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 below
You 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:
What is your next step?CorrectIncorrect -
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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DAVID MASIH says
Really i like this scenior becouse am gaining more knowldge. Thanks very much and always wlcm.
rnflame@hotmail says
YOU SHOCK AT 360 THAT IS THE ANSWER, I KNOW SHOCK BUT WOULD IT NOT BE AT 300 JOULES BIPHASIC
Jeff with admin. says
The shock sequence in this scenario is 120, then 200, 300J, then 360J. I’m not sure which question you were referring to, but the AHA sequence for defibrillation if 120 J is the first shock would be 2nd shock: 200 J; 3rd Shock: 300 J; 4th shock 360 J.
Kind regards,
Jeff
Leung Kwai Chiu says
Q no 6 #
ACLS guideline 2010 states that the epinephrine infusion is 0.1-0.5mcg/kg/min.
different from that of 2-10mcg/ min.
Jeff with admin. says
You are referring to the epinephrine dosing for post-cardiac arrest hypotension: The dosing of 0.1-0.5 mcg/kg/min is for post-cardiac arrest hypotension not bradycardia Kind regards, Jeff
goar0701 says
In question # 4; suppose that besides of the answers 1,2,3,4, you also have: 5. perform High quality chest compressions. In that case what needs to be next step, 1. attempt transcutaneous pacing or 5. perform High quality chest compressions.
Jeff with admin. says
At question #4 you are dealing with the bradycardia algorithm. Chest compressions are not used in the bradycardia algorithm. There is much debate over this issue and some providers choose to initiate chest compressions even with a weak bradycardic pulse present. This would be outside of the AHA ACLS guidelines. According to the AHA ACLS bradycardia algorithm pacing would be the correct treatment.
If a provider decides to give chest compressions this is their choice, but this is outside of the AHA ACLS Guidelines.
Kind regards,
Jeff
goar0701 says
Thanks! now is clear.
lucile says
For #16 why is the answer not 150 of amiodarone since pt is still in vf.? Is it because you should defib again first before attempting next dose of amiodarone of the 150?
Jeff with admin. says
Yes, that is correct. Defibrillation should be attempted prior to the 2nd administration of amiodarone. Always if any rhythm check reveals pulseless VT of VF, your next intervention will always be defibrillation about the rhythm check. Rhythm check —-VF or Pulseless VT—-Defibrillation. Kind regards, Jeff
barbara.fuller says
what is TCP and perfusion how do u pace
Jeff with admin. says
Transcutaneous pacing (TCP) is performed by placing pads on top of the skin (transcutaneous). These pads conduct an electrical current that stimulate the heart to contract. TCP is used when sever bradycardia leads to decreased circulation which is the same as poor blood perfusion.
Kind regards, Jeff
MICHAEL GUTH says
Why wouldn’t you start chest compressions before securing the airway?
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
Cecilia says
She has a palpable pulse, so algorithm/Jeff, correct.
jezzygirl says
But there is poor perfusion?
Jeff with admin. says
“Poor perfusion would dictate the use of the bradycardia algorithm. Unstable bradycardia is treated with the bradycardia algorithm not the cardiac (pulseless) arrest algorithm.
There is some controversy with this. Some institutions say go straight to compressions. This is not the stance of AhA at this time.
Kind regards,
Jeff
Rebecca Pacheco says
Hello,
Q3 states that there is clearly signs of poor perfusion and one would think that CAB would play into this scenario by starting chest compressions but the answer is to give Atropine..I understand she has a pulse but this answer doesn’t make sense to me. How will Atropine increase this patient’s perfusion at this point? And all I have seen on this website is that compressions and shocks override giving drugs…
Please advise,
Thanks.
Jeff with admin. says
If a patient has a pulse then the bradycardia algorithm should be used to treat the patient. If the patient is unstable and symptomatic, there is some debate whether to skip atropine and go straight to pacing. Atropine could increase the patient’s perfusion, buy increasing the heart rate. An increase in heart rate would most likely be beneficial to the patient’s cardiac output. If giving atropine would delay TCP then you should go with TCP. In this case, it would have be ok to attempt atropine if it would not delay any other treatments. Also, on the AHA written exam, you will come across several questions regarding atropine. AHA has put some emphasis on attempting atropine if it does not delay TCP in the symptomatic and unstable patient.
joannaickes says
I would tend to agree that the patient needs chest compressions. The question details nothing about the patient’s oxygen level… And further, if her bradycardia is severe enough, she would have a loss of consciousness. While waiting for others to arrive, I would begin chest compressions to begin recirculating blood to her organs.
rejordan says
Starting chest compressions would not be following the algorithm as it states to identify and treat underlying causes first. In this case the patients respiration is shallow and sporadic and you note her 6L/min NC is completely off. This should give you a clear indication that the brady is most likely due to hypoxia.
slaughts says
I also thought it was supposed to be CAB, not ABC. Please comment.
rcain says
We’ve already done the “C” in CAB when we verified that the patient has a definitive pulse. And despite the poor cardiac output and perfusion, it’s very debatable whether or not pumping on someone’s chest helps or hurts when they already have organized cardiac activity that is producing a measurable blood pressure (albeit a low one). It’s important to remember that even the best CPR only produces maybe 25-30% of normal cardiac output. That’s pretty rotten if you think about it, yet it’s often lifesaving if you’re starting with zippo cardiac output. In our scenario above, how much cardiac output remains at the patient’s bradycardic rate? Is it less than 25-30% that the BEST CPR might be able to produce? Beats me, and I think that’s at least part of the reason why the subject is up to so much debate.
robert says
to me i feel starting chest compressions would be appropriate while getting atropine and TCP, shes not perfusing
Jeff with admin. says
The patient does have a pulse. Perfusion is compromised and this would classify as symptomatic bradycardia which is treated with the bradycardia algorithm. However, there is some debate in these situation whether chest compressions should be started even if the patient has a pulse. If you are familiar with any studies or literature regarding the matter of starting chest compressions in the presence of severe bradycardia please let me know.
Kind regards,
Jeff
Swedenmamma says
Hello, this is a wonderful resource! In question 13, shock CPR shouldn’t it be a medication next?
Thank you!
Swedenmamma says
It hasn’t been two minutes I assume?
Jeff with admin. says
The Questions reads: “13. You shock the patient with 120 J and continue CPR immediately. After 5 cycles of CPR, your rhythm check reveals no pulse and continued ventricular fibrillation. What is your next step?”
So after CPR the rhythm check reveals no pulse with VF. The correct choice would be to shock.
Kind regards,
Jeff
Heartbreak says
I will think positive. I can do this! I took This 5 yrs ago and passed, don’t know how. Very stressful! The person doing the Megacode was so cocky and talked down to me so that I vowed never to take this again since it was not required. Different job, it is required now. I can do this. I am an OB nurse.
Jeff with admin. says
You can do it! You will do great. Use the checklist in the download library to ensure that you cover everything on the site. After you have gone through the site, you will be fully prepared and go into certification confident.
Kind regards,
Jeff
Farmer1960 says
WHY do the instructors act this way? If they don’t want to help us learn , stay at home, besides we’re never going to code by ourselves!!!!
Linda Mainzer says
Hi Jeff. This site is so helpful in studying for my ACLS test. Thank you so much for all the symulations and for giving the rt. Answers and reasoning behind them.
Jeff with admin. says
You are very welcome. I am so glad that the site has been helpful for you.
Kind regards,
Jeff
shone_glng@yahoo.com says
What is the meaning of “signal gain”
Jeff with admin. says
Signal Gain means the size of the waveform. If the waveform is large and prominent then it is considered strong signal gain. If the waveform is obscure and looks more like a flat line or just very small in size then it is considered weak signal gain. Put simply, it has to do with the amount of electricity that is being picked up by the ECG monitor.
Kind regards,
Jeff
ehudsonhines says
why chest compressions the first action even in a hospital setting? per aha C A B
Jeff with admin. says
Chest compressions gets oxygen filled blood to the vital organs. If there is no oxygenated blood circulating then there will be a greater amount of ischemia. Thus chest compressions gets blood to the vital organs.
Kind regards,
Jeff
Christopher Scibelli says
Isn’t the Amiodarone maintenance drip obsolete?
Jeff with admin. says
Amiodarone maintenance infusion can be used in the post-arrest phase only if there are tachyarrhythmias in the post-arrest period. Amiodarone is no longer to be used as a preventive. According to AHA, “The prophylactic use is no longer recommended and it should not be used unless there are tachyarrhythmias persist.”
Kind regards,
Jeff
ricoli7771 says
#10: According to the algorithm, it seems like you would give a shock and not give epi until after the second shock. Please explain.
Jeff with admin. says
In Question #10, you are still using the right branch of the pulseless arrest algorithm (asystole). With the right branch of the cardiac arrest algorithm, the epinephrine is given with the first round of CPR. Here is a link to the cardiac arrest algorithm: Take a look at the right branch.
Kind regards,
Jeff
ricoli7771 says
#4: I’m not sure why pacing would be next intervention after an initial dose of Atropine. It seems to me that you would give another round of Atropine (up to 3mg) before you would begin pacing. Please explain.
Jeff with admin. says
In this scenario by question #3, the patient is experiencing clear signs of poor perfusion and the first dose of atropine did not have any effect. In this case, you should not let medication administration delay the use of external pacing. You can always give another dose of atropine while pacing. Pacing is noninvasive, effective, and be discontinued quickly.
Kind regards,
Jeff