ACLS ACTIVITY

Scenario 1
You are a Registered Nurse working in the Emergency Room. You have
just received a 50-year-old male patient from triage. He weighs 100
kilograms. You have placed him in your “code room" because of his
vital signs. His chief complaint is palpitations in his chest. He feels
weak and dizzy all over (WADAO). His blood pressure is 70/36mmHg.
He has a history of cardiac arrhythmias. The code room contains
everything you need to manage this patient. After just placing him to
the monitor, this is the rhythm that your patient has.

Your first thought would be Airway, Oxygen, Monitor, Assess, and IV.
You have called for help. Your help is here. You patient has a pulse but
his blood pressure is still around 76/doppler. You request an IV line to
be started with Normal Saline and Oxygen via non-rebreather mask at
12-15 L/min.

Your rhythm is?*

Sinus Tachycardia
PSVT Narrow complex
Ventricular Tachycardia
Ventricular Fibrillation

Your patient’s condition is?*

Stable
Unstable
Dead

Your first treatment would be?*

Adenosine 6 mg. IV over 3 seconds
Lidocaine 1.5 mg./kg. IV
Consider sedation and prepare to do synchronized cardioversion at 100 joules
Start CPR and call a code
Your patient remains in the above rhythm. He still has a pulse and
blood pressure of 70/doppler.

Your next treatment would be?*

Give another Lidocaine IV bolus of 1.5 mg./kg.
Repeat the Adenosine; this time, give 12 mg. IV
Synchronized cardioversion; this time, go to 200 joules
Continue CPR
Because of your last intervention your patient's rhythm is now this,
see below.

Your patient responds to deep tactile stimuli. His oxygen saturation is

99%. His pulse is 80 bpm, strong and regular. His blood pressure is
130/76mmHg.

Scenario 2
You are a Registered Nurse working in the Intensive Care Unit. You
have been caring for a 70-year-old male patient recovering from an
acute Inferior Wall MI. The patient is preoccupied with having a bowel
movement. You have just explained he had a large bowel movement
yesterday. However, the patient insists on using the bedside
commode. Reluctantly, you assist him to the bedside commode. You
caution the patient not to strain. Immediately, the patient strains hard
and exclaims, "I have to go!" Suddenly his eyes roll to the back of his
head and he slumps to the back of the commode chair. You hear the
monitor a 3-star alarm and look up at the monitor. This is the rhythm
that your patient has.
You gently lower the patient to the floor in the rescue position.
You call for help and your team members immediately arrive with the
code cart.
Your first thought would be Airway, Oxygen, Monitor, Assess, and IV.
You have called for help. Your help is here. You patient has a pulse but
his blood pressure is still around 70/doppler. His airway is clear and he
is breathing on his own at 18 breaths per minute. You request an IV
line be started with Normal Saline (his IV came out when you lowered
him to the floor) and Oxygen via non-rebreather mask at 12-15 L/min.

Your rhythm is?*

Sinus Bradycardia
Second Degree AV Block
Very Slow V-Tach
Third Degree AV Block

Your patient’s condition is?*

Stable
Unstable
Dead

Your first treatment would be?*

Atropine 1 mg. IV
Lidocaine 1.5 mg./kg. IV
Immediate Transcutaneous Pacing (TCP)
Start CPR and call a code
Because of your last intervention your patient’s rhythm is now this,
see below.
Your patient responds to tactile stimuli. His oxygen saturation is 94%.
His pulse is 80 bpm strong and regular. His blood pressure is
78/44mmHg.
His blood pressure and vital signs are now stable. He is awake, alert,
and oriented times 3. You assist him back to bed with the help of your
team. The patient’s physician arrives while the patient is requesting a
bedpan. You ask the patient to wait until his physician considers the
options of putting in a transvenous pacemaker. The nursing supervisor
is waiting for you outside his room. You go to her smiling, knowing she
is going to commend you on a fine job! The nursing supervisor hands
you an incident report and says, “Here. Fill this out and get it back to
me before you leave your shift!" You look at her in dismay, and she
says, “Well, he fell on the floor, didn’t he? Ain’t it the truth?”

Scenario 3
You are a Registered Nurse working in the Emergency Room. The
paramedics coordinator notifies you that she just received a patch
that the paramedics are en route with a patient with chest pain. His
vitals are stable at this time. She lost the patch before she could get
his rhythm. You rapidly move the patient out of Room 6 (Private Room)
and place blue pads around the gurney. Your team members hand you
a disposable gown, mask, goggles, and gloves. Mr. John Doe arrives by
stretcher and the paramedics transfer him to your gurney. Mr. Doe is
yelling and smells strongly of alcohol. Mr. Doe’s tattered clothes are
covered with vomit. You start taking a brief history and Mr. Doe spits
at you. You place him to the monitor and this is his rhythm. You
question whether he is having pain, and he says, “No”. His vitals are
stable with BP of 142/88mmHg.
Your rhythm is?*
Sinus Tachycardia
Second Degree AV Block
Atrial Tachycardia
Atrial Flutter

Mr. Doe looks like he’s going to vomit, but suddenly passes out. This is
his new rhythm below. He is pulseless and is not breathing. You verify
the new rhythm in two EKG leads.

Your patient’s condition is?*

Stable
Unstable
Dead

Your first treatment would be?*

Atropine 1 mg. IV
Lidocaine 1.5 mg./kg. IV
Defibrillate immediately at 200 joules
Start CPR and call a code
CPR is in progress now. The medics intubated him and are bagging him
with 100% O2 with bag-valve-device with reservoir. His breath sounds
are equal with no epigastric sounds on ventilation. Your second team
nurse starts an IV line with normal saline. You have good pulse with
CPR, none without CPR.

Your next intervention would be?*

Atropine 1 mg. IV
Epinephrine 1 mg. 1:10,000 solution IV
 Start a norepinephrine drip
Smack the medic who brought him in

You get no response from the drug. The code team continues to work
with good CPR and you increase the fluids to wide open.

Scenario 4
You found Mr. Smith, a 66-year-old male in full cardiac arrest. His wife
and his neighbor were doing bystander CPR, your estimated down time
on arrival was 4-5 minutes. Mr. Smith had an MI six months ago with
successful angioplasty of his RCA. Mrs. Smith states her husband has
been doing well until late this afternoon after playing 36 holes of golf.
He came home with his friend and complained of feeling very weak,
sat in the chair and collapsed. His wife called 911 and started CPR
with a friend. From his initial assessment you found him in ventricular
fibrillation and pulseless. Your crew has already defibrillated him,
intubated him, continued CPR, started an IV with Normal Saline, and
given him one dose of Epinephrine 1 mg 1:10,000 solution. Pulses are
good with CPR and breath sounds are equal with no sounds in the
epigastric area. After the Epinephrine was given you did a fourth
defibrillation. This is the rhythm you have now.

Your rhythm is?*

Sinus Bradycardia
Third Degree AV Block
Second Degree AV Block
Junctional Rhythm

Mr. Smith has no pulse with the above rhythm. You recheck pulses,
and they are still absent.

Your patient’s condition is?*

 Stable
Unstable
Dead

You tell your team members the patient’s condition is…?*

Pretty serious
Defibrillate immediately at 200 Joules
Dead; give him Lidocaine 1.5 mg./kg. IV
In PEA (Pulseless Electrical Activity) and start CPR

Your next intervention would be?*

Atropine 1 mg. IV
Epinephrine 1mg 1:10000 solution IV
Start a Dopamine Drip
Give 2.5 mg. of Verapamil
The code team continues to work with CPR. You have good pulses
with CPR, but still no pulses without CPR.

What might be a cause of Mr. Smith’s condition?*

Hypovolemia secondary to dehydration
Pulmonary Embolism
Massive Myocardial Infarction
Hypoxemia secondary to Tension Pneumothorax
He may have any of the above
The patient’s BP is 78/30mmHg. You have given him a total of 2,000cc
of Normal Saline.

Scenario 4
You are a Registered Nurse assigned to a Telemetry Unit. Mrs. Ewok
was admitted with “fainting spells”. So far, her work-up has nothing
unusual. You are at her bedside taking her vitals when she states, “I
have that funny feeling again in my chest." Your team member calls
into her room, “Mrs. Ewok is in…!”

Your rhythm is?*

Sinus Tachycardia
 A-Flutter w/ Rapid Response
Ventricular Tachycardia
SVT
Mrs. Ewok remains alert and orientated. She denies chest pain and
shortness of breath. Her vitals are Pulse 180 bpm, BP is 136/52mmHg,
Respirations are 20, and oxygen saturation is 99% on 2 LPM nasal
prongs. She has a #18 Jelco in her left antecubital space with Normal
Saline at 15cc an hour.

Your patient’s condition is?*

Stable
Unstable
Dead

Based on the information you have this far, you call for the “crash
cart” and do the following:*
Do a synchronized cardioversion at 50 joules
Give her Lidocaine 1.5 mg./kg. IV
Defibrillate immediately at 200 joules
Give her adenosine 6 mg. IV rapidly at the site, followed by 20 ml. normal saline push

Because of your intervention, you now have the following rhythm

below. You should…*

Call a code and start CPR

Say, “Uh Oh”, and state, “I need to check my other patients”
Call for the external pacemaker
Wait for at least another 6 seconds before you start to sweat
Because of your last intervention Mrs. Ewok’s Rhythm is now this (see
below). She is slow to respond and her Blood Pressure is now
68/30mmHg. What should you do next?*
 Increase the fluids and start a Levophed Drip
Give her another close of 6mg of Adenosine
Give her 12 mg. of Adenosine
Do a synchronized cardioversion at 50 joules
Because of your last intervention, Mrs. Ewok is in the rhythm below.
She is awake, alert and orientated. Her Pulse is in the 80’s. Blood
pressure is 120/64mmHg, and Respirations are 20 BPM.

Because of your quick thinking, fast intervention, and help from your
team members, Mrs. Ewok is doing well. Later that afternoon you hear
Mrs. Ewok’s physician state to her, “Well, young lady, I have found out
why you have those fainting spells.”