ACLS Megacode – NurseCheung.com https://nursecheung.com From "You're Not Good Enough" To "Look At Me Now!" Wed, 06 Dec 2023 15:11:37 +0000 en-US hourly 1 https://wordpress.org/?v=6.4.3 https://2hya11.p3cdn1.secureserver.net/wp-content/uploads/2023/01/nurse-cheung-logo-Logo-1000-×-1000-px-2-150x150.png ACLS Megacode – NurseCheung.com https://nursecheung.com 32 32 Out-Of-Hospital ACLS Airway Management Megacode: The Best Strategies for Saving Lives https://nursecheung.com/aclsmegacode-ooh-airwaymanagement/ Sat, 07 Jan 2023 17:14:33 +0000 https://nursecheung.com/out-of-hospital-acls-airway-management-megacode-the-best-strategies-for-saving-lives/

Table of Contents

Adult Out-Of-Hospital Respiratory Arrest Megacode Scenario

The following is a scenario in which you would use the out-of-hospital adult respiratory arrest Megacode:

You are a paramedic and arrive on the scene for a woman having an asthma attack at home.

Demonstrate what you would do next

Initial Impression

The woman is conscious and reports difficulty breathing during her evening meal. The woman begins to have respiratory distress and a decrease in mental status.

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

Airway: The airway is starting to swell. The flow through the trachea is impaired.

Breathing: Oxygenation is showing less than 50% on room air. Agonal gasps are noted.

Circulation: Blood pressure is 60/38, heart rate is 120/min, and the pulse is present but weak.

Disability: Decrease in mental status. Responsive to verbal stimulation.

Exposure: No obvious signs of trauma, bleeding, burns, markings, or medical alert bracelet.

Change in Condition

After assessment of the initial impression and primary assessment, the woman becomes unresponsive.

What are your next actions?

  1. Check responsiveness: Tap the shoulders and shout, “Are you okay?” There is no response.
  2. Activate the emergency response system. You direct the second rescuer to activate the emergency response system and get an AED.
  3. Check for breathing: Look for visible chest rising and falling. No breathing 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 decision between oropharyngeal or nasopharyngeal airway can be difficult, but there are a few things to consider when making the decision.
  3. Oropharyngeal airways are inserted into the mouth, and nasopharyngeal airways are inserted into the nose. Oropharyngeal airways are more likely to be successful the first time, but nasopharyngeal airways are less likely to cause vomiting.
  4. Administer oxygen. Oxygen saturation is less than 50%. 
  5. 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).
 

The woman is stable and oxygen saturation is rising. What are your next steps?

Secondary Survey (SAMPLE)

Signs and Symptoms: Signs and symptoms are improving; however, swelling is still present.

Allergies: The woman’s friend states she has an allergy to peanuts.

Medications: Albuterol inhaler and an epinephrine pen

Past Medical History: Asthma

Last Meal, Liquid Consumed: Last meal and liquid consumed during the asthma attack. This ordered Chinese takeout Pai Thai.

Events: No events lead up to the asthma attack.

What are your text interventions?

  • Epinephrine
  • Diphenhydramine
  • Albuterol
  • Vital signs monitoring
  • Monitor for any changes
 
 

You will begin the transfer to the nearest hospital. Your scenario has concluded.

]]> Emergency Department ACLS Airway Management Megacode: The Best Strategies for Saving Lives https://nursecheung.com/aclsmegacode-ed-airwaymanagement/ Sat, 07 Jan 2023 17:14:31 +0000 https://nursecheung.com/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.

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.

]]> Inpatient ACLS Airway Management Megacode: The Best Strategies for Saving Lives https://nursecheung.com/aclsmegacode-ip-airwaymanagement/ Sat, 07 Jan 2023 17:14:29 +0000 https://nursecheung.com/inpatient-acls-airway-management-megacode-the-best-strategies-for-saving-lives/

The Airway Management section of the AHA Inpatient 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 inpatient setting.

Adult Inpatient Respiratory Arrest Megacode Scenario

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

You are the healthcare provider taking care of a female patient with a history of diabetes in the intermediate care unit. The patient is noncompliant with medications for her asthma and heart failure and is well known by the cardiologist and pulmonologist. She has been intubated and sedated prior to coming to you.

Demonstrate what you would do next

Initial Impression

The woman is currently on CPAP at 10 as part of her heart failure treatment. She is becoming restless, short of breath, and trying to take the mask off.

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

Airway: There is a CPAP mask present. It is hard to determine if the woman’s airway is patent due to her restlessness and combativeness.

Breathing: Oxygen saturation is showing 80% with CPAP 100% oxygen. Respiratory rate is 28/min. The patient states “I can’t keep this up much longer.” Breath sounds are diminished bilaterally. Wheezing and crackles are noted upon auscultation.

Circulation: Blood pressure is 128/90, heart rate is 82/min, and the pulse is present but weak. Capillary refill is 3 seconds.

Disability: The woman is alert, oriented, and restless. She is attempting to remove the CPAP mask and eventually takes it off.

Exposure: Skin is cool to the touch.

Change in Condition

After assessment of the initial impression and primary assessment, the woman becomes unresponsive while attempting to place the mask back on and waiting for respiratory therapy/rapid response.

What are your next actions?

  1. Check responsiveness: Tap the shoulders and shout, “Are you okay?” The woman is unresponsive and doesn’t answer any stimuli.
  2. Activate the emergency response system. Shout for backup and announce what room you are in. It is perfectly acceptable to hit the code button for faster backup.
  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. Start providing oxygenation via bag valve mask with oxygen while waiting for help to arrive. 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.
  3. Consider endotracheal re-intubation due to condition deterioration. After endotracheal intubation, the oxygen saturation is 99% with positive color changes on the CO2 Detector. Waveform capnography is the gold standard.
 

The woman is stable, restless, and oxygen saturation is within normal but falling slowly due to her biting on the tube. What are your next steps?

Secondary Survey (SAMPLE)

Signs and Symptoms: Signs and symptoms are improving; however, no spontaneous breathing is noted.

Allergies: Allergic to morphine and acetaminophen

Medications: Albuterol, Metformin, and digoxin

Past Medical History: Diabetes, asthma, and congestive heart failure

Last Meal, Liquid Consumed: Unknown when the last meal and liquid were consumed as she was transferred to your unit without a full report.

Events: No events were noted outside of what was discussed.

What are your text interventions?

  • Albuterol
  • Sedation for restlessness
  • Arterial Blood Gases
  • Maybe Fluid – Depends on the Heart Failure
  • Waveform Capnography
  • Critical Care Consult
  • Transfer back to a higher level of care – Intensive Care Unit
 
 

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

]]> Out-Of-Hospital ACLS Unstable Bradycardia Megacode: How to Respond in an Emergency Situation https://nursecheung.com/alcsmegacode-ooh-unstablebradycardia/ Sat, 07 Jan 2023 17:14:28 +0000 https://nursecheung.com/out-of-hospital-acls-unstable-bradycardia-megacode-how-to-respond-in-an-emergency-situation/

In this blog post, we will discuss how to respond to an out-of-hospital ACLS unstable bradycardia megacode. This is a serious emergency situation that requires quick action.

If you are not familiar with the megacode, don’t worry! We will go over the steps that you need to take in order to provide lifesaving care for the patient.

Adult Out-Of-Hospital Unstable Bradycardia Megacode Scenario

The following is a scenario in which you would use the out-of-hospital adult unstable bradycardia Megacode:

You are a paramedic responding to a call of a person with altered mental status.

Demonstrate what you would do next upon arrival

Initial Impression

The 60-year-old male person is sitting upright on a couch. He is disoriented, pale, and diaphoretic.

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

Airway: The airway is patent. The flow through the trachea is not impaired.

Breathing: Oxygenation is showing 86% on room air. You provide oxygen 4LNC.

Circulation: Blood pressure is 80/68, heart rate is 40/min, a rhythm check shows third-degree heart block, and the pulse is present but weak.

Disability: Decrease in mental status. Responsive to painful stimulation.

Exposure: No obvious signs of trauma, bleeding, burns, markings, or medical alert bracelet.

Change in Condition

After assessment of the initial impression and primary assessment, the man becomes unresponsive.

What are your next actions?

  1. Check responsiveness: Tap the shoulders and shout, “Are you okay?” There is no response.
  2. Activate the emergency response system. You direct the second rescuer to activate the emergency response system and get an AED.
  3. Check for breathing: Look for visible chest rising and falling. Breathing is present but weak.
  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 and breathing is present so we will not begin CPR starting with compressions.
 

Unstable Bradycardia Algorithm

Identify and Treat the Underlying Cause

  1. Maintain patent airway, assist with breathing if necessary – Airway is patent and breathing is spontaneous
  2. Oxygen (if hypoxemic) – person is on 4LNC upon Primary Assessment
  3. Cardiac monitor, blood pressure, oximetry – Third Degree Heart Block, BP 80/68, 98% on 4LNC
  4. IV Access – 20 gauge in the right antecubital
  5. 12-Lead ECG if available and doesn’t delay therapy – Not readily available
  6. Consider hypoxic and toxicologic causes – Myocardial Ischemia/infarction, calcium-channel blockers, beta-blockers, digoxin, hypoxia, hyperkalemia
 

Persistent Bradyarrhthmia Causing

  • Hypotension? – YES
  • Acutely altered mental status? – YES
  • Signs of shock (low blood pressure, altered mental status, cold moist skin, weak or rapid pulse, rapid breathing, decreased urine output) – YES
  • Ischemic chest discomfort? – Wife states the man experienced chest pain prior to becoming unresponsive – YES
  • Acute heart failure (heavy breathing, suffocating sensation, struggle to breathe while lying down, tight chest, arrhythmia, cough, fluid retention, loss of consciousness)? – YES
 

Interventions

What interventions could you perform next?

  • Atropine 1mg bolus – relatively contraindicated in high-degree blocks

If atropine is not effective or contraindicated:

  • Transcutaneous pacing – YES
  • Dopamine
  • Epinephrine
 
 

You will begin the transfer to the nearest hospital. Your scenario has concluded.

]]> Emergency Department ACLS Unstable Bradycardia Megacode: How to Respond in an Emergency Situation https://nursecheung.com/aclsmegacode-ed-unstablebradycardia/ Sat, 07 Jan 2023 17:14:26 +0000 https://nursecheung.com/emergency-department-acls-unstable-bradycardia-megacode-how-to-respond-in-an-emergency-situation/

In this blog post, we will discuss how to respond to an emergency department ACLS unstable bradycardia megacode. This is a serious emergency situation that requires quick action.

If you are not familiar with the megacode, don’t worry! We will go over the steps that you need to take in order to provide lifesaving care for the patient.

Adult Emergency Department Unstable Bradycardia Megacode Scenario

The following is a scenario in which you would use the ED adult unstable bradycardia Megacode:

You are a healthcare provider working in the emergency department. You are assessing a woman with a history of syncopal episodes. She is present in the ED as she feels she is going to have another syncopal episode.

Demonstrate what you would do next

Initial Impression

The 75-year-old female is sitting upright on a stretcher. She is feeling dizzy, light-headed, weak, and faint. There are no complaints of chest pain, dyspnea, or palpitations. Overall she has been healthy with no recent changes to her medications.

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

Airway: The airway is patent. The flow through the trachea is not impaired.

Breathing: Oxygenation is showing 98% on room air.

Circulation: Blood pressure is 76/50, heart rate is 30/min, a rhythm check shows second-degree heart block Type II, and the pulse is present but weak.

Disability: The patient is oriented but drowsy. Overall alert, but responsive to verbal stimuli at times.

Exposure: No obvious signs of trauma, bleeding, burns, markings, or medical alert bracelet.

Change in Condition

After assessment of the initial impression and primary assessment, the patient’s mental status starts to deteriorate and the monitor shows a third-degree AV block.

What are your next actions?

  1. Check responsiveness: Tap the shoulders and shout, “Are you okay?” There is a slight response.
  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. Breathing is present but weak.
  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?

Pulse and breathing is present so we will not begin CPR starting with compressions.

Unstable Bradycardia Algorithm

Identify and Treat the Underlying Cause

  1. Maintain patent airway, assist with breathing if necessary – Airway is patent and breathing is spontaneous
  2. Oxygen (if hypoxemic) – The patient is not hypoxemic at this time and does not require oxygen.
  3. Cardiac monitor, blood pressure, oximetry – Third Degree Heart Block, BP 76/50, 98% on room air
  4. IV Access – 20 gauge in the left and right antecubital
  5. 12-Lead ECG if available and doesn’t delay therapy – Not readily available
  6. Consider hypoxic and toxicologic causes – Myocardial Ischemia/infarction, calcium-channel blockers, beta-blockers, digoxin, hypoxia, hyperkalemia
 

Persistent Bradyarrhthmia Causing

  • Hypotension? – YES
  • Acutely altered mental status? – YES
  • Signs of shock (low blood pressure, altered mental status, cold moist skin, weak or rapid pulse, rapid breathing, decreased urine output) – YES
  • Ischemic chest discomfort? – Unknown at this time but declined on previous assessment
  • Acute heart failure (heavy breathing, suffocating sensation, struggle to breathe while lying down, tight chest, arrhythmia, cough, fluid retention, loss of consciousness)? – YES
 

Interventions

What interventions could you perform next?

  • Atropine 1mg bolus – relatively contraindicated in high-degree blocks

If atropine is not effective or contraindicated:

  • Transcutaneous pacing – YES
  • Dopamine
  • Epinephrine
  • Labs – electrolytes and cardiac biomarkers
  • Urinalysis
  • Fluids
  • Chest x-ray
  • Cardiac Consultation
  • Transfer to a higher level of care
 
 

You will begin the transfer to a higher level of care. Your scenario has concluded.

]]> Inpatient ACLS Unstable Bradycardia Megacode: How to Respond in an Emergency Situation https://nursecheung.com/aclsmegacode-ip-unstablebradycardia/ Sat, 07 Jan 2023 17:14:24 +0000 https://nursecheung.com/inpatient-acls-unstable-bradycardia-megacode-how-to-respond-in-an-emergency-situation/

In this blog post, we will discuss how to respond to an inpatient ACLS unstable bradycardia megacode. This is a serious emergency situation that requires quick action.

If you are not familiar with the megacode, don’t worry! We will go over the steps that you need to take in order to provide lifesaving care for the patient.

Adult Inpatient Unstable Bradycardia Megacode Scenario

The following is a scenario in which you would use the inpatient adult unstable bradycardia Megacode:

You are a healthcare provider working in the cardiac telemetry observation unit. You are performing your morning patient assessment when you note that the monitor is showing bradycardia.

Demonstrate what you would do next

Initial Impression

The 45-year-old male is sitting upright on the hospital bed. He is feeling cold and clammy. There are no complaints of chest pain, dyspnea, or palpitations. Overall he has been healthy with no recent changes to his medications.

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

Airway: The airway is patent. The flow through the trachea is not impaired.

Breathing: Oxygenation is showing 98% on 2LNC.

Circulation: Blood pressure is 90/50, heart rate is 30/min, a rhythm check shows sinus bradycardia, and the pulse is present but weak.

Disability: The patient is alert and oriented.

Exposure: No obvious signs of trauma, bleeding, burns, markings, or medical alert bracelet.

Change in Condition

After assessment of the initial impression and primary assessment, the patient states he is having some chest discomfort and his extremities feel cool to the touch.

What are your next actions?

  1. Check responsiveness: Tap the shoulders and shout, “Are you okay?” This step is not necessary as the patient is awake, alert, and oriented.
  2. Activate the emergency response system. Call your charge nurse, call rapid response, and place a page out to the doctor.
  3. Check for breathing: Look for visible chest rising and falling. Breathing is present but slightly weak.
  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?

Pulse and breathing is present so we will not begin CPR starting with compressions.

Unstable Bradycardia Algorithm

Identify and Treat the Underlying Cause

  1. Maintain patent airway, assist with breathing if necessary – Airway is patent and breathing is spontaneous
  2. Oxygen (if hypoxemic) – The patient is not hypoxemic at this time and already has 2LNC on.
  3. Cardiac monitor, blood pressure, oximetry – Sinus Bradycardia, BP 90/50 (confirmed this is low for the patient), 98% on 2LNC
  4. IV Access – 20 gauge in the left and right antecubital
  5. 12-Lead ECG if available and doesn’t delay therapy – Not readily available
  6. Consider hypoxic and toxicologic causes – Myocardial Ischemia/infarction, calcium-channel blockers, beta-blockers, digoxin, hypoxia, hyperkalemia
 

Persistent Bradyarrhthmia Causing

  • Hypotension? – YES
  • Acutely altered mental status? – No
  • Signs of shock (low blood pressure, altered mental status, cold moist skin, weak or rapid pulse, rapid breathing, decreased urine output) – YES
  • Ischemic chest discomfort? – YES
  • Acute heart failure (heavy breathing, suffocating sensation, struggle to breathe while lying down, tight chest, arrhythmia, cough, fluid retention, loss of consciousness)? – YES
 

Interventions

What interventions could you perform next?

  • Atropine 1mg bolus – Atropine was successful

If atropine was not effective or contraindicated:

  • Transcutaneous pacing
  • Dopamine
  • Epinephrine
  • Labs – electrolytes and cardiac biomarkers
  • Urinalysis
  • Fluids
  • Chest x-ray
  • Cardiac Consultation
  • Transfer to a higher level of care – Cardiac or Medical PCU
 
 

You will begin the transfer to a higher level of care. Your scenario has concluded.

]]> Out-Of-Hospital ACLS Unstable Tachycardia Megacode: The Most Effective Strategies https://nursecheung.com/aclsmegacode-ooh-unstabletachycardia/ Sat, 07 Jan 2023 17:14:22 +0000 https://nursecheung.com/out-of-hospital-acls-unstable-tachycardia-megacode-the-most-effective-strategies/

ACLS or Advanced Cardiac Life Support is a set of clinical guidelines that are used to treat cardiac arrest and other life-threatening medical emergencies.

One of the most common arrhythmias that ACLS providers will encounter is unstable tachycardia.

In this blog post, we will discuss the most effective strategies for managing unstable tachycardia using the ACLS megacode.

Adult Out-Of-Hospital Unstable Tachycardia Megacode Scenario

The following is a scenario in which you would use the out-of-hospital adult unstable tachycardia megacode:

You are working on an advanced life support ambulance and are dispatched to a person who doesn’t feel right.

Demonstrate what you would do next upon arrival

Initial Impression

The person is a 58-year-old female lying down in the front doorway of her home. She is anxious, pale, and dizzy.

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

Airway: The airway is patent but is experiencing mild respiratory distress. The flow through the trachea is not impaired.

Breathing: Oxygenation is showing 92% on room air. You provide oxygen 2LNC.

Circulation: Blood pressure is 92/60, heart rate is not being captured on the monitor, the rhythm check shows monomorphic wide complex ventricular tachycardia and the pulse is present.

Disability: The woman is alert but anxious and diaphoretic.

Exposure: No obvious signs of trauma, bleeding, burns, markings, or medical alert bracelet. The woman’s son states he helped her to the doorway to get some cold air. He denies any falls or injuries.

What are your next actions?

  1. Check responsiveness: Tap the shoulders and shout, “Are you okay?” The woman responds but is weak.
  2. Activate the emergency response system. You direct the second rescuer to activate the emergency response system and get an AED.
  3. Check for breathing: Look for visible chest rising and falling. Breathing is rapid and 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 fast.
 

What are your next actions?

Pulse and breathing are present so we will not begin CPR starting with compressions.

Unstable Tachycardia Algorithm

Identify and Treat the Underlying Cause

  1. Maintain patent airway, assist with breathing if necessary – Airway is patent and breathing is spontaneous
  2. Oxygen (if hypoxemic) – The woman is on 2LNC upon Primary Assessment
  3. Cardiac monitor, blood pressure, oximetry – monomorphic wide complex ventricular tachycardia, BP 92/60, 96% on 2LNC
  4. IV Access – 20 gauge in the right antecubital
  5. 12-Lead ECG if available and doesn’t delay therapy – Not readily available
 

Persistent Tachyarrhythmia Causing

  • Hypotension? – YES
  • Acutely altered mental status? – NO
  • Signs of shock (low blood pressure, altered mental status, cold moist skin, weak or rapid pulse, rapid breathing, decreased urine output) – YES
  • Ischemic chest discomfort? – YES, woman states chest discomfort
  • Acute heart failure (heavy breathing, suffocating sensation, struggle to breathe while lying down, tight chest, arrhythmia, cough, fluid retention, loss of consciousness)? – YES
 

Interventions

What interventions could you perform next?

  • Synchornized Cardioversion – Consider sedation
 

If synchronized cardioversion is not effective or contraindicated:

  • Amiodarone IV Drip: 1-4 mg/min
  • Procainamide 20-50 mg/min until the arrhythmia is suppressed, hypotension ensues, QRS duration increases. There is a maintenance infusion dose.
  • Sotalol 100 mg (1.5 mg/kg) over 5 minutes. Avoid if QT is prolonged.
 

Outcomes

Two attempts at synchronized cardioversion were performed unsuccessfully. No change in rhythm was noted.

Amiodarone infusion started. After 5 minutes, another attempt at synchronized cardioversion was attempted and successful.

Rhythm is now normal sinus rhythm at 80 bpm.

 

You will begin the transfer to the nearest hospital. Your scenario has concluded.

]]> Emergency Department ACLS Unstable Tachycardia Megacode: The Most Effective Strategies https://nursecheung.com/aclsmegacode-ed-unstabletachycardia/ Sat, 07 Jan 2023 17:14:20 +0000 https://nursecheung.com/emergency-department-acls-unstable-tachycardia-megacode-the-most-effective-strategies/

ACLS or Advanced Cardiac Life Support is a set of clinical guidelines that are used to treat cardiac arrest and other life-threatening medical emergencies.

One of the most common arrhythmias that ACLS providers will encounter is unstable tachycardia.

In this blog post, we will discuss the most effective strategies for managing unstable tachycardia using the ACLS megacode.

Adult Emergency Department Unstable Tachycardia Megacode Scenario

The following is a scenario in which you would use the emergency department adult unstable tachycardia megacode:

You are working in the emergency department and are assessing a woman who has had multiple reports of syncopal episodes and palpitations.

Demonstrate what you would do next upon arrival

Initial Impression

The patient is a 32-year-old female lying down on the stretcher. She is anxious, pale, weak, and dizzy. She states these episodes have happened over the last few years but have become more frequent recently.

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

Airway: The airway is patent. The flow through the trachea is not impaired.

Breathing: Oxygenation is showing 96% on room air.

Circulation: Blood pressure is 84/60, heart rate is 160 bpm, the rhythm check shows narrow complex supraventricular tachycardia and the pulse is present.

Disability: The woman is alert but anxious and diaphoretic.

Exposure: No obvious signs of trauma, bleeding, burns, markings, or medical alert bracelet.

Change in Condition

After assessment of the initial impression and primary assessment, the patient’s palpitations become worse and she is short of breath.

What are your next actions?

  1. Check responsiveness: Tap the shoulders and shout, “Are you okay?” The woman responds but is becoming increasingly weak.
  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. Breathing is rapid and 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 fast.
 

What are your next actions?

Pulse and breathing are present so we will not begin CPR starting with compressions.

Unstable Tachycardia Algorithm

Identify and Treat the Underlying Cause

  1. Maintain patent airway, assist with breathing if necessary – Airway is patent and breathing is spontaneous
  2. Oxygen (if hypoxemic) – The woman is on 4LNC upon Primary Assessment
  3. Cardiac monitor, blood pressure, oximetry – narrow complex supraventricular tachycardia, BP 84/60, 94% on 4LNC
  4. IV Access – 20 gauge in the right and left antecubital
  5. 12-Lead ECG if available and doesn’t delay therapy – Not readily available
 

Persistent Tachyarrhythmia Causing

  • Hypotension? – YES
  • Acutely altered mental status? – NO
  • Signs of shock (low blood pressure, altered mental status, cold moist skin, weak or rapid pulse, rapid breathing, decreased urine output) – YES
  • Ischemic chest discomfort? – YES, the patient states chest discomfort from palpitations
  • Acute heart failure (heavy breathing, suffocating sensation, struggle to breathe while lying down, tight chest, arrhythmia, cough, fluid retention, loss of consciousness)? – YES
 

Interventions

What interventions could you perform next?

  • Synchronized Cardioversion – Consider sedation
 

If synchronized cardioversion is not effective or contraindicated:

  • Adenosine IV – First dose 6mg rapid IV push followed by NS flush, Second dose 12 mg if required
 

Outcomes

Two attempts at synchronized cardioversion were performed successfully.

Rhythm is now normal sinus rhythm at 80 bpm.

Next steps for this patient:

  • Labs – electrolytes and cardiac biomarkers
  • Fluids
  • Chest x-ray
  • Cardiac Consultation
  • Transfer to a higher level of care
 
 

You will begin the transfer to a higher level of care. Your scenario has concluded.

]]> Inpatient ACLS Unstable Tachycardia Megacode: The Most Effective Strategies https://nursecheung.com/aclsmegacode-ip-unstabletachycardia/ Sat, 07 Jan 2023 17:14:18 +0000 https://nursecheung.com/inpatient-acls-unstable-tachycardia-megacode-the-most-effective-strategies/

ACLS or Advanced Cardiac Life Support is a set of clinical guidelines that are used to treat cardiac arrest and other life-threatening medical emergencies.

One of the most common arrhythmias that ACLS providers will encounter is unstable tachycardia.

In this blog post, we will discuss the most effective strategies for managing unstable tachycardia using the ACLS megacode.

Adult inpatient Unstable Tachycardia Megacode Scenario

The following is a scenario in which you would use the emergency department adult unstable tachycardia megacode:

You are a healthcare provider working in the cardiovascular intermediate care unit. You are caring for a post-motor vehicle trauma patient with a chest tube. The patient’s wife runs into the nurse’s station yelling that her husband needs help.

Demonstrate what you would do next upon arrival

Initial Impression

The patient is a 30-year-old male lying down in a hospital bed. He is anxious, pale, weak, and dizzy. He states his chest feels funny.

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

Airway: The airway is patent. The flow through the trachea is not impaired.

Breathing: Oxygenation is showing 96% on room air.

Circulation: Blood pressure is 84/60, heart rate is 160 bpm, the rhythm check shows narrow complex supraventricular tachycardia and the pulse is present.

Disability: The patient is alert but anxious and diaphoretic.

Exposure: No obvious signs of trauma, bleeding, burns, markings, or medical alert bracelet.

Change in Condition

After assessment of the initial impression and primary assessment, the patient’s palpitations become worse and he is short of breath.

What are your next actions?

  1. Check responsiveness: Tap the shoulders and shout, “Are you okay?” The man responds but is becoming increasingly weak.
  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. Breathing is rapid and 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 fast.
 

What are your next actions?

Pulse and breathing are present so we will not begin CPR starting with compressions.

Unstable Tachycardia Algorithm

Identify and Treat the Underlying Cause

  1. Maintain patent airway, assist with breathing if necessary – Airway is patent and breathing is spontaneous
  2. Oxygen (if hypoxemic) – The patient is on 4LNC after a change in condition
  3. Cardiac monitor, blood pressure, oximetry – narrow complex supraventricular tachycardia, BP 84/60, 94% on 4LNC
  4. IV Access – 20 gauge in the right and left antecubital
  5. 12-Lead ECG if available and doesn’t delay therapy – Not readily available
 

Persistent Tachyarrhythmia Causing

  • Hypotension? – YES
  • Acutely altered mental status? – NO
  • Signs of shock (low blood pressure, altered mental status, cold moist skin, weak or rapid pulse, rapid breathing, decreased urine output) – YES
  • Ischemic chest discomfort? – YES, the patient states chest discomfort from palpitations
  • Acute heart failure (heavy breathing, suffocating sensation, struggle to breathe while lying down, tight chest, arrhythmia, cough, fluid retention, loss of consciousness)? – YES
 

Interventions

What interventions are available for you to perform next?

  • Synchronized Cardioversion – Consider sedation
  • Adenosine IV – First dose 6mg rapid IV push followed by NS flush, Second dose 12 mg if required
 

What are we Missing?

The chest tube is a vital piece of equipment during our assessment that may be a contributing factor. Previously during our initial assessment, there was minimal drainage. Now the drainage is over 1,500 mL.

Outcomes

The patient was taken to the Operating Room and found to have a hemothorax.

Next steps for this patient:

  • Post-operative care
  • Chest tube management
  • Physical therapy and walking schedule
  • Labs – electrolytes and cardiac biomarkers
  • Fluids including blood products
  • Chest x-ray
  • Cardiac Consultation
  • Transfer to a higher level of care
 
 

You will begin the transfer to a higher level of care. Your scenario has concluded.

]]> Out-Of-Hospital ACLS Cardiac Arrest Megacode: The Most Effective Strategies https://nursecheung.com/aclemegacode-ooh-cardiacarrest/ Sat, 07 Jan 2023 17:14:16 +0000 https://nursecheung.com/out-of-hospital-acls-cardiac-arrest-megacode-the-most-effective-strategies/

ACLS or Advanced Cardiac Life Support is a set of clinical guidelines that are used to treat cardiac arrest and other life-threatening medical emergencies.

One of the most complex ACLS algorithms providers will encounter is cardiac arrest. We will cover both shockable and unshockable rhythms.

In this blog post, we will discuss the most effective strategies for managing cardiac arrest using the ACLS megacode.

Adult Out-Of-Hospital Cardiac Arrest Megacode Scenario

The following is a scenario in which you would use the out-of-hospital adult cardiac arrest megacode:

You are working as a paramedic responding to an altered mental status call. Upon arrival, you hear a person screaming loudly attempting to wake up a middle-aged man.

Demonstrate what you would do next upon arrival

Initial Impression

The person is a 60-year-old male lying down on the floor in the living room of their home. He is agonal breathing and not responsive.

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

Airway: The airway is patent but agonal breathing 3 breaths per minute is noted upon assessment. The flow through the trachea is not impaired.

Breathing: Oxygenation is showing 60% on room air. You provide oxygen via a bag valve mask.

Circulation: Blood pressure is 60/40, heart rate is not being captured on the monitor, the rhythm check is not being captured on the monitor, and the pulse is present but very weak.

Disability: The man is responsive to painful stimuli only.

Exposure: No obvious signs of trauma, bleeding, burns, markings, or medical alert bracelet. The man’s wife states he had been burping more than normal and was complaining of indigestion.

What are your next actions?

  1. Check responsiveness: Tap the shoulders and shout, “Are you okay?” The man does not respond.
  2. Activate the emergency response system. You direct the second rescuer to activate the emergency response system and get an AED.
  3. Check for breathing: Look for visible chest rising and falling. Breathing is no longer spontaneous.
  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 no longer present.
 

What are your next actions?

Pulse and breathing are no longer present so we will begin CPR starting with compressions.

Cardiac Arrest Algorithm

Adult Compressions

Perform High-Quality Compressions

  • Hands should be placed on the lower half of the sternum
  • 30 compressions at a rate of 100 to 120 compressions per minute
  • Compresses at least 2 inches (5 cm)
  • Complete chest recoil after each compression
 

Adult Rescue Breaths

Give 2 breaths with a barrier device

  • Each breath should be given over 1 second
  • Visible chest rise and fall with each breath
  • resume compressions in less than 10 seconds
 

You will need to perform one to two rounds of high-quality CPR.

Automated External Defibrillator (AED)

  1. Turn on the AED and follow the prompts
  2. Correctly attached pads and plug-in connector. Remove any barriers including medication patches, water, or clothing.
  3. Clear for AED analysis. Stop chest compressions. Call out “stand clear.”
  4. Push the analyze button and allow time for analysis.
  5. Deliver shock if recommended by AED.
 

The AED does not advise a shock. This means the man is either in asystole or pulseless electrical activity.

What are your next steps?

Resume CPR immediately!

Interventions

What interventions could you perform next?

  • IV/IO Access
  • Epinephrine 1 mg every 3 to 5 minutes.
  • Placement of advanced airway
 

H's and T's

It is important to consider your H’s and T’s for these rhythms and treat accordingly.

H’s and T’s are mnemonics for the major causes of arrest:

  • Hypovolemia
  • Hypoxia
  • Hydrogen ions (acidosis)
  • Hyperkalemia or hypokalemia
  • Hypothermia
  • Tamponade (cardiac, tension)
  • Toxins
  • Tension pneumothorax
  • Thrombosis (coronary, pulmonary) – may most likely be the cause
 

Outcomes

Two attempts at delivering a shock were not advised. The man received 3 doses of epinephrine. Upon the third attempt, a deliverable shock was advised.

The team continued high-quality chest compressions and ROSC was achieved.

 

You will begin the transfer to the nearest hospital. Your scenario has concluded.

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