Megacode Teaching (ACLS Algorithms)


Here it is, the grand-daddy of them all: the
megacode. And in this megacode scenario, a combined
knowledge of procedures and treatments from all of the ACLS algorithms will be necessary. In our scenario you’ll be the ACLS team
leader with a 45 year old male patient who appears to be unresponsive. A witness states that the person had a choking
emergency where an object was removed. The patient was brought to advanced medical
care because he was having a difficult time breathing afterwards. As you begin to talk to the patient he stops
responding to all questions. Remember to use basic life support before
we go to advanced life support. The patient should be checked for responsiveness. If unresponsive a code should be called. Then, you would check for a pulse and breathing. In our scenario the patient is in respiratory
arrest. A basic airway, like an OPA or an NPA, should
be inserted. Then, we’re gonna start rescue breathing
with a bag valve mask at 15 liters of oxygen. We’re gonna deliver that at 1 breath every
5 seconds. Vitals should be taken and an ECG monitor
would be attached. The rhythm on the ECG is a normal sinus with
PVC’s (or preventricular contractions) at 78 beats per minute but it’s irregular. Knowing that a rhythm with multiple and frequent
PVC’s could deteriorate quickly, we start an IV in order to administer IV saline, and/or
drugs. After a little time the monitor is no longer
detecting a pulse. And on the monitor it looks like ventricular
fibrillation. We check for a pulse physically, to find that
the patient has no pulse. It’s now time to start CPR with cycles of
30 compressions to 2 breaths. The defib pads are applied while CPR is in
progress. And when the pads are in place the leader
will tell everyone to stand clear while the rhythm is analyzed. V-Fib is still present on the ECG. With a monophasic defibrillator, we’re going
to go ahead and charge to 360 joules to shock our patient. A quick look at the monitor shows that the
patient is still in v-fib and CPR is continued. Since we have V-Fib, the first shock has been
given, and an IV is established, it’s now time to go with our first medication. Epinephrine 1mg of 1:10,000 while CPR is still
in progress. This helps to circulate the medication throughout
the body and especially get it to the heart. Remember that CPR is not stopped when drugs
are administered. Now after 2 minutes of CPR, it’s important
that the compressor switches with the defibrillator. This helps to make sure that we have a fresh
compressor who will be able to give us consistent compressions at a rate between 100-120 times
per minute at the appropriate depth. Before resuming CPR a look at the monitor
though reveals persistent V-Fib. Another shock with a monophasic defibrillator
is given at 360 joules. This time when the monitor is checked, and
our sinus rhythm is evident. A pulse should checked to make sure that we
have a perfusing rhythm. In our scenario, the patient has a pulse,
but he’s still not breathing. Breaths should continue at 1 breath every
5 seconds. The leader needs to call for a set of vitals
to determine the next treatment. We find a blood pressure of 88 systolic when
we have achieved ROSC, which means “return of spontaneous circulation,” after a cardiac
arrest, a systolic pressure below 90 requires a 1-2 liter bolus of normal saline to get
the blood pressure up. Since our patient is still in respiratory
arrest, we need to get an ET tube in place and monitor capnography. With capnography we can verify tube placement
when a persistent capnographic waveform is present at 35-40 millimeters of mercury. Capnography measures the concentration of
carbon dioxide in exhaled air at the end of the expiration. The CO2 that is detected by capnography in
exhaled air is produced in the body and delivered to the lungs by circulating blood. This is why it also helps us to know when
compressions are being done well by producing circulation through the body that gets that
CO2 out to the lungs to be exhaled. That gives us a chance to know that our CPR
is being quite effective or when the body is actually starting to biologically come
to, and we see that exchange of gases of oxygen and CO2. Our megacode scenario will end with getting
a 12 lead ECG, another set of vitals and considering why this patient went into cardiac arrest
so that this patient’s life can be saved by correcting those underlying problems.

6 thoughts on “Megacode Teaching (ACLS Algorithms)”

  1. For all of you that are watching this:
    According to AHA guidelines you DO NOT check for pulse or the monitor after defibrillation!!! You resume chest compressions imidiatley!

  2. You're going to get on the radio and call a code after checking responsiveness but BEFORE checking for a pulse?? Why? You don't need additional resources for an unresponsive.

  3. Super out of date, stay on the chest for more than 50% of the damn time and your ROSC percentage would increase significantly

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