You are a healthcare provider working in a surgical recovery unit. One of your patients is a 63-year-old male who is 4-hrs post-op from an unremarkable ACL reconstruction surgery. They are receiving supplemental oxygen via NC at 6 L/min. Upon entering their recovery room, you find the patient unconscious with the NC on the floor beside the bed. A rapid initial assessment reveals the following:

Vital signs

Pulse rate: 25/min
Blood pressure: Unobtainable
Respiratory rate: 6/min
Temperature: Not taken

Physiological systems

Integumentary: Warm, diaphoretic
Cardiovascular: Faintly palpable central pulses bilaterally
Respiratory: Labored, shallow
Neurological: Unresponsive

1. A rhythm check reveals sinus bradycardia at 25/min. You have activated the Code Team. What are your initial actions?*

Secure the airway and begin supported ventilation via BVM

Start CPR (five cycles)

Ensure adequate IV access and administer epinephrine 1.0 mg IV/IO

Consider synchronized cardioversion

You secure the airway and begin supported ventilation via BVM. In addition to respiratory support, you recognize the need to ensure adequate IV access and monitor cardiovascular changes.

2. What is the correct treatment order in the given scenario?*

Monitor ECG and vitals, assist breathing, administer oxygen, ensure adequate IV access

Ensure adequate IV access, administer oxygen, monitor ECG and vitals, assist breathing

Ensure adequate IV access, monitor ECG and vitals, administer oxygen, assist breathing

Assist breathing, administer oxygen, monitor ECG and vitals, ensure adequate IV access

Adequate IV access has been ensured and a rhythm check reveals unchanged sinus bradycardia. The patient is progressively deteriorating, and signs of inadequate perfusion become rapidly apparent.

3. What are your next actions?*

Start CPR (five cycles)

Continue monitoring the ECG and observing vitals

Administer adenosine 6.0 mg IVP

Administer atropine 1.0 mg IVP

Atropine 1.0 mg IVP is administered with no change in condition. A rhythm check reveals unchanged sinus bradycardia. The HR is unchanged at 25/min.

4. What are your next actions?*

Attempt transcutaneous pacing (TCP)

Administer atropine 1.0 mg IVP

Administer adenosine 1.0 mg IVP

Administer lidocaine 0.75 mg/kg IVP

TCP is attempted at a rate of 60/min. After 45 seconds, the attempt to capture is unsuccessful and there is no change in condition. You consider additional pharmacological intervention at this time.

5. What two drugs should you consider in your next actions?*

Dopamine and epinephrine

Lidocaine and dopamine

Dopamine and Amiodarone

Epinephrine and Amiodarone

An epinephrine infusion is prepared and transvenous pacing is considered. During this time, a rhythm check reveals a conversion from sinus bradycardia to asystole.

6. What should you verify to confirm if the rhythm is truly asystolic?*

All the above

Loose or unconnected ECG leads

Attempt to palpate one of the peripheral pulses

ECG signal gain

True asystole has been confirmed.

7. What are your next actions?*

Administer atropine 1.0 mg IVP and re-attempt transcutaneous pacing

Start CPR (five cycles) and administer epinephrine 1.0 mg IVP

Intubate and administer epinephrine 1.0 mg IVP

Intubate and deliver a single unsynchronized shock of 120 J

The first cycle of CPR is completed and epinephrine 1.0 mg IVP is administered. Following five cycles of CPR, a rhythm check reveals a conversion from asystole to ventricular fibrillation. The patient remains unresponsive.

8. What are your next steps?*

Deliver three stacked shocks with brief pauses between each defibrillation

Administer epinephrine 1.0 mg IVP

Resume CPR (five cycles)

Deliver a single unsynchronized shock of 120 J

A single shock of 120 J is delivered, and CPR is resumed for another five cycles. Following five cycles of CPR, a rhythm check that reveals unchanged ventricular fibrillation.

9. What are your next actions?*

Resume CPR (five cycles

Deliver a single unsynchronized shock of 200 J

Administer atropine 0.5 mg IVP

Administer epinephrine 1.0 mg IVP

A single unsynchronized shock of 200 J is delivered, and CPR is resumed for another five cycles.

10. During the first cycle of CPR, what are your next actions?*

Transport to the intensive care unit or seek expert consultation

Administer lidocaine or another antiarrhythmic drug

Administer epinephrine 1.0 mg IVP without interrupting chest compressions

Deliver a single unsynchronized shock at a higher setting (200-360 J)

Epinephrine is administered and the remaining cycles of CPR are performed. Following five cycles of CPR, a rhythm check reveals unchanged ventricular fibrillation. A single unsynchronized shock of 300 J is delivered, CPR is resumed for another five cycles, and amiodarone 300 mg IVP is administered. Following five cycles of CPR, a rhythm check reveals unchanged ventricular fibrillation.

11. What are your next actions?*

Deliver a single unsynchronized shock of 360 J

Administer magnesium sulfate 2.0-4.0 g IV

Administer atropine 0.5 mg IV

Administer amiodarone 150 mg IV

A single unsynchronized shock of 360 J is delivered, and CPR is resumed for another five cycles. Following five cycles of CPR, a rhythm check reveals a conversion from ventricular fibrillation to sinus rhythm. The patient now has a palpable pulse. HR 71/min, BP 110/70, RR 11/min. Maintenance antiarrhythmic therapy is considered.

12. What drug is the ideal choice for you to administer via infusion in the given scenario?*

Magnesium sulfate

Epinephrine

Amiodarone

Lidocaine

ACLS Megacode 3 In-Hospital

Hurry, don’t let time run out!