MEGACODE MEDICINE 2020

Advanced Cardiovascular Life Support UPDATED

The ACLS instructor will give you a scenario such as the nurse refers to you a patient in ER who is complaining of chest pain and dyspnea.
This is the stage of pre-arrest.

V – Visualize – As you are coming closer to the patient, say whatever you see. If the patient is conscious, perform ACLS. If the patient is unresponsive,
do BLS. “The patient is conscious, in pain, cyanotic, and diaphoretic”

Verbalize – Introduce yourself and make a quick history of chest pain (PQRST)
“I am Dr. — how are you feeling today? What were you doing when the pain started? What does it feel like? Where is the pain
located? Does the pain radiate? How severe is the pain? When did it start and how long does it last?

Vital Signs – Ask the nurse for the vital signs (HR, BP, RR, temperature, and O2 saturation).
“Ma’am/ Sir what are the vital signs?”
If the O2 saturation is below 95% then administer oxygen.

O – Administer OXYGEN via: Nasa cannula at 2-4 liters

Face mask at 6-10 liters
Non-rebreather mask at 11-15 liters

M – Attach the MONITORING PADS. “White on the right, smoke over fire”
3-lead ECG: White at 2nd ICS RMCL 5-lead ECG: White at 2nd ICS RMCL
Black at 2nd ICS LMCL Black at 2nd ICS LMCL
Red at 5th ICS LMCL Red at 5th ICS LMCL
Green at 5th ICS RMCL
Brown is between black and red

I – Start an INTRAVENOUS access through cubital vein. After 2 failed attempts, use the INTRAOSSEOUS route via promixal humerus or tibia.

T – TREATMENT depends on the cardiac rhythm on ECG monitoring.

The ACLS Instructor will now show you an ECG tracing. Your treatment depends whether the rhythm is slow, fast and narrow, or fast and wide.

SLOW RHYTHM
Sinus Bradycardia
ATDE

Atrophine – 0.5 mg IV every 3-5 mins., maximum of 6 doses or 3 mg

Transcutaneous Pacing
Dopamine – renal dose of 2 mcg/kg/min.
cardiac dose of 5 mcg/kg/min.
vasopressor dose of 10 mcg/kg/min.
Epinephrine – 2-10 mcg/min.

DEN | Sources: AHA ACLS Provider Manual, Notes Page 1 of 4

 MEGACODE AHA – ACLS

FAST & NARROW

Supraventricular Tachycardia

Systolic BP <90 mmHg Systolic BP >90 mmHg

Unstable – SS Stable – PP

Sedate – Midazolam or Diazepam at 5 mg Physiologic – Vagal Maneuver: carotid massage or cough

Syncronized Cardioversion – 50 Joules Pharmacologic – Adenosine 6 mg rapid IV push q 3-5 mins.
then 12mg rapid IV push

FAST & WIDE

Ventricular Tachycardia with Pulse

Systolic BP <90 mmHg Systolic BP >90 mmHg

Unstable – SS Stable – P

Sedate – Midazolam or Diazepam at 5 mg Pharmacologic – Amiodarone 150 mg

Syncronized Cardioversion – 120 Joules

The ACLS instructor will now tell you that the patient becomes unresponsive. You are now in the stage of arrest. Perform BLS right away.

“Hey! Hey! Hey! Are you okay? Patient is unresponsive. Activate code blue.”
Check the carotid pulse and breathing.
“Patient has no pulse, no breathing. I am now starting high quality CPR.”

The ACLS instructor will now tell you that your team has arrived. You are the team leader.

Class I – High-quality CPR

Class IIa – Shock at 360 Joules
Class IIb – Administer medication

“Compressor, please take over on 3. 1, 2, 3”

Assign the other roles (Defibrillator, Airway, Medication, Recorder)

2 minutes – “Let’s stop, analyze, and switch roles”

“The patient is in ventricular tachycardia”
Class I – “Please continue high quality CPR”
Class IIa – “Shock at 360 Joules”
Defibrillator: “Charging at 360 Joules.”
“Clear. Shocking on 3. 1, 2, 3. Shock delivered.”
“Please continue high quality CPR and...
Class IIb – … please prepare Epinephrine 1mg at 1:10,000 dilution and 20cc NSS”

DEN | Sources: AHA ACLS Provider Manual, Notes Page 2 of 4

 MEGACODE AHA – ACLS

2 minutes – “Let’s stop, analyze, and switch roles.”

“The patient is still in ventricular tachycardia. Please continue high quality CPR and shock at 360 Joules”
Defibrillator: “Charging at 360 Joules
“Clear. Shocking on 3. 1, 2, 3. Shock delivered.”
“Please continue high quality CPR and please administer Epinephrine”
Medication: “Delivered Epinephrine 1mg at 1:10,000 dilution followed by 20cc NSS”
“Please prepare Amiodarone 300mg and 20cc NSS”
Medication: “Preparing Amiodarone 300mg and 20cc NSS”

2 minutes – “Let’s stop, analyze, and switch roles.”

“The patient is still in ventricular tachycardia. Please continue high quality CPR and shock at 360 Joules”
Defibrillator: “Charging at 360 Joules.”
“Clear. Shocking on 3. 1, 2, 3. Shock delivered.”
“Please continue high quality CPR and please administer Amiodarone”
Medication: “Delivered Amiodarone 300mg followed by 20cc NSS”
“Please prepare Epinephrine 1mg at 1:10,000 dilution and 20cc NSS”
Medication: “Preparing Epinephrine 1mg at 1:10,000 dilution and 20cc NSS”

2 minutes – “Let’s stop, analyze, and switch roles.”

“The patient is still in ventricular tachycardia. Please continue high quality CPR and shock at 360 Joules”
Defibrillator: “Charging at 360 Joules
“Clear. Shocking on 3. 1, 2, 3. Shock delivered.”
“Please continue high quality CPR and please administer Epinephrine”
Medication: “Delivered Epinephrine 1mg at 1:10,000 dilution followed by 20cc NSS”
“Please prepare Amiodarone 150mg and 20cc NSS”
Medication: “Preparing Amiodarone 150mg and 20cc NSS”

2 minutes – “Let’s stop, analyze, and switch roles.”

“The patient is still in ventricular tachycardia. Please continue high quality CPR and shock at 360 Joules”
Defibrillator: “Charging at 360 Joules.”
“Clear. Shocking on 3. 1, 2, 3. Shock delivered.”
“Please continue high quality CPR and please administer Amiodarone”
Medication: “Delivered Amiodarone 150mg followed by 20cc NSS”
“Please prepare Epinephrine 1mg at 1:10,000 dilution and 20cc NSS”
Medication: “Preparing Epinephrine 1mg at 1:10,000 dilution and 20cc NSS”

2 minutes – “Let’s stop, analyze, and switch roles.”

“The patient is still in ventricular tachycardia. Please continue high quality CPR and shock at 360 Joules”
Defibrillator: “Charging at 360 Joules”
“Clear. Shocking on 3. 1, 2, 3. Shock delivered.”
“Please continue high quality CPR and please administer Epinephrine”
Medication: “Delivered Epinephrine 1mg at 1:10,000 dilution followed by 20cc NSS”

The ACLS instructor will now show you a non-shockable rhythm (asystole or pulseless electrical activity).
These can be differentiated by the presence of electrical activity without a pulse (PEA) or absence of electrical activity and pulse (asystole).
Your treatment depends on what was the last medication you administered.

If the last medication was Amiodarone, continue giving high-quality CPR and administer Epinephrine every 3-5 minutes
“The monitor reveals a nonshockable rhythm. Please check for pulse. Still without a pulse. Please continue giving high quality CPR and
administer Epinephrine 1mg at 1:10,000 dilution and 20cc NSS.

If the last medication was Epinephrine, continue giving high quality CPR and administer Epinephrine after 3 minutes.
“The monitor reveals a nonshockable rhythm. Please check for pulse. Still without a pulse. Please continue giving high quality CPR”

DEN | Sources: AHA ACLS Provider Manual, Notes Page 3 of 4

 MEGACODE AHA – ACLS

The ACLS instructor will now show you a normal sinus rhythm. Check for pulse.
No pulse, it is puleseless electrical activity (PEA), give Epinephrine and high-quality CPR.
Below are the 10 most common reversible causes of secondary pulseless electrical activity.

If the patient has normal sinus rhythm and with pulse, this is return of spontaneous circulation (ROSC). Continue to post-arrest care.

Check for blood pressure. If it is low, give 1L to 2L of NSS or PLR fast drip but check first for presence of congestion. If with congestion, give

DEN

Dopamine – 10 mcg/kg/min.
Epinephrine – 2-10 mcg/min.
Norepinephrine – 2-10 mcg/min.

Check for breathing and oxygen saturation. If it is inadequate, provide ventilation via advance airway such as endotracheal tube. Insert first an
oropharyngeal airway (OPA). Place the OPA against the side of the face. A proper size of OPA is when the flange is at the corner of the mouth and
the tip is at the angle of the mandible.

Then check for the placement of endotracheal tube. Auscultate for 3 points. One on each side of the chest to check for equal breath sounds and
one at the epigastric area. Unequal breath sounds or presence of gurgling sound at the epigastric area, you must remove the tube and reinsert. You
may also confirm the ET tube through waveform capnography, it must read 35-40 mmHg. This represents improvement in blood flow. CO2 detector
must change color from purple to yellow.

Then check for disability by asking the patient to squeeze your hand. If he is able to follow your command, proceed to TTM. If there is no response,
he is GCS 3.

Targeted Temperature Management (TTM), core body temperature must be maintained at 32-36 degrees Celcius by administering ice-cold 4
degrees Celcius NSS or PLR at 30 cc/kg body weight to run for 24 hours.
NGT
Lastly, prepare the patient for transport to ICU. Do the “sign of the cross”.
Insert NGT, 12-lead ECG, IV line, portable x-ray, and foley catheter.

XRAY ECG
IV

FOLEY

DEN | Sources: AHA ACLS Provider Manual, Notes Page 4 of 4