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90-1011_ACLS_Part5_Appendix_A.

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ACLS Megacode Case 1: Sinus Bradycardia


(Bradycardia VF/Pulseless VT
Asystole ROSC)

Megacode Testing Checklist 1/2


Bradycardia VF/Pulseless VT Asystole ROSC
Student Name: __________________________________________ Test Date: ___________________
if done
correctly

Critical Performance Steps

Out-of-Hospital Scenario
You are a paramedic and arrive on the scene to find a 57-year-old woman complaining of indigestion. She is cold, clammy, and diaphoretic. She tells you she
is about to faint. EMS responders have obtained vital signs: HR 38/min, BP 70
mm Hg/palpable, RR 16/min, and O2 saturation 93%. No other assessment or
management has been performed. Now you assume the role of team leader.

Case Development
Initial
Assessment

Bradycardia
Algorithm

This woman may have an ACS. The case focus, however, is


bradycardia. The team leader should begin to take a history
and direct team members to start oxygen (if not initiated)
and an IV and place monitor leads. Nitroglycerin at this point
would be inappropriate in the absence of typical ischemictype discomfort and given the womans vital signs (severe
bradycardia and hypotensioncontraindicated).
The student is presented with bradycardia and needs to follow the Bradycardia Algorithm. A critical action is noting that
symptoms are due to bradycardia that requires management.
Actions at this point should include at least an initial dose
of atropine and preparation for TCP or use of chronotropic
drugs (epinephrine or dopamine infusion).

12/22/10 5:25 PM

Cardiac
Arrest
Algorithm
(VF/Pulseless
VT)

The patient suddenly develops VF. The team leader will follow
the Cardiac Arrest Algorithm. Now the student team leader
will assign additional team functions and monitor for highquality CPR. The case should continue through safe defibrillation, administration of a vasopressor, and consideration of
an antiarrhythmic drug.

Cardiac
Arrest
Algorithm
(Asystole)

After a shock, the patient becomes asystolic. The student


continues to monitor high-quality CPR and follows the asystole pathway of the Cardiac Arrest Algorithm.

Immediate
PostCardiac
Arrest Care
Algorithm

The team continues high-quality chest compressions, the


patient has ROSC, and the Immediate PostCardiac Arrest
Care Algorithm is initiated.

Bradycardia Management
Starts oxygen if needed, places monitor, starts IV
Places monitor leads in proper position
Recognizes symptomatic bradycardia
Administers correct dose of atropine
Prepares for second-line treatment

VF/Pulseless VT Management
Recognizes VF
Clears before ANALYZE and SHOCK
Immediately resumes CPR after shocks
Appropriate airway management
Appropriate cycles of drugrhythm check/shockCPR
Administers appropriate drug(s) and doses

Asystole Management
Recognizes asystole
Verbalizes potential reversible causes of asystole/PEA (Hs and Ts)
Administers appropriate drug(s) and doses
Immediately resumes CPR after rhythm checks

PostCardiac Arrest Care


Identifies ROSC
Ensures BP and 12-lead ECG are performed, O2 saturation is monitored, verbalizes need
for endotracheal intubation and waveform capnography, and orders laboratory tests
Considers therapeutic hypothermia

STOP TEST
Test Results

2011 American Heart Association

Team Leader
Ensures high-quality CPR at all times
Assigns team member roles
Ensures that team members perform well

Circle P or NR to Indicate Pass or Needs Remediation:

Instructor signature affirms that


skills tests were done according
to AHA Guidelines. Save this
sheet with course record.

NR

Instructor Signature: _______________________________


Print Instructor Name: ______________________________
Date: ________________

90-1011_ACLS_Part5_Appendix_A.indd 124

ACLS Megacode Case 2: Mobitz Type II


AV Block
(Bradycardia VF/Pulseless VT
Asystole ROSC)
In-Hospital Scenario
You are evaluating a 57-year-old woman complaining of indigestion. She is
brought immediately from triage (arrived by personal car) and placed in ED
room 2. She is cold, clammy, and diaphoretic. She states that she feels as if
she is about to faint. The triage nurse is working with you and has obtained vital
signs: HR 38/min, BP 70 mm Hg/palpable, RR 16/min, and O2 saturation 91%.

Case Development
Initial
Assessment

Bradycardia
Algorithm

This woman may have an ACS. The case focus, however, is


bradycardia. The team leader should begin to take a history
and direct team members to start oxygen (if not initiated) and
gain IO access (not able to get an IV in) and place monitor
leads. Nitroglycerin at this point would be inappropriate in the
absence of typical ischemic-type discomfort and given the
patients vital signs (severe bradycardia and hypotension
contraindicated).
The student is presented with bradycardia and needs to follow the Bradycardia Algorithm. A critical action is noting that
symptoms are due to bradycardia that requires management.
Actions at this point should include at least an initial dose
of atropine and preparation for TCP or use of chronotropic
drugs (epinephrine or dopamine infusion).

Cardiac
Arrest
Algorithm
(VF/Pulseless
VT)

The patient suddenly develops VF. The team leader will follow
the Cardiac Arrest Algorithm. Now the student team leader
will assign additional team functions and monitor for highquality CPR. The case should continue through safe defibrillation, administration of a vasopressor, and consideration of
an antiarrhythmic drug.

Cardiac
Arrest
Algorithm
(Asystole)

After a shock, the patient becomes asystolic. The student


continues to monitor high-quality CPR and follows the
asystole pathway of the Cardiac Arrest Algorithm.

Immediate
PostCardiac
Arrest Care
Algorithm

The team continues high-quality chest compressions, the


patient has ROSC, and the Immediate PostCardiac Arrest
Care Algorithm is initiated.

Megacode Testing Checklist 1/2


Bradycardia VF/Pulseless VT Asystole ROSC
Student Name: __________________________________________ Test Date: ___________________
if done
correctly

Critical Performance Steps


Team Leader
Ensures high-quality CPR at all times
Assigns team member roles
Ensures that team members perform well

Bradycardia Management
Starts oxygen if needed, places monitor, starts IV
Places monitor leads in proper position
Recognizes symptomatic bradycardia
Administers correct dose of atropine
Prepares for second-line treatment

VF/Pulseless VT Management
Recognizes VF
Clears before ANALYZE and SHOCK
Immediately resumes CPR after shocks
Appropriate airway management
Appropriate cycles of drugrhythm check/shockCPR
Administers appropriate drug(s) and doses

Asystole Management
Recognizes asystole
Verbalizes potential reversible causes of asystole/PEA (Hs and Ts)
Administers appropriate drug(s) and doses
Immediately resumes CPR after rhythm checks

PostCardiac Arrest Care


Identifies ROSC
Ensures BP and 12-lead ECG are performed, O2 saturation is monitored, verbalizes need
for endotracheal intubation and waveform capnography, and orders laboratory tests
Considers therapeutic hypothermia

STOP TEST
Test Results

Circle P or NR to Indicate Pass or Needs Remediation:

Instructor signature affirms that


skills tests were done according
to AHA Guidelines. Save this
sheet with course record.

NR

Instructor Signature: _______________________________


Print Instructor Name: ______________________________
Date: ________________

1/22/11 11:21 AM

90-1011_ACLS_Part5_Appendix_A.indd 125

ACLS Megacode Case 3: Tachycardia


(VT)Cardioversion
(Tachycardia VF/Pulseless VT PEA
ROSC)
Out-of-Hospital Scenario
You are a paramedic and arrive on the scene to find a 65-year-old man complaining of palpitations and chest discomfort. He is cold, clammy, and diaphoretic. He
states that he feels as if he is about to faint. EMS responders have placed oxygen
and obtained vital signs: HR 160/min, BP 70 mm Hg/palpable, RR 16/min, and O2
saturation 96%.

Case Development
Initial
Assessment

Tachycardia
Algorithm

This man may have an ACS. The case focus, however, is


initially a tachycardia. The student should begin to take a history, start an IV, and attach monitor electrodes or pads to the
patient. Nitroglycerin at this point would be inappropriate and
contraindicated because of hypotension. Aspirin may be given.
The student is presented with tachycardia and needs to follow
the Tachycardia Algorithm. A critical action is noting that
symptoms are due to tachycardia that requires management.
The monitor shows a wide-complex tachycardia: VT. The
student should recognize that the patient is symptomatic and
prepare for immediate cardioversion. Consideration of drug
therapy should not delay cardioversion.

125

12/22/10 5:25 PM

Cardiac
Arrest
Algorithm
(VF/Pulseless
VT)

The patient should suddenly develop VF. The student will


follow the VF/pulseless VT pathway of the Cardiac Arrest
Algorithm. Now the student team leader will assign team
functions and monitor for high-quality CPR. The case should
continue through safe defibrillation, administration of a
vasopressor, and consideration of an antiarrhythmic drug.

Cardiac
Arrest
Algorithm
(PEA)

The patient is now in PEA. The student continues to monitor


high-quality CPR and follows the PEA pathway of the Cardiac
Arrest Algorithm. Although the patient is likely in cardiogenic
shock, the student should state a differential diagnosis of PEA.

Immediate
PostCardiac
Arrest Care
Algorithm

The team continues high-quality chest compressions, the


patient has ROSC, and the Immediate PostCardiac Arrest
Care Algorithm is initiated.

Megacode Testing Checklist 3


Tachycardia VF/Pulseless VT PEA ROSC
Student Name: __________________________________________ Test Date: ___________________
if done
correctly

Critical Performance Steps


Team Leader
Ensures high-quality CPR at all times
Assigns team member roles
Ensures that team members perform well

Tachycardia Management
Starts oxygen if needed, places monitor, starts IV
Places monitor leads in proper position
Recognizes unstable tachycardia
Recognizes symptoms due to tachycardia
Performs immediate synchronized cardioversion

VF/Pulseless VT Management
Recognizes VF
Clears before ANALYZE and SHOCK
Immediately resumes CPR after shocks
Appropriate airway management
Appropriate cycles of drugrhythm check/shockCPR
Administers appropriate drug(s) and doses

PEA Management
Recognizes PEA
Verbalizes potential reversible causes of PEA/asystole (Hs and Ts)
Administers appropriate drug(s) and doses
Immediately resumes CPR after rhythm and pulse checks

PostCardiac Arrest Care


Identifies ROSC
Ensures BP and 12-lead ECG are performed, O2 saturation is monitored, verbalizes need
for endotracheal intubation and waveform capnography, and orders laboratory tests
Considers therapeutic hypothermia

STOP TEST
Test Results

Circle P or NR to Indicate Pass or Needs Remediation:

Instructor signature affirms that


skills tests were done according
to AHA Guidelines. Save this
sheet with course record.

NR

Instructor Signature: _______________________________


Print Instructor Name: ______________________________
Date: ________________

90-1011_ACLS_Part5_Appendix_A.indd 126

ACLS Megacode Case 4: Tachycardia


(SVT)Drug Therapy
(Tachycardia VF/Pulseless VT PEA
ROSC)
In-Hospital Scenario
In the ED, you are evaluating a 65-year-old man complaining of palpitations. He is
in no distress. He has a history of coronary artery disease and had a stent placed
in the past. Otherwise, he is healthy, with no other medical problems. His vital
signs are HR 170/min, BP 110/70 mm Hg, RR 16/min, and O2 saturation 95%.

Case Development
Initial
Assessment

Tachycardia
Algorithm

This man has mild symptoms and is hemodynamically stable.


The case focus, however, is initially a tachycardia. The student
should begin to take a history, start an IV, and place a monitor.
Nitroglycerin at this point would be inappropriate because of
the rapid tachycardia. Aspirin may be given.
The student is presented with tachycardia and needs to
follow the Tachycardia Algorithm. A critical action is noting
that the patient is asymptomatic except for palpitations and
is hemodynamically stable. He does not require immediate
cardioversion. Note or show that he has a regular narrowcomplex tachycardia. The team leader should follow the
algorithm and indicate vagal maneuvers and initial therapy
with adenosine.

Cardiac
Arrest
Algorithm
(VF/Pulseless
VT)

During this treatment, the patient suddenly develops VF. The


student will follow the VF/pulseless VT pathway of the Cardiac
Arrest Algorithm. Now the student team leader will assign team
functions and monitor for high-quality CPR. The case should
continue through safe defibrillation, administration of a vasopressor, and consideration of an antiarrhythmic drug.

Cardiac
Arrest
Algorithm
(PEA)

After a shock, the patient is now in PEA. The student continues to monitor high-quality CPR and follow the PEA pathway
of the Cardiac Arrest Algorithm. Although the patient is likely
in cardiogenic shock, the student should verbalize a differential diagnosis of PEA.

Immediate
PostCardiac
Arrest Care
Algorithm

The team continues high-quality chest compressions, the


patient has ROSC, and the Immediate PostCardiac Arrest
Care Algorithm is initiated.

Megacode Testing Checklist 4


Tachycardia VF/Pulseless VT PEA ROSC
Student Name: __________________________________________ Test Date: ___________________
if done
correctly

Critical Performance Steps


Team Leader
Ensures high-quality CPR at all times
Assigns team member roles
Ensures that team members perform well

Tachycardia Management
Starts oxygen if needed, places monitor, starts IV
Places monitor leads in proper position
Recognizes tachycardia (specific diagnosis)
Recognizes no symptoms due to tachycardia
Attempts vagal maneuvers
Gives appropriate initial drug therapy

VF/Pulseless VT Management
Recognizes VF
Clears before ANALYZE and SHOCK
Immediately resumes CPR after shocks
Appropriate airway management
Appropriate cycles of drugrhythm check/shockCPR
Administers appropriate drug(s) and doses

PEA Management
Recognizes PEA
Verbalizes potential reversible causes of PEA/asystole (Hs and Ts)
Administers appropriate drug(s) and doses
Immediately resumes CPR after rhythm and pulse checks

PostCardiac Arrest Care


Identifies ROSC
Ensures BP and 12-lead ECG are performed, O2 saturation is monitored, verbalizes need
for endotracheal intubation and waveform capnography, and orders laboratory tests
Considers therapeutic hypothermia

STOP TEST
Test Results

Circle P or NR to Indicate Pass or Needs Remediation:

Instructor signature affirms that


skills tests were done according
to AHA Guidelines. Save this
sheet with course record.

NR

Instructor Signature: _______________________________


Print Instructor Name: ______________________________
Date: ________________

12/22/10 5:25 PM

90-1011_ACLS_Part5_Appendix_A.indd 127

ACLS Megacode Case 5: Tachycardia


(SVT)Cardioversion
(Tachycardia VF/Pulseless VT PEA
ROSC)
Out-of-Hospital Scenario
You arrive on the scene to find a male, age 58 years, lying in his bed. The patient
says he began having what he thought was indigestion about 4 hours earlier, but
the chest discomfort suddenly became worse about 30 minutes ago while at rest,
and he now complains of palpitations. The patient is pale, diaphoretic, and appears
in distress. His BP is 136/92 mm Hg, his heart rate is 184/min and regular, and his
RR is 16/min.

Case Development
Initial
Assessment
Tachycardia
Algorithm

The EMS crew should quickly obtain a history (nonsignificant


and no allergies) and investigate the chief complaint. The crew
should place the patient on a pulse oximeter (Spo2 = 93%) and
an ECG monitor (narrow-complex tachycardia).
The crew should prepare for immediate synchronized cardioversion. It is reasonable for the crew to place the patient on
supplemental oxygen at 4 L/min by nasal cannula, ask the
patient to chew 2 to 4 baby aspirins, and administer a sublingual dose of nitroglycerin (after verifying the absence of erectile dysfunction medication use). Before cardioversion can
be performed, the patient has what appears to be a grand
mal seizure that lasts for about 10 seconds. Once the seizure
subsides, the patient appears unconscious.

1/22/11 11:21 AM

Cardiac
Arrest
Algorithm
(VF/Pulseless
VT)

ECG rhythm assessment reveals VF. The students will follow


the VF/pulseless VT pathway of the Cardiac Arrest Algorithm.
The team leader should check patient responsiveness and
verify that the lead wires were not disconnected during the
seizure. Upon confirming pulselessness, the team leader
should monitor the CPR performance of the team members.
The case should continue through safe defibrillation and
vasopressor administration.

Cardiac
Arrest
Algorithm
(PEA)

After 2 defibrillation attempts and vasopressor administration, the patient develops PEA. The students will follow the
PEA pathway of the Cardiac Arrest Algorithm. The team leader
should continue to monitor the quality of the CPR performance.
The team leader should order the administration of another dose
of a vasopressor and recite the possible causes of PEA.

Immediate
PostCardiac
Arrest Care
Algorithm

The team continues high-quality chest compressions, the


patient has ROSC, and the Immediate PostCardiac Arrest
Care Algorithm is initiated.

Megacode Testing Checklist 5


Tachycardia VF/Pulseless VT PEA ROSC
Student Name: __________________________________________ Test Date: ___________________
if done
correctly

Critical Performance Steps


Team Leader
Ensures high-quality CPR at all times
Assigns team member roles
Ensures that team members perform well

Tachycardia Management
Starts oxygen if needed, places monitor, starts IV
Places monitor leads in proper position
Recognizes unstable tachycardia
Recognizes symptoms due to tachycardia
Performs immediate synchronized cardioversion

VF/Pulseless VT Management
Recognizes VF
Clears before ANALYZE and SHOCK
Immediately resumes CPR after shocks
Appropriate airway management
Appropriate cycles of drugrhythm check/shockCPR
Administers appropriate drug(s) and doses

PEA Management
Recognizes PEA
Verbalizes potential reversible causes of PEA/asystole (Hs and Ts)
Administers appropriate drug(s) and doses
Immediately resumes CPR after rhythm and pulse checks

Post-Cardiac Arrest Care


Identifies ROSC
Ensures BP and 12-lead ECG are performed, O2 saturation is monitored, verbalizes need
for endotracheal intubation and waveform capnography, and orders laboratory tests
Considers therapeutic hypothermia

STOP TEST
Test Results

Circle P or NR to Indicate Pass or Needs Remediation:

Instructor signature affirms that


skills tests were done according
to AHA Guidelines. Save this
sheet with course record.

NR

Instructor Signature: _______________________________


Print Instructor Name: ______________________________
Date: ________________

128

90-1011_ACLS_Part5_Appendix_A.indd 128

ACLS Megacode Case 6: Tachycardia


(VT)Drug Therapy
(Tachycardia VF/Pulseless VT PEA
ROSC)
In-Hospital Scenario
A clinic nurse delivers a male, age 65 years, to the inpatient unit as a direct
hospital admission from the medicine clinic in a wheelchair. The patient developed
sudden palpitations that began while driving home and came straight to his
doctors office in the hospitals outpatient clinic. The patient appears stable with
no distress. His BP is 148/88 mm Hg, his heart rate is 160/min and regular, and
his RR is 12/min.

Case Development
Initial
Assessment

The team leader should quickly obtain a history (hypertension


and no allergies) and investigate the chief complaint. Team
members should place the patient on a pulse oximeter
(Spo2 = 97%) and an ECG monitor (regular, wide-complex
tachycardia).

Tachycardia
Algorithm

The team leader should direct team members to assess the


patients hemodynamics for stability, get a 12-lead ECG, and
prepare for drug therapy. During 12-lead ECG acquisition, the
patient states that he feels like he needs to vomit and then
loses consciousness.

Cardiac
Arrest
Algorithm
(VF/Pulseless
VT)

ECG rhythm assessment reveals VF. The students will follow


the VF/pulseless VT pathway of the Cardiac Arrest Algorithm.
The team leader should check patient responsiveness, and
then monitor the CPR performance of the team members.
The case should continue through safe defibrillation and
vasopressor administration.

12/22/10 5:26 PM

Cardiac
Arrest
Algorithm
(PEA)

After 2 defibrillation attempts and vasopressor administration,


the patient develops PEA. The students will follow the PEA
pathway of the Cardiac Arrest Algorithm. The team leader
should continue to monitor the quality of the CPR performance. The team leader should order the administration of
another dose of a vasopressor and recite the possible causes
of PEA.

Immediate
PostCardiac
Arrest Care
Algorithm

The team continues high-quality chest compressions, the


patient has ROSC, and the Immediate PostCardiac Arrest
Care Algorithm is initiated.

Megacode Testing Checklist 6


Tachycardia VF/Pulseless VT PEA ROSC
Student Name: __________________________________________ Test Date: ___________________
if done
correctly

Critical Performance Steps


Team Leader
Ensures high-quality CPR at all times
Assigns team member roles
Ensures that team members perform well

Tachycardia Management
Starts oxygen if needed, places monitor, starts IV
Places monitor leads in proper position
Recognizes tachycardia (specific diagnosis)
Recognizes no symptoms due to tachycardia
Attempts vagal maneuvers
Gives appropriate initial drug therapy

VF/Pulseless VT Management
Recognizes VF
Clears before ANALYZE and SHOCK
Immediately resumes CPR after shocks
Appropriate airway management
Appropriate cycles of drugrhythm check/shockCPR
Administers appropriate drug(s) and doses

PEA Management
Recognizes PEA
Verbalizes potential reversible causes of PEA/asystole (Hs and Ts)
Administers appropriate drug(s) and doses
Immediately resumes CPR after rhythm and pulse checks

PostCardiac Arrest Care


Identifies ROSC
Ensures BP and 12-lead ECG are performed, O2 saturation is monitored, verbalizes need
for endotracheal intubation and waveform capnography, and orders laboratory tests
Considers therapeutic hypothermia

STOP TEST
Test Results

Circle P or NR to Indicate Pass or Needs Remediation:

Instructor signature affirms that


skills tests were done according
to AHA Guidelines. Save this
sheet with course record.

NR

Instructor Signature: _______________________________


Print Instructor Name: ______________________________
Date: ________________