90-1011_ACLS_Part5_Appendix_A.

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ACLS Megacode Case 1: Sinus Bradycardia Megacode Testing Checklist 1/2

(Bradycardia ➔ VF/Pulseless VT ➔ Bradycardia ➔ VF/Pulseless VT ➔ Asystole ➔ ROSC
Asystole ➔ ROSC) Student Name: __________________________________________ Test Date: ___________________
✓ if done
Critical Performance Steps
correctly
Out-of-Hospital Scenario
Team Leader
You are a paramedic and arrive on the scene to find a 57-year-old woman com- Ensures high-quality CPR at all times
plaining of indigestion. She is cold, clammy, and diaphoretic. She tells you she Assigns team member roles
is about to faint. EMS responders have obtained vital signs: HR 38/min, BP 70 Ensures that team members perform well
mm Hg/palpable, RR 16/min, and O2 saturation 93%. No other assessment or Bradycardia Management
management has been performed. Now you assume the role of team leader.
Starts oxygen if needed, places monitor, starts IV
Case Development Places monitor leads in proper position
Recognizes symptomatic bradycardia
Initial This woman may have an ACS. The case focus, however, is Administers correct dose of atropine
bradycardia. The team leader should begin to take a history
Assessment Prepares for second-line treatment
and direct team members to start oxygen (if not initiated)
and an IV and place monitor leads. Nitroglycerin at this point VF/Pulseless VT Management
would be inappropriate in the absence of typical ischemic- Recognizes VF
type discomfort and given the woman’s vital signs (severe
Clears before ANALYZE and SHOCK
bradycardia and hypotension—contraindicated).
Immediately resumes CPR after shocks
Bradycardia The student is presented with bradycardia and needs to fol- Appropriate airway management
low the Bradycardia Algorithm. A critical action is noting that Appropriate cycles of drug–rhythm check/shock–CPR
Algorithm
symptoms are due to bradycardia that requires management.
Administers appropriate drug(s) and doses
Actions at this point should include at least an initial dose
of atropine and preparation for TCP or use of chronotropic Asystole Management
drugs (epinephrine or dopamine infusion). Recognizes asystole
Cardiac The patient suddenly develops VF. The team leader will follow Verbalizes potential reversible causes of asystole/PEA (H’s and T’s)
the Cardiac Arrest Algorithm. Now the student team leader Administers appropriate drug(s) and doses
Arrest
will assign additional team functions and monitor for high- Immediately resumes CPR after rhythm checks
Algorithm quality CPR. The case should continue through safe defibril-
(VF/Pulseless lation, administration of a vasopressor, and consideration of
Post–Cardiac Arrest Care
VT) an antiarrhythmic drug. Identifies ROSC
Ensures BP and 12-lead ECG are performed, O2 saturation is monitored, verbalizes need
Cardiac After a shock, the patient becomes asystolic. The student for endotracheal intubation and waveform capnography, and orders laboratory tests
continues to monitor high-quality CPR and follows the asys- Considers therapeutic hypothermia
Arrest
tole pathway of the Cardiac Arrest Algorithm.
Algorithm STOP TEST
(Asystole)
Test Results Circle P or NR to Indicate Pass or Needs Remediation: P NR
Immediate The team continues high-quality chest compressions, the
Instructor signature affirms that
patient has ROSC, and the Immediate Post–Cardiac Arrest Instructor Signature: _______________________________
Post–Cardiac skills tests were done according
Care Algorithm is initiated. Print Instructor Name: ______________________________
Arrest Care to AHA Guidelines. Save this
Algorithm sheet with course record. Date: ________________
12/22/10 5:25 PM

© 2011 American Heart Association

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ACLS Megacode Case 2: Mobitz Type II Megacode Testing Checklist 1/2

AV Block Bradycardia ➔ VF/Pulseless VT ➔ Asystole ➔ ROSC
(Bradycardia ➔ VF/Pulseless VT ➔ Student Name: __________________________________________ Test Date: ___________________

Asystole ➔ ROSC) Critical Performance Steps

✓ if done
correctly
Team Leader
In-Hospital Scenario Ensures high-quality CPR at all times
You are evaluating a 57-year-old woman complaining of indigestion. She is Assigns team member roles
brought immediately from triage (arrived by personal car) and placed in ED Ensures that team members perform well
room 2. She is cold, clammy, and diaphoretic. She states that she feels as if Bradycardia Management
she is about to faint. The triage nurse is working with you and has obtained vital
Starts oxygen if needed, places monitor, starts IV
signs: HR 38/min, BP 70 mm Hg/palpable, RR 16/min, and O2 saturation 91%.
Places monitor leads in proper position
Case Development Recognizes symptomatic bradycardia
Administers correct dose of atropine
Initial This woman may have an ACS. The case focus, however, is Prepares for second-line treatment
bradycardia. The team leader should begin to take a history
Assessment and direct team members to start oxygen (if not initiated) and VF/Pulseless VT Management
gain IO access (not able to get an IV in) and place monitor
leads. Nitroglycerin at this point would be inappropriate in the
Recognizes VF
absence of typical ischemic-type discomfort and given the Clears before ANALYZE and SHOCK
patient’s vital signs (severe bradycardia and hypotension— Immediately resumes CPR after shocks
contraindicated).
Appropriate airway management
Bradycardia The student is presented with bradycardia and needs to fol- Appropriate cycles of drug–rhythm check/shock–CPR
low the Bradycardia Algorithm. A critical action is noting that Administers appropriate drug(s) and doses
Algorithm symptoms are due to bradycardia that requires management.
Actions at this point should include at least an initial dose Asystole Management
of atropine and preparation for TCP or use of chronotropic Recognizes asystole
drugs (epinephrine or dopamine infusion).
Verbalizes potential reversible causes of asystole/PEA (H’s and T’s)
Cardiac The patient suddenly develops VF. The team leader will follow Administers appropriate drug(s) and doses
the Cardiac Arrest Algorithm. Now the student team leader Immediately resumes CPR after rhythm checks
Arrest will assign additional team functions and monitor for high-
Algorithm quality CPR. The case should continue through safe defibril- Post–Cardiac Arrest Care
lation, administration of a vasopressor, and consideration of
(VF/Pulseless Identifies ROSC
an antiarrhythmic drug.
VT) Ensures BP and 12-lead ECG are performed, O2 saturation is monitored, verbalizes need
for endotracheal intubation and waveform capnography, and orders laboratory tests
Cardiac After a shock, the patient becomes asystolic. The student Considers therapeutic hypothermia
continues to monitor high-quality CPR and follows the
Arrest asystole pathway of the Cardiac Arrest Algorithm. STOP TEST
Algorithm
(Asystole) Test Results Circle P or NR to Indicate Pass or Needs Remediation: P NR
Instructor signature affirms that Instructor Signature: _______________________________
Immediate The team continues high-quality chest compressions, the
patient has ROSC, and the Immediate Post–Cardiac Arrest skills tests were done according
Post–Cardiac Print Instructor Name: ______________________________
Care Algorithm is initiated. to AHA Guidelines. Save this
Arrest Care sheet with course record. Date: ________________
Algorithm
1/22/11 11:21 AM
90-1011_ACLS_Part5_Appendix_A.indd 125

ACLS Megacode Case 3: Tachycardia Megacode Testing Checklist 3

(VT)—Cardioversion Tachycardia ➔ VF/Pulseless VT ➔ PEA ➔ ROSC
(Tachycardia ➔ VF/Pulseless VT ➔ PEA ➔ Student Name: __________________________________________ Test Date: ___________________

ROSC) Critical Performance Steps

✓ if done
correctly
Team Leader
Out-of-Hospital Scenario Ensures high-quality CPR at all times
You are a paramedic and arrive on the scene to find a 65-year-old man complain- Assigns team member roles
ing of palpitations and chest discomfort. He is cold, clammy, and diaphoretic. He Ensures that team members perform well
states that he feels as if he is about to faint. EMS responders have placed oxygen Tachycardia Management
and obtained vital signs: HR 160/min, BP 70 mm Hg/palpable, RR 16/min, and O2 Starts oxygen if needed, places monitor, starts IV
saturation 96%. Places monitor leads in proper position
Recognizes unstable tachycardia
Case Development
Recognizes symptoms due to tachycardia
Initial This man may have an ACS. The case focus, however, is Performs immediate synchronized cardioversion
initially a tachycardia. The student should begin to take a his-
Assessment VF/Pulseless VT Management
tory, start an IV, and attach monitor electrodes or pads to the
patient. Nitroglycerin at this point would be inappropriate and Recognizes VF
contraindicated because of hypotension. Aspirin may be given. Clears before ANALYZE and SHOCK
Immediately resumes CPR after shocks
Tachycardia The student is presented with tachycardia and needs to follow
the Tachycardia Algorithm. A critical action is noting that
Appropriate airway management
Algorithm Appropriate cycles of drug–rhythm check/shock–CPR
symptoms are due to tachycardia that requires management.
The monitor shows a wide-complex tachycardia: VT. The Administers appropriate drug(s) and doses
student should recognize that the patient is symptomatic and
PEA Management
prepare for immediate cardioversion. Consideration of drug
therapy should not delay cardioversion. Recognizes PEA
Verbalizes potential reversible causes of PEA/asystole (H’s and T’s)
Cardiac The patient should suddenly develop VF. The student will
Administers appropriate drug(s) and doses
follow the VF/pulseless VT pathway of the Cardiac Arrest
Arrest Immediately resumes CPR after rhythm and pulse checks
Algorithm. Now the student team leader will assign team
Algorithm functions and monitor for high-quality CPR. The case should Post–Cardiac Arrest Care
(VF/Pulseless continue through safe defibrillation, administration of a
Identifies ROSC
VT) vasopressor, and consideration of an antiarrhythmic drug.
Ensures BP and 12-lead ECG are performed, O2 saturation is monitored, verbalizes need
for endotracheal intubation and waveform capnography, and orders laboratory tests
Cardiac The patient is now in PEA. The student continues to monitor
high-quality CPR and follows the PEA pathway of the Cardiac Considers therapeutic hypothermia
Arrest
Arrest Algorithm. Although the patient is likely in cardiogenic STOP TEST
Algorithm shock, the student should state a differential diagnosis of PEA.
(PEA) Test Results Circle P or NR to Indicate Pass or Needs Remediation: P NR

Immediate The team continues high-quality chest compressions, the Instructor signature affirms that Instructor Signature: _______________________________
patient has ROSC, and the Immediate Post–Cardiac Arrest skills tests were done according
Post–Cardiac Print Instructor Name: ______________________________
Care Algorithm is initiated. to AHA Guidelines. Save this
Arrest Care
sheet with course record. Date: ________________
Algorithm
12/22/10 5:25 PM

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ACLS Megacode Case 4: Tachycardia Megacode Testing Checklist 4

(SVT)—Drug Therapy Tachycardia ➔ VF/Pulseless VT ➔ PEA ➔ ROSC
(Tachycardia ➔ VF/Pulseless VT ➔ PEA ➔ Student Name: __________________________________________ Test Date: ___________________

ROSC) Critical Performance Steps

✓ if done
correctly
Team Leader
In-Hospital Scenario Ensures high-quality CPR at all times
In the ED, you are evaluating a 65-year-old man complaining of palpitations. He is Assigns team member roles
in no distress. He has a history of coronary artery disease and had a stent placed Ensures that team members perform well
in the past. Otherwise, he is healthy, with no other medical problems. His vital Tachycardia Management
signs are HR 170/min, BP 110/70 mm Hg, RR 16/min, and O2 saturation 95%. Starts oxygen if needed, places monitor, starts IV
Places monitor leads in proper position
Case Development
Recognizes tachycardia (specific diagnosis)
Initial This man has mild symptoms and is hemodynamically stable. Recognizes no symptoms due to tachycardia
The case focus, however, is initially a tachycardia. The student Attempts vagal maneuvers
Assessment
should begin to take a history, start an IV, and place a monitor. Gives appropriate initial drug therapy
Nitroglycerin at this point would be inappropriate because of
the rapid tachycardia. Aspirin may be given. VF/Pulseless VT Management
Recognizes VF
Tachycardia The student is presented with tachycardia and needs to
Clears before ANALYZE and SHOCK
follow the Tachycardia Algorithm. A critical action is noting
Algorithm Immediately resumes CPR after shocks
that the patient is asymptomatic except for palpitations and
is hemodynamically stable. He does not require immediate Appropriate airway management
cardioversion. Note or show that he has a regular narrow- Appropriate cycles of drug–rhythm check/shock–CPR
complex tachycardia. The team leader should follow the Administers appropriate drug(s) and doses
algorithm and indicate vagal maneuvers and initial therapy
with adenosine. PEA Management
Recognizes PEA
Cardiac During this treatment, the patient suddenly develops VF. The
Verbalizes potential reversible causes of PEA/asystole (H’s and T’s)
student will follow the VF/pulseless VT pathway of the Cardiac
Arrest Administers appropriate drug(s) and doses
Arrest Algorithm. Now the student team leader will assign team
Algorithm functions and monitor for high-quality CPR. The case should Immediately resumes CPR after rhythm and pulse checks
(VF/Pulseless continue through safe defibrillation, administration of a vaso- Post–Cardiac Arrest Care
VT) pressor, and consideration of an antiarrhythmic drug.
Identifies ROSC
Cardiac After a shock, the patient is now in PEA. The student contin- Ensures BP and 12-lead ECG are performed, O2 saturation is monitored, verbalizes need
ues to monitor high-quality CPR and follow the PEA pathway for endotracheal intubation and waveform capnography, and orders laboratory tests
Arrest
of the Cardiac Arrest Algorithm. Although the patient is likely Considers therapeutic hypothermia
Algorithm in cardiogenic shock, the student should verbalize a differen-
STOP TEST
(PEA) tial diagnosis of PEA.
Test Results Circle P or NR to Indicate Pass or Needs Remediation: P NR
Immediate The team continues high-quality chest compressions, the
patient has ROSC, and the Immediate Post–Cardiac Arrest Instructor signature affirms that Instructor Signature: _______________________________
Post–Cardiac
Care Algorithm is initiated. skills tests were done according
Arrest Care Print Instructor Name: ______________________________
to AHA Guidelines. Save this
Algorithm sheet with course record. Date: ________________
12/22/10 5:25 PM
90-1011_ACLS_Part5_Appendix_A.indd 127

ACLS Megacode Case 5: Tachycardia Megacode Testing Checklist 5

(SVT)—Cardioversion Tachycardia ➔ VF/Pulseless VT ➔ PEA ➔ ROSC
(Tachycardia ➔ VF/Pulseless VT ➔ PEA ➔ Student Name: __________________________________________ Test Date: ___________________
ROSC) ✓ if done
Critical Performance Steps
correctly

Out-of-Hospital Scenario Team Leader

Ensures high-quality CPR at all times
You arrive on the scene to find a male, age 58 years, lying in his bed. The patient Assigns team member roles
says he began having what he thought was indigestion about 4 hours earlier, but
Ensures that team members perform well
the chest discomfort suddenly became worse about 30 minutes ago while at rest,
and he now complains of palpitations. The patient is pale, diaphoretic, and appears Tachycardia Management
in distress. His BP is 136/92 mm Hg, his heart rate is 184/min and regular, and his Starts oxygen if needed, places monitor, starts IV
RR is 16/min. Places monitor leads in proper position
Recognizes unstable tachycardia
Case Development Recognizes symptoms due to tachycardia
Initial The EMS crew should quickly obtain a history (nonsignificant Performs immediate synchronized cardioversion
and no allergies) and investigate the chief complaint. The crew VF/Pulseless VT Management
Assessment should place the patient on a pulse oximeter (SpO2 = 93%) and
an ECG monitor (narrow-complex tachycardia). Recognizes VF
Clears before ANALYZE and SHOCK
Tachycardia The crew should prepare for immediate synchronized cardio-
Immediately resumes CPR after shocks
version. It is reasonable for the crew to place the patient on
Algorithm supplemental oxygen at 4 L/min by nasal cannula, ask the Appropriate airway management
patient to chew 2 to 4 baby aspirins, and administer a sublin- Appropriate cycles of drug–rhythm check/shock–CPR
gual dose of nitroglycerin (after verifying the absence of erec-
tile dysfunction medication use). Before cardioversion can
Administers appropriate drug(s) and doses
be performed, the patient has what appears to be a grand PEA Management
mal seizure that lasts for about 10 seconds. Once the seizure
subsides, the patient appears unconscious. Recognizes PEA
Verbalizes potential reversible causes of PEA/asystole (H’s and T’s)
Cardiac ECG rhythm assessment reveals VF. The students will follow Administers appropriate drug(s) and doses
the VF/pulseless VT pathway of the Cardiac Arrest Algorithm.
Arrest The team leader should check patient responsiveness and Immediately resumes CPR after rhythm and pulse checks
Algorithm verify that the lead wires were not disconnected during the Post-Cardiac Arrest Care
seizure. Upon confirming pulselessness, the team leader
(VF/Pulseless Identifies ROSC
should monitor the CPR performance of the team members.
VT) The case should continue through safe defibrillation and Ensures BP and 12-lead ECG are performed, O2 saturation is monitored, verbalizes need
vasopressor administration. for endotracheal intubation and waveform capnography, and orders laboratory tests
Cardiac After 2 defibrillation attempts and vasopressor administra- Considers therapeutic hypothermia
tion, the patient develops PEA. The students will follow the STOP TEST
Arrest PEA pathway of the Cardiac Arrest Algorithm. The team leader
Algorithm should continue to monitor the quality of the CPR performance. Test Results Circle P or NR to Indicate Pass or Needs Remediation: P NR
The team leader should order the administration of another dose
(PEA) Instructor signature affirms that
of a vasopressor and recite the possible causes of PEA. Instructor Signature: _______________________________
skills tests were done according
Immediate The team continues high-quality chest compressions, the Print Instructor Name: ______________________________
patient has ROSC, and the Immediate Post–Cardiac Arrest
to AHA Guidelines. Save this
Post–Cardiac Care Algorithm is initiated. sheet with course record. Date: ________________
Arrest Care
1/22/11 11:21 AM

Algorithm
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ACLS Megacode Case 6: Tachycardia Megacode Testing Checklist 6

(VT)—Drug Therapy Tachycardia ➔ VF/Pulseless VT ➔ PEA ➔ ROSC
(Tachycardia ➔ VF/Pulseless VT ➔ PEA ➔ Student Name: __________________________________________ Test Date: ___________________

ROSC) Critical Performance Steps

✓ if done
correctly
Team Leader
In-Hospital Scenario Ensures high-quality CPR at all times
A clinic nurse delivers a male, age 65 years, to the inpatient unit as a direct Assigns team member roles
hospital admission from the medicine clinic in a wheelchair. The patient developed Ensures that team members perform well
sudden palpitations that began while driving home and came straight to his Tachycardia Management
doctor’s office in the hospital’s outpatient clinic. The patient appears stable with Starts oxygen if needed, places monitor, starts IV
no distress. His BP is 148/88 mm Hg, his heart rate is 160/min and regular, and Places monitor leads in proper position
his RR is 12/min. Recognizes tachycardia (specific diagnosis)
Recognizes no symptoms due to tachycardia
Case Development
Attempts vagal maneuvers
Initial The team leader should quickly obtain a history (hypertension Gives appropriate initial drug therapy
and no allergies) and investigate the chief complaint. Team VF/Pulseless VT Management
Assessment
members should place the patient on a pulse oximeter
(SpO2 = 97%) and an ECG monitor (regular, wide-complex Recognizes VF
tachycardia). Clears before ANALYZE and SHOCK
Immediately resumes CPR after shocks
Tachycardia The team leader should direct team members to assess the
patient’s hemodynamics for stability, get a 12-lead ECG, and Appropriate airway management
Algorithm
prepare for drug therapy. During 12-lead ECG acquisition, the Appropriate cycles of drug–rhythm check/shock–CPR
patient states that he feels like he needs to vomit and then Administers appropriate drug(s) and doses
loses consciousness.
PEA Management
Cardiac ECG rhythm assessment reveals VF. The students will follow Recognizes PEA
the VF/pulseless VT pathway of the Cardiac Arrest Algorithm.
Arrest Verbalizes potential reversible causes of PEA/asystole (H’s and T’s)
The team leader should check patient responsiveness, and
Algorithm then monitor the CPR performance of the team members. Administers appropriate drug(s) and doses
(VF/Pulseless The case should continue through safe defibrillation and Immediately resumes CPR after rhythm and pulse checks
vasopressor administration.
VT) Post–Cardiac Arrest Care
Identifies ROSC
Cardiac After 2 defibrillation attempts and vasopressor administration,
the patient develops PEA. The students will follow the PEA Ensures BP and 12-lead ECG are performed, O2 saturation is monitored, verbalizes need
Arrest
pathway of the Cardiac Arrest Algorithm. The team leader for endotracheal intubation and waveform capnography, and orders laboratory tests
Algorithm should continue to monitor the quality of the CPR perfor- Considers therapeutic hypothermia
(PEA) mance. The team leader should order the administration of
another dose of a vasopressor and recite the possible causes STOP TEST
of PEA.
Test Results Circle P or NR to Indicate Pass or Needs Remediation: P NR
Immediate The team continues high-quality chest compressions, the Instructor signature affirms that Instructor Signature: _______________________________
patient has ROSC, and the Immediate Post–Cardiac Arrest
Post–Cardiac skills tests were done according
Care Algorithm is initiated. Print Instructor Name: ______________________________
Arrest Care to AHA Guidelines. Save this
Algorithm sheet with course record. Date: ________________
12/22/10 5:26 PM