ACLS Case Study 10: In-Hospital

You are a healthcare provider working in the emergency department. An 83-year-old female in chronic kidney failure arrives by ambulance with complaints of myalgia, nausea, and progressive fatigue over the last 48-hrs. Their last dialysis appointment was three days ago. A rapid initial assessment reveals the following:

Vital signs

• Pulse rate: 41/min
• Blood pressure: Unobtainable
• Respiratory rate: Unobtainable
• Temperature: Unobtainable

Physiological systems

• Integumentary: Cool
• Cardiovascular: Weak radial pulses bilaterally
• Respiratory: Lungs CTA bilaterally
• Neurological: Weak, responsive

The AHA ACLS 2020-2025 bradycardia algorithm has two pathways: observation and intervention.

You provide supplemental oxygen, perform a 12-lead ECG, monitor vitals, and establish IV access. You determine that the patient is not perfusing adequately and decide to administer atropine 1.0 mg IV bolus. A rhythm check reveals unchanged sinus bradycardia. There are no changes in spontaneous circulation.

Transcutaneous pacing is not always available depending on the provider or environment. Certain drugs can be administered as an alternative to transcutaneous pacing for patients with symptomatic sinus bradycardia.

As you prepare transcutaneous pacing, the patient complains of a sudden tightness in their chest and a feeling of breathlessness. A rhythm check reveals a conversion from sinus bradycardia to a third-degree atrioventricular block. An attempt to pace the rhythm is unsuccessful and a second rhythm check reveals a conversion from a third-degree atrioventricular block to ventricular fibrillation. The patient no longer has a palpable pulse.

A single unsynchronized shock of 120 J is delivered, and CPR is started for five cycles. Following five cycles of CPR, a rhythm check reveals unchanged ventricular fibrillation.

A single unsynchronized shock of 200 J is delivered, and CPR is resumed for five cycles. During the first cycle of CPR, you administer epinephrine 1.0 mg IVP. Following five cycles of CPR, a rhythm check reveals unchanged ventricular fibrillation. A single unsynchronized shock of 300 J is delivered, and CPR is resumed for another five cycles. You consider administering an antiarrhythmic drug, but the Code Team advises you that amiodarone is not available.

Lidocaine is a class IB antiarrhythmic that increases the electrical stimulation threshold of the ventricle, suppressing the automaticity of conduction through the tissue.

Lidocaine 1.0-1.5 mg/kg is administered, and CPR is resumed for five cycles. Following five cycles of CPR, a rhythm check reveals a conversion from ventricular fibrillation to sinus rhythm. The patient now has a palpable pulse and vital signs are HR 91/min, BP 106/70, RR 6/min. A return of spontaneous circulation is observed but the patient remains unresponsive.

Amongst other actions, you have decided to implement targeted temperature management. An optimal target temperature range should be achieved and maintained for at least 24 hrs following cardiac arrest.