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ACLS Case Study
» Out of Hospital Case Study 2
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
Establish IV access and administer epinephrine 1.0 mg IV/IO
Deliver a single unsynchronized shock 120 J
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 1.0 mg IV
Administer epinephrine 0.5 mg IV
Epinephrine 1.0 mg IV is administered, and the remaining cycles of CPR are performed.
3. What are your next actions?
*
Administer a second dose of epinephrine 1.0 mg IV
Perform a rhythm check
Administer amiodarone 150 mg IV
Deliver a single unsynchronized shock 120 J
A rhythm check reveals a conversion from asystole to ventricular tachycardia. Palpable peripheral pulses remain absent.
4. What are your next actions?
*
Deliver a single unsynchronized shock of 120 J
Administer amiodarone 300 mg IVP
Resume CPR (five cycles)
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?
*
Resume CPR (five cycles)
Administer epinephrine 1.0 mg IV
Perform a rhythm check
Administer amiodarone 150 mg IV
CPR is resumed for another five cycles.
6. During the first cycle of CPR, what drug should you administer?
*
Epinephrine
Lidocaine
Amiodarone
Atropine
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 epinephrine 1.0 mg IVP
Administer dopamine 20 mcg/kg/min IV fluid bolus
Administer amiodarone 300 mg IVP
Administer lidocaine 1.0-1.5 mg/kg 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?
*
Resume CPR (five cycles)
Palpate for a peripheral pulse
Administer epinephrine 1.0 mg IVP
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?
*
Administer epinephrine 1.5 mg IVP
Administer atropine 1.0 mg IVP
Perform synchronized cardioversion
Perform transcutaneous pacing (TCP)
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?
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Dopamine and epinephrine
Magnesium sulfate and epinephrine
Epinephrine and atropine
Dopamine and magnesium sulfate
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