You are a healthcare provider working in the emergency department. An 83-year-old female in chronic kidney failure arrives by ambulance with complaints of myalgia, nausea, and progressive fatigue over the last 48-hrs. Their last dialysis appointment was three days ago. A rapid initial assessment reveals the following:

Vital signs

Pulse rate: 41/min
Blood pressure: Unobtainable
Respiratory rate: Unobtainable
Temperature: Unobtainable

Physiological systems

Integumentary: Cool
Cardiovascular: Weak radial pulses bilaterally
Respiratory: Lungs CTA bilaterally
Neurological: Weak, responsive

1. A cardiac monitor is attached to the patient. A rhythm check reveals sinus bradycardia at 41/min. The patient is considered symptomatic. What are your initial actions?*

Provide supplemental oxygen

All the above

Perform a 12-lead ECG and monitor their vital signs continuously

Establish IV access

The AHA ACLS 2020-2025 bradycardia algorithm has two pathways: observation and intervention.

2. What clinical factor must be considered in determining the appropriate pathway?*

Use of vasodilators such as albuterol

Adequate perfusion

History of myocardial infarction

Use of statin drugs

You provide supplemental oxygen, perform a 12-lead ECG, monitor vitals, and establish IV access. You determine that the patient is not perfusing adequately and decide to administer atropine 1.0 mg IV bolus. A rhythm check reveals unchanged sinus bradycardia. There are no changes in spontaneous circulation.

3. What are your next actions?*

Prepare for transcutaneous pacing

Consider starting CPR (five cycles)

Administer epinephrine 1.0 mg IVP

Administer atropine 1.5 mg IVP

Transcutaneous pacing is not always available depending on the provider or environment. Certain drugs can be administered as an alternative to transcutaneous pacing for patients with symptomatic sinus bradycardia.

4. What two drugs would you consider in the given scenario?*

Dopamine and atropine

Atropine and epinephrine

Dopamine and epinephrine

None of these drugs are appropriate alternatives for transcutaneous pacing

As you prepare transcutaneous pacing, the patient complains of a sudden tightness in their chest and a feeling of breathlessness. A rhythm check reveals a conversion from sinus bradycardia to a third-degree atrioventricular block. An attempt to pace the rhythm is unsuccessful and a second rhythm check reveals a conversion from a third-degree atrioventricular block to ventricular fibrillation. The patient no longer has a palpable pulse.

5. What are your next actions?*

Continue to attempt transcutaneous pacing

Deliver a single unsynchronized shock of 120 J

Administer epinephrine 1.0 mg IVP

Start CPR (five cycles)

A single unsynchronized shock of 120 J is delivered, and CPR is started for five cycles. Following five cycles of CPR, a rhythm check reveals unchanged ventricular fibrillation.

6. What are your next actions?*

Deliver a single unsynchronized shock of 300 J

Administer epinephrine 1 mg IVP

Deliver a single unsynchronized shock of 200 J

A single unsynchronized shock of 200 J is delivered, and CPR is resumed for five cycles. During the first cycle of CPR, you administer epinephrine 1.0 mg IVP. Following five cycles of CPR, a rhythm check reveals unchanged ventricular fibrillation. A single unsynchronized shock of 300 J is delivered, and CPR is resumed for another five cycles. You consider administering an antiarrhythmic drug, but the Code Team advises you that amiodarone is not available.

7. Which drug is considered an appropriate alternative in the given scenario?*

Lidocaine

Dopamine

Amlodipine

Metoprolol

Lidocaine is a class IB antiarrhythmic that increases the electrical stimulation threshold of the ventricle, suppressing the automaticity of conduction through the tissue.

8. What is the appropriate dosage for the initial dose of lidocaine in the given scenario?*

0.5-0.75 mg/kg

1.0-1.5 mg/kg

3.0 mg/kg

2.0 mg/kg

Lidocaine 1.0-1.5 mg/kg is administered, and CPR is resumed for five cycles. Following five cycles of CPR, a rhythm check reveals a conversion from ventricular fibrillation to sinus rhythm. The patient now has a palpable pulse and vital signs are HR 91/min, BP 106/70, RR 6/min. A return of spontaneous circulation is observed but the patient remains unresponsive.

9. What are your next actions?*

All the above

Continue providing ventilatory support

Start targeted temperature management

Transport the patient to the intensive care unit

Amongst other actions, you have decided to implement targeted temperature management. An optimal target temperature range should be achieved and maintained for at least 24 hrs following cardiac arrest.

10.What should the temperature range be in the given scenario?*

32-36 °C

30-40 °C

35-40 °C

30-36 °C

ACLS Megacode 10 In-Hospital

Hurry, don’t let time run out!