ACLS Megacode Case Study 1 In-Hospital

You are an internist at a local hospital. One of your patients is a 25-year-old male who was admitted yesterday evening for chronic abdominal pain and a history of gastrointestinal ulcers. You arrive in their hospital room to discuss their lab results when you find them in bed unresponsive. There is a half-eaten sandwich on the table next to the bed, so you assume they were eating shortly beforehand. A rapid initial assessment reveals the following:
Vital signs
- Pulse rate: Unobtainable
- Blood pressure: Unobtainable
- Respiratory rate: Unobtainable
- Temperature: Unobtainable
Physiological systems
- Integumentary: Moist, cool
- Cardiovascular: No palpable pulse
- Respiratory: No audible respirations, visible chest rising
- Neurological: Unresponsive
1. Based on your initial assessment, you determine the patient is in cardiac arrest and activate the Code Team. IV access has already been established. A cardiac monitor is not attached to the patient at this time. What are your initial actions?*
- Administer epinephrine 1 mg IVP
- Deliver a single unsynchronized shock of 120 J
- Check for an airway obstruction without commencing CPR
- Start CPR (five cycles)

You have started CPR and members of the Code Team begin arriving at the room.
2. Which of the following drugs should you consider administering?*
- Dopamine 1 mcg/kg
- Atropine 1 mg IV/IO
- Dopamine 20 mcg/kg/min IV fluid bolus
- Epinephrine 1 mg IV/IO

Five cycles of CPR are completed, epinephrine 1.0 mg IVP is administered, and a cardiac monitor is attached to the patient. During CPR, a large bolus of food was dislodged from the patients’ airway. Following five cycles of CPR, a rhythm check reveals pulseless electrical activity.
3. Which of the following H’s and T’s is the most likely cause of the arrest?*
- Hypoxia
- Hydrogen ion (acidosis)
- Tamponade (cardiac)
- Tension pneumothorax

CPR is resumed for another five cycles. Following five cycles of CPR, a rhythm check reveals unchanged pulseless electrical activity.
4. What are your next actions?*
- Resume CPR (five cycles)
- Deliver a single unsynchronized shock of 120 J
- Administer epinephrine 1 mg IVP
- Administer amiodarone 300 mg IVP

CPR is resumed for another five cycles. Following five cycles of CPR, a rhythm check reveals a conversion from pulseless electrical activity to ventricular tachycardia.
5. What are your next actions?*
- Resume CPR (five cycles)
- Administer epinephrine 1 mg IVP
- Deliver a single unsynchronized shock of 120 J
- Administer adenosine 6 mg IVP

A single unsynchronized shock of 120 J is delivered, and CPR is resumed for another five cycles. Following five cycles of CPR, a rhythm check reveals unchanged ventricular tachycardia.
6. What are your next actions?*
- Deliver a single unsynchronized shock of 200 J
- Administer amiodarone 300 mg IVP
- Administer epinephrine 1 mg IVP
- Administer atropine 1 mg IVP

A single unsynchronized shock of 200 J is delivered, and CPR is resumed for another five cycles.
7. Following defibrillation, during the first cycle of CPR, what drug should you consider administering?*
- Administer epinephrine 1.0 mg IVP
- Administer lidocaine 1.0-1.5 mg/kg IVP
- Administer atropine 1.0 mg IVP
- Administer amiodarone 300 mg IVP

Epinephrine 1 mg IVP is administered while simultaneously continuing CPR.
8. According to AHA ACLS guidelines, what should be done after giving any drug during cardiac arrest?*
- Perform a pulse check
- Flush the IV line with NS 10 m
- Perform a rhythm check
- Flush the IV line with NS 20 ml

CPR is resumed for another five cycles. Following five cycles of CPR, a rhythm check reveals unchanged ventricular tachycardia. A single unsynchronized shock of 300 Joules is delivered, and CPR is resumed for another five cycles.
9. What drug is indicated in the given scenario?*
- Amiodarone 300 mg IVP
- Dopamine 2-10 mcg/kg/min
- Amiodarone 150 mg IVP
- Epinephrine 1.5 mg IVP

Amiodarone 300 mg IVP is administered, and CPR is resumed for another five cycles. Following five cycles of CPR, a rhythm check reveals a conversion from ventricular tachycardia to sinus tachycardia. A pulse check reveals a faint and weak pulse. Vital signs are HR 162, BP 108/64. There are no spontaneous respirations, and the patient remains unconscious.
10. What are your next actions?*
- Monitor for hypotension and signs of inadequate perfusion
- Place an advanced airway and provide ventilatory assistance via BVM
- Transport to the intensive care unit
- Seek expert consultation

ACLS Megacode 1 In-Hospital