You are a healthcare provider working in a rehabilitation center with ALS capabilities. A 66-year-old female 11 days post-op from a total hip arthroplasty complains of general malaise and heavy palpitations. The patient does not report any pain or difficulty breathing. A rapid initial assessment reveals the following:

Vital signs

Pulse rate: 161/min
Blood pressure: 120/80
Respiratory rate: 18/min
Temperature: 37.4 °C

Physiological systems

Integumentary: Pale, dry
Cardiovascular: Palpable peripheral pulses bilaterally
Respiratory: Lungs CTA bilaterally
Neurological: Alert, oriented

1.A cardiac monitor is attached to the patient. A rhythm check reveals sinus tachycardia at 161/min. The patient soon experiences a short run of ventricular tachycardia that converts spontaneously back to sinus tachycardia. During this run, you observe that the patient held their chest and appeared to have difficulty breathing, which has since subsided. What are your initial actions?

Prepare the defibrillator and establish IV access Attempt vagal maneuvers Activate a code blue Provide supplemental oxygen

The defibrillator is prepared and IV access is established. Shortly after, the patient soon complains of rapid palpitations and pain radiating down their left arm. A rhythm check reveals conversion from sinus tachycardia to narrow complex supraventricular tachycardia.

2.What are your next actions?

Perform synchronized cardioversion Administer adenosine 6.0 mg IVP Deliver a single unsynchronized shock of 120 J Attempt vagal maneuvers

Vagal maneuvers are attempted with no change in condition. A rhythm check reveals unchanged narrow complex supraventricular tachycardia.

3.What are your next actions?

Prepare to perform synchronized cardioversion Administer adenosine 12.0 mg IVP Administer adenosine 6.0 mg IVP Continue to attempt vagal maneuvers until conversion to sinus rhythm is observed

Adenosine 6.0 mg IVP is administered with no change in condition. You decide to administer a second dose of adenosine at 12.0 mg IVP further showing no change in condition. You decide to perform synchronized cardioversion. As you prepare to cardiovert, the patient becomes unresponsive, and a pulse is no longer palpable. A rhythm check reveals ventricular tachycardia.

4.What are your next actions?

Continue with performing synchronized cardioversion Start CPR (five cycles) Administer epinephrine 1.0 mg IVP without delay Deliver a single unsynchronized shock of 120 J

A single unsynchronized shock of 120 J is delivered, and CPR is started for five cycles. Following five cycles of check compressions, a pulse check reveals a faint but palpable pulse. The monitor shows a HR of 189/min, but an unchanged narrow-complex tachycardia. The patient is not breathing spontaneously. Supported ventilation is provided via BVM. You perform synchronized cardioversion at 100 J with no change in condition.

5.What are your next actions?

Perform synchronized cardioversion at 150 J Administer amiodarone 300 mg IVP Resume CPR (five cycles) Perform a pulse check

You perform a pulse check which reveals that a palpable pulse is still present. You consider performing synchronized cardioversion at a higher setting.

6.What setting should you use in the given scenario?

Cardiovert at 125 J Cardiovert at 100 J Cardiovert at 220 J Cardiovert at 200 J

Synchronized cardioversion is performed at 200 J, and a rhythm check reveals a conversion from ventricular tachycardia to sinus rhythm.

7.If cardioversion was unable to convert the rhythm, what other actions would you have considered?

Administration of epinephrine 1.0 mg IVP Administration of adenosine 12.0 mg IVP Attempting vagal maneuvers Delivering a single unsynchronized shock of 200 J

The patient has been stabilized and transferred to the intensive care unit.

8.What is the name of the ACLS algorithm that should be followed immediately after cardiac arrest resuscitation?

Post-cardiac arrest care Post-arrest care Post-cardiac care Post-resuscitative care

9.The ACLS Post-Cardiac Arrest Care algorithm emphasizes prevention of what three clinical conditions following cardiac arrest?

Hypoxia, hypercapnia, hyperkalemia Hypercapnia, hypotension, hypoxia Hyperkalemia, hyperoxia, hypotension Hyperoxia, hypoxia, hypotension

ACLS Case Study 8: Out-of-Hospital

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Turn this success into CME Credit

Don’t stop here - Turn this into a learning opportunity

Vital signs

Physiological systems

The defibrillator is prepared and IV access is established. Shortly after, the patient soon complains of rapid palpitations and pain radiating down their left arm. A rhythm check reveals conversion from sinus tachycardia to narrow complex supraventricular tachycardia.

Vagal maneuvers are attempted with no change in condition. A rhythm check reveals unchanged narrow complex supraventricular tachycardia.

You perform a pulse check which reveals that a palpable pulse is still present. You consider performing synchronized cardioversion at a higher setting.

Synchronized cardioversion is performed at 200 J, and a rhythm check reveals a conversion from ventricular tachycardia to sinus rhythm.

The patient has been stabilized and transferred to the intensive care unit.

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ACLS Case Study 8: Out-of-Hospital

Hurry, don't let time run out!

Turn this success into CME Credit

Don’t stop here - Turn this into a learning opportunity

Vital signs

Physiological systems

The defibrillator is prepared and IV access is established. Shortly after, the patient soon complains of rapid palpitations and pain radiating down their left arm. A rhythm check reveals conversion from sinus tachycardia to narrow complex supraventricular tachycardia.

Vagal maneuvers are attempted with no change in condition. A rhythm check reveals unchanged narrow complex supraventricular tachycardia.

You perform a pulse check which reveals that a palpable pulse is still present. You consider performing synchronized cardioversion at a higher setting.

Synchronized cardioversion is performed at 200 J, and a rhythm check reveals a conversion from ventricular tachycardia to sinus rhythm.

The patient has been stabilized and transferred to the intensive care unit.

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