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

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1 ACLS Megacode Case 1: Sinus Bradycardia (Bradycardia VF/Pulseless VT Asystole 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 O 2 saturation 93%. No other assessment or management has been performed. Now you assume the role of team leader. Bradycardia (Asystole) Post Care 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 woman s vital signs (severe bradycardia and hypotension contraindicated). The student is presented with bradycardia and needs to follow the Bradycardia. 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). The patient suddenly develops VF. The team leader will follow the. 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. After a shock, the patient becomes asystolic. The student continues to monitor high-quality CPR and follows the asystole pathway of the. patient has ROSC, and the Post Care is initiated. Megacode Testing Checklist 1/2 Bradycardia VF/Pulseless VT Asystole ROSC Bradycardia Management Recognizes symptomatic bradycardia Administers correct dose of atropine Prepares for second-line treatment Asystole Management Recognizes asystole Verbalizes potential reversible causes of asystole/pea (H s and T s) ly resumes CPR after rhythm checks Post Care Instructor signature affirms that sheet with course record. Instructor Signature: Date: 2011 American Heart Association

2 ACLS Megacode Case 2: Mobitz Type II AV Block (Bradycardia VF/Pulseless VT Asystole 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 O 2 saturation 91%. Bradycardia (Asystole) Post Care 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 patient s vital signs (severe bradycardia and hypotension contraindicated). The student is presented with bradycardia and needs to follow the Bradycardia. 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). The patient suddenly develops VF. The team leader will follow the. 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. After a shock, the patient becomes asystolic. The student continues to monitor high-quality CPR and follows the asystole pathway of the. patient has ROSC, and the Post Care is initiated. Megacode Testing Checklist 1/2 Bradycardia VF/Pulseless VT Asystole ROSC Bradycardia Management Recognizes symptomatic bradycardia Administers correct dose of atropine Prepares for second-line treatment Asystole Management Recognizes asystole Verbalizes potential reversible causes of asystole/pea (H s and T s) ly resumes CPR after rhythm checks Post Care Instructor signature affirms that sheet with course record. Instructor Signature: Date:

3 ACLS Megacode Case 3: ( Cardioversion 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 O 2 saturation 96%. Post Care 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. 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. The patient should suddenly develop VF. The student will follow the VF/pulseless VT pathway of the. 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. The patient is now in PEA. The student continues to monitor high-quality CPR and follows the PEA pathway of the. Although the patient is likely in cardiogenic shock, the student should state a differential diagnosis of PEA. patient has ROSC, and the Post Care is initiated. Megacode Testing Checklist 3 Management Recognizes unstable tachycardia Recognizes symptoms due to tachycardia Performs immediate synchronized cardioversion ly resumes CPR after rhythm and pulse checks Post Care 125

4 ACLS Megacode Case 4: (S Drug Therapy 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 O 2 saturation 95%. Post Care 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. 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. During this treatment, the patient suddenly develops VF. The student will follow the VF/pulseless VT pathway of the. 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. After a shock, the patient is now in PEA. The student continues to monitor high-quality CPR and follow the PEA pathway of the. Although the patient is likely in cardiogenic shock, the student should verbalize a differential diagnosis of PEA. patient has ROSC, and the Post Care is initiated. Megacode Testing Checklist 4 Management Recognizes tachycardia (specific diagnosis) Recognizes no symptoms due to tachycardia Attempts vagal maneuvers Gives appropriate initial drug therapy ly resumes CPR after rhythm and pulse checks Post Care

5 ACLS Megacode Case 5: (S Cardioversion 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. Post Care 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 (Spo 2 = 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. ECG rhythm assessment reveals VF. The students will follow the VF/pulseless VT pathway of the. 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. After 2 defibrillation attempts and vasopressor administration, the patient develops PEA. The students will follow the PEA pathway of the. 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. patient has ROSC, and the Post Care is initiated. Megacode Testing Checklist 5 Management Recognizes unstable tachycardia Recognizes symptoms due to tachycardia Performs immediate synchronized cardioversion ly resumes CPR after rhythm and pulse checks Post- Care

6 128 ACLS Megacode Case 6: ( Drug Therapy 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 doctor s office in the hospital s 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. Post Care 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 (Spo 2 = 97%) and an ECG monitor (regular, wide-complex tachycardia). The team leader should direct team members to assess the patient s 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. ECG rhythm assessment reveals VF. The students will follow the VF/pulseless VT pathway of the. 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. After 2 defibrillation attempts and vasopressor administration, the patient develops PEA. The students will follow the PEA pathway of the. 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. patient has ROSC, and the Post Care is initiated. Megacode Testing Checklist 6 Management Recognizes tachycardia (specific diagnosis) Recognizes no symptoms due to tachycardia Attempts vagal maneuvers Gives appropriate initial drug therapy ly resumes CPR after rhythm and pulse checks Post Care

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