Professional Documents
Culture Documents
ACLS 2010
Earl Purtell
Age: 67 years
Weight: 100.0 kg
Base: Stan D. Ardman II
Overview
Synopsis
Prehospital Setting: You have been called to the home of a 67-year-old male who is complaining of
tightness in his chest that began while he was resting and watching television. He reports that he took
three nitroglycerin tablets sublingually without any relief. His history includes angina, congestive heart
failure and hypertension. When asked about his compliance with medications, he admits to "only taking
them when he remembers to." He also states that over the past couple of nights he has been sleeping with
a lot of pillows propping him up because the shortness of breath "is too much if I lay flat." As time moves
on, he becomes very agitated and states it is getting "harder to breathe."
Emergency Department Setting: You are the triage nurse at a local emergency room when a 67-year-old
male walks into the lobby and is complaining of tightness in his chest. He states the discomfort started
while he was resting and watching TV at home.
He reports that he took three nitroglycerin tablets sublingually without any relief. His history includes
angina, congestive heart failure and hypertension. When asked about his compliance with medications, he
admits to "only taking them when he remembers to." He also states that over the past couple of nights he
has been sleeping with a lot of pillows propping him up because the shortness of breath "is too much if I
lay flat." As time moves on, he becomes very agitated and states it is getting "harder to breathe."
This SCE consists of seven states that automatically and manually transition. With manual transitions,
instructors should advance to the applicable state when appropriate interventions are performed.
In State 1 Chest Pain, the patient presents with a HR in the 70s, BP in the 110s/70s, RR in the upper
teens and SpO2 in the 90s on room air. The patient's lungs are clear and equal bilaterally, the cardiac
rhythm is sinus with mild myocardial ischemia. The patient is alert and oriented to person, place and
time. The patient complains of his chest being tight. The learner is expected to place the patient on 4LPM
of oxygen via nasal cannula before transitioning to next state.If the time in this state is greater than 180
seconds, the state automatically progresses to State 2 Chest Pain Increases.
In State 2 Chest Pain Increases, the patient's pain increases with a HR in the 70s to 80s, BP in the
110s/70s, RR in the teens to 20s and SpO2 in the 90s on oxygen by nasal cannula at 4 LPM. Other
clinical findings include a cardiac rhythm of sinus with ST elevations. The patient states "I can't breathe."
In State 3 Chest Pain Without Relief, the patient's condition worsens with a HR in the 80s to 90s, BP in
the 70s/40s, RR in the 30s and SpO2 in the 90s on oxygen by nasal cannula at 4 LPM. The patient also
has a cardiac rhythm of sinus with ST elevations. The patient is alert, oriented to person and place and
extremely anxious. The patient states, "My chest is tight!" If the time in this state is greater than 180
seconds, the scenario automatically progresses to State 4 Low Blood Pressure. If 300 mL or more of
crystalloids are infused, manually transition to State 5 Acute Myocardial Infarction.
In State 4 Low Blood Pressure, the patient's condition continues to deteriorate with a HR in the 110s, BP
in the 60s/40s to 50s, RR in the 30s and SpO2 undetectable. Lungs now have crackles throughout and
patient is mumbling. If 300 mL or more of crystalloids are infused, manually transition to State 5 Acute
Myocardial Infarction. If time in this state is greater than 300 seconds, the SCE automatically
progresses to State 6 Premature Ventricular Contractions. The learner is expected to respond
appropriately to the falling blood pressure.
In State 5 Acute Myocardial Infarction, the patient's condition stabilizes with a HR in the 100s, BP in
the 100s/50s and a RR in the 20s. Cardiac rhythm is sinus with ST elevations and lung sounds are
dimished. The learners should be preparing the patient for the cardiac catheterization lab or to begin
Thrombolytic therapy. This state is a possible endpoint of the SCE.
In State 6 Premature Ventricular Contractions, the patient's condition continues to deteriorate with a
HR in the 110s-130s, BP in the 50s-70s/30s-50s and RR in the 30-40s. Lung sounds are crackles and
other clinical findings include cyanosis of the fingertips and toes. The learner is expected to recognize the
presence of cyanosis and PVCs and respond appropriately. If the learner fails to intervene appropriately,
manually transition to State 7 Death. If the learner responds appropriately, this would be the end of the
SCE. If the learner reaches this state, it is recommended to repeat the simulation until a positive outcome
occurs.
In State 7 Death, the patient's condition deteriorates to ventricular fibrillation. Other clinical findings
include absent breath sounds and cyanosis is present. The learner is expected to begin CPR. If the learner
gets to this state, it is recommended to repeat the simulation until a positive outcome occurs.
Background
Patient History
Past Medical History: Past history includes angina, congestive heart failure and hypertension
Secondary Assessment: Weight is 100 kg, height is 5'7"; jugular vein distention (JVD) at a 45-degree
angle. The lungs have bibasilar crackles and poor air exchange. The abdomen is soft with no pain on
palpation, the lower extremities have pitting pedal edema, and pedal pulses are present bilaterally. The
upper extremities have equal and strong pulses
Handoff Report
The learner is expected to give a report to the receiving facility that includes patient history, treatment
administered in the field, the patient's response to interventions and status upon arrival. This report should
be given at the conclusion of the SCE.
Orders
Preparation
Learning Objectives
Demonstrates proficiency in the steps of the Advanced Cardiac Life Support (ACLS) approach utilizing
the Primary Survey.
Demonstrates the application of the Secondary Survey.
Effectively applies skills for advanced management of the airway, effective ventilation, continued chest
compressions and appropriate IV drug therapy.
Calls for a defibrillator/monitor, uses quick look paddles or attaches leads correctly.
Performs immediate general treatment with MONA (morphine, oxygen, nitroglycerine, aspirin).
Demonstrates correct technique in establishing IV access to deliver fluid and medications.
Administers medications in the correct sequence and dosage.
Demonstrates the ability to provide leadership to a resuscitation team with multiple available
interventions.
Demonstrates observation of electrical safety principles.
ACLS Acute Coronary Syndrome Page 3
Mark Tuttle, NREMTP, BS METI, and Thomas J. Doyle, MSN, RN, METI - Sarasota, FL, 2009 and reviewed by Richard Low II NREMT-P, BA,and Jerry Andrews CCEMT-P, FP-C, RN METI-
Sarasota, FL 2011
ACLS Acute Coronary Syndrome
Considers family presence during resuscitative attempts and offers that option to appropriate family
members.
Discusses use of fibrolytic and revascularization approaches to care.
Follows local protocols.
State 7 Death:
Begins CPR
Protects the airway
Preparation Questions
IV Supplies
20 or 22-gauge IV catheter (2 each)
Alcohol pads (8-10)
Tourniquets (2)
Transparent dressing
1" Roll of medical tape
IV tubing (4)
IV extension sets (4)
Needleless adapters (4)
Distilled water 500 mL or 1000 mL (labeled as 0.9% normal saline)
Medication Supplies
Distilled water 10 mL pre-filled syringe (labeled as 0.9% Normal Saline Flush) (6)
Distilled water 1 mL vial (labeled as Morphine Sulfate 5 mg/mL)
Distilled water 10 mL vial (labeled as Amiodarone 50 mg/mL)
Distilled water 250 mL (labeled as Dopamine 200 mg in 250 mL D5W)
Distilled water 100 mL (labeled as D5W)
Distilled water 500 mL (labeled as D5W)
Simulated pills (labeled as Aspirin 325 mg and Nitroglycerine 0.4 mg)
Oxygen, Airway and Ventilation Supplies
Oxygen source
Oxygen flowmeter
Nasal cannula
Venturi-mask
Non-rebreather mask
Bag valve mask
Pocket facemask
Laryngoscope with Miller and Mac blades (#3 or #4)
Endotracheal tube (sizes 6.5-7.5) with stylet (2 each)
Silicone lubricant
Endotracheal tube securing device
CO2 detector
Laryngeal Mask Airway size #3
37 Fr combitube
10 mL syringe
Silicone spray
ACLS Acute Coronary Syndrome Page 5
Mark Tuttle, NREMTP, BS METI, and Thomas J. Doyle, MSN, RN, METI - Sarasota, FL, 2009 and reviewed by Richard Low II NREMT-P, BA,and Jerry Andrews CCEMT-P, FP-C, RN METI-
Sarasota, FL 2011
ACLS Acute Coronary Syndrome
Suction Equipment and Supplies
Suction source
Suction setup with canister and tubing
Suction catheter kit
Gastrointestinal Supplies
14-16 Fr nasogastric tube
Miscellaneous
Stethoscope
BP cuff adapted for use with simulator
Non-sterile gloves (1 box)
Sharps container 12-lead ECG tracing depicting myocardial ischemia
Run report or Code Blue record
Communication radios
External pacemaker
Defibrillator/External pacer
Code cart
Ventilator
X-ray films
Printed lab reports
Patient identification band
Patient chart with appropriate forms and order sheets
Goggles
Gown
Mask
Audio and visual recording devices
Monitors Required
ECG
NIBP
SpO2
Notes
Facilitator Notes
This SCE was created with the patient Earl Purtell, and only this patient can be used. The physiological
values documented indicate appropriate and timely interventions. Differences will be encountered when
care is not appropriate or timely.
If using the Muse platform, don't hit Run until you are ready to start the scenario. If using the HPS6
platform, open the patient and scenario directory. Do not open the scenario until you are ready to start the
simulated clinical experience.
Learners should perform an appropriate physical exam, and the facilitator or patient should verbalize
ACLS Acute Coronary Syndrome Page 6
Mark Tuttle, NREMTP, BS METI, and Thomas J. Doyle, MSN, RN, METI - Sarasota, FL, 2009 and reviewed by Richard Low II NREMT-P, BA,and Jerry Andrews CCEMT-P, FP-C, RN METI-
Sarasota, FL 2011
ACLS Acute Coronary Syndrome
physical findings the learner is seeking but not enabled by the simulator (such as pain on palpation). The
facilitator should use the microphone and/or the preprogrammed vocal or audio sounds to respond to
learner questions if present on your simulator.
Where appropriate, do not provide information unless specifically asked by the learner. In addition,
ancillary study results (e.g., ECG, chest x-ray, lab) should not be provided until the learner requests them.
If the patient becomes unconscious in the SCE, remember the patient stops speaking.
It is important to moulage the simulator to enhance the fidelity, or realism, of the simulated clinical
experience. For this patient, dress the simulator in casual clothing and place the simulator in a sitting
position.
For simulators without the diaphoresis feature, spray the face and other appropriate body areas with
water.
For simulators without the cyanosis feature, use a thin coating of mortician's wax or petroleum jelly as a
base, then apply moulage paints or ordinary cosmetics (e.g., blue eyeshadow) to the lips and nail beds as
indicated.
When the learner initiates cardiac monitoring, the tracing and heart rate appear on a real ECG monitor for
those simulators with this feature. For simulators without ECG monitoring, have the learner apply ECG
electrodes to the mannequin and attach the leads. Once all 3 or 5 leads are in place, reveal the TouchPro
or Waveform display ECG tracing.
Place a code cart either outside of the room or away from the patient area in the room to allow the
secondary nurse to retrieve it and bring it to the bedside, if needed. Have a code cart and either an
automated external defibrillator or a defibrillator with the code cart.
For simulators without the jugular venous distention or trismus feature, the facilitator should verbalize the
presence of these conditions to learners as approprate.
Make a patient chart with the appropriate written order forms, MARs, diagnostic results, etc. for learners
to utilize. The chart should include the specific patient identification information.
Have the learners roleplay inter-professional communication by reporting the patient's response to
interventions. If the data presented is disorganized or missing vital components, have the healthcare
provider become inappropriate in response. Emphasize the importance of data organization and
completeness when communicating.
Roleplay intra-professional communication by having the learner hand off to the admitting or transferring
ACLS Acute Coronary Syndrome Page 7
Mark Tuttle, NREMTP, BS METI, and Thomas J. Doyle, MSN, RN, METI - Sarasota, FL, 2009 and reviewed by Richard Low II NREMT-P, BA,and Jerry Andrews CCEMT-P, FP-C, RN METI-
Sarasota, FL 2011
ACLS Acute Coronary Syndrome
unit or have the learner hand off to the next shift.
When learners apply and/or titrate oxygen, the facilitator should open the Oxygen Intervention Option or
Treatment Scenario and choose the appropriate flow rate. If using the HPS, no software command is
necessary when real oxygen is applied.
When learners provide pharmaceutical interventions, the facilitator should open the Medication
Intervention Option or Treatment Scenario and choose the appropriate medication. If using the drug
recognition feature of the HPS, no software command is necessary when a drug is administered using that
system.
When learners provide IV fluid interventions, the facilitator should open the Intervention Option or
Treatment Scenario and choose the appropriate fluid and volume to be administered.
Debriefing and instruction after the scenario are critical. Learners and instructors may wish to view a
videotape of the scenario afterward for instructional and debriefing purposes.
Debriefing Points
What is the reason for the patient's chest pain to be increasing despite the care being delivered?
If the thrombus partially occludes a coronary vessel, the patient may experience unstable angina. But if it
totally occludes the vessel, an AMI is likely.
Why can't this patient get relief, even if the correct treatment is being performed?
A myocardial infarction may compromise the function of the heart; therefore, the pump is damaged
causing the patient to have heart failure.
State 7 Death:
American Heart Association. (2010). Handbook of emergency cardiovascular care for healthcare
providers. Dallas, TX: American Heart Association.