In this ACLS megacode scenario, use the appropriate ACLS algorithms to treat the patient. There are 17 questions for this ACLS training scenario.
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Question 1 of 17
1. Question
You are caring for a 50-year-old female. She is 2 days post-op. from a total hip replacement. 6L/min by nasal cannula. When you enter the patient's room, she appears to be unconscious and you note that her nasal cannula is laying beside her bed. Your initial assessment reveals:
SKIN: ashen, diaphoretic, warm
CVS: Carotid pulse only, HR 25, unable to obtain blood pressure
RESP: sporadic and shallow
CNS: Unresponsive
Monitor: See belowYou have called for help. Being an in-hospital setting emergency, your first priority is to:
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Question 2 of 17
2. Question
Which is the correct order for treatment in this scenario?
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Question 3 of 17
3. Question
An IV has been established. The patient is showing clear signs of poor perfusion with the following rhythm.
What should be your next intervention?
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Question 4 of 17
4. Question
You give atropine 1 mg IV push. There is no change in the patients rhythm/rate. What will be your next intervention?
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Question 5 of 17
5. Question
Transcutaneous pacing is attempted. You set the pacing rate for 60/min and attempt capture. After trying for about 30-40 seconds, you are unable to achieve capture. What other medication may now be considered for use in the bradycardia algorithm?
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Question 6 of 17
6. Question
7. As you prepare for an epinephrine infusion and consider transvenous pacing, the patient's rhythm suddenly changes. This is what you see on the monitor.
What should be checked to ensure that this is true asystole?
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Question 7 of 17
7. Question
Which is the correct dosing for an epinephrine infusion in the bradycardia algorithm?
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Question 8 of 17
8. Question
You confirm that this is true asystole and that the patient has no pulse. You begin the cardiac arrest algorithm. Your first step is to:
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Question 9 of 17
9. Question
After you begin CPR what is your next step?
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Question 10 of 17
10. Question
As you begin CPR, you recall the number of CPR cycles that are to be delivered between other interventions is ________ and you also recall that the correct compression-to-ventilation ratio is __________.
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Question 11 of 17
11. Question
As you finish up with the first cycle of CPR and give the first dose of epinephrine (1mg IVP), the rhythm changes. The rhythm below is what you now see on the monitor. The patient remains unresponsive. What is this rhythm?
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Question 12 of 17
12. Question
You determine that this rhythm is ventricular fibrillation, and you begin the VF cardiac arrest algorithm (left branch). What is your first intervention?
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Question 13 of 17
13. Question
You shock the patient with 120 J and continue CPR immediately. After 5 cycles of CPR, your rhythm check reveals continued ventricular fibrillation. What is your next step?
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Question 14 of 17
14. Question
A second shock is delivered at 200 J, and CPR is continued. Your next intervention is to:
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Question 15 of 17
15. Question
The epinephrine is given, and after the cycle of CPR is completed a rhythm check reveals continued ventricular fibrillation. You give a third shock (300 J) and resume CPR. What is your next intervention during CPR?
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Question 16 of 17
16. Question
You give the amiodarone 300 mg IV and after completing the 5 cycles of CPR you check the rhythm:
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Question 17 of 17
17. Question
You shock the patient and complete 5 cycles of CPR. After the CPR, you see the following rhythm on the monitor.
You perform a pulse check. The patient now has a palpable pulse. VS are: HR 60; BP 105/65; RR 5-8
You have corrected the ventricular fibrillation and the patient is stabilizing but has had several short runs of ventricular tachycardia post-arrest. You now consider maintenance antiarrhythmic therapy that can be started if any arrhythmias persist in the post-arrest phase. Which is the best drug of choice in this scenario?
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Anita1 says
Thank you so much Jeff and team, I passed my ACLS today this was not a recertification but my first ACLS I was awesome
Thanks Anita RN
Jeff with admin. says
Great job on your first ACLS! Thanks for the feedback and letting us know how things went!
Kind regards,
Jeff
topazkimc says
question #17 . You now consider maintenance antiarrhythmic therapy that can be started if any arrhythmias persist in the post arrest phase. Which is the best drug of choice in this scenario?
How come it is amiodarone and not epi? I do not see this information in my provider manual.
Jeff with admin. says
Epinephrine is not an antiarrhythmic. You would use epinephrine, dopamine, or norepinephrine if the patient is hypotensive BP<90.
The question about amiodarone is not in the AHA ACLS Provider manual. However, in the past, the manual included the use of prophylactic amiodarone in the post arrest phase if it was used in the treatment of cardiac arrest. Now AHA states in their literature that amiodarone can be used as a post arrest antiarrhythmic if any arrhythmias persist in the post arrest phase.
Kind regards,
Jeff
nebs23 says
Amiodarone was used to convert the patient out of vfib therefore it is the best antiarrhythmic to give.
Jeff with admin. says
correct.
robin524 says
Hi Jeff,
Why wouldn’t you give another dose of atropine prior to initiating transcutaneous pacing? I thought 0.5 mg of atropine should be repeated every 3-5 minutes to a maximum of 3mg?
Thanks
Jeff with admin. says
In this scenario, the pt. is showing clear signs of poor perfusion. This was after the first dose of atropine. Due to the 3-5 minute lag time after the first dose and the patient not responding to the dose of atropine, you should move on to TCP. The extra doses of atropine are often times used after the patient has responded well to the first dose and then the HR begins to drop again.
Kind regards,
Jeff
Les Dixon says
Hey,Jeff, I thought we changed from ABC to CAB? Would you please clarify. Thank you!!!!!!!!
Jeff with admin. says
CAB applies to the BLS sequence of actions for initiating CPR. You asked this question on Megacode Scenario #2. Was there a specific question in this scenario that you were asking about.
Kind regards,
Jeff
criley says
Jeff quest 1.
Why dont we start chest compression before securing the Airway. CAB right?
Jeff with admin. says
In this scenario, the patient has a palpable carotid pulse with a rate of 25. She is unstable but the rhythm is bradycardia. The bradycardia algorithm calls for treatment of reversible causes and then treatment with TCP asap and the use of atropine while TCP is being prepared.
Given the scenario, the most likely cause of this arrest is hypoxia.
Some health care providers would initiate CPR in this case due to the instability, but rapid treatment of the bradycardia by reversing the hypoxia is the most important intervention. Health care providers may tailor the treatment to the most likely cause of the arrest.
Kind regards,
Jeff
larryon38 says
Needs iv access and atropine first in my opinion.
tetratetra says
ASYSTOLE——- Should we not check in a 2nd Lead?
Jeff with admin. says
AHA ACLS Guidelines do not require the check of a 2nd lead. If the monitor shows asystole and your pulse check revels a state of pulselessness then it is appropriate to interventions using the right branch of the pulseless arrest algorithm.
Kind regards,
Jeff
Jill Cisowski says
I thought if the pt goes “witnessed” Asystole, shock is indicated? Can you clarify?
Jeff with admin. says
Asystole is not treated with shocks. Only pulseless VT and VF are treated with shocks.
Asystole is treated using the right branch of the pulseless arrest algorithm. The treatment would be CPR and epinephrine given every 3-5 minutes.
Kind regards,
Jeff
Jill Cisowski says
Darn it! I keep making the same mistake! Thanks!
Taylormcc says
Isn’t the dose for dopamine 2-10mg not epi?
Jeff with admin. says
When epinephrine is used in the bradycardia algorithm as an alternative to TCP, the dosage is 2-10 mcg/min.
When dopamine is use in the bradycardia algorithm as an alternative to TCP, the dosage is 2-10 mcg/kg per minute.
You can find this information on page 110 of the AHA ACLS provider manual.
Kind regards,
Jeff
eileenreilly says
This is a nonperfusing, bradycardiac rhythm of an unconscious pt, chest compressions should start first?
Jeff with admin. says
The patient does have a palpable carotid pulse. According to AHA, if a pulse is palpable, the bradycardia algorithm should be initiated. I do understand were you are coming from with your statement and this scenario could go either way. On this site, I try and stick strictly to the AHA guidelines for consistency between scenarios. Since the patient does have a palpable carotid pulse, the bradycardia algorithm was initiated.
Kind regards, Jeff
kdb0220 says
I thought we were still using the biphasic at 200 now its a 360 shock? please advise did we switch to a monophasic
Jeff with admin. says
Dosing for defibrillation using a biphasic defibrillator increases in a stepwise fashion. 120 then 200 then 300, then 360. 360 J is the max on most biphasic defibrillators. All of the scenarios on this site will be considered biphasic unless mentioned in the question. Also, in the AHA ACLS defibrillator dose as 120-200 J. This 120-200 J is the starting dose. You can begin anywhere from 120-200 J. 120 J is a reasonable place to start in most cases.
Kind regards,
Jeff
jdituri says
actually there is only one defibrillator that has 360j biphasic capabilities. That is the the Medtronic physio control defibrillator. Zoll and all other ones just reach 200J which is pretty standard in all of WA unless you have a EP lab.
nabeel997 says
16. You give the amiodarone 300 mg IV and after 5 more cycles of CPR you check the rhythm which remains in ventricular fibrillation. What is your next
d. both A and C
Dory i can t understand it , I know in this case ” – drug – during CPR- stock – drug. I thinke must be take epinephrine because retun to first algorithm .please can you explain to me
Jeff with admin. says
After the first dose of epinephrine, it is basically on its own time table (every 3-5 minutes). As you are shocking, the guidelines state that you should be considering the administration of a 2nd dose of amiodarone to be given during CPR after the 4th shock.
Kind regards,
Jeff
Ricardo says
what i am unsure about is the sequence. After a shock a rhythm is checked. I keep thinking that this is done after each drug given once drugs have commenced.
Is it that there is not hard and fast rule
Jeff with admin. says
For the Pulseless arrest algorithm (Left branch) which is treatment of pulseless VT/VF. The starting point may be a little different depending if you have a defibrillator on hand.
Shock – CPR –Rhythm check – Shock – CPR – Epi (during CPR) –Rhythm check –Shock – CPR — Amio 300 (during CPR) – Rhythm check – Shock – CPR – Amio 150 (during CPR) – Rhythm check
Let me make it look a little different. It may help:
Shock
CPR
Rhythm check
Shock
CPR (Epi)
Rhythm check
Shock
CPR (Amio 300)
Rhythm check
Shock
CPR (Amio 150)
Rhythm check
I hope this help you see the patter. For the left branch of the pulseless arrest algorithm.
Kind regards,
Jeff
shaneparkk says
Q13: I wanted to give epi 1mg but it said to shock. Is the algorithm shock CPR shock CPR and then introduce meds? Or can I shock CPR and give epi considering that I already have if/io in place?
Jeff with admin. says
AHA Guidelines have the first dose of epinephrine after the 2nd shock. Therefore per AHA guidelines, I would say to give the epinephrine after the 2nd shock during CPR.
In my experience, when a code team is working together and there is a designated person taking care of IV access and drugs the epinephrine is give as soon as it can be drawn up and IV access is established.
The main thing is to make sure you do not focus on medications. High quality CPR and early defibrillation saves lives.
Kind regards,
Jeff
boscy says
Glad I Found this site again. I go up for ACLS on feb 14. my birthday. Hope I do well. Boscy
Jeff with admin. says
Happy Birthday and good luck with certification!
Kind regards,
Jeff
luke123 says
Wouldn’t question 8 on megacode scenario 2 be a witnessed arrest. Why wouldn’t you immediately cardiovert?
Jeff with admin. says
The patient’s rhythm went from bradycardia to asystole. In this situation, cardioversion or shock would not be an option. Asystole is treated with the right branch of the pulseless arrest algorithm. This calls for CPR. No shocks are used with asystole.
Kind regards,
Jeff
Rosa M Strohbehn says
I need to lear alot more.