ACLS MEGACODE SCRIPT AND ALGORITHM (ROLEPLAY NELEC2.

(SETTING LOCAL EMERGENCY SETTING)

CHIEF COMPLAIN: EPIGASTRIC PAIN AND BACK COMFORT

PRE-ARREST
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 presses the code blue button) (Team arrives on scrubsuit)

DOCTOR: TEAM LEADER
MEMBER 1: COMPRESSION
MEMBER 2: AIRWAY
MEMBER 3: DEFIBRILLATOR
MEMBER 4: RECORDING
MEMBER 5: IV ACCESS
(CLEAR ROLES AND RESPONSIBILITIES)
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. (KNOW YOUR LIMITATION)

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

1ST CYCLE DONE

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

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

MEMBER5: 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. (CLEAR MESSAGES)

MEMBER5: Preparing 1 milligram Epinephrine. (CLOSED LOOP COMMUNICATION/STATING THE OBVIOUS)

(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. (MUTUAL RESPECT)

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. (SUMMARIZING and REEVALUATION)

MEMBER5: Okay 40 units of Vasopressin. (CLOSED LOOP COMMUNICATION/REPEATING THE OBVIOUS)

(BACK OUT, CUT)

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

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? (CONSTRUCTIVE CRITICISM)

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 of it?
(CONSTRUCTIVE INTERVENTION)

(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 inserting 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 at 32-36 degree Celsius. (THERAPEUTIC INDUCED HYPOTHERMIA)
MEMBER5: Okay, for the bolus, let’s switch out to cold saline
MEMBER2: Tubes in. (Continues to ventilate) (ETT/ARTIFICIAL AIRWAY)
(DOCTOR CHECKS BY 4 POINTS AUSCULTATON, 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.