ACLS Megacode Case Study 4 In-Hospital

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?*
- Attempt vagal maneuvers
- Deliver a single unsynchronized shock of 120 J
- Administer oxygen, establish IV access, perform a 12-lead ECG
- Investigate for reversible causes

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)
- Deliver a single unsynchronized shock of 200 J
- Perform a rhythm check

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
- Amiodarone
- Lidocaine

Epinephrine 1.0 mg IVP is administered with no change in condition.
4. What are your next actions?*
- Resume CPR (five cycles)
- Deliver a single unsynchronized shock of 360 J
- Perform a pulse check
- 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?*
- Resume CPR (five cycles)
- Deliver a single unsynchronized shock of 360 J
- Perform synchronized cardioversion
- Administer epinephrine 1.0 mg IVP

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
- Deliver a single unsynchronized shock of 360 J
- Provide transcutaneous pacing
- 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?*
- Insert an ETT while simultaneously continuing compressions
- Insert a nasopharyngeal airway
- Complete the remaining three cycles of CPR before inserting an advanced 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?*
- Resume CPR (five cycles)
- Deliver a single unsynchronized shock of 360 J
- Perform a pulse check
- Administer epinephrine 1.5 mg IVP

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?*
- Seek expert consultation
- Ensure adequate perfusion
- Ensure prevention of further arrhythmias
- Ensure return of spontaneous circulation

ACLS Megacode 4 In-Hospital