ACLS Megacode Scenario 3 | ACLS-Algorithms.com

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  1. casmoore says

    Jeff and team, MEGA DITTOS on the site, very helpful and informative. Thanks for the hard work. I have been studying with it and expect to have no problem with recertification. One thing I have noticed in using my kindle is that the “submit and add comments” buttons are too close together so I often hit the wrong one and end up scrolling. Certainly not the end the world but a little aggravating. Again thank you, my anxiety is greatly reduced! Cass

    • Jeff with admin. says

      First, thank you for the encouragement. I will continue to try and make the site a great, low stress learning experience. Second, I checked the distance of the submit button and comments link on my iPhone and it was not to close to cause this problem. This may be something technical with the way the kindle browser is reading the page. You may want to try and different browser on your kindle if possible. This may give you a better experience.

  2. mcampbell says

    Hi, Jeff,

    RE: question #15. Why wouldn’t you intubate if there is no return of spontaneous breathing? Are you treating the underlying cause first with TCP?

    • Jeff with admin. says

      Symptomatic 3rd degree block should be treated with TCP. I do agree that intubation should be mentioned here and I will try and work this into the scenario. Thank you for the feedback.

      Kind regards,
      Jeff

  3. Sylvia says

    Sometimes after you shock you check pulse other times you continue CPR what is the criteria? How do you know which to do?

    • Jeff with admin. says

      I’m not sure where you saw a pulse check performed just after a shock. This would be incorrect. In the pulseless arrest algorithm, after a shock, you would always complete 5 cycles of CPR.

      Kind regards,
      Jeff

  4. Jill RN says

    The first line of action with brady is to give Atropine 0.5 while preparing for TCP. In this scenario, #17, we didn’t give Atropine and no pacing was available, so why start with EPI and Dopamine?

    • Jeff with admin. says

      In this question, I was specifically asking about the alternatives to TCP which are epinephrine or dopamine drip.
      Also, for 3rd degree heart block, atropine cannot be depended upon due to it’s lack of effectiveness for treatment of complete heart block. It is not contraindicated, but it will usually not be effective for treating symptomatic complete heart block.

      Kind regards,
      Jeff

  5. cyagen22 says

    I don’t understand #7….I thought that you never deliver a shock to a patient who is pulseless. This rhythm shows PEA….and no shocks are ever indicated in PEA, correct?

    • Jeff with admin. says

      The rhythm in question #7 is pulseless ventricular tachycardia. Pulseless ventricular tachycardia is not considered PEA. Both pulseless ventricular tachycardia and ventricular fibrillation fall into their own category. They are treated using the left branch of the pulseless arrest algorithm. These two rhythms require delivery of a shock.
      Kind regards, Jeff

    • Jeff with admin. says

      The rationals are provided for the practice tests, but not the scenarios. If you do not understand something while going through the megacode scenarios, you can leave a comment on that page, and I will reply to you by e-mail providing explanations and rationales. You many also find the other comments in the megacode scenarios helpful as many of the students have similar questions.

      Kind regards,
      Jeff

    • Jeff with admin. says

      Once epinephrine has been started, it is given every 3-5 minutes on its own time table. It does not need to be coordinated with the chest compressions. It is just given every 3-5 minutes. The recorder should call out when it is due. Amiodarone has two doses in the algorithm 300mg and then 150mg if needed. There is no place for subsequent doses. The first dose of amiodarone is given after the 3rd shock and the 2nd dose of amiodarone is given at the earliest after the 4th shock. The main thing that you need to make sure of is that each medication has time to circulate before it is repeated. 2-4 minutes of high quality chest compressions should be sufficient to circulate a medication in to the system.
      Kind regards,
      Jeff

  6. Tami1 says

    Question 8 asks what is your next step after the first shock at 120J. Why would you not check a pulse before resuming CPR? If you palpate a pulse after the first shock then CPR is not necessary, right? Am I over thinking this? Your patient’s condition may only warrant compressions or ventilation or neither based upon your assessment findings.
    Thanks,
    Tami

    • Jeff with admin. says

      When treating Pulseless VT and VF, after a shock you always immediately begin chest compressions for 5 cycles and then check for a pulse.

      After a shock if the rhythm changes, you may be dealing with PEA. A pulse check wastes precious time and blood perfusion drastically drops when chest compressions are not being performed.

      Also, if the pt. achieves ROSC, the blood perfusion will be very low for a time, and therefore you will want to maintain perfusion through compressions for 5 cycles.

      After the 5 cycles check the pulse.

      Kind regards,
      Jeff

    • Jeff with admin. says

      Generally speaking, when dealing with symptomatic bradycardia. You can try atropine first. If it you do not see any improvement in the patients symptoms then you could move on to an epi or dopamine drip.
      You could also use TCP at this time. TCP and epi/dopamine are considered equally effective for treatment of symptomatic bradycardia.

      Kind regards,
      Jeff

  7. orangele says

    I thought that for biphasic defibrillators the range for shocks in the pulse less arrest is 120-200J, why in question 13 is 300J used? Is there a specified progression for progressive shocks used in the pulse less arrest algorithm, and if so, what is it?

      • NONNIE says

        where / what page in the ACLS manual is that stated … I have been looking but have not found that statement anywhere… I know in the past that was true … but every time I take ACLS there are changes and I have not found that information yet..

        NONNIE

      • Jeff with admin. says

        2010 AHA ACLS Provider Manual pg. 113: “An alternative to pacing if symptomatic bradycardia is unresponsive to atropine is a chronotropic drug infusion to stimulate the heart.” For epinephrine, initiate at 2-10 mcg/min and titrate to patient response.”
        Kind regards, Jeff

  8. orangele says

    Epi and Dopamine are considered acceptable alternatives and/or backups to transcutaneous pacing with 3rd degree heart block?

    • catbehan says

      when I made this above comment it was further into the question where the rhythm had changed I can see the above asystole
      thank you

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