ACLS Megacode Case Study 8 Out-of-Hospital

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?*
- Provide supplemental oxygen
- Attempt vagal maneuvers
- Activate a code blue
- 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
- Administer adenosine 6.0 mg IVP
- Deliver a single unsynchronized shock of 120 J
- Attempt vagal maneuvers

Vagal maneuvers are attempted with no change in condition. A rhythm check reveals unchanged narrow complex supraventricular tachycardia.
3. What are your next actions?*
- Continue to attempt vagal maneuvers until conversion to sinus rhythm is observed
- Administer adenosine 6.0 mg IVP
- Prepare to perform synchronized cardioversion
- Administer adenosine 12.0 mg IVP

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?*
- Deliver a single unsynchronized shock of 120 J
- Administer epinephrine 1.0 mg IVP without delay
- Continue with performing synchronized cardioversion
- 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
- Resume CPR (five cycles)
- Perform synchronized cardioversion at 150 J

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 220 J
- Cardiovert at 200 J
- Cardiovert at 100 J
- Cardiovert at 125 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 epinephrine 1.0 mg IVP
- Administration of adenosine 12.0 mg IVP
- Delivering a single unsynchronized shock of 200 J
- Attempting vagal maneuvers

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-arrest care
- Post-cardiac arrest care
- Post-cardiac care
- Post-resuscitative 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
- Hypoxia, hypercapnia, hyperkalemia
- Hypercapnia, hypotension, hypoxia

ACLS Megacode 8 Out-of-Hospital