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In this next scenario, it's called a megacode, and it combines the knowledge of procedures and treatments from multiple ACLS algorithms. 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 after the obstruction was removed. Now, as you begin to talk to the patient, he stops responding to all questions. Remember to use your basic life support before moving to advanced life support. The patient should be checked for responsiveness. If unresponsive, a code should be called. Then check for a pulse and for 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 going to deliver one breath every five seconds. Remember vitals should be taken and an ECG monitor should be attached. The rhythm on the ECG is a normal sinus rhythm 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're gonna start an IV in order to administer IV saline and have a route for medications. After some time of rescue breathing, the monitor appears to show a pulseless rhythm. It looks like ventricular fibrillation. We check for a pulse physically to find that the patient has no pulse. So, it's now time to start CPR with cycles of 30 compressions to two rescue breaths. The defib pads are applied while CPR is in progress. 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, and CPR is then 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 at 1mg of 1:10,000 while CPR is still in progress. The CPR 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 two 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 compressions per minute at the appropriate depth. Before resuming CPR, a look at the monitor reveals persistent V-Fib. Another shock with a monophasic defibrillator is given at 360 joules. This time when the monitor is checked, a 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 one breath every five seconds. The leader needs to call for a set of vitals to determine the next treatment. We find a blood pressure of 88 by systolic when we have achieved R-O-S-C or ROSC, which means return of spontaneous circulation. After a cardiac arrest, a systolic blood pressure below 90 really requires a liter or two bolus of normal saline to get the blood pressure up. Since our patient is still in respiratory arrest, we need to get an endotracheal tube in place and monitor capnography. With capnography, we can verify tube placement when we a persistent capnographic waveform. Capnography measures the concentration of carbon dioxide in exhaled air at the end of the expiration. The CO2 that is detected by capnography is produced in the body and delivered to the lungs by circulating blood. A sudden increase of detectable CO2 may be an indication that ROSC is likely and effective gas exchange at the cell level is occurring. The normal range after ROSC is between 35-45 millimeters of mercury. Persistent low values less than 10 millimeters of mercury during CPR could be an indication that ROSC may be unlikely. Our megacode scenario will end with getting a 12 lead EKG, 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.
In this lesson, we're going to let you play the role of team leader during a megacode emergency, also known as the granddaddy of all cardiac emergencies. From start to finish, you'll be in charge of assessing the patient and providing therapy and treatment recommendations. A megacode scenario will require a combined knowledge of procedures and treatments from many or all ACLS algorithms.
In this scenario, you've been presented with a 45-year-old male patient who now appears unresponsive. Witnesses state that the victim was choking, and the object was removed. He was brought to advanced medical care because afterward he had difficulty breathing.
While you're talking with the patient, he goes unresponsive. It's important to remember to use basic life support skills before any advanced life support skills.
Your initial assessment recap:
You or a member of your team check for responsiveness using taps and shouts. His unresponsiveness is confirmed so you call in a code and check for a pulse and signs of normal breathing. You find that the patient is in respiratory arrest.
You call for an advanced airway, either an NPA or OPA, to be inserted, then start rescue breaths with a bag valve mask at 15 liters of oxygen delivered at 1 breath every 6 seconds.
You call for his vitals to be taken and an ECG monitor to be attached. According to the ECG, the patient has a normal sinus rhythm with pre ventricular contractions (PVC) at 78 beats per minute but they are irregular.
Knowing that a rhythm with multiple and frequent PVCs could quickly deteriorate, you start an IV to administer saline and other medications. And a short time later, the monitor is indicating that no pulse is being detected. It now looks like the patient is in ventricular fibrillation (VFib).
You check the patient for a pulse to confirm and do not find one. You now call for CPR at 30 compressions to 2 rescue breaths, while defibrillator pads are applied. When the pads are in place, you instruct everyone to stand clear while the rhythm is analyzed.
VFib is still present on the ECG.
Using a monophasic defibrillator, you ask that it be charged to 360 joules to shock the patient. CPR resumes immediately after delivery of the first shock.
Since the patient is in VFib, a first shock has been delivered, and an IV has been established, it's now time to administer the first medication – epinephrine at 1 mg 1:10,000 concentration.
Pro Tip #1: You remind your team that CPR must continue during drug administration, because doing so will help circulate the medication throughout the body and especially into the heart.
After the recorder lets you know that it's been 2 minutes since CPR began, you call for the compressor and monitor/defibrillator team members to switch. it's important that you always have a fresh compressor that can deliver high quality compressions between 100 and 120 compressions per minute and at the appropriate depth.
However, during the switch and before resuming CPR, you take a quick look at the monitor. It reveals persistent VFib. You then call for another shock with the monophasic defibrillator at 360 joules.
This time, when you check the monitor, you notice that the patient now has a normal sinus rhythm. You check for a pulse to confirm a perfusing rhythm. You find a pulse, but the patient still isn't breathing
You call for rescue breaths to continue at 1 breath every 6 seconds. And you call for a set of vitals to determine the next course of treatment. You find a blood pressure of 88 systolic after achieving ROSC (return of spontaneous circulation).
Pro Tip #2: A systolic blood pressure below 90 requires a 1 to 2-liter bolus of normal saline in order to raise the patient's blood pressure.
Since the patient is still in respiratory arrest, you call for an ET tube to be put in place and begin to monitor capnography. With capnography in place, you can verify proper tube placement when a persistent waveform is present at 35 to 40 mmHg.
Capnography measures the concentration of carbon dioxide in the patient's exhaled air at the end of expiration. The CO2 detected by capnography in this exhaled air is produced in the body and delivered to the lungs by circulating blood.
Pro Tip #3: This is why it's so helpful to know when compressions are being done correctly, by producing circulation though the body that gets that CO2 out to the lungs to be exhaled. This helps you know that CPR is effective or when the body is returning biologically, and you can see that exchange of gases – oxygen and CO2.
Your megacode scenario ends with you calling for a 12 lead ECG and another set of vitals as you and your team begin to consider the underlying causes that went into this patient's cardiac arrest. And by finding those causes, you can begin correcting them and save the patient's life.