International Seminar and Workshop:

UPDATE Nursing Management in ACLS

Topic: Cardiac Arrest Megacode

Presenter:
Md Khairulamin AS
Nursing Lecturer
PAPRSB Institute of
Health Sciences UBD
Msc Adv Clinical Pract, PGCTE, BA Nursing, Dip Nursing,
AHA ITC Training Coordinator, AHA BLS & ACLS Instructor, PHTLS Provider,
Pan Asia Simulation Society for Healthcare General Secretary
 MegaCode
The Mega Code is a simulated cardiac arrest during which students practice as members
of a team and learn to integrate the knowledge and protocols of multiple ACLS
algorithms that includes:

ACS
Stroke
Cardiac arrest
VT
VF
Asystole
PEA
Tachycardia and bradycardia stable and unstable

What is your assessment

What Drugs given
ECG interpretation
Team Dynamic
High Quality CPR
 Simulation
You are given the scenario and act based on the scenario given and information
taken from the “patient”

E.G A 40 year old man arrives at the ER accompanied by his

family. He is complaining of palpitations after working
outside for several hours.

History taking and assessment

Identify if pt Stable or Unstable

Responses to changes
 Is heart Attack = cardiac arrest? Yes/No

Heart attack is
the myocardium Cardiac is heart
receive rhythm disturbances
insufficient leading to
oxygen due to insufficient/absent
blood flow cardiac output
disruption from
narrowing or
blockage
Knowing the cardiac rhythm

Do nurses need to know or Not?

Or

Leave it to the doctor??

Blood Flow Disruption

ECG with ST - Elevation

Cardiac Arrest Rhythm
 Pre-Arrest rhythm, e.g

Bradycardia Tachycardia
Why do you need to know the
rhythms during MegaCode?

To guide the selection of Algorithm to follow

To mind mapping treatment/intervention to be given
To ensure correct treatment
To identify present of ROSC
Scenario:
A 30 yrs old body builder man come to
ED complain of chest pain
with holding his hand on his left, look Instructors say:
pale and sweating. - Weight lifting
- Taking supplement
1st Step: - Chest pain radiating to left arm
Initial assessment and - Vs: p 66, bp 98/54, spo2 99%
MegaCode history taking
e.g

Intervention:
ECG

Determine if this pt is stable or unstable?

Pt condition detoriating:
- c/o Heart racing out Cardiac Arrest algorithm
- Feel of passing out withVT
- Sweating +++
- Eventually not responding

BLS Assessment

Cardiac Arrest algorithm

High Quality CPR with VF
During rhythm
check your
cardiac monitor
show this rhythm

Instructor: No pulse

Cardiac Arrest algorithm

With PEA
Cardiac Arrest algorithm
HIGH QUALITY CPR

SHOCKABLE OR NON-SHOCKABLE
RHYTHM
 BLS assessment HIGH QUALITY CPR Rapid Defibrilation

 Danger: safe or not

 Check response Push Fast: 100-120 C/Min
 Call for help Push Hard: 5 cm (adult) 4 cm(infant)
 Check for pulse and Allow chest recoil
breathing 5-10secs Minimize interruption >10secs
Avoid excessive Ventilation
 Questions??

Why AHA emphasis on DRCAB than DRABC?

Ans: To minimize the time to initiation of the chest compression

Why need to Push Fast:100-120 C/Min whereby the normal heart rate is 60-100 beats/min?

Ans: Evidened by study found that increase survival rate with compression rate of 100-120

Ans: Physiological reason chest compression is not comparable to myocardium contraction

in giving cardiac output, Thus need faster compression rate than normal heart rate
Why do you need to allow the chest to recoil?
Ans: To allow time for the blood to fill the heart chambers

Why do you need to minimize interruption?

Why do you need to avoid excessive Ventilation?

 In ACLS

AED Mode OR Manual Mode

WHY?
Charging on Paddle button or on machine charging panel button

3 issues:
- Time
- Safety
- Competency
Giving shock using Paddle OR Pad?

2 issues:
- Cost
- Safety
- Effectiveness =
- Most recommended??
Delivering shock using Thumb OR Index Finger?

Shock and Oxygen?

Principle of Defibrillation administration

1. Minimize CPR interruption

2. Safe administration
Do you shock all
cardiac arrest patient?
How much Joules needed to shock the patient?

Fix or Escalating dose?

Single Shock or Stacked Shocked

- VF termination at high success with

biphasic
- Brief period of asystole after shock,
perfusing rhythm is unlikely
- Minimise chest compression interuption
 Shock Sequence
Do you check rhythm
during cardiac arrest
before OR after shock? Megacode
 What drugs given during cardiac arrest?

• Vasoconstrictor

• Increase myocardial
Refractory VT/VF contractility
β-blockers

Which of these 2, the

Effect needed during
resuscitation??

Q: Will the drugs convert VT/VF to organised perfusing rhythm??

Epinephrine 1mg/ml

To Dilute OR Not prior to injection?

A patient was brought in to ED by his family , they rush in to
you saying that “My father is not breathing”.

You initiate your BLS assessment and commence CPR

immediately. One of your team member put the patient on
cardiac monitor and showing you this ECG.
During the resuscitation rhythm check, your monitor
showing you this ECG. What should you do?
Non-Shockable rhythm
H’s & T’s
The last sequence of Megacode is
Post Cardiac Arrest Care
A

I
A Airway: Consider ETT, Suctioning, Head-tilt chain lift

B Breathing: Ensure chest rise with ventilation, avoid excessive ventilation, Auscultation RR, SPO2 <94%, tiltrate oxygen,
pETCO2 35-40mmHg

C Circulation: BP ( SBP < 90mmHg),

Drugs: Epinephrine/Dopamine/Norepinephrine Infusion

D

E ECG

F Fluid/IVI

Glucose
G
Hypothermia: Target Temperature Management
H

I Investigation and ICU

Target Temperature Management

TTM

Induced hypothermia

If post-ROSC patient in “Comatose state”

Target: 32-36 degrees Celsius

Duration: 24-48 hrs

 Pre-Hospital TTM

Recommended OR Not

No diff in survival and neurological recovery post-cardiac arrest

Risk of pulmonary edema and re-arrest
During resuscitation state 3 occasions
when to check the pulse.

1.During BLS assessment

2.Present of organize rhythm
3.When ROSC
Why in the guideline recommendation of ETT intubation is at the end of the algorithm?

In what condition ETT intubation might be considered during the resus?

Avoid routine intubation