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 two 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 lying 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:
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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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stein008 says
For Question 17, Megacode Scenario #2
“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?”
I correctly selected amiodarone as the answer given that amiodarone 300 mg was given in the prior question and the patient successfully converted to sinus rhythm with administration of amiodarone.
My concern is that the AHA guidelines do not include amiodarone in the post-cardiac arrest algorithm, which only includes vasopressor infusion (epinephrine, dopamine, or norephinephrine).
Did I miss something?
Thanks.
Jeff with admin. says
Within the post cardiac arrest period you may need to utilize one of the other ACLS algorithms. If tachycardia occurs you would utilize the tachycardia algorithm. If bradycardia occurs then you would utilize the bradycardia algorithm.
An anti-arrhythmic infusion can be used to control runs of ventricular tachycardia irrespective of whether they are pre-arrest or postarrest. The tachycardia algorithm outlines the use of amiodarone for the treatment of tachycardia. The maintenance infusion of 1 mg per minute for the first six hours would be the recommended starting point.
Kind regards,
Jeff
Sofia says
Jeff thank you so very much for creating this site, it has helped me immensely to prepare for and pass ACLS, but above all to understand what I am doing, not just memorize algorithms. I have one question. If one does not shock PEA, cardiovert monophasic unstable Vtach, and defib VFib, why is it that we shock (defib) pulseless Vtach? Why is it that pulseless Vtach doesn’t fall under PEA? thank you.
Jeff with admin. says
The treatment for ventricular fibrillation is high energy shocks which is defibrillation.
The treatment for any tachycardia with a pulse is synchronize cardioversion and less the machine will not sync with the patient’s heart rate. In this case you would perform defibrillation if the patient is unstable.
Pulseless ventricular tachycardia is technically a form of PEA, however since it responds very well to high-energy shocks/defibrillation is treated with the left branch of the cardiac arrest algorithm the same way that ventricular fibrillation is treated.
If you do not understand this and you need further explanation you can call the technical support line, and I can discuss it with you 316-243-7096.
Kind regards,
Jeff
johnjawad48 says
Hi,
My question is, after we give one 0.5mg of Atropine, with the pt. being hemodynamically unstable we immediately try transcutaneous pacing. Why would you try epinephrine or dopamine instead of Atropine again, considering the maximum dose for Atropine is 3.0mg?
Thank You
Jeff with admin. says
Studies indicate that epinephrine and dopamine are effective alternatives to transcutaneous pacing. If you saw that atropine had some type of positive effect after giving the first dose then it would be appropriate to give another dose of atropine. If saw no effect or if the patient becomes more unstable then it would be appropriate to attempt TCP or begin an epinephrine or dopamine infusion since they have been shown to be acceptable alternatives to TCP.
If I had my preference, I would choose TCP. This is because TCP is very effective, easy to start, and stop, and only affects the heart rate. The same can be said about epinephrine and dopamine except these medications may have other side effects that must be monitored.
Kind regards,
Jeff
lullrich says
Hi Jeff –
I noticed for this scenario, Megadose scenario #2, the patient’s rhythm changed to v-fib and was shocked 4 times before he converted to normal sinus rhythm. What would the scenario be if he didn’t convert to normal sinus (with low respirations)? How many times should/could CPR / shock be done before the code was called or is it up to the physician who is running the code? Also, if the Amiodarone (dose #2) did didn’t work after shock #3, then would another medication be given and if so, what would that medication be? Thanks. Linda
Jeff with admin. says
It is really up to the physician and team that is performing the code. There is no set time to stop resuscitation efforts.
Lidocaine is still listed as a medication that can be used if amiodarone is not available or if amiodarone fails to convert the rhythm. I have seen lidocaine used after amiodarone did not help.
Kind regards,
Jeff
Maureen G Newman says
Some updating needed, drug recommendations and CPR sequence nor ABCD
Jeff with admin. says
The site and all of the scenarios are up to date with the 2015-2020 AHA ACLS Guidelines. These scenarios are fully compliant. Please let me know which questions you addressing within the scenario and I would be glad to explain any concerns with the answers you have.
Kind regards,
Jeff
emmurphyfnp says
in megacode 2# question 3 I believe with poor perfusion CPR should begin and atropine can stimulate but CPR to aid perfusion in the described poor perfusion situation should not be delayed ?
Jeff with admin. says
Poor perfusion CPR is address in PALS but not within the framework of ACLS.
The patient does have a carotid pulse and the rate is 30. This would be classified as bradycardia and in adult cardiac arrest, chest compressions are not indicated within the algorithm. I do try to keep all of these questions within the AHA ACLS guidelines.
I agree that a health care provider may choose to diverge away from the AHA guidelines in this situation and perform CPR for poor perfusion bradycardia as they treat the underlying problem here which is most likely hypoxia.
Thank you for your feedback.
Kind regards,
Jeff
CAN says
My book states the usual infusion rate for Dopamine is 2-20 mcg/kg per minute. Titrate to patient response & taper slowly. Is that not correct?
Jeff with admin. says
Yes, that is correct. Also, the infusion rate for epinephrine is 2-10 mcg/min
Kind regards,
Jeff
solyamma says
Question #8 ACLS Megacode Scenario #2
Why wouldn’t we shock if it is a witnessed asystole? and the Defibrillator is available
Jeff with admin. says
Asystole does not respond to defibrillation because there is no electrical pulse being generated from a heart that is in asystole.
Defibrillation can only be effective on a heart that is still generating some sort of electrical impulse.
The protocol for asystole would be to use the right branch of the cardiac arrest algorithm which calls for high quality CPR and epinephrine every 3-5 minutes.
Kind regards,
Jeff
pjbrant says
Regarding question 16 , Megacode Scenario 2: After 5 cycles of CPR & a rhythm check, when does one check a pulse ( or do you just know by the VF rhythm that there would not be a pulse anyway)?
Jeff with admin. says
You only check for a pulse if you see a rhythm change to a rhythm that is organized and would possibly generate a palpable pulse.
You are correct about ventricular fibrillation. After a patient goes into ventricular fibrillation, and you have confirmed a pulseless state you would not need to check a pulse if the patient remains in ventricular fibrillation.
Kind regards,
Jeff
glenvi says
Jeff,
re:Q6 Which is the correct dosing for an epinephrine infusion in the bradycardia algorithm?
The correct answer would then be option #3 : 2-10 mcg/min and not option 2 correct?
Thanks again!
Jeff with admin. says
That is correct. The correct dosing for an epinephrine infusion in the bradycardia algorithm is 2-10 mcg/min. Kind regards, Jeff
bcmhnurse says
Why would you not check for a pulse here?
Jeff with admin. says
I am not sure which question in the scenario you were referring to. Can you clarify on the question Number within the scenario that you were referring to. Kind regards,
Jeff
sking93311 says
In my 2015-2020 AHA Handbook, I do not see a mention of amiodarone as a drug to be used in the immediate post-cardiac arrest algorithm. The algorithm only includes epinephrine, dopamine and norepinephrine infusions. It is, however, mentioned under the section of Life Support Drugs.
Jeff with admin. says
It is not listed under the ROUTINE medications to be used for post cardiac arrest. It would be listed under the tachycardia algorithm and would be used as needed to treat continually arrhythmias. I am your room is no longer used prophylactically but rather only used if any arrhythmias persist post-arrest.
Kind regards,
Jeff
samsmama says
my acls book says 2-10 mcg/kg/min ?
Jeff with admin. says
See pg. 126 AHA ACLS Provider Manual:
Epinephrine infusion should be started at 2-10 mcg/min and titrated to the patient response.
Dopamine infusion should be started at 2-10 mcg/kg/min and titrated to the patient response.
Note that epinephrine is not weight based in the bradycardia algorithm.
Note that dopamine is weight based in the bradycardia algorithm.
Kind regards, Jeff
tcurn79 says
On the final question there is not picture of a rhythm even though it suggests there is supposed to be one.
Also, there are no rationales for the incorrect responses.
Jeff with admin. says
Thank you for pointing out the missing image. This has been corrected. The rationales are all being updated at this time and there are some questions that do not have them filled in. If you have any specific questions, please leave a comment and I will be glad to answer your question.
Kind regards,
Jeff
allen says
I just want to know, you had asystole and gave epi 1mg.
you have a rhythm change to v-fib.
you are still in your 3-5 minutes, why would you not consider amiodarone 300mg for v-fib?
Jeff with admin. says
If we are sticking strictly to the AHA guidelines, when you have a rhythm change, you would start at the top of whatever algorithm is applicable. With cardiac arrest, you have a left and right branch. If your rhythm changes from asystole (right branch) to VF (left branch) you would go from where ever you are in the right branch to the top of the left branch and begin progression down the respective algorithm. Kind regards, Jeff