ACLS Megacode Scenario 1 |


    • Emily L says

      If the patient has an unstable tachyarrhythmia then the first intervention is immediate synchronized cardioversion

    • ACLS says

      Because this was a witness cardiac arrest and the patient is connected to the defibrillator, the first intervention should be defibrillation. Kind regards, Jeff


      YES you have to begin CPR every unresponsive patient without pulse or you are unable to detect pulse with 10 seconds initiate chest compression

    • ACLS says

      Within the framework of ACLS during cardiac arrest, after five cycles of CPR (two minutes) always perform a rhythm check.

      Kind regards,

  1. jai qlate says

    please explain to me regarding the post cardiac arrest ROSC, why we need to maintain the pt temperature?
    my second question, what the normal range for temperature pt in intubated condition.

    • Hazem Azzam says

      Induced hypothermia just for 24 hrs for patients post cardiac arrest will decrease the metabolism rate then will help in decreasing the consumption of oxygen then will decrease the workload of the heart. It is like preserving energy of the heart after arrest.

    • Bill says

      jai qlate, I am a resident physican at UCLA John Hopkins. I am on my upteennth round of ACLS/PEDACLS renewals in my long and storied career as a Emergency/Cardiology Physician Specialist…

      Now, regarding your two part question:

      1. The temperature needs to be maintained at this point post resuscitation for a couple reasons.. Remember, we have now restored normal sinus rhytmn, but during this one of many unique emergency trauma scenarios, a couple things happened. The obvious point is that heat loss occurred and the core temperature likely dropped, In in case, we would like to prevent any further cyanosis (ABG chemistry imbalance) and subsequent tissue damage (brain, heart, especially). If you could imagine the situation in real life, not only do we have a patient who has unregulated breathing, but also even during the resuscitation process, heat loss very may well occur as well, as the elements (mind you, I work in emergency now, so I do not know your background, so apologies for that) can be unpredictable in these situations.

      2. regarding the actual temp during intubation, of course the same homeostatic principles apply. … I’m not sure how to best answer that question.. but you can certainly reach out if you need any further assistance.

      Good luck on your journey of the art and science of EM medicine.


      In ROSC Targeted temperature management simply called TTM it the safe and effective strategy to grant that patient in a comatose a neuroprotection and to to alleviate mortality and improve neurological outcomes in unresponsive patients who achieve ROSC after cardiac arrest.

      in the second question, there is no specific temperature range for patient in intubated condition but rather patient who gain ROSC and under TTM is perform under 32-36 degrees Celsius

      Seth Jechie Kelly

  2. Mayflor Altamira says

    Good day..pls show me the difference between monomorphic ventricular tachycardia and polymorphic ventricular tachycardia.i thought question no.3 would be answered perform early defibrillation I’m confused.pls help..

    • Jeff with admin. says

      In question 3, what is important is not the difference between monomorphic and polymorphic in this situation. The important difference is that the patient is unstable. Any unstable tachycardia whether monomorphic or polymorphic requires immediate synchronize cardioversion.

      In question number 4, once the patient is pulseless then what is important is immediate defibrillation. It doesn’t matter whether the ventricular tachycardia is monomorphic or polymorphic.

      Kind regards,

      • Gina Thompson says

        Hello Jeff,

        Can unstable polymorphic tachycardia be successfully treated with synchronized cardioversion, how do we sync on the R with so many variations in this rhythm?

      • Jeff with admin. says

        It is unlikely that the defibrillator will synchronize with polymorphic ventricular tachycardia. When you attempt synchronization, the machine will promptly tell you that synchronization is not possible.

        In that situation, you should revert to manual unsynchronized defibrillation.

        Kind regards,

  3. David Quatrochi says

    Hi Jeff,
    I know different agencies have different protocols. Our protocols changed about 2 years ago for Adenosine. Used to be 6mg 12mg 12mg for Adenosine. Our protocol is 12mg , may repeat 1 time (Denver Metro Protocol).
    Thanks, Dave Q

    • Jeff with admin. says

      That sounds like a fine protocol. I have seen 6 mg fail many times and 12 mg usually does the trick. Remember, the American Heart Association guidelines are just guidelines. A lot of different emergency units develop protocols that deviate in small ways from American heart guidelines and this is fine.

      AHA still says give 6mg if it fails then give 12 mg.

      Kind regards,

  4. crslmrn says

    Great site, Jeff!

    this is my 3rd or 4th review on this site, I was always successful with my recertification. My next recertification is 9/9/18 and I am confident that I will be successful after my review.

    Thank you!!


  5. johnathan montgomery says

    Question number 3. Should be an immediate defibrillation with unstable vtach. Synch Cardioversion is for your unstable atrials

    • Jeff with admin. says

      Your statement is incorrect. Per the tachycardia algorithm, any monomorphic regular unstable tachycardia should receive synchronized cardioversion.

      Defibrillation is reserved for pulseless ventricular tachycardia, ventricular fibrillation and polymorphic ventricular tachycardia. Unstable Polymorphic ventricular tachycardia will receive unsynchronized cardioversion due to the fact that synchronization cannot occur with polymorphic ventricular tachycardia.

      Kind regards,

  6. Ahmed Al Jahwary says

    Excellent scenarios: but there should be sequential and complete each on its own before they are made to change to worse. If pt has palpitation and found to have SVT IN SINUS RHYTHM then let us complete that to the end with its all necessary details WHY change it to VF or VT (these should be allocated on their own different scenarios with all their associated procedures). There could be some cases that are purposely made to deteriorate BUT after finishing all individual scenarios.

    • Elayne says

      Thanks, I have the same opinion. That was the part I struggled and get confuse. Today is the skill/ training part and I nervous . …hope this not interfere.

      • Jeff with admin. says

        Hi Elayne,
        I do plan on developing a series of simplified megacode simulations that go through each sequence with the algorithms. I do appreciate the feedback. Kind regards, Jeff

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