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ACLS Case Study
» In Hospital Case Study 4
ACLS Megacode 4 In-Hospital
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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?
*
Administer oxygen, establish IV access, perform a 12-lead ECG
Deliver a single unsynchronized shock of 120 J
Investigate for reversible causes
Attempt vagal maneuvers
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?
*
Administer epinephrine 1.0 mg IVP
Start CPR (five cycles)
Perform a rhythm check
Deliver a single unsynchronized shock of 200 J
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
Epinephrine
Lidocaine
Amiodarone
Epinephrine 1.0 mg IVP is administered with no change in condition.
4. What are your next actions?
*
Resume CPR (five cycles)
Perform a pulse check
Prepare to intubate
Deliver a single unsynchronized shock of 360 J
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?
*
Deliver a single unsynchronized shock of 360 J
Perform synchronized cardioversion
Administer epinephrine 1.0 mg IVP
Resume CPR (five cycles)
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
Resume CPR (five cycles)
Deliver a single unsynchronized shock of 360 J
Provide transcutaneous pacing
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?
*
Insert an ETT while simultaneously continuing compressions
Complete the remaining three cycles of CPR before inserting an advanced airway
Insert a nasopharyngeal airway
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?
*
Administer epinephrine 1.5 mg IVP
Perform a pulse check
Deliver a single unsynchronized shock of 360 J
Resume CPR (five cycles)
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 adequate perfusion
Ensure return of spontaneous circulation
Ensure prevention of further arrhythmias
Seek expert consultation
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