ACLS Megacode Case Study 7 Out-of-Hospital

You are a healthcare provider working as part of an ALS-equipped medical team at a major sports venue. During a collegial basketball game, a security officer requests medical assistance for a 47-year-old female spectator that appears to be experiencing a syncopal episode. You and another team member arrive at their location in the stadium within 2 min, at which point the spectator has regained consciousness, but is now feeling nauseated and complaining of generalized weakness. A rapid initial assessment reveals the following:
Vital signs
- Pulse rate: 38/min
- Blood pressure: 81/52
- Respiratory rate: 16/min
- Temperature: 38.2 °C
Physiological systems
- Integumentary: Pale, dry
- Cardiovascular: Palpable peripheral pulses bilaterally
- Respiratory: Lungs CTA bilaterally
- Neurological: Alert, oriented
1. A cardiac monitor is attached to the patient. A rhythm check reveals a second-degree atrioventricular block at 38/min. You provide the patient with supplemental oxygen via NC while your partner establishes IV access. What are your initial actions?*
- Attempt vagal maneuvers
- Deliver a single unsynchronised shock of 120 J
- Administer epinephrine 2-0 mcg/min infusion
- Administer atropine 1.0 mg IVP

Atropine 1.0 mg IVP is administered with no change in condition. A rhythm check reveals a conversion from a second-degree atrioventricular block to a third-degree atrioventricular block. The HR changes from 38/min to 27/min. The patient is complaining of progressive weakness and soon becomes unresponsive to verbal commands. Signs of inadequate perfusion are noted.
2. What are your next actions?*
- Start CPR (five cycles)
- Attempt transcutaneous pacing (TCP)
- Attempt transvenous pacing
- Administer atropine 1.0 mg IVP

TCP is not always available
3. According to the algorithm for bradycardia, what two ACLS drugs can be administered via IV infusion as alternatives to TCP?*
- Dopamine and magnesium sulfate
- Epinephrine and adenosine
- Dopamine and epinephrine
- Adenosine and dopamine

Dopamine and epinephrine can be administered as alternatives when TCP is not available.
4. What is the appropriate dosage for a dopamine IV infusion?*
- 10-14 mcg/kg/min
- 5-20 mcg/kg/min
- 15-22 mcg/kg/min
- 4-8 mcg/kg/min

Dopamine and epinephrine can be administered as alternatives when TCP is not available.
5. What is the appropriate dosage for an epinephrine IV infusion?*
- 6-12 mcg/min
- 1-5 mcg/min
- 2-10 mcg/min
- 5-10 mcg/min

TCP is prepared, but before an attempt to capture can be performed, the patient deteriorates, a drop in BP occurs, and they become unresponsive. A rhythm check reveals a conversion from a third-degree atrioventricular block to ventricular fibrillation. Respiratory support is provided via BVM.
6. What are your next actions?*
- Place an advanced airway
- Administer epinephrine 1.0 mg IVP without delay
- Start CPR
- Deliver a single unsynchronized shock of 120 J

Epinephrine is administered and the remaA single unsynchronized shock of 120 J is delivered, and CPR is started for five cycles. After five cycles of CPR, a rhythm check reveals unchanged ventricular fibrillation.
7. What are your next actions?*
- Resume CPR (five cycles)
- Perform synchronized cardioversion
- Deliver a single unsynchronized shock of 200 J
- Administer epinephrine 1.0 mg IVP

A single unsynchronized shock of 200 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 a second-degree atrioventricular block. A central pulse is weakly palpable, and the patient remains unresponsive. HR 31/min, BP 77/41.
8. What are your next actions?*

ACLS Megacode 7 Out-of-Hospital