ACLS Case Study 3: In-Hospital

You are a healthcare provider working in a surgical recovery unit. One of your patients is a 63-year-old male who is 4-hrs post-op from an unremarkable ACL reconstruction surgery. They are receiving supplemental oxygen via NC at 6 L/min. Upon entering their recovery room, you find the patient unconscious with the NC on the floor beside the bed. A rapid initial assessment reveals the following:

Vital signs

• Pulse rate: 25/min
• Blood pressure: Unobtainable
• Respiratory rate: 6/min
• Temperature: Not taken

Physiological systems

• Integumentary: Warm, diaphoretic
• Cardiovascular: Faintly palpable central pulses bilaterally
• Respiratory: Labored, shallow
• Neurological: Unresponsive

You secure the airway and begin supported ventilation via BVM. In addition to respiratory support, you recognize the need to ensure adequate IV access and monitor cardiovascular changes.

Adequate IV access has been ensured and a rhythm check reveals unchanged sinus bradycardia. The patient is progressively deteriorating, and signs of inadequate perfusion become rapidly apparent.

Atropine 1.0 mg IVP is administered with no change in condition. A rhythm check reveals unchanged sinus bradycardia. The HR is unchanged at 25/min.

TCP is attempted at a rate of 60/min. After 45 seconds, the attempt to capture is unsuccessful and there is no change in condition. You consider additional pharmacological intervention at this time.

An epinephrine infusion is prepared and transvenous pacing is considered. During this time, a rhythm check reveals a conversion from sinus bradycardia to asystole.

True asystole has been confirmed.

The first cycle of CPR is completed and epinephrine 1.0 mg IVP is administered. Following five cycles of CPR, a rhythm check reveals a conversion from asystole to ventricular fibrillation. The patient remains unresponsive.

A single shock of 120 J is delivered, and CPR is resumed for another 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 another five cycles.

Epinephrine is administered and the remaining cycles of CPR are performed. Following five cycles of CPR, a rhythm check reveals unchanged ventricular fibrillation. A single unsynchronized shock of 300 J is delivered, CPR is resumed for another five cycles, and amiodarone 300 mg IVP is administered. Following five cycles of CPR, a rhythm check reveals unchanged ventricular fibrillation.

A single unsynchronized shock of 360 J is delivered, and CPR is resumed for another 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. HR 71/min, BP 110/70, RR 11/min. Maintenance antiarrhythmic therapy is considered.