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
- Administer epinephrine 2-0 mcg/min infusion
- Administer atropine 1.0 mg IVP
- 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?*
- Attempt transvenous pacing
- Administer atropine 1.0 mg IVP
- Attempt transcutaneous pacing (TCP)
- Start CPR (five cycles)

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
- Dopamine and epinephrine
- Dopamine and magnesium sulfate
- Epinephrine and adenosine

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
- 5-20 mcg/kg/min
- 4-8 mcg/kg/min
- 10-14 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?*
- 5-10 mcg/min
- 1-5 mcg/min
- 2-10 mcg/min
- 6-12 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
- Place an advanced airway
- Deliver a single unsynchronized shock of 120 J
- Administer epinephrine 1.0 mg IVP without delay

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
- Deliver a single unsynchronized shock of 200 J
- Administer epinephrine 1.0 mg IVP
- Resume CPR (five cycles)

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?*
- Use of statin drugs
- History of STEMI
- Ischemic chest discomfort
- Hypertension

ACLS Megacode 7 Out-of-Hospital