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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Lori1234 says
In question #13, I was taught that the sequence is after shocking give med, shock-med, shock-med? Why are we to deliver another shock?
Jeff with admin. says
When using the left branch of the cardiac arrest algorithm, epinephrine is given for the first time after the second shock.
According to the American Heart Association ACLS cardiac arrest algorithm, there is no medication given after the first shock. After the first shock, you start CPR immediately.
Many healthcare providers deviate from the American Heart Association recommendations and give epinephrine after the first shock. Remember, the American Heart Association guidelines are just guidelines and recommendations. Physicians can adjust their treatment based upon their own clinical judgment.
Kind regards,
Jeff
chintharsam says
I love these mega code scenarios!!!
It’s a very good way to practice what I learnt from your site. I wish this type of learning is available on Healthstream in hospitals for nurses to practice their knowledge.
MYTURNER says
I SECOND THAT!
charmley says
Sorry, figured it out.
charmley says
In question #8 it says to start CPR, but I thought you should shock asap??
Thanks
Love, love, love the site
Wajma says
I am having a hard time with this senerio and the answers that are showing correct.
My thoughts are if no BP and pulse is 25, start CPR…. Why is this not true???
Jeff with admin. says
There are some that recommend starting CPR in such a case, however, the AHA recommendation for Bradycardia with a pulse does not include CPR. AHA does allow for health care providers to tailor the sequence of events to best suit the needs of the situation that is at hand. Therefore, a health care provider has the discretion to deviate from the algorithm. However, on this site, I try to stick directly with the algorithms so as not to confuse students who are preparing for the AHA ACLS Provider course. Kind regards, Jeff
dawusa1 says
Jeff,
Regarding Question #6:
Shouldn’t Epinephrine infusion dosing be weight-based?
If this is true, then the correct answer for Question 6 would change.
Deb Weaver
Jeff with admin. says
See page 112 of the AHA ACLS provider manual. It states:
“Begin epinephrine infusion at a dose of 2 to 10 mcg/min and titrate to the patient response.”
The epinephrine infusion when used within the bradycardia algorithm is not eight based. Dopamine is weight based within the bradycardia algorithm.
Kind regards,
Jeff
afrey says
Hi, Question 17 the correct answer was amiodorone. Where do I find that in the text? The drugs listed in the algorithm on page 73 are epi, dopamine, norepi for hypotension <90 syst.
Thanks 🙂
Jeff with admin. says
The question reads: “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?”
This question is regarding antiarrhythmic therapy not therapy to treat postarrest hypotension. The antiarrhythmic of choice during the post cardiac arrest phase is amiodarone.
Kind regards,
Jeff
Ariel says
Jeff, I have a concern about the medications. I’am nurse, and as a nurse we give medications to someone according to doctor’s order. During emergency, am I allowed or is it legal to order my teammate to give those emergency drugs during running megacodes since I’am certified ACLS?
Jeff with admin. says
You would not be giving anyone any orders as a registered nurse.
There are many hospitals that have standing protocols that may be followed by nurses during code situations. It would depend upon the standing protocols that your hospital has. If your Hospital has a protocol that allows you to provide medications then you would be OK requesting that someone administer epinephrine. You would need to look in Standing orders or standard operating procedure for the specific place where you work.
Remember however, the two most effective interventions that can be provided for cardiac arrest are high-quality chest compressions and early defibrillation. Both of these can be administered during a code blue by a registered nurse. Again, check with your standing orders or your hospital protocol to find out specific details about what you can do as a registered nurse out a physicians verbal order.
Kind regards,
Jeff
mlevy says
Jeff, so in these scenarios, a thready or weak pulse = a pulse, hence no CPR? Is that correct? Even if unable to get a blood pressure?
Thanks mark
mlevy says
let me modify the question: unresponsive and (very) bradycardia, but with a palpable jugular pulse = a pulse nonetheless, so the “C” of CAB is addressed, and it is on to airway. It that correct?
mark
Jeff with admin. says
Yes it would be a pulse, and the best course of action would be to treat this patient using the bradycardia algorithm which does not include CPR.
In this case if you are performing the ACLS survey, you would use ABCD which is the acronym for the ACLS survey. Airway, breathing, circulation, differential diagnosis.
CAB addresses the sequence of events for CPR. Chest compressions, airway, breathing.
Kind regards,
Jeff
Jeff with admin. says
Yes, that is correct. A pulse = not pulseless and not in cardiac arrest. This criteria ensures that people are using the correct algorithm to treat a patient in an emergency. If you do not feel a pulse, and you have a bradycardia rhythm you are dealing with PEA if you feel a pulse at all then you are dealing with bradycardia.
If you feel no pulse and the rhythm shows a very rapid rate you’re dealing with pulseless ventricular tachycardia which is treated using the cardiac arrest algorithm if you feel a pulse you will use the unstable tachycardia algorithm.
In real life scenarios may not be so cut and dry and can be very fluid. You may be dealing with a patient that is deteriorating very rapidly and will soon be pulseless. In times like this, a team may to begin CPR while trying to determine causes or while they prepare to treat underlying causes. Remember the guidelines are simply guidelines and a healthcare team made diverge from the guidelines when necessary to ensure the best patient outcome.
Kind regards,
Jeff
juddsont says
In question 14 the answer is to give Epinephrine again. Why would you not give Amiodorone since your last med was already epinephrine?
Jeff with admin. says
In the scenario (Scenario #2 Question 14), the rhythm had recently changed and treatment was started from the top of the left branch of the cardiac arrest algorithm. The first drug given in the pulseless arrest algorithm is 1mg epinephrine. When the rhythm changes during a code and a different algorithm/protocol is started, best practice is to start from the top of the algorithm.
In this case since epinephrine had been administered during asystole, the physician may move right into the administration of amiodarone. This is ok since physicians may tailor interventions according to the situation and what they deem to be the best course f action.
Kind regards,
Jeff
chenwenw says
If there is no or poor perfusion, medication would not work. That is why we emphasis so much on 2 min cycle of CPR before you do anything. I disagree with your answer on this question 3. Please explain your logic. Thanks.
Jeff with admin. says
The patient has a pulse and should be treated with the bradycardia algorithm. Poor perfusion does not mean no perfusion. The bradycardia algorithm does not contain chest compressions as an intervention for poor perfusion. The interventions would be atropine and then TCP (chemical/electrical). If the patient is or becomes pulseless then the cardiac arrest algorithm would be used. The algorithms are in place to guide best practice for cardiopulmonary resuscitation.
Kind regards,
Jeff
dakota05 says
Hi. In questions, I am confused when one uses the CAB’s of BLS vs. the ABC’s of ACLS vs. other management. In real life settings, it all just kind of takes place at once! For example, when finding someone unresponsive as in question 1. I had a hard time deciding which answer was the FIRST step. I was wanting to start with C (circulation) and establish IV access. Can you shed some light on how to best answer these questions?
Thanks!
dakota05 says
I apologize. I mixed up my CAB’s and ABC’s! With my earlier comment, I should have technically started with compressions from the CAB mneumonic. But still same basic question. When finding someone unresponsive, does one not start with BLS then advance to ACLS?
Jeff with admin. says
You would start with the CAB of BLS and quickly move forward through this and into the ABCD’s of ACLS.
Kind regards,
Jeff
Jeff with admin. says
The treatment sequence would call for BLS first and therefore you would perform the “C” of BLS first. You are correct that some of these interventions will occur rapidly from one to another and some simultaneously. However, the algorithm help guide the provider and not miss any critical interventions as they move forward.
Kind regards,
Jeff
COLLEEN1 says
IN QUESTION 17 ROSC DOESNT SAY TO GIVE AMIODORONE
flipwerd says
Question 1, bag ventilate with no bp and a HR of 25? Seems perfusion would be inadequate.
Jeff with admin. says
With unstable bradycardia, the perfusion is inadequate This is the definition of unstable bradycardia, and this is why you start treatment using the bradycardia algorithm. Some say that you should start chest compressions, and 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 at this time. 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.
In this situation, the most likely cause of the bradycardia is hypoxia. A correction in hypoxia and improved respiratory status could quickly correct this problem.
Kind regards,
Jeff
Mmhill says
Your explanations follows AHA guidelines & are logical & helpful. Thank you.
Gtgeorgio says
However, this patient is hemodynamically unstable. Bagging certainly does not seem like the most appropriate next step. What happened to atropine and getting transcutaneous pacing setup in case needed ? Certainly correcting hypoxia can help her since it is the underlying problem but that will take some time and won’t correct her hemodynamics quickly enough.
cscott says
Question 10- I thought you had to wait until after the second shock before you give epi?
cscott says
Nvm, figured it out. haha thx anyways
Kat says
For #11, please still not clear how to differentiate a fib from ventricular fib ( haven’t got to the rhythm review yet) . They look very similar to me. BTW, loving this site. Slowly but surely this is beginning to make sense to me. Yay!
Jeff with admin. says
Atrial fibrillation will have a normal QRS complex. You will see no P waves and the rhythm will be irregular.
Ventricular fibrillation on the other hand is completely different. You will see no organized rhythm, no QRS complex, no P-wave, nothing but a weird squiggly line. Also, your patient will be unresponsive, or he will be unresponsive within five seconds of entering this rhythm. Hope that helps.
Make sure to review this section: Rhythms
Kind regards,
Jeff