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.