ACLS Megacode Case Study 9 Out-of-Hospital

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, monitor vital signs, assist ventilation via BVM, establish IV access
- Provide oxygen, assist ventilation via BVM, establish IV access, monitor vital signs
- 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
- Administer adenosine 6 mg IVP
- Start CPR (five cycles)
- Administer atropine 1.0 mg IVP and begin setting up the defibrillator

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?*
- 2.5 mg
- 1.5 mg
- 3.0 mg
- 2.0 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 epinephrine 1.0 mg IVP
- Administer lidocaine 1.0-1.5 mg/kg IVP
- Administer atropine 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?*
- Resume CPR (five cycles)
- Administer epinephrine infusion 2-5 mcg/min
- Deliver a single unsynchronized shock of 120 J
- Administer epinephrine 1.0 mg IVP

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
- 4 min
- 90 sec
- 2 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?*

ACLS Megacode 9 Out-of-Hospital