. Although the patient is likely in cardiogenic shock, the student should verbalize a differential diagnosis of PEA.
Immediate Post–Cardiac Arrest Care Algorithm
The team continues high-quality chest compressions, the patient has ROSC, and the Immediate Post–Cardiac Arrest Care Algorithm is initiated.
Megacode Testing Checklist 4 Tachycardia ➔ VF/Pulseless VT ➔ PEA ➔ ROSC Student Name: __________________________________________ Test Date: ___________________ ✓ if done correctly
Critical Performance Steps Team Leader Ensures high-quality CPR at all times Assigns team member roles Ensures that team members perform well
Tachycardia Management Starts oxygen if needed, places monitor, starts IV Places monitor leads in proper position Recognizes tachycardia (specific diagnosis) Recognizes no symptoms due to tachycardia Attempts vagal maneuvers Gives appropriate initial drug therapy
VF/Pulseless VT Management Recognizes VF Clears before ANALYZE and SHOCK Immediately resumes CPR after shocks Appropriate airway management Appropriate cycles of drug–rhythm check/shock–CPR Administers appropriate drug(s) and doses
PEA Management Recognizes PEA Verbalizes potential reversible causes of PEA/asystole (H’s and T’s) Administers appropriate drug(s) and doses Immediately resumes CPR after rhythm and pulse checks
Post–Cardiac Arrest Care Identifies ROSC Ensures BP and 12-lead ECG are performed, O2 saturation is monitored, verbalizes need for endotracheal intubation and waveform capnography, and orders laboratory tests Considers therapeutic hypothermia
STOP TEST Test Results
Circle P or NR to Indicate Pass or Needs Remediation:
Instructor signature affirms that skills tests were done according to AHA Guidelines. Save this sheet with course record.
P
NR
Instructor Signature: _______________________________ Print Instructor Name: ______________________________ Date: ________________
12/22/10 5:25 PM
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ACLS Megacode Case 5: Tachycardia (SVT)—Cardioversion (Tachycardia ➔ VF/Pulseless VT ➔ PEA ➔ ROSC) Out-of-Hospital Scenario You arrive on the scene to find a male, age 58 years, lying in his bed. The patient says he began having what he thought was indigestion about 4 hours earlier, but the chest discomfort suddenly became worse about 30 minutes ago while at rest, and he now complains of palpitations. The patient is pale, diaphoretic, and appears in distress. His BP is 136/92 mm Hg, his heart rate is 184/min and regular, and his RR is 16/min.
Case Development Initial Assessment Tachycardia Algorithm
The EMS crew should quickly obtain a history (nonsignificant and no allergies) and investigate the chief complaint. The crew should place the patient on a pulse oximeter (SpO2 = 93%) and an ECG monitor (narrow-complex tachycardia). The crew should prepare for immediate synchronized cardioversion. It is reasonable for the crew to place the patient on supplemental oxygen at 4 L/min by nasal cannula, ask the patient to chew 2 to 4 baby aspirins, and administer a sublingual dose of nitroglycerin (after verifying the absence of erectile dysfunction medication use). Before cardioversion can be performed, the patient has what appears to be a grand mal seizure that lasts for about 10 seconds. Once the seizure subsides, the patient appears unconscious.
1/22/11 11:21 AM
Cardiac Arrest Algorithm (VF/Pulseless VT)
ECG rhythm assessment reveals VF. The students will follow the VF/pulseless VT pathway of the Cardiac Arrest Algorithm. The team leader should check patient responsiveness and verify that the lead wires were not disconnected during the seizure. Upon confirming pulselessness, the team leader should monitor the CPR performance of the team members. The case should continue through safe defibrillation and vasopressor administration.
Cardiac Arrest Algorithm (PEA)
After 2 defibrillation attempts and vasopressor administration, the patient develops PEA. The students will follow the PEA pathway of the Cardiac Arrest Algorithm. The team leader should continue to monitor the quality of the CPR performance. The team leader should order the administration of another dose of a vasopressor and recite the possible causes of PEA.
Immediate Post–Cardiac Arrest Care Algorithm
The team continues high-quality chest compressions, the patient has ROSC, and the Immediate Post–Cardiac Arrest Care Algorithm is initiated.
Megacode Testing Checklist 5 Tachycardia ➔ VF/Pulseless VT ➔ PEA ➔ ROSC Student Name: __________________________________________ Test Date: ___________________ ✓ if done correctly
Critical Performance Steps Team Leader Ensures high-quality CPR at all times Assigns team member roles Ensures that team members perform well
Tachycardia Management Starts oxygen if needed, places monitor, starts IV Places monitor leads in proper position Recognizes unstable tachycardia Recognizes symptoms due to tachycardia Performs immediate synchronized cardioversion
VF/Pulseless VT Management Recognizes VF Clears before ANALYZE and SHOCK Immediately resumes CPR after shocks Appropriate airway management Appropriate cycles of drug–rhythm check/shock–CPR Administers appropriate drug(s) and doses
PEA Management Recognizes PEA Verbalizes potential reversible causes of PEA/asystole (H’s and T’s) Administers appropriate drug(s) and doses Immediately resumes CPR after rhythm and pulse checks
Post-Cardiac Arrest Care Identifies ROSC Ensures BP and 12-lead ECG are performed, O2 saturation is monitored, verbalizes need for endotracheal intubation and waveform capnography, and orders laboratory tests Considers therapeutic hypothermia
STOP TEST Test Results
Circle P or NR to Indicate Pass or Needs Remediation:
Instructor signature affirms that skills tests were done according to AHA Guidelines. Save this sheet with course record.
P
NR
Instructor Signature: _______________________________ Print Instructor Name: ______________________________ Date: ________________
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ACLS Megacode Case 6: Tachycardia (VT)—Drug Therapy (Tachycardia ➔ VF/Pulseless VT ➔ PEA ➔ ROSC) In-Hospital Scenario A clinic nurse delivers a male, age 65 years, to the inpatient unit as a direct hospital admission from the medicine clinic in a wheelchair. The patient developed sudden palpitations that began while driving home and came straight to his doctor’s office in the hospital’s outpatient clinic. The patient appears stable with no distress. His BP is 148/88 mm Hg, his heart rate is 160/min and regular, and his RR is 12/min.
Case Development Initial Assessment
The team leader should quickly obtain a history (hypertension and no allergies) and investigate the chief complaint. Team members should place the patient on a pulse oximeter (SpO2 = 97%) and an ECG monitor (regular, wide-complex tachycardia).
Tachycardia Algorithm
The team leader should direct team members to assess the patient’s hemodynamics for stability, get a 12-lead ECG, and prepare for drug therapy. During 12-lead ECG acquisition, the patient states that he feels like he needs to vomit and then loses consciousness.
Cardiac Arrest Algorithm (VF/Pulseless VT)
ECG rhythm assessment reveals VF. The students will follow the VF/pulseless VT pathway of the Cardiac Arrest Algorithm. The team leader should check patient responsiveness, and then monitor the CPR performance of the team members. The case should continue through safe defibrillation and vasopressor administration.
12/22/10 5:26 PM
Cardiac Arrest Algorithm (PEA)
After 2 defibrillation attempts and vasopressor administration, the patient develops PEA. The students will follow the PEA pathway of the Cardiac Arrest Algorithm. The team leader should continue to monitor the quality of the CPR performance. The team leader should order the administration of another dose of a vasopressor and recite the possible causes of PEA.
Immediate Post–Cardiac Arrest Care Algorithm
The team continues high-quality chest compressions, the patient has ROSC, and the Immediate Post–Cardiac Arrest Care Algorithm is initiated.
Megacode Testing Checklist 6 Tachycardia ➔ VF/Pulseless VT ➔ PEA ➔ ROSC Student Name: __________________________________________ Test Date: ___________________ ✓ if done correctly
Critical Performance Steps Team Leader Ensures high-quality CPR at all times Assigns team member roles Ensures that team members perform well
Tachycardia Management Starts oxygen if needed, places monitor, starts IV Places monitor leads in proper position Recognizes tachycardia (specific diagnosis) Recognizes no symptoms due to tachycardia Attempts vagal maneuvers Gives appropriate initial drug therapy
VF/Pulseless VT Management Recognizes VF Clears before ANALYZE and SHOCK Immediately resumes CPR after shocks Appropriate airway management Appropriate cycles of drug–rhythm check/shock–CPR Administers appropriate drug(s) and doses
PEA Management Recognizes PEA Verbalizes potential reversible causes of PEA/asystole (H’s and T’s) Administers appropriate drug(s) and doses Immediately resumes CPR after rhythm and pulse checks
Post–Cardiac Arrest Care Identifies ROSC Ensures BP and 12-lead ECG are performed, O2 saturation is monitored, verbalizes need for endotracheal intubation and waveform capnography, and orders laboratory tests Considers therapeutic hypothermia
STOP TEST Test Results
Circle P or NR to Indicate Pass or Needs Remediation:
Instructor signature affirms that skills tests were done according to AHA Guidelines. Save this sheet with course record.
P
NR
Instructor Signature: _______________________________ Print Instructor Name: ______________________________ Date: ________________
