In this ACLS Megacode scenario, use the appropriate ACLS algorithms to treat the patient. There are 17 questions for this ACLS megacode scenario.
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meez_dre says
I’m confused, when they say repeat epinephrine every 3-5 mins, does that mean skip amniodarone until max dose of epi has been administered? How many epi can u give?
Jeff with admin. says
Once the first dose of epinephrine is given, it is basically on its own time table of every 3-5 min.
All other interventions continue as indicated by the algorithm. You can give as much epi as you need there is no max dose.
Kind regards,
Jeff
Susan Odido says
Hi Jeff is it advisable to stop CPR to shock before completing the 5cycles. This is susan
Jeff with admin. says
You should always finish the 5 cycles of CPR before performing a rhythm check.
Kind regards,
Jeff
yalwakza says
On pulseless Vtach/Vfib I am not sure about the sequence. Post shock it is obvious to perform 5cycles of cpr, but post med administration it is not. After giving my meds, do I finish five cycles of cpr. Then perfrom a rhytm/pulse check and shock. As oppose to question 14 and push my med do the cycle of cpr, not 5 cycles, notice still in VT and shock. In other words, do I need to always do 5cycles of cpr after every med or shock given or can I shock after EVERY 5cycles and give meds every other 5 cycles?
Also, do I alternate between an antirhytmic and epi or do I give amio 300mg then 150mg with my next medication cycle?
Thank you.
Jeff with admin. says
Answer:
Medications should always be given towards the beginning of a round of CPR. This will ensure that the medication is adequately circulated before the next shock.
After the first dose of epinephrine, it is given every 3 to 5 minutes regardless of where you are in the scenario. It is better to give it towards the beginning of around the CPR if possible.
The first antiarrhythmic is given after the third shock and the second dose of the antiarrhythmic is given after the fourth shock. This antiarrhythmic would be amiodarone.
Kind regards,
Jeff
http://www.acls-algorithms.com
Jpaulheb says
How do you decide whether to begin with atropine or TCP?
Jeff with admin. says
Here is what the AHA ACLS Manual states about the use of atropine from page 111:
“Atropine remains the first-line drug for acute symptomatic bradycardia. Atropine administration should not delay implementation of external pacing for patients with poor perfusion.”
“Use atropine cautiously in the presence of acute coronary ischemia or MI. An atropine-mediated increase in the heart rate may worsen ischemia or increase the infarct size.”
“Do not rely on atropine in Mobitz type II or 3rd degree AV Block or in patient with 3rd degree AV block with a new wide QRS complex.”
Kind regards,
Jeff
Andrew Dorfman says
I HAD A SIMILAR QUESTION — THANKS FOR POINTING OUT THIS IMPORTANT QUOTE.
ANDREW
Yemi13 says
So Jeff,
Why we chose TCP before administering Atropine on Q 15?
Thank you!
Jeff with admin. says
In this scenario, the defibrillator/pacer is already attached. The patient is in 3rd degree block which is a rhythm that requires pacing. TCP can be rapidly initiated. It will allow for greater control over the patient’s clinical condition whereas atropine’s affect cannot be as tightly controlled.
In this situation, TCP would be a better option to manage the patient’s condition.
Kind regards,
Jeff
jeingram says
I am not seeing any rhythm strip…Where is it? It says monitor rhythm strip below.
Jeff with admin. says
The rhythm strip for question #1 is just below the gray horizontal line. The image does seem to be showing up in the browser window.
You may want to check your browser settings to make sure that it is set to show images.
Kind regards,
Jeff
ahandati@gmail.com says
Hey man, love the site. Question #7 on megacode simulator 3, the pt goes from asystole to monomorphic VT. The question is what do you do next and the answer is give one UNsynchronized shock. I realize that shocking would be the right move here (PA algorithm) but I have always been trained that unless the pt is in VF you never give an unsynchronized shock bc of the risk of putting them into VF. So I thought that that should have been a Synchronized shock in this scenario– I’m more of a medical device guy so please correct me if I’m wrong…
Jeff with admin. says
Ventricular tachycardia without a pulse is basically has the same outcome as vfib, and it should get an I synchronized shock. Both rhythms are pulseless with the origin of electricity coming from the ventricles.
Kind regards,
Jeff
dreem says
ACLS book says, first line treatment for all types of symptomatic brady is Atropine, then, highlighted in red, it says “if atropine is ineffective” , do tcp
Jeff with admin. says
The AHA ACLS provider manual pg. 111 also states “do not rely on Atropine for 2nd degree Type 2 and 3rd degree block. If the patient has poor perfusion TCP and is in either one of these blocks, TCP is indicated.
Kind regards, Jeff
dreem says
Ok, thanks
kk2bf says
For question 15 I know we’re supposed to give 0.5 mg bolus and not 1 mg but why is the first step TCP and not atropine?
Jeff with admin. says
For symptomatic 3rd degree block TCP should not be delayed. Everything is already connected to the patient. All you have to do is set the current and the rate and start pacing.
Kind regards,
Jeff
chhshortstay says
I do not see a rhythm, are we using the first rhythm of asystole?
Jeff with admin. says
The first rhythm in the scenario is asystole. It will be treated with the right branch of the pulseless arrest algorithm which is used to treat PEA and Asystole.
Kind regards,
Jeff
Jackie1 says
If TCP unavailable as the patient is in CHB could isoprenaline be used as an alternative to epi and vaso.
Jeff with admin. says
The only medication alternatives that are AHA approved in the ACLS guidelines at this time are epinephrine and dopamine. I would stick with these alternatives.
Kind regards,
Jeff
Grape123 says
After pacing, or if pacing was not available, why would you not go right to Atropine 0.5mg in the stabilizing pt? The last question in this test states that you would use Dopamine or Epinephrine?
Jeff with admin. says
The question at the end was a general question and not pertaining to the actual scenario. The AHA ACLS manual states on pg. 111 to not rely on atropine for high degree blocks.
The question was really just geared to help remind people of the new guideline change that included dopamine and epinephrine infusions as an alternative to TCP.
Kind regards,
Jeff
jothy says
pls clarify which is ideal time to do rhythm check? after cpr
Jeff with admin. says
A rhythm check is always done after you finish 5 cycles of CPR.
Kind regards,
Jeff
Pamela Green says
I am not unsure as to why is vasopressin can replace epinephrine as stated below? Need Rational.
5. What medication can replace the first or second dose of epinephrine?
vasopressin 40 U IV
Jeff with admin. says
Vasopressin is considered an effective replacement for the first or second dose of epinephrine because it has been shown to be effective for treatment of some pulseless arrest states. You can learn more about vasopressin here.
Kind regards,
Jeff
Grape123 says
i understand the epi and vasopressin but my question is if ive given epi and it doesnt change the rhythm should i give vasopressin as the next drug? and if i give vasopressin as the second drug and then im ready for the third drug would i go to amiodarone or give epi ? i guess just wondering if the third drug is always amiodarone?
jody
Jeff with admin. says
Epinephrine and vasopressin are not given to change the rhythm. It is used for its potent vasoconstrictive effects and also for its ability to increase cardiac output. Epinephrine is considered a vasopressor. Vasopressin raises blood pressure by inducing moderate vasoconstriction.
Once you give the first dose of epinephrine, it is essentially on its own time-table and is to be given every 3-5 minutes. A dose of vasopressin can replace the first or 2nd dose of epinephrine.
Amiodarone is given after the 3rd shock. Don’t think about it regarding the sequence of drugs to be given. Just remember Epinephrine after the 2nd shock then every 3-5 minutes. Amiodarone after the 3rd shock.
Also if you don’t have amiodarone available, lidocaine can be used as a replacement for amiodarone after the 3rd shock.
Kind regards,
Jeff
Stavan Patel says
Question 14 why do you do another round of CPR if you just finished doing a the 5 cycles already?
Jeff with admin. says
Question 14 reads:
“You give amiodarone 300 mg IV and finish the cycle of CPR, your rhythm check reveals continued pulseless VT, continuing on, you shock the patient again. What is your intervention at this time.
So you perform a rhythm check, then shock. The next intervention after shocking in the pulseless arrest algorithm is to begin CPR.
Kind regards,
Jeff
Stavan Patel says
When you do a rhythm check (is this after a number of shocks)?
Jeff with admin. says
In the pulseless arrest algorithm (ie during CPR) you will always perform a rhythm check after completing 5 cycles of CPR. The sequence will be Shock then 5 cycles of CPR then rhythm check. You will give medications while you are performing chest compressions.
Kind regards,
Jeff