You are a healthcare provider working in the cardiac care unit of your hospital. A 51-year-old female who underwent percutaneous coronary intervention 4 hrs ago is reporting severe nausea and light-headedness. A rapid initial assessment reveals the following:

Vital signs

Pulse rate: 160/min
Blood pressure: 127/80
Respiratory rate: 22/min
Temperature: 37.2 °C

Physiological systems

Integumentary: Warm, dry
Cardiovascular: Strong peripheral pulses bilaterally
Respiratory: CTA bilaterally
Neurological: Alert

1. You ensure adequate IV access and perform a 12-lead ECG, which reveals narrow-complex supraventricular tachycardia at 160/min. You determine the arrythmia to be stable given the absence of hypotension, changes in consciousness, shock, or chest pain. What are your initial actions?*

Perform immediate synchronized cardioversion

Administer adenosine 6.0 mg IVP

Prepare for the placement of an advanced airway

Attempt vagal maneuvers

Vagal maneuvers are attempted with no change in condition. A rhythm check reveals unchanged narrow complex supraventricular tachycardia.

2. What are your next actions?*

Administer adenosine 6.0 mg IVP

Administer amiodarone 150 mg IV infusion over 8 min and repeat as needed

Administer adenosine 12.0 mg IVP

Continue attempting vagal maneuvers until conversion to sinus rhythm occurs

Adenosine 6.0 mg IVP is administered with no change in condition. A second dose of adenosine at 12.0 mg IVP is given, following which the patient develops severe central chest pain and. BP is unobtainable and HR increases to 225/min. Radial pulses become faint and weak bilaterally. The patient is no longer responding to verbal commands.

3. What are your next actions?*

Place an advanced airway and begin assisted ventilation

Deliver a single unsynchronized shock of 120 J

The patient is now unstable; perform immediate synchronized cardioversion

Administer a third dose of adenosine 12.0 mg IVP

Immediate synchronized cardioversion is performed with no change in condition, and the patient continues to deteriorate. The patient loses consciousness and peripheral pulses are no longer palpable bilaterally. A rhythm check reveals a conversion from narrow complex supraventricular tachycardia to ventricular tachycardia.

4. What are your next actions?*

Place an advanced airway and begin assisted ventilation

Deliver a single unsynchronized shock of 120 J

Administer epinephrine 1.0 mg IVP

Start CPR (five cycles)

A single unsynchronized shock of 120 J is delivered, and CPR is started. Following five cycles of CPR, a rhythm check reveals unchanged ventricular tachycardia. A single unsynchronized shock of 200 J is delivered, and CPR is resumed for another five cycles.

5. What are your next actions?*

Administer dopamine 20 mcg/kg/min IV fluid bolus

Pharmacological intervention is not indicated at this time

Administer epinephrine 1.0 mg IVP during the first cycle of CPR

Administer epinephrine 0.5 mg IVP during the last cycle of CPR

Five cycles of CPR are performed, and you have administered epinephrine 1.0 mg IVP with no change in condition. You prepare to deliver a third shock.

6. Assuming a biphasic defibrillator is being used, what setting will you use for the third shock?*

300 J

220 J

120 J

180 J

A single unsynchronized shock of 300 J is given, and CPR is resumed for another five cycles. You have decided to administer amiodarone during the first cycle of CPR.

7. What dose should you be administering?*

300 mg IVP followed by a second dose of 150 mg IVP if no effect is noted

200 mg IVP

400 mg IV infusion over 45 min

150 mg IVP

Amiodarone 300 mg IVP is administered, and CPR is resumed for another five cycles. Following five cycles of CPR, a rhythm check reveals conversion from ventricular tachycardia to sinus rhythm. Return of spontaneous circulation is noted. During the post-cardiac arrest phase, a short run of ventricular tachycardia is observed, and an amiodarone infusion is started as part of the post-resuscitation care.

8. What is the maximum cumulative dose of amiodarone that can be administered in a 24-hour period following cardiac arrest?*

3.7 g

2.2 g

1.8 g

4.1 g

Antiarrhythmic drugs such as lidocaine can be used instead of amiodarone to promote the return of spontaneous circulation during cardiac arrest resulting from ventricular fibrillation or pulseless ventricular tachycardia.

9. What is the appropriate dosage for the administration of lidocaine in the given scenario?*

0.5-1.0 mg/kg IVP

1.5 mg/kg IV, then 0.75 mg/kg IV

1.0-1.5 mg/kg IV, then 0.5-0.75 mg/kg IV

2.5 mg/kg rapid IVP

The patient has been stabilized, but during a post-cardiac arrest assessment, fails to respond to verbal commands. They are subsequently moved to the intensive care unit for observation.

10. What are your next actions?*

Obtain a metabolic panel

Monitor oxygen saturation

Induce therapeutic hypothermia

Monitor waveform capnography

ACLS Megacode 5 In-Hospital

Hurry, don’t let time run out!