ACLS MEGACODE SCRIPT AND ALGORITHM! NELEC 2 ROLEPLAY.

(SETTING LOCAL EMERGENCY SETTING)

CC: EPIGASTRIC PAIN AND BACK COMFORT

Doctor: Hello I’m doctor, what’s bothering you today?

Patient: I don’t feel good, I feel really bad. I’m dizzy and my stomach is painful. My son is
really worried about me.

Doctor: Are you having chest pain right now?

Patient: No but I’m hurting. Started in my stomach and now it’s in my back.

Doctor: We’re gonna see if we can find what’s going on okay? Nurse1, do we have a set of
vital sign from our patient?

Nurse1: Blood pressure is 70/40, heart rate is 45 cpm, respiratory rate is 16 bpm and oxygen
saturation is 92%.

Doctor: Okay let’s go ahead and start her on 2 liters per minute of oxygen.
Ma’am we’ve got you hooked up to a monitor so we can look at your heart rate and we’ve
started you on oxygen so you can breathe a little easier. (Nurse 1 hooking oxygen and
monitor after getting vitals and being ordered by doctor, then monitors saturation.)

Nurse1: Her oxygen saturation is 95% with 2 liters of oxygen.

Patient: Ohh, doctor I’m not feeling good.

(Doctor looks at the monitor)

Doctor: Okay looks like we are having a sinus bradycardia. Nurse2 let’s go ahead and get an
IV started right now.

(Patient becomes unresponsive)

Nurse1: Ma’am? Can you hear me? (Tapping) Ma’am? Can you hear me?
Nurse2: (Checking carotid pulse and breathing) She’s unresponsive. I can feel no pulse.

Doctor: Okay let’s call a code.

Nurse2: (Press the code blue button)

(Team arrives on scrubsuit)

1 TEAM LEADER (DOCTOR)

5 TEAM MEMBER

MEMBER 1: COMPRESSION
MEMBER 2: AIRWAY
MEMBER 3: DEFIBRILLATOR
MEMBER 4: RECORDING
MEMBER 5: IV ACCESS

DOCTOR: Patient’s gone to VFIB, MEMBER1 start chess compression (MEMBER1 starts
compression). MEMBER2 you’ll manage the airway. MEMBER3, you’ll be on defibrillator.
MEMBER4, you’ll be recording. MEMBER5, have you been able to establish an IV access yet?

MEMBER5: I’ve tried several times but it failed.

DOCTOR: Let’s move on to IO access please.

1ST CYCLE DONE

(MEMBER3 patches the defibrillator while MEMBER1 keeps on compressing the 2nd cycle)

MEMBER3: Charging at 200 joules. Shock ready. Clear the patient. Shocking in 3, 2, 1.
Shocking. Shock delivered.

MEMBER 5: I have IO access now.

DOCTOR: Great, we’ll continue CPR for 2 minutes/5cycles and evaluate need for additional
defibrillation. MEMBER 4, I’ll rely on you to monitor the quality of compressions. MEMBER5,
you’ll need to draw and prepare the drugs up before each rhythm check. So if the arrest
persists, we can move quickly to drug therapy. Let’s begin with 1 milligram of Epinephrine.

MEMBER5: Preparing 1 milligram Epinephrine.

FAST FORWARD CUT

MEMBER4: (2minutes done)

DOCTOR: Okay, let’s analyze. Switch roles. Okay the patient remains in VFIB. The protocols
for this biphasic device is escalated dosing. Let’s shock again at 300 joules.

MEMBER3: Shocking at 300J. Charging. Clear the patient. Shocking on 3. 1,2,3 shocking.
Shock delivered.

DOCTOR: Continue CPR. MEMBER5, please give the 1 milligrams of Epinephrine.

MEMBER5: 1 milligram of Epinephrine given and the IO is flushed.

DOCTOR: Great, we’ve given 2 shocks and 1 mg of Epinephrine. The next medication to
consider is Amiodarone 300 mg. MEMBER5, please prepare 300mg of Amiodarone.

MEMBER5: Okay I will prepare it.

DOCTOR: MEMBER2 are getting good chest rise?

MEMBER2: Yes and I’m being careful not to deliver ventilations too quickly or forcefully.

DOCTOR: Okay that’s good.

MEMBER4: 2 minutes done.

DOCTOR: Okay stop, let’s analyze. Swtich your roles. (Doctor looks at monitor)
Okay, the patient is in persistent VFIB. Let’s shock again at 360J.

MEMBER3: Charging at 360J. Shock ready. Clear the patient. Shocking in 3…. 1,2,3. Shocked
delivered.

DOCTOR: Continue CPR

MEMBER4: We can give Amiodarone now.
DOCTOR: Thanks MEMBER4. Okay MEMBER5, please give 300 miligrams of Amiodarone.

MEMBER5: 300mg of Amiodarone given and the IO is flushed.

DOCTOR: Okay we’ve given 3 shocks, after the second shock we administered 1 milligram of
Epinephrine and at 3rd shock we’ve just given 300 milligram of Amiodarone. Our next drug to
consider is Vasopressin. MEMBER5, please prepare 40 units of Vasopressin.

MEMBER5: Okay 40 units of Vasopressin.

(BACK OUT, CUT)

DOCTOR: Let’s review any reversible causes by considering the H’s and T’s.

MEMBER5: What about Hypervolemia?

DOCTOR: That’s a good thought. We have IO access established but no obvious sign of
external or internal bleeding. Anybody else have any other suggestions?

MEMBER3: Have we considered Hypoxia?

DOCTOR: Is the airway still patent?

MEMBER2: Still getting good chest rise.

MEMBER5: She came in with Epigastric discomfort and symptomatic bradycardia. Have we
considered Coronary Thrombosis?

DOCTOR: That’s a great point. Everything seems to suggest a STEMI.

MEMBER4: 2 MINUTES DONE.

DOCTOR: Okay stop, analyze, switch roles. Okay, the monitor shows Sinus Bradycardia. Do
we have a pulse?

(MEMBER2 checking carotid on left side, right carotid of patient, if he is facing the head)
MEMBER2: I don’t feel a pulse.

DOCTOR: Continue chest compressions.

MEMBER1: Continuing chest compressions.

(BLACK OUT, FAST FORWARD, CUT)

DOCTOR: MEMBER4, how long has it been since our last dose of Ephinephrine?

MEMBER4: Three minutes.

DOCTOR: MEMBER5, let’s go ahead and give 40 units of Vasopressin.

MEMBER5: 40 units of Vasopressin administered and the IO is flushed.

(COMPRESSOR SLOWS COMPRESSION)

MEMBER4: MEMBER5 your compressions are slowing down, can you pick up the pace.

(COMPRESSOR REGAINS RATE OF COMPRESSION)

MEMBER4: 2 minutes done

DOCTOR: Okay stop, let’s analyze, let’s switch roles. Okay the monitor shows Sinus
Tachycardia. MEMBER2 do we have a pulse?

MEMBER2: I can feel a rapid weak pulse. (RETURN OF SPONTANEOUS CIRCULATION)

POST CARDIAC ARREST CARE:

DOCTOR: Okay great, let’s initiate immediate post cardiac arrest care. MEMBER5 let’s get a
blood pressure and a complete set of vital signs, pulse ox and labs. MEMBER3, let’s start a 12
lead ECG please. Can we check to see if this patient is breathing unresponsive?

MEMBER1: Ma’am can you squeeze my fingers? She’s still unresponsive. (COMA GCS3)
DOCTOR: Okay let’s insert and advanced airway and prepare for therapeutic hypothermia.

MEMBER5: The patient’s blood pressure is 82 over 40. Heart rate is 130. (Looks at the
monitor.) And the rhythms signs of tachycardia.

(MEMBER2 inserts artificial airway ET)

DOCTOR: Okay, the patient is hypotensive, let’s start with a liter of Saline since we’ve
started with hypothermia, let’s use cold saline.
MEMBER5: For the bolus, let’s switch out to cold saline.
MEMBER2: Tubes in. (Continues to ventilate)

(DOCTOR CHECKS BY STETHOSCOPE, LEFT LOWER, LEFT UPPER, RIGHT UPPER, RIGHT LOWER)

DOCTOR: Okay we’ve got good breath sounds. Let’s establish waveform capnography. The
O2 saturation 96%.

(CUT, FAST FORWARD BLACK OUT)

MEMBER3: Heres the 12-led ECG result.
DOCTOR: Okay she has a STEMI. MEMBER3, please tell the CATH LAB that we have a STEMI
patient. PCI and hypothermia can be safely combined after cardiac arrest.