In this ACLS Megacode scenario, use the appropriate ACLS algorithms to treat the patient. There are 12 questions for this ACLS megacode scenario. Assume the use of biphasic defibrillator in all scenarios.
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Question 1 of 12
1. Question
A 40-year-old man arrives at the ER accompanied by his family. He is complaining of palpitations after working outside for several hours. The assessment is as follows:
SKIN: Hydrated, pale, warm and dry
CVS: Strong peripheral pulses and a BP of 125/80
CNS: Fully intact
RESP: RR is 22, no resp. difficulties, lungs CTAYou start an IV on the patient. The monitor shows a narrow complex SVT (160).
What is your next intervention?
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Question 2 of 12
2. Question
You have performed vagal maneuvers. This is what you see on the monitor:
What is your next step?CorrectIncorrect -
Question 3 of 12
3. Question
You give 6mg Adenosine rapid IV push with no effect. 12mg Adenosine rapid IV push is then given. The patient develops severe chest pain, his rhythm is the same, and his vital signs are: HR 220, BP (not obtainable), and weak pulse. The patient also has LOC changes. Your next step should be?
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Question 4 of 12
4. Question
After synchronized cardioversion is unsuccessful, the pt. continues to deteriorate. The patient is now unconscious with pulseless ventricular tachycardia. Below is what you see on the monitor:
What is the first and most important intervention?
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Question 5 of 12
5. Question
You perform defibrillation with 120 J. What is your next intervention?
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Question 6 of 12
6. Question
After completing 5 cycles of CPR, the rhythm is unchanged. You shock a second time with 200 J and resume CPR. While completing the cycle of CPR what else should be done?
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Question 7 of 12
7. Question
You have given the epinephrine and completed the 5 cycles of CPR. A rhythm check reveals no change. You attempt a third defibrillation. What will be your defibrillator setting?
(In all scenarios, assume that the biphasic defibrillator shock setting can be from 50-360 Joules. The shock selection on many biphasic defibrillators can vary.)CorrectIncorrect -
Question 8 of 12
8. Question
The third shock is delivered and you restart CPR (5 cycles). What medication should be given after the 3rd shock during CPR?
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Question 9 of 12
9. Question
What is the correct dosing for amiodarone in the Cardiac Arrest Algorithm?
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Question 10 of 12
10. Question
You give amiodarone 300 mg (first dose) and finish the cycle of CPR. Upon a rhythm check, you see, the patient has converted to a normal sinus rhythm and has a pulse (ROSC). As you begin the post-arrest phase, the patient has a short run of VT. In light of the continued arrhythmia, you are instructed to start an amiodarone drip for post-resuscitation maintenance therapy. What is maximum cumulative dose for amiodarone in a 24 hour period?
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Question 11 of 12
11. Question
Lidocaine can be used instead of amiodarone as an antiarrhythmic during cardiac arrest. What is the proper dosing of lidocaine?
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Question 12 of 12
12. Question
Great Job! You saved the patient He has been stabilized and intubated, but does not respond to verbal commands. He is transported to the hospital's ICU. Since the patient is not responsive what would be the most important intervention in the post-cardiac arrest phase.
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Stanley Harris says
This patient presented to ER with good vital signs, lungs clear, no difficulty breathing. Why start the O2 @ 2 LPM at this point? Thought the current guidelines were to be more conservative with O2 therapy.
Jeff with admin. says
Good point. Thanks for pointing this out. This was inadvertently left in the scenario when it was last updated. Yes, AHA is using a more conservative approach to the use of oxygen, and oxygen would not need to be applied unless the oxygen saturation is less than 94%. “administer oxygen and titrate therapy to provide the lowest administered oxygen concentration that will maintain the oxyhemoglobin saturation 94%.”
I appreciate the feedback.
Kind regards,
Jeff
IAMMD says
DO YOU HAVE ANY GOOD PNEUMONICS. IE SHOCK, SHOCK, SHOCK EVERYBODY SHOCK. BIG SHOCK , LITTLE SHOCK, MAMA SHOCK PAPA SHOCK.
IAMMD says
MNEUMONICS. SORRY.
Jeff with admin. says
I do not have any educational Mneumonics that I use regularly for teaching ACLS.
Kind regards,
Jeff
SUSAN ISAAC says
Jeff . the pulse is WEAK and he has LOC,so isn’t defib the choice.
regards ,Susan.
Jeff with admin. says
Unstable tachycardia with a pulse is always treated with synchronized cardioversion unless the defibrillator machine cannot synchronize with the patients rhythm.
If the defibrillator machine cannot synchronize with the patients rhythm then you would use on synchronize cardioversion which is also known as defibrillation.
Please let me know if you have any other questions.
Kind regards,
Jeff
Elaine McKinney says
Enjoyed taking this test I felt I have learned somethings. The questions and answers are a wonderful tool THANKS
Fiona Higgins says
This answer to question 5 of 12 on the ACLS megacode simulator cannot be to give 5 cycles of CPR after 120j defibrillation. That is just ridiculous!
Jeff with admin. says
The American Heart Association AC LS provider manual Pg. 98 states: “immediately resume CPR, beginning with chest compressions. Do not perform a rhythm or pulse check at this point unless the patient is showing signs of life or advanced monitoring indicates ROSC.”
The rationale for this is that when a heart is in cardiac arrest and defibrillation results in conversion to an organized rhythm, it can take a few moments for ROSC to occur. The full two minutes of CPR allows for the heart to progress to a sufficient cardiac output.
Kind regards,
Jeff
Fiona Higgins says
Hi Jeff,
thanks for the reply. I understand that CPR has to be started. I just thought that going in with 5 cycles was excessive before checking for a pulse. As you said above, two minutes (1 cycle) allows the heart to progress to sufficient cardiac output.
I’m guessing the answer of 5 cycles assumes a pulse check after the first round.
Fiona
Jeff with admin. says
CPR without an advanced airway in place is performed at 30:2. This is 30 chest compressions to every 2 respirations. 1 of these rounds is considered one cycle of CPR. Five of these (5 cycles) should be completed prior to performing a pulse check.
Kind regards,
Jeff
raul ramirez says
the 2nd doses of amiodarone is immediately after the 1st doses if necessary?
Jeff with admin. says
You would want to wait for at least one full cycle of CPR (2 minutes) before giving the 2nd dose of amiodarone. This would ensure full circulation of the first dose after 2 minutes of high-quality CPR.
Kind regards,
Jeff
obusby says
Hi jeff.took my acls yesterday.noticed they changed format that is very similar to you teaching for mat.needless to say I scored 100% on test. Ya baby
Thank you for your website.I have told many people about it…
Jeff with admin. says
That’s great. I’m glad that the site was helpful for you. Kind regards, Jeff
KathyJ says
what is CTA? as used in the scenario
Jeff with admin. says
CTA stands for clear to auscultation.
Kind regards,
Jeff
trudy66 says
Jeff
Out biphasic defibrillator is 200J MAX. These scenarios say 120, 200 and 300j in that order. Is this by chance using a monophasic defirillator.
Jeff with admin. says
There are some defibrillators that have a maximum setting of 200 J. This is OK (see below). There are other biphasic defibrillator’s that go up to 360 J.
Many of the newer models have a max of 200 J. This is because 200 J has been found to be sufficient for conversion in almost all cases if VF and VT.
I think that the American Heart Association will soon adjuster guidelines to account for this.
Kind regards,
Jeff
Michael Lowe says
In 30 years the AHA has continually maintained escalation of energy protocol. This will not change and if you are unfortunate enough to have a Zoll, Phillips or another brand that only charges to 200 Joules, your patient suffers. Usually this is due to cost, a defib that max energy is 200 j is considerable less than one that can escalate to 360j, which may save your patients life. Are we allowing people to not be resuscitated because we want to save few dollars? I trained as a flight medic in the Army and was field paramedic for 12 years and always had the ability to escalate energy. What do you do when you shock your patient with 200j, it does not convert? Try another 200 j that wont convert? Troubling issus
Jeff with admin. says
I agree. It is unfortunate that hospitals purchase defibrillators that will not escalate past 200 J. Kind regards, Jeff regards, Jeff
lara67@mail.com says
(: i didn’t know that, it is sad.
NELSON ENRIQUE MONTOYA LOPEZ says
I BELIVE THAT THE ANSWER IS REVALUATED IN THIS TIME, ´CAUSE THE COMPLICATIONS OF THA PROCEDURE
Jeff with admin. says
I’m not sure which question you are asking about, and I don’t understand your question. Kind regards, Jeff
Kenneth Wright says
Jeff, another question isn’t the rhythm in number 4 Vtach. That is a synchronized rhythm is it not?
Kenneth
Jeff with admin. says
For the purposes of the type of shock delivery two things matter.
Kind regards,
Jeff
Kenneth Wright says
Hi Jeff.
I do not fully understand defibrillation and cardio version.
Is cardioversion to convert a synchronized rhythm such as v-tach and defibrillation to stop an unsychronized rhythm such as V-fib so the heart can restart as regular sinus rhythm?
Best regards.
Ken
Jeff with admin. says
First let me clairify this. When the word cardioversion is used it typically means synchronized cardioversion. When the word defibrillation is used it means unsynchronized cardioversion.
So you have synchronized cardioversion and unsynchronized cardioversion. The word synchronized is used because it means that the timing of the administration of the electrial shock is synchronized with the impulse of the heart so that it can be delivered at a specific time during the impulse of the heart.
When a defibrillation is delivered, it is not timed (not synchronized) with the electrical impulse of the heart. It is an immediate blunt delivery of electricity.
Here is a page that may help explain this further: synchronized vs. unsynchronized cardioversion
Kind regards,
Jeff
Melody says
This looks great, very effective.
Jeff with admin. says
I think you will find that it helps considerably. If you have any questions, feel free to comment or send an email through the admin menu at the top. There is a link titled “contact.” Kind regards, Jeff
Roos says
For question 5: it is nowadays allowed to give up to 3 stacked shocks to a patient with a witness VT, right?
Jeff with admin. says
That is no longer recommended by the AHA within ACLS protocol. Stacked shocks are not recommended. 1 shock and then CPR for 2 minutes (5 cycles) is recommended. Kind regards, Jeff
ShannonKay says
For this particular case, VT, How will the machine find a QRS to put markers on, in order to cardiovert?
Jeff with admin. says
The defibrillator is programmed to recognize the peak of the R-wave, and then times the shock to be delivered on or just after the R-wave. This is why there may be a slight delay in the shock while the defibrillator is calculating the shock delivery time.
With cardioversion, the objective is to avoid shocking the patient during repolarization of the heart.
Kind regards,
Jeff
flieswithsun says
There is no R wave. I do not know what Jeff is talking about.
Jeff with admin. says
The R wave is the first upward deflection after the P wave and is part of the QRS complex. Kind regards, Jeff