ACLS Megacode 4 In-Hospital Hurry, don’t let time run out! Sorry, time is up! 0 Hours 0 mins 0 secs Step 1 of 9 11% You are a healthcare provider working in the emergency department at a major metropolitan hospital. A 43-year-old female with a history of STEMI presents at triage with complaints of sudden and progressive chest pain that started roughly 20 min prior. They report that the pain they are feeling is similar to what they felt at the time of their STEMI which occurred 18 months prior. A rapid initial assessment reveals the following: Vital signs Pulse rate: 81/min Blood pressure: 112/77 Respiratory rate: 10/min Temperature: 38.0 °C Physiological systems Integumentary: Pale, cool Cardiovascular: Strong palpable peripheral pulses bilaterally Respiratory: Prolonged expirations, visible intercostal retractions Neurological: Weak, but responsive 1. The patient is attached to a cardiac monitor. A rhythm check reveals multifocal premature ventricular contractions at 81/min. What are your initial actions?* Investigate for reversible causes Attempt vagal maneuvers Deliver a single unsynchronized shock of 120 J Administer oxygen, establish IV access, perform a 12-lead ECG The patient complains that their chest pain is worsening and that it is becoming increasingly difficult for them to inhale. Moments later, the patient loses consciousness, and a rhythm check reveals a conversion from multifocal premature ventricular contractions to ventricular fibrillation. A single unsynchronized shock of 120 J is delivered. 2. What are your next actions?* Deliver a single unsynchronized shock of 200 J Administer epinephrine 1.0 mg IVP Perform a rhythm check Start CPR (five cycles) Five cycles of CPR are performed. Following five cycles of CPR, a rhythm check reveals unchanged ventricular fibrillation. A single unsynchronized shock of 200 J is delivered, and CPR is resumed. 3. During the first cycle of CPR, what drug should you administer?* Atropine Amiodarone Epinephrine Lidocaine Epinephrine 1.0 mg IVP is administered with no change in condition. 4. What are your next actions?* Perform a pulse check Resume CPR (five cycles) Deliver a single unsynchronized shock of 360 J Prepare to intubate CPR is resumed for another five cycles. Following five cycles of CPR, a rhythm check reveals unchanged ventricular fibrillation. 5. What are your next actions?* Administer epinephrine 1.0 mg IVP Deliver a single unsynchronized shock of 360 J Resume CPR (five cycles) Perform synchronized cardioversion A single unsynchronized shock of 360 J is delivered, and CPR is resumed for another five cycles. During the last cycle of CPR, amiodarone 300 mg IVP is administered. Following the last cycle of CPR, a rhythm check reveals a conversion from ventricular fibrillation to asystole. 6. What are your next actions?* Administer epinephrine 1.0 mg IVP Provide transcutaneous pacing Deliver a single unsynchronized shock of 360 J Resume CPR (five cycles) Two cycles of CPR are performed when the patient begins showing signs of inadequate ventilation. You are having difficulty maintaining their airway. 7. What are your next actions?* Complete the remaining three cycles of CPR before inserting an advanced airway Insert a nasopharyngeal airway Insert an ETT while simultaneously continuing compressions Insert an oropharyngeal airway CPR is continued while another team member intubates the patient. Once intubated, epinephrine 1.0 mg IVP is administered. Following five cycles of CPR, a rhythm check reveals a conversion from asystole to ventricular fibrillation. 8. What are your next actions?* Resume CPR (five cycles) Administer epinephrine 1.5 mg IVP Deliver a single unsynchronized shock of 360 J Perform a pulse check A single unsynchronized shock of 360 J is delivered, and CPR is resumed for five cycles. Following five cycles of CPR, a rhythm check reveals a conversion from ventricular fibrillation to sinus rhythm. HR 56/min, BP 81/54. There are no spontaneous respirations, and the patient remains unresponsive. A pulse check reveals a faint, but palpable pulse. 9. What are your next actions?* Ensure return of spontaneous circulation Seek expert consultation Ensure prevention of further arrhythmias Ensure adequate perfusion
