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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Question 1 of 17
1. Question
Scenario data: A 65-year-old male collapses as he is out for his morning walk. A bystander witnessed the collapse, activates EMS, and begins CPR. The EMS team arrives 6 minutes later. The monitor is attached and the assessment is as follows:
Skin: cold/clammy/cyanotic
Cardiovascular: no pulse
Respiratory: no respirations
CNS: no response
Monitor: rhythm strip below
What ACLS algorithm are you going to begin this scenario with?
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Question 2 of 17
2. Question
As an EMS provider in the out of hospital setting, your first step is to:
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Question 3 of 17
3. Question
While the EMS team is providing 5 cycles of CPR what other activities can be completed?
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Question 4 of 17
4. Question
After your IV is secure, your next step involves giving a medication. What medication should be used?
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Question 5 of 17
5. Question
(True or False)
Vasopressin 40 U IV can replace the 1st or 2nd dose of epinephrine in the cardiac arrest algorithm.CorrectIncorrect -
Question 6 of 17
6. Question
Epinephrine should be repeated at what frequency for the treatment of Asystole?
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Question 7 of 17
7. Question
You give epinephrine 1 mg IV and finish the cycle of CPR. What is your next intervention?
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Question 8 of 17
8. Question
After giving the first dose of epinephrine you finish the cycle of CPR. A rhythm check shows that the patient's rhythm changed from asystole to the rhythm below. He also remains pulseless. Your first action is to:
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Question 9 of 17
9. Question
You deliver 1 shock of 120J. After the shock what is the your next step?
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Question 10 of 17
10. Question
You have resumed CPR. Your next intervention after 5 cycles of CPR is to:
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Question 11 of 17
11. Question
Your rhythm check reveals continued pulseless VT. What are your next 2 steps?
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Question 12 of 17
12. Question
You give a second shock and perform 5 cycles of CPR. What medication should you give after the second shock during CPR?
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Question 13 of 17
13. Question
The epinephrine is given and the round of CPR completed. A rhythm check reveals no change in the rhythm and pulseless VT continues. You shock with 300 J and start another cycle of CPR. What medication are you going to give at this time?
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Question 14 of 17
14. Question
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 with 360 J. What is your intervention at this time.
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Question 15 of 17
15. Question
After completing 5 cycles of CPR a rhythm check reveals the following:
Your pulse check reveals a faint palpable pulse. VS are: HR 30; BP 78/58; and the patient does not have spontaneous breathing. What is the next step?
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Question 16 of 17
16. Question
You recognize this rhythm because there is no apparent relationship between the P-waves and the QRS complexes. What is the rhythm?
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Question 17 of 17
17. Question
After you initiate TCP the patient continues to stabilize. VS are: HR 70; BP 105/75; RR 5; You continue to support ventilation with the bag valve mask, and TCP continues. If transcutaneous pacing was not available, what medication can be considered as an alternative?
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cederholms says
Why shock PEA
Jeff with admin. says
I believe that your question was referring to the 2nd rhythm strip which was pulseless VT. Pulseless VT is treated using the left branch of the Cardiac Arrest Algorithm which would call for shocks. Pulseless VT is not treated as PEA even though it is technically a type of PEA.
Treat Pulseless VT and VF with the left branch of the cardiac arrest algorithm.
Kind regards,
Jeff
ASUNMA says
QUESTION 2 HOW CAN ONE PROVIDER ABLE TO CARRY OUT THREE ACTIVITIES WHILE GIVING CPR UNLESS THERE IS A HELPER
ASUNMA says
I MEAN QUESTION 3
Jeff with admin. says
In the scenarios, helpers are assumed. The scenarios are designed to teach all the aspects of each roll. Kind regards, Jeff
David Frid says
why a rhythm check and not a shock?
Jeff with admin. says
I’m not sure what part of the scenario you were addressing. I looked through the scenario, but cannot determine which question you were referring to. Can you give the specific number to the question that was being asked?
Kind regards,
Jeff
ALEJANDRO TERRAZAS says
2.- My answered is better perform intubation and mechanical ventilation, then i will try drip of epinephrine for helping raise arterial pressure and chronotropic effect raise the rate, but if it does not work the next step is TCP prior sedation, without suspend drip amine. Maybe the manual said TCP it is firstable correct, but when you are besides the bed of patient in ER, it very common that in this kind of rhythm have another problems like metabolic acidosis, hyperkalemia, myocardial infarct, then you must treated simultaneously.
ALEJANDRO TERRAZAS says
Sorry friends! The rhythm is third block with nodal complex response. I am not agree with this answered on # 15 question, 1.- true, the case, you have rhythm with rate 30 and low pressure, BUT the patient was not breathing on his own!!!, after all this time it is very probably he had prolonged central nervous ischemia and hypoxia with hypercapnia and it is true you will not take more time for TCP then intubate him. Give assistance with BVM could help while you apply TCP, but get more time rise PaO2, that it not easy and you must add some sedation (or not?) for TCP with the risk of depres more the arterial pressure.
After all, maybe you could have a problem, with epinephrine and dopamine you can increase the rhythm then you could induce VF pulseless vs asystole, because increase the sensibility with the both are pro-arrhythmic effects. you must evaluate benefits vs risk of this drugs in third degree block with nodal rhythm. Also in some places TCP is not available. And atropine, it is avoided since second block degree Mobitz II to third block degree, because it is very easy to conduce asystole. I think we must reevaluate TCP vs intubated in this case.
nasa27 says
Hi Jeff,
I was wondering, for question 15, why is transcutaneous pacing considered before atropine? Does it have to do with the fact that it’s a 3rd degree heart block?
Also for question 17, what is the reason why atropine is not tried before epi or dopamine infusion?
Thank you!
Jeff with admin. says
There are a couple of reasons for using the TCP instead. Since the defibrillator is already attached, the TCP can quickly be started. The TCP can easily be stopped or adjusted to the patient’s needs. Also, 3rd degree block is less likely to respond to atropine.
To address your second question. The epinephrine drip was started to improve the post-arrest hypotension (BP was 78/58) that the patient was experiencing. Atropine is used to treat bradycardia and would not be indicated for the treatment of hypotension.
Kind regards,
Jeff
nasa27 says
Thank you so much for the explanation!
alexp says
howdy jeff , for question 17 , why epi or dopamine instead of atropine ? thanks.
Jeff with admin. says
The question was “If transcutaneous pacing was not available, what medication can be considered as an alternative.”
An epinephrine or dopamine infusion are now considered acceptable alternatives to TCP and would be used in the case of complete block. Here is what the AHA ACLS provider manual states pg. 163:
“For symptomatic bradycardia, the AHA now recommends IV infusion of chronotropic agents (dopamine or epinephrine) as an equally effective alternative to external transcutaneous pacing when atropine is ineffective.”
Kind regards,
Jeff
nancyc7 says
to Rahsaan022
I would say during ACLS, follow the AHA rules, not professional opinions. That will get you in trouble during your testing.
Bahareh Ezzati says
Hi Jeff,
While I was reading the comments I noticed the rhythm was verified as second degree type two heart block. But the PP intervals are not equal. To me this rhythm seems to be second degree type one which the PR interval increases until one bit is escaped.
If we would have a Type I Mobitz can we give Atropine?
Thanks
Jeff with admin. says
The rhythm in Question #15 and #16 is 3rd degree heart block. The QRS and the P-waves are completely disassociated. I recently updated this scenario and some of the comments may not match the scenario. I will check through and try to delete the ones that do not apply.
Kind regards,
Jeff
Stephanie says
Is it standard that you do not give the antiarrhythmic until the 3rd shock?
Jeff with admin. says
Yes, this is the standard. Normally, you would not give the antiarrhythmic until after the third shock.
Kind regards,
Jeff
Young Phil Cho says
I am the most beginner, but the condition of patient regarding no spontaneous breathing bothers me.
Is there any solution?
Thanks in advance!
Jeff with admin. says
In this scenario, you have already been performing CPR which would include the use of a bag-valve-mask to provide respirations. You would continue providing respiratory support with the BVM and you would intubate the patient as soon as possible. (The statement was simply to point out that the patient was not breathing on his own.)
Kind regards,
Jeff
larryon38 says
Agree previous tab would be beneficial.
IMJ says
Yes!!!
Rhiannon Updenkelder says
Question 7 for this scenario; if the pt changed from asystole to PEA, wouldn’t the first step be 5 cycles of CPR?
Jeff with admin. says
The patient’s rhythm changed from asystole to pulseless VT. Pulseless VT is treated with high energy unsynchronized shocks.
Kind regards,
Jeff
pablo.diazba says
Jeff, acording to ACLS book, the flow shart for AV block II says that we should try Atropine, and then try transcutaneous pacing… can you help me?
Jeff with admin. says
On page 111 of the AHA Provider Manual it states:
“Atropine administration should not delay the implementation of external pacing for patients with poor perfusion.”
Also on page 111 it states:
“Do not rely on atropine in Mobitz Type II and also 3rd degree block or in patients with third-degree AV block with a new wide QRS complex.”
The above would be the main reason for skipping over the atropine and going straight to TCP if it is ready for use.
Kind regards,
Jeff
Rahsaan022 says
On page 111 of the AHA Provider Manual it states:
“Atropine administration should not delay the implementation of external pacing for patients with poor perfusion.”
Hmm, clinically I’d find this ambiguous. “Poor perfusion” could mean just AMS or cold, unconscious, w/ barely palpable pulse. This comes up in another algorithm and I think the moderator’s approach was an effective clarification. If there is a pulse, bradycardia algorithm, if there isn’t, PEA algorithm.
In the scenario above, having given epinephrine already, you’re entering the symptomatic bradycardia algorithm at an advanced step. Further it’s a step that already has failed, so I’d escalate therapy and begin pacing, if available.
Just my professional opinion. 😉
Jeff with admin. says
Thank you for the input. Kind regards, Jeff
matsonpl says
I love your site, but one improvement that I think would be really helpful is along with the “next” question tab giving a “previous” tab so that a person (in case they were interrupted, etc.) can look back on what has been happening in the scenario. Thanks.