INSTITUTE FOR MEDICAL SIMULATION & EDUCATION ACLS PRACTICAL SCENARIOS
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1 Practical Teaching for Respiratory Arrest with a Pulse (Case 1) You are a medical officer doing a pre-operative round when 60-year old patient started coughing violently and becomes unconscious. Fortunately you have a nurse with you. 1. Perform initial steps of the universal algorithm: Assess Responsiveness Unresponsive 2. Perform initial steps of the primary ABC survey. Breathing - Look, listen & feel No Breathing Circulation - Feel carotid artery Pulse present 3. Assess rhythm Using quick look defibrillator paddles Or Attach to ECG lead as soon as possible 4. Initial rescue breathing by Bag-valve mask Resuscitation trolley is Select Sinus Reassess adequacy of ventilation Patient cyanosed 5. Intubate at once Confirm tube placement 6. Establish iv access Antecubital or external jugular vein Normal saline solution 7. Monitor vital signs Evaluate for causes of problem Arrange for further ventilating support Page 1 of 15
2 Practical Teaching for Witnessed VF Adult Cardiac Arrest (Case 2) A 55 year old man is visiting his mother, a patient in the general medicine ward. He suddenly grasps his chest, and crumple slowly to the floor. 1. Perform initial steps of the universal algorithm: Assess Responsiveness Unresponsive 2. Perform initial steps of the primary ABC survey. Breathing - Look, listen & feel No Breathing Circulation - Feel carotid artery No Pulse 3. Perform CPR immediately, until defibrillator is 4. Assess rhythm Using quick look defibrillator paddles Or Attach to ECG lead as soon as possible 5. Immediate defibrillation Apply gel or pads to patient Apply defibrillator paddles to patient Check synchronizer switch OFF Charge to 360 J (monphasic) or J (biphasic) (First shock must be within 60 sec) Confirm rhythm is VF Shout Stand clear and shock patient Reinitiate CPR immediately after shock (at least for 1 2 mins) Look at the rhythm again after a few moments Resuscitation trolley is Select VF Select Sinus 6. Check pulse & check respiration pulse present, no breathing 7. Intubate at once (1st rescuer) Confirm tube placement Page 2 of 15
3 Practical Teaching for Witnessed VF Adult Cardiac Arrest (Case 2) - <cont d> ( or ) 8. Establish iv access Antecubital or external jugular vein Normal saline solution 9. Provide Medications appropriate for blood pressure, heart rate and rhythm Transfer to CCU with Lignocaine infusion Page 3 of 15
4 Practical Teaching for Refractory VF/Pulseless VT (Case 3) A 60 year old woman collapsed in the A & E department while a 12 lead ECG was done for her. You are the only Medical Officer at around and you have a nurse to assist you. 1. Perform initial steps of the universal algorithm: Assess Responsiveness Unresponsive 2. Perform initial steps of the primary ABC survey. Breathing - Look, listen & feel No Breathing Circulation - Feel carotid artery No Pulse 3. Perform CPR immediately, until defibrillator is Resuscitation trolley is 4. Assess rhythm Using quick look defibrillator paddles Or Attach to ECG lead as soon as possible Select VF 5. Immediate defibrillation Apply gel or pads to patient Apply defibrillator paddles to patient Check synchronizer switch OFF Charge to 360 J (monophasic) or J (biphasic) (First shock must be within 60 sec) Confirm rhythm is VF Shout Stand clear then shock patient Reinitiate CPR immediately after shock (at least for 1 2 mins) Look at the rhythm again after a few moments Select VF Continue CPR 6. Intubate at once Confirm tube placement 7. Establish iv access Antecubital or external jugular vein Normal saline solution 8. Adrenaline 1 mg iv push Give mg diluted in 10 ml of normal saline via ETT If iv access delayed Page 4 of 15
5 Practical Teaching for Refractory VF/Pulseless VT (Case 3) - <cont d> 9. Continue CPR for secs after drug 10. Defibrillate at 360J within sec after drug administration Check synchronizer switch OFF Charge to 360 J Confirm rhythm is VF Inform trainee that rhythm is still in VF Shout Stand clear then shock patient Reinitiate CPR immediately after shock (at least for 1 2 mins) Look at the rhythm again Continue CPR Inform trainee that rhythm is still in VF, Select VF 10. Adrenaline 1 mg iv push If iv access delayed Give mg diluted in 10 ml of normal saline via ETT 11. Continue CPR for secs Defibrillate at 360J within sec after drug administration Reinitiate CPR immediately after shock (at least for 1 2 mins) Look at the rhythm again Continue CPR 12. IV Lignocaine mg bolus or IV Amiodarone 150 mg bolus 13. Continue CPR for secs Defibrillate at 360J within sec after drug administration Reinitiate CPR immediately after shock (at least for 1 2 mins) Look at the rhythm again Continue CPR 14. IV Lignocaine mg bolus or IV Amiodarone 150 mg bolus 15. Continue CPR for secs Defibrillate at 360J within sec after drug administration Reinitiate CPR immediately after shock (at least for 1 2 mins) Look at the rhythm again Page 5 of 15 rhythm is still in VF rhythm is still in VF
6 Continue CPR INSTITUTE FOR MEDICAL SIMULATION & EDUCATION Practical Teaching for Refractory VF/Pulseless VT (Case 3) - <cont d> 16. Consider : IV Magnesium sulfate 1-2 gm over 5 mins Torsades de pointes 17. Check pulse & check respiration Pulse present, no breathing 18. Support Airway & Breathing 19. Provide Medications Appropriate for Blood Pressure Transfer to CCU with Lignocaine infusion / amiodarone 150 mg Page 6 of 15
7 Practical Teaching for Pulseless Electrical Activity (Case 4) You are called to attend a patient found collapsed in the Ward. He was admitted 2 days ago for Chronic Obstructive Airway Disease. You have a nurse to assist you. ( or ) 1. Perform initial steps of the universal algorithm: Assess Responsiveness Unresponsive 2. Perform initial steps of the primary ABC survey. Breathing - Look, listen & feel No Breathing Circulation - Feel carotid artery No Pulse 3. Perform CPR immediately, until defibrillator is 4. Assess rhythm using quick look defibrillator paddles or attach to ECG lead as soon as possible 5. Intubate at once Confirm tube placement 6. Establish iv access antecubital or external jugular vein normal saline solution Resuscitation trolley is Select junctional/sinus rhythm 7. Consider possible causes: Hypovolemia history of vomiting, bleeding GIT Hypoxia history of COPD Cardiac tamponade history of DXT, uraemia, chestpain, Neck veins distended, normal breath sound Tension pneumothorax history of COPD, chest injury. Neck veins distended, trachea deviation, unilateral breath sound diminish Massive pulmonary embolism history of recent operation, use of oral contraceptive, pleuritic chest pain Drug overdose history of ingestion, pill bottle, young patient Hypothermia history of cold water drowning Page 7 of 15
8 Practical Teaching for Pulseless Electrical Activity (Case 4) - <cont d> ( or ) Electrolyte imbalance history of renal failure, calcium intake, ECG peaked T, wide QRS, Sine wave 8. Continue CPR Adrenaline 1 mg iv push Give mg diluted in 10 ml of normal saline via ETT Atropine 0.6 mg iv (if absolute Bradycardia, <60 bpm) 9. Specific treatment If iv access delayed Fluid infusion Hypovolemia Ventilation Hypoxia Pericardiocentesis Cardiac Tamponade Needle decompression Tension pneumothorax Thrombolytic or surgery Pulmonary embolism Calcium chloride, bicarbonate, insulinglucose Hyperkalemia Specific antidote or treatment Drug overdose 10. Prolonged resuscitation Adrenaline 1mg iv push every 3-5 mins Atropine 0.6 mg iv every 3-5 min to total of 0.04mg/kg Consider sodium bicarbonate 1 meq/kg (Class IIb) If intubated and continued long arrest interval upon return of spontaneous circulation after long arrest interval Page 8 of 15
9 Practical Teaching for Asystole (Case 5) A 55 year old patient is admitted to Medical Ward for chest pain. Patient becomes unresponsive. You are Medical Officer of the ward. You have a nurse to assist you. 1. Perform initial steps of the universal algorithm: Assess Responsiveness Unresponsive 2. Perform initial steps of the primary ABC survey. Breathing - Look, listen & feel No Breathing Circulation - Feel carotid artery No Pulse 3. Perform CPR immediately, until defibrillator is 4. Assess rhythm using quick look defibrillator paddles or attach to ECG lead as soon as possible confirm Asystole in another lead 5. Intubate at once Confirm tube placement 6. Establish iv access antecubital or external jugular vein normal saline solution 7. Consider possible causes: Resuscitation trolley is Select Asystole Hypoxia history of COPD Hypokalemia Hyperkalemia CRF Hypothermia history of cold water drowning Acidosis Drug overdose Tricyclic Antidepressant, history of ingestion, pill bottle 8. Continue CPR Adrenaline 1 mg iv push Give mg diluted in 10 ml of normal saline via ETT If iv access delayed Page 9 of 15
10 Atropine 2.4 mg stat dose Practical Teaching for Asystole (Case 5) - <cont d> Trainee Action Instructor Action Completed ( or ) 9. Specific treatment Ventilation Hypoxia Calcium chloride, bicarbonate, insulinglucose Hyperkalemia Specific antidote or treatment Drug overdose Consider sodium bicarbonate 1 meq/kg (Class II a) 10. Prolonged resuscitation Adrenaline 1mg iv push every 3-5 mins Consider sodium bicarbonate 1 meq/kg (Class IIb) preexisting bicarbonate responsive acidosis overdose with tricyclic antidepressant to alkalinize urine in drug overdose cases (phenobarbital) If intubated and continued long arrest interval upon return of spontaneous circulation after long arrest interval Page 10 of 15
11 Practical Teaching for Bradycardia (Case 6) You are at A & E, attending to a 67 year old women complain of chest pain. You have a nurse to assist you. 1. Perform initial steps of the universal algorithm: Assess Responsiveness Conscious 2. Perform initial steps of the primary ABC survey. Breathing - Look, listen & feel Breathing normal Circulation - Feel carotid artery Pulse present 3. Give oxygen via face mask 4. Establish iv access antecubital or external jugular vein normal saline solution Resuscitation trolley is 5. Assess rhythm attach to ECG lead as soon as possible select 3rd degree heart block 6. Monitor vital sign B.P. 126/50, H.R. 42, RR 12 bpm 7. Check for serious signs and symptoms Symptoms - chest pain, shortness of breath, giddiness Haemodynamically stable Signs - confused, pulmonary congestion 8. Do 12 lead ECG Select decrease rate to 30 bpm Inform trainee that patient is confused (Pale, sweaty, BP 80/40 mm Hg) 9. Atropine 0.6 mg-1.2 mg (Max 0.04 mg/kg) Transcutaneous pacing Dopamine 5-20 μg/kg/min Adrenaline 1 mg to 500 ml 5%Dextrose at 1-10 μg/min Patient Stabilised Page 11 of 15
12 Practical Teaching for Wide Complex Tachycardia (Case 7) A 55 year old women presents to the emergency department complaining of palpitation and mild chest discomfort. You are the Medical Officer on duty, you have a nurse to assist you. 1. Perform initial steps of the universal algorithm: Assess Responsiveness Responsive 2. Perform initial steps of the primary ABC survey. Breathing - Look, listen & feel Breathing present Circulation - Feel carotid artery Pulse present 3. Give oxygen via face mask 4. Establish iv access antecubital or external jugular vein normal saline solution Resuscitation trolley is 5. Assess rhythm attach to ECG lead as soon as possible 6. Assess the vital signs Do a 12 lead ECG 7. IV Lignocaine mg/kg over 2 min or IV Amiodarone 150 mg over 15 mins Check vital sign 8. Repeat IV Lignocaine mg/kg over 2 min or IV Amiodarone 150 mg over 15 mins Check vital signs 9. If not definite VT: IV Adenosine 6 mg rapid iv push, repeat IV Adenosine 12 mg rapid iv push if not converted check vital signs 10. Prepare for immediate cardioversion IV sedation, hyperventilate patient Immediate synchronised cardioversion Select VT Heart Rate : 180/min, Blood Pressure (BP): 150/70 BP: 120/60 BP: 100/55 BP: 70/50 Page 12 of 15
13 Apply gel or pads to patient Apply defibrillator paddles to patient Practical Teaching for Wide Complex Tachycardia (Case 7) - <cont d> ( or ) Check synchronizer switch ON Charge to 100 J Confirm rhythm is VT Shout Stand clear then shock patient Evaluate outcome Select Sinus 10. Check pulse Present 11. Ask Team member to check blood pressure BP 100/ Check breathing No Respiration 13. Open airway Ventilate patient with Bag-valve mask unit Patient cyanosed 14. Intubate patient at once confirm tube placement 15. Monitor vital signs Arrange for mechanical ventilation and transfer to ICU with antiarrhythmic drug therapy. (IV lignocaine infusion) Page 13 of 15
14 Practical Teaching for Narrow Complex Tachycardia (Case 8) A 54 year old woman presents to the emergency department complaining of palpitation for 2 days, with a pulse of 180 bpm. You are the Medical Officer on duty. You have a nurse to assist you. 1. Perform initial steps of the universal algorithm: Assess Responsiveness Responsive 2. Perform initial steps of the primary ABC survey. Breathing - Look, listen & feel Breathing normal Circulation - Feel carotid artery Carotid pulse felt Resuscitation trolley is 3. Assess rhythm Select SVT attach to ECG lead as soon as possible 4. Ask team member to check blood pressure. BP: 130/80 Ask patient whether she has shortness of breath and chest pain 5. Give oxygen via face mask 6. Establish iv access antecubital or external jugular vein normal saline solution 7. Do a 12 lead ECG ECG: SVT rate 180 p/min 8. Vagal maneuver Carotid sinus massage Valsalva manveuver 9. IV Adenosine 6 mg flush iv line with 20 ml of normal saline IV Adenosine 12 mg flush iv line with 20 ml of normal saline IV Verapamil 1 mg / min (up to max 20 mg) Not converted Not converted Converted but recur 15 min later, not converted Page 14 of 15
15 Practical Teaching for Narrow Complex Tachycardia (Case 8) - <cont d> ( or ) 10. Check BP BP: 70/60 Patient restless/weakness 11. Prepare for immediate synchronised cardioversion IV sedation Apply gel or pads to patient Apply defibrillator paddles to patient Check synchronizer switch ON Charge to 50 J Confirm rhythm is SVT Shout Stand clear then shock patient Evaluate outcome [if not converted, perform sychronised cardioversion 100J, 200J] Select Sinus 12. Check pulse Present 13. Ask Team member to check blood pressure BP 100/ Check breathing Respiration present 15. Assess responsiveness Regain conscious 16. Oxygen via face mask 17. Transfer to CCU Page 15 of 15
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