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ACLS Megacode 2 Out-of-Hospital

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You are a healthcare provider working on an ALS ambulance. You receive a call from dispatch advising you that an individual witnessed their 70-year-old female neighbour collapse outside their home. The bystander has begun providing CPR. Your response time to the scene is 4 min. A rapid initial assessment reveals the following:

Vital signs

Pulse rate: Unobtainable
Blood pressure: Unobtainable
Respiratory rate: Unobtainable
Temperature: Unobtainable

Physiological systems

Integumentary: Cold, cyanotic
Cardiovascular: No palpable pulse
Respiratory: No audible respiration, no visible chest rising
Neurological: Unresponsive

1. Your partner opens the jump bag and begins attaching the cardiac monitor to the patient. What are your initial actions?*

Establish IV access and administer atropine 1.0 mg IV/IO

Deliver a single unsynchronized shock 120 J

Establish IV access and administer epinephrine 1.0 mg IV/IO

Take over chest compressions

You have taken over CPR (five cycles). A rhythm check reveals asystole. Your co-worker secures the airway, provides the patient with supplemental oxygen, and establishes IV access. During this time, there are no changes in condition

2. What else can be done at this stage of the intervention?*

Administer atropine 1.5 mg IV

Perform a pulse check

Administer epinephrine 0.5 mg IV

Administer epinephrine 1.0 mg IV

Epinephrine 1.0 mg IV is administered, and the remaining cycles of CPR are performed.

3. What are your next actions?*

Deliver a single unsynchronized shock 120 J

Administer a second dose of epinephrine 1.0 mg IV

Perform a rhythm check

Administer amiodarone 150 mg IV

A rhythm check reveals a conversion from asystole to ventricular tachycardia. Palpable peripheral pulses remain absent.

4. What are your next actions?*

Resume CPR (five cycles)

Administer amiodarone 300 mg IVP

Deliver a single unsynchronized shock of 120 J

Administer epinephrine 1.0 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 pulseless ventricular tachycardia. You deliver a single unsynchronized shock of 200 J.

5. What are your next actions?*

Administer epinephrine 1.0 mg IV

Administer amiodarone 150 mg IV

Perform a rhythm check

Resume CPR (five cycles)

CPR is resumed for another five cycles.

6. During the first cycle of CPR, what drug should you administer?*

Atropine

Lidocaine

Epinephrine

Amiodarone

Epinephrine is administered and the remaining cycles of CPR are performed. Following five cycles of CPR, a rhythm check reveals unchanged pulseless ventricular tachycardia. A single unsynchronized shock of 300 J is delivered, and CPR is resumed for another five cycles.

7. What are your next actions?*

Administer dopamine 20 mcg/kg/min IV fluid bolus

Administer amiodarone 300 mg IVP

Administer lidocaine 1.0-1.5 mg/kg IVP

Administer epinephrine 1.0 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 unchanged pulseless ventricular tachycardia. A single unsynchronized shock of 360 J is delivered.

8. What are your next actions?*

Administer epinephrine 1.0 mg IVP

Resume CPR (five cycles)

Palpate for a peripheral pulse

Administer amiodarone infusion 400 mg per hour

CPR is resumed for another five cycles. Following five cycles of CPR, a rhythm check reveals a conversion from pulseless ventricular tachycardia to a third-degree atrioventricular block. The patient now has a faintly palpable pulse. HR 42/min, BP 72/56. There are no spontaneous respirations.

9. What are your next actions?*

Perform synchronized cardioversion

Perform transcutaneous pacing (TCP)

Administer atropine 1.0 mg IVP

Administer epinephrine 1.5 mg IVP

TCP further stabilizes the patient, and supported ventilation is continued via BVM. You transport the patient to the hospital without any additional cardiac events.

10. If transcutaneous pacing was not available, what two drugs would you have administered as alternatives in the given scenario?*

Dopamine and magnesium sulfate

Dopamine and epinephrine

Magnesium sulfate and epinephrine

Epinephrine and atropine

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