You are a healthcare provider working on an ALS ambulance. You are dispatched to a bus terminal where a 38-year-old male is having a grand mal seizure. Your response time to the scene is 3 min. Upon arrival, a bystander informs you that the seizure ended 1 min prior to your arrival. A rapid initial assessment reveals the following:

Vital signs

Pulse rate: 28/min
Blood pressure: Unobtainable
Respiratory rate: 28/min
Temperature: 38.7 °C

Physiological systems

Integumentary: Cyanotic, diaphoretic, cool
Cardiovascular: No palpable peripheral pulses bilaterally
Respiratory: Lungs CTA bilaterally
Neurological: Unresponsive

1. A cardiac monitor is attached to the patient. A rhythm check reveals sinus bradycardia at 28/min. The patient is considered symptomatic. You decide to provide supportive care. In order of importance, what are your initial actions?*

Identify H’s and T’s, perform a 12-lead ECG, provide oxygen, establish IV access

Provide oxygen, assist ventilation via BVM, establish IV access, monitor vital signs

Provide oxygen, monitor vital signs, assist ventilation via BVM, establish IV access

Establish IV access, provide oxygen, monitor vital signs, perform a 12-lead ECG

Supportive care has been provided for 2 min. A rhythm check reveals unchanged sinus bradycardia at 28/min.

2. What are your next actions?*

Continue providing supportive care

Start CPR (five cycles)

Administer atropine 1.0 mg IVP and begin setting up the defibrillator

Administer adenosine 6 mg IVP

Atropine 1.0 mg IVP is administered with no change in condition. While another team member attaches the defibrillator and prepares for transcutaneous pacing, you administer a second dose of atropine 1.0 mg IVP.

3. What is the maximum cumulative dose of atropine that can be administered in the given scenario?*

2.0 mg

2.5 mg

1.5 mg

3.0 mg

A second dose of atropine 1.0 mg IVP is administered with no change in condition. Transcutaneous pacing is attempted. Soon after an initial pacing attempt, a rhythm check reveals conversion from sinus bradycardia to asystole.

4. What are your next actions?*

Perform a pulse check

Administer epinephrine 1.0 mg IVP

Deliver a single unsynchronized shock of 120 J

Start CPR (five cycles)

CPR is started for five cycles. During the first cycle of CPR, you consider pharmacological intervention to assist with conversion.

5. What are your next actions?*

Administer adenosine 6.0 mg IVP

Administer atropine 1.0 mg IVP

Administer lidocaine 1.0-1.5 mg/kg IVP

Administer epinephrine 1.0 mg IVP

Epinephrine 1.0 mg IVP is administered and flushed with NS 20 ml. CPR is continued without interuptions. Following five cycles of CPR, a rhythm check reveals a conversion from asystole to ventricular fibrillation.

6. What are your next actions?*

Administer epinephrine 1.0 mg IVP

Administer epinephrine infusion 2-5 mcg/min

Resume CPR (five cycles)

Deliver a single unsynchronized shock of 120 J

A single unsynchronized shock of 120 J is delivered, and CPR is resumed for another five cycles. Following five cycles of CPR, a rhythm check reveals unchanged ventricular fibrillation. You decide to deliver a single unsynchronized shock of 200 J, and CPR is resumed for another five cycles.

7. Approximately how long should five cycles of CPR take to complete?*

3 min

2 min

90 sec

4 min

During the first cycle of CPR, you administer epinephrine 1.0 mg IVP. Following five cycles of CPR, a rhythm check reveals unchanged ventricular fibrillation. You deliver a single unsynchronized shock of 200 J and CPR is resumed for another five cycles.

8. During the first cycle of CPR, what drug should you consider administering?*

Amiodarone 150 mg IVP

Amiodarone 300 mg IVP

Epinephrine 1.5 mg IVP

Epinephrine 1.0 mg IVP

Amiodarone 300 mg IVP is administered, and CPR is resumed for another five cycles. Following five cycles of CPR, a rhythm check reveals a conversion from ventricular fibrillation to sinus rhythm with premature ventricular contraction. The patient now has a palpable pulse, return of spontaneous circulation is achieved, and supportive measures are implemented. Shortly after arriving at the hospital, the patient experiences several short runs of ventricular tachycardia. As a result, you know that the resuscitation team will likely start the patient on an amiodarone infusion.

9. What would be the appropriate dosage in the given scenario, assuming the infusion would be given over 6 hrs?*

190 mg slow infusion

280 mg slow infusion

240 mg slow infusion

360 mg slow infusion

Amiodarone infusions are often used in post cardiac arrest care for the management of persisting arrhythmias.

10. Which of the following statements regarding amiodarone infusions are correct?*

Maximum cumulative dose is 2.2 g in 24 hrs

All the above

150 mg IV bolus over 10 min, then 1 mg/min for 6 hrs, then 0.5 mg/min for 18 hrs

Patients should be monitored closely for hypotension and pulmonary toxicity

ACLS Megacode 9 Out-of-Hospital

Hurry, don’t let time run out!

Vital signs

Physiological systems

Supportive care has been provided for 2 min. A rhythm check reveals unchanged sinus bradycardia at 28/min.

Atropine 1.0 mg IVP is administered with no change in condition. While another team member attaches the defibrillator and prepares for transcutaneous pacing, you administer a second dose of atropine 1.0 mg IVP.

A second dose of atropine 1.0 mg IVP is administered with no change in condition. Transcutaneous pacing is attempted. Soon after an initial pacing attempt, a rhythm check reveals conversion from sinus bradycardia to asystole.

CPR is started for five cycles. During the first cycle of CPR, you consider pharmacological intervention to assist with conversion.

Epinephrine 1.0 mg IVP is administered and flushed with NS 20 ml. CPR is continued without interuptions. Following five cycles of CPR, a rhythm check reveals a conversion from asystole to ventricular fibrillation.

A single unsynchronized shock of 120 J is delivered, and CPR is resumed for another five cycles. Following five cycles of CPR, a rhythm check reveals unchanged ventricular fibrillation. You decide to deliver a single unsynchronized shock of 200 J, and CPR is resumed for another five cycles.

During the first cycle of CPR, you administer epinephrine 1.0 mg IVP. Following five cycles of CPR, a rhythm check reveals unchanged ventricular fibrillation. You deliver a single unsynchronized shock of 200 J and CPR is resumed for another five cycles.

Amiodarone infusions are often used in post cardiac arrest care for the management of persisting arrhythmias.

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