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Show full transcript for Megacode Teaching video

In this lesson, we're going to let you play the role of team leader during a megacode emergency, also known as the granddaddy of all cardiac emergencies. From start to finish, you'll be in charge of assessing the patient and providing therapy and treatment recommendations. A megacode scenario will require a combined knowledge of procedures and treatments from many or all ACLS algorithms.

In this scenario, you've been presented with a 45-year-old male patient who now appears unresponsive. Witnesses state that the victim was choking, and the object was removed. He was brought to advanced medical care because afterward he had difficulty breathing.

While you're talking with the patient, he goes unresponsive. It's important to remember to use basic life support skills before any advanced life support skills.

Your initial assessment recap:

  • 45-year-old male
  • Appears unresponsive
  • Was choking but object removed
  • Brought to medical care for difficulty breathing

You or a member of your team check for responsiveness using taps and shouts. His unresponsiveness is confirmed so you call in a code and check for a pulse and signs of normal breathing. You find that the patient is in respiratory arrest.

You call for an advanced airway, either an NPA or OPA, to be inserted, then start rescue breaths with a bag valve mask at 15 liters of oxygen delivered at 1 breath every 6 seconds.

You call for his vitals to be taken and an ECG monitor to be attached. According to the ECG, the patient has a normal sinus rhythm with pre ventricular contractions (PVC) at 78 beats per minute but they are irregular.

Knowing that a rhythm with multiple and frequent PVCs could quickly deteriorate, you start an IV to administer saline and other medications. And a short time later, the monitor is indicating that no pulse is being detected. It now looks like the patient is in ventricular fibrillation (VFib).

You check the patient for a pulse to confirm and do not find one. You now call for CPR at 30 compressions to 2 rescue breaths, while defibrillator pads are applied. When the pads are in place, you instruct everyone to stand clear while the rhythm is analyzed.

VFib is still present on the ECG.

Using a monophasic defibrillator, you ask that it be charged to 360 joules to shock the patient. CPR resumes immediately after delivery of the first shock.

Since the patient is in VFib, a first shock has been delivered, and an IV has been established, it's now time to administer the first medication – epinephrine at 1 mg 1:10,000 concentration.

Pro Tip #1: You remind your team that CPR must continue during drug administration, because doing so will help circulate the medication throughout the body and especially into the heart.

After the recorder lets you know that it's been 2 minutes since CPR began, you call for the compressor and monitor/defibrillator team members to switch. it's important that you always have a fresh compressor that can deliver high quality compressions between 100 and 120 compressions per minute and at the appropriate depth.

However, during the switch and before resuming CPR, you take a quick look at the monitor. It reveals persistent VFib. You then call for another shock with the monophasic defibrillator at 360 joules.

This time, when you check the monitor, you notice that the patient now has a normal sinus rhythm. You check for a pulse to confirm a perfusing rhythm. You find a pulse, but the patient still isn't breathing

You call for rescue breaths to continue at 1 breath every 6 seconds. And you call for a set of vitals to determine the next course of treatment. You find a blood pressure of 88 systolic after achieving ROSC (return of spontaneous circulation).

Pro Tip #2: A systolic blood pressure below 90 requires a 1 to 2-liter bolus of normal saline in order to raise the patient's blood pressure.

Since the patient is still in respiratory arrest, you call for an ET tube to be put in place and begin to monitor capnography. With capnography in place, you can verify proper tube placement when a persistent waveform is present at 35 to 40 mmHg.

Capnography measures the concentration of carbon dioxide in the patient's exhaled air at the end of expiration. The CO2 detected by capnography in this exhaled air is produced in the body and delivered to the lungs by circulating blood.

Pro Tip #3: This is why it's so helpful to know when compressions are being done correctly, by producing circulation though the body that gets that CO2 out to the lungs to be exhaled. This helps you know that CPR is effective or when the body is returning biologically, and you can see that exchange of gases – oxygen and CO2.

Your megacode scenario ends with you calling for a 12 lead ECG and another set of vitals as you and your team begin to consider the underlying causes that went into this patient's cardiac arrest. And by finding those causes, you can begin correcting them and save the patient's life.