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Home » Free Resources » ACLS Case Study » Out of Hospital Case Study 8

ACLS Megacode 8 Out-of-Hospital

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You are a healthcare provider working in a rehabilitation center with ALS capabilities. A 66-year-old female 11 days post-op from a total hip arthroplasty complains of general malaise and heavy palpitations. The patient does not report any pain or difficulty breathing. A rapid initial assessment reveals the following:

Vital signs

Pulse rate: 161/min
Blood pressure: 120/80
Respiratory rate: 18/min
Temperature: 37.4 °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 sinus tachycardia at 161/min. The patient soon experiences a short run of ventricular tachycardia that converts spontaneously back to sinus tachycardia. During this run, you observe that the patient held their chest and appeared to have difficulty breathing, which has since subsided. What are your initial actions?*

Activate a code blue

Attempt vagal maneuvers

Provide supplemental oxygen

Prepare the defibrillator and establish IV access

The defibrillator is prepared and IV access is established. Shortly after, the patient soon complains of rapid palpitations and pain radiating down their left arm. A rhythm check reveals conversion from sinus tachycardia to narrow complex supraventricular tachycardia.

2. What are your next actions?*

Perform synchronized cardioversion

Attempt vagal maneuvers

Administer adenosine 6.0 mg IVP

Deliver a single unsynchronized shock of 120 J

Vagal maneuvers are attempted with no change in condition. A rhythm check reveals unchanged narrow complex supraventricular tachycardia.

3. What are your next actions?*

Administer adenosine 12.0 mg IVP

Prepare to perform synchronized cardioversion

Administer adenosine 6.0 mg IVP

Continue to attempt vagal maneuvers until conversion to sinus rhythm is observed

Adenosine 6.0 mg IVP is administered with no change in condition. You decide to administer a second dose of adenosine at 12.0 mg IVP further showing no change in condition. You decide to perform synchronized cardioversion. As you prepare to cardiovert, the patient becomes unresponsive, and a pulse is no longer palpable. A rhythm check reveals ventricular tachycardia.

4. What are your next actions?*

Continue with performing synchronized cardioversion

Administer epinephrine 1.0 mg IVP without delay

Deliver a single unsynchronized shock of 120 J

Start CPR (five cycles)

A single unsynchronized shock of 120 J is delivered, and CPR is started for five cycles. Following five cycles of check compressions, a pulse check reveals a faint but palpable pulse. The monitor shows a HR of 189/min, but an unchanged narrow-complex tachycardia. The patient is not breathing spontaneously. Supported ventilation is provided via BVM. You perform synchronized cardioversion at 100 J with no change in condition.

5. What are your next actions?*

Administer amiodarone 300 mg IVP

Perform a pulse check

Perform synchronized cardioversion at 150 J

Resume CPR (five cycles)

You perform a pulse check which reveals that a palpable pulse is still present. You consider performing synchronized cardioversion at a higher setting.

6. What setting should you use in the given scenario?*

Cardiovert at 125 J

Cardiovert at 200 J

Cardiovert at 100 J

Cardiovert at 220 J

Synchronized cardioversion is performed at 200 J, and a rhythm check reveals a conversion from ventricular tachycardia to sinus rhythm.

7. If cardioversion was unable to convert the rhythm, what other actions would you have considered?*

Administration of adenosine 12.0 mg IVP

Attempting vagal maneuvers

Delivering a single unsynchronized shock of 200 J

Administration of epinephrine 1.0 mg IVP

The patient has been stabilized and transferred to the intensive care unit.

8. What is the name of the ACLS algorithm that should be followed immediately after cardiac arrest resuscitation?*

Post-resuscitative care

Post-arrest care

Post-cardiac care

Post-cardiac arrest care

9. The ACLS Post-Cardiac Arrest Care algorithm emphasizes prevention of what three clinical conditions following cardiac arrest?*

Hyperoxia, hypoxia, hypotension

Hyperkalemia, hyperoxia, hypotension

Hypercapnia, hypotension, hypoxia

Hypoxia, hypercapnia, hyperkalemia

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