Emergency Department ACLS Airway Management Megacode: The Best Strategies for Saving Lives

The Airway Management section of the AHA Emergency Department (ED) ACLS algorithm is one of the most important, and it can be difficult to know what to do when someone is choking or has another airway emergency.

We will provide you with a step-by-step guide on how to manage an airway emergency, as well as some tips for avoiding common mistakes.

In this blog post, we will discuss the best strategies for saving lives in the Emergency Department setting.

Table of Contents

Adult ED Respiratory Arrest Megacode Scenario

The following is a scenario in which you would use the ED adult respiratory arrest Megacode:

You are working the day shift in an emergency department. You are asked to see a new patient in your bay. A bystander called 911 after finding a man unconscious in a ditch.

Demonstrate what you would do next

Initial Impression

The man is unconscious with mildly cyanotic lips. The paramedics placed a nasopharyngeal airway and have been trying to ventilate but have had difficulty. The paramedics also noted that there were drug paraphernalia on the scene and an empty syringe.

Primary Assessment Survey (A, B, C, D, E)

Airway: There is a nasopharyngeal airway present. It is being ventilated by paramedics on arrival and taken over by respiratory. The flow through the trachea is impaired by the tongue.

Breathing: Oxygenation is showing 75% with bag valve mask ventilation. The man has no spontaneous breaths.

Circulation: Blood pressure is 100/60, heart rate is 140/min, the rhythm is narrow-complex rapid tachycardia, and the pulse is present but weak.

Disability: Unresponsive to any stimuli. Pupils are dilated bilaterally at 7 mm (commonly misused drugs that dilate pupils are amphetamines, bath salts, benzodiazepines, cocaine, crystal meth, ecstasy, LSD)

Exposure: Numerous track marks are located on the man’s arms.

Change in Condition

After assessment of the initial impression and primary assessment, the man’s oxygen continues to decline and his heart rate increases.

What are your next actions?

  1. Check responsiveness: Tap the shoulders and shout, “Are you okay?” Found unresponsive during the primary survey, move on to the next step.
  2. Activate the emergency response system. Shout for backup and announce what room you are in.
  3. Check for breathing: Look for visible chest rising and falling. No spontaneous breathing was present.
  4. Check for a pulse: Place your fingers on the inside of the patient’s neck, just below the angle of the jaw. You will palpate the carotid pulse for no more than 10 seconds. Pulse is present but weak.

What are your next actions?

  1. Pulse is present so we will not begin CPR starting with compressions.
  2. The nasopharyngeal airway is not working effectively. It may be time to switch to endotracheal intubation.
  3. Administer oxygen. After endotracheal intubation, the oxygen saturation is 99% with positive color changes on the CO2 Detector. Waveform capnography is the gold standard.
  4. Perform bag-mask ventilation for 1 minute effectively at the proper rate (1 breath every 6 seconds), speed (over 1 second), and volume (about half a bag) until the ventilator arrives.

The man is stable and oxygen saturation is normal. What are your next steps?

Secondary Survey (SAMPLE)

Signs and Symptoms: Signs and symptoms are improving, heart rate has decreased to 90 bpm normal sinus rhythm; however, no spontaneous breathing is noted.

Allergies: Unknown if there are any allergies.

Medications: Unknown if there are any medications.

Past Medical History: Unknown if there is any past medical history.

Last Meal, Liquid Consumed: Unknown when the last meal and liquid were consumed.

Events: No events were noted outside of what was discussed with the paramedic team.

What are your text interventions?

  • Drug urinalysis
  • Labs
  • Fluids
  • Naloxone trial with escalating doses
  • Transfer to a higher level of care – Intensive Care Unit

You will begin the transfer to the unit. Your scenario has concluded.


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