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ACLS Megacode 7 Out-of-Hospital
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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?
*
Administer atropine 1.0 mg IVP
Attempt vagal maneuvers
Administer epinephrine 2-0 mcg/min infusion
Deliver a single unsynchronised shock of 120 J
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?
*
Administer atropine 1.0 mg IVP
Attempt transvenous pacing
Start CPR (five cycles)
Attempt transcutaneous pacing (TCP)
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?
*
Adenosine and dopamine
Epinephrine and adenosine
Dopamine and epinephrine
Dopamine and magnesium sulfate
Dopamine and epinephrine can be administered as alternatives when TCP is not available.
4. What is the appropriate dosage for a dopamine IV infusion?
*
15-22 mcg/kg/min
10-14 mcg/kg/min
4-8 mcg/kg/min
5-20 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?
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2-10 mcg/min
6-12 mcg/min
5-10 mcg/min
1-5 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?
*
Start CPR
Administer epinephrine 1.0 mg IVP without delay
Place an advanced airway
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?
*
Perform synchronized cardioversion
Resume CPR (five cycles)
Administer epinephrine 1.0 mg IVP
Deliver a single unsynchronized shock of 200 J
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?
*
Place an advanced airway and continue assisted ventilation
Administer atropine 1.0 mg IVP
Administer magnesium sulfate 2.0-4.0 g IV
Provide TCP
Transcutaneous pacing is attempted, and capture is successful. Strong peripheral pulses are noted bilaterally. HR 59/min, BP 91/70. Spontaneous respirations are noted, and the patient is transported to the hospital for post-cardiac arrest care.
9. Which of the following clinical conditions are indications for following the algorithm pathway for an unstable bradycardic rhythm?
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Ischemic chest discomfort
History of STEMI
Use of statin drugs
Hypertension
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