My Mega Code
I assure the scene is safe and enter wearing my Personal Protective Equipment.
My patient is talking to me so I know that he has an open airway, is breathing and has a pulse.
I assess his Level Of Conciousness and find that he is Alert and Oriented X3.
He is talking so i know that he does not need immediate defibrillation.
I move on to my secondary ABCD and set him up with Oxygen delivered by a non-rebreather mask at 15 liters 100% o2.
I find his rate to be 24 bpm and ask him to coach himself down to settle a bit.
I place him on the monitor, ask him his allergies and start my IV access.
The monitor is turned on to reveal a Ventricular Tachycardic Rhythm.
However, my patient is still talking, so he has a pulse.
V-Tach W/ a Pulse
I get a quick medical history. He is allergic to Motrin and Aspirin.
Since my patient is stable and is in V-Tach with a pulse I chose to go for Medicine before Edison.
I know I wil have to treat this patient with whatever anti-dyrhythmic I chose to use.
I go with Amiodarone.
I know that if his rhythm changes (which it will) Amiodarone will be the easiest to change dosages.
I order up 150 mg of Amiodarone delivered over 10 minutes.
I reassess and see no change in condistion.
I chose to go to Electricity and synchronize cardiovert him at 100J (joueles).
After the first shock, my patient falls into ventricular Fibrillation and goes unconsious.
V-FIB
I immiediately dial up 200J and turn off sync and defibrilate him
nothing
300j defib
nothing
360J
nothing
I Intubate my patient with an endotracheal airway and begin CPR.
I draw up 1mg of epinephrine, starting my epi regimen of 1mg every 3-5 mins.
I push the epi, do 30 second of CPR and Shock again at 360J
His ventricles are fibrilating and need some chemical help so for my anti-dysrhythmic i have already started the Amiodarone, but no with a cardiac standstill rhythm i need to double it.
I push Amiodarone 300mg.
CPR for 30-60 seconds.
Shock at 360J
Another Epi
CPR for 30-60 seconds
Shock at 360J
At this point I am stuck until his downtime exceeds 15 mins, at which point i need to use Sodium Bicarbonate @ 1m/Eq
I give the bicarb and the patient's rhythm changes to a sinus rhythm with an AV block.
Sinus Rhythm with a 2nd degree type I AV nodal Block, (winkebach)
I assess for a pulse to make sure my patient is not in Pulseless Electrical Activity.
He has a pulse.
He is unconscious.
His blood pressure is 80/30
His pulse is 40-50bpm
I recheck the monitor as my treatment depends heavily on the Degree of this AV block.
I ask if I am allowed to print out a strip. On paper it is much easier to distinguish between 2nd degree type I, 2nd degree type II, and 3rd degree complete heart block. On type II and 3rd the Use of Atropine is contraindicated because it will cause over generation of P-waves, which would not help at all.
Since I cannot completely distinguish the rhythm I err on the side of caution and withhold the Atropine.
(it turns out i called it right, and it was 2nd degree type II. I should have given atropine, so I get marked down for with-holding that treatment)
As this is a Bradycardic Rhythm, the next treament is Transcutaneous Cardiac Pacing. This will override the electrical activity of the heart and hopefully create a more favorable pulse-rate, which is my goal at this point.
I start pacing, but never gain electrical capture.
Unable to override his heart electrically, I stop the pacing.
My next treatment is a dopamine drip @ 5-20 mcg/kg/min
I arbitrarily pick 10mcg/kg/min and re-assess.
His blood pressure is now at 120/80
His pulse is still in the 40's
I need to pick up his pulse so the next available treatment is an Epinepherine Drip @ 2-10 mcg/min
I give him a drip at 5mcg/min and his rhythm changes to a narrow complex tachycardia
PSVT (paroxysmal supraventricular tachycardia)
I check to make sure my patient has maintained his pulse as his rhythm has changed.
He has a pulse of about 112
He is still unconscious.
BP is still at 120/80
Since he is unconscious I will not be able to get him to stimulate his vagal nerve by baring down, so I have to go to my adenosine.
I push adenosine 3 times at 6mg, 12mg, and 12mg... each followed by a 20ml saline flush.
Each produces a 5 second period of cardiac standstill and returns to PSVT without displaying anyhting diagnostic or converting the rhythm into normal sinus.
I look over my patient. He has gone through a cardiac standstill rhythm/CPR rhythm and i have brought him back from death to a narrow complex tach. He's intubated and unconscious, but alive.
Alive is important so the next few steps are crucial.
I need to slow him down, but i don't want to fuck up all the work i have done thus far.
For a patient in this rough of shape (in some other context) cardiversion would be indicated just like the V-Tach with a pulse... But i don't want to mess with my good thing.
I stare at my teacher.
I recount everything that I have done for this patient and how drastic my measures have been.
I have given Amiodarone twice, numerous epi's, a dopamine drip and an epi drip.
I realize while talking to him that the epi drip is infact, making my problem worse at this point.
My teacher is giving me this look like i've just stumbled upon a goldmine.
I chose to leave the dopamine drip running, to keep the blood pressure up at the picturesque 120/80.
I thnk about it and chose to stop the Epi drip and end it's stimulating effects on the ehart, in an effort to slow it down.
The rate does not change.
Back to my PSVT treatments...
I need to use a blocking agent like a Ca Channel Blocker, or a Beat Blocker.
I chose Lopressor (a beta blocker) 5mg IV push
My patient's rhythm changes to a normal sinus.
I check pulse.
He has a pulse.
My teacher hands me my scorecard and congratulates me. I have just passed the ACLS mega-code