NCMB 418 - RLE A.K.
A
ADVANCED CARDIAC LIFE SUPPORT RETURN DEMONSTRATION
VOMIT SCRIPT
Pre-Arrest / ACLS Survey
VISUALIZE Tightening the straps around the head.”
The team leader will arrive and assess the patient. Team Leader: “Gathering supplies. Nasal
(Describe how the patient appears.) Cannula and face mask is not available. Will use
non-rebreather mask instead. Connecting tubing
Team Leader: “Assessing what is going on.
to the flow meter. Setting oxygen flow at
Assessing if the patient appears conscious.
prescribed rate which is 11 to 15 liters per unit.
Assessing done. The patient is sweating profusely
Partially inflating the reservoir bag. Placing the
and has agonal breathing and cyanosis.”
mask over the patient’s mouth and nose. Securing
VERBALIZE a firm seal. Placing the patient in an upright
position as clinically appropriate.”
The team leader will tap the patient and ask:
MONITORING
Team Leader: “Sir, are you alright? Can you tell
me how are you feeling? Is everything okay?” Team Leader: “Establishing cardiac monitoring
using (3-lead ECG or 5-lead ECG).”
The patient will respond.
3-Lead: White on the right. Smoke over fire.
VITAL SIGNS 5-Lead: White on the right. Smoke over fire.
Team Leader: “I will now take the following vital Snow over grass and let’s melt some
signs: Temp, Pulse Rate, RR, o2 Sat, and BP.” chocolates.
The CI will provide the vital signs. IV/IO ESTABLISH
Team Leader: “Oxygen Saturation is low. Will IV: Intravenous. On the vein.
provide oxygen therapy.” IO: Intraosseous. On the bone.
Use IO after 3 FAILED attempts of IV.
OXYGEN SATURATION
Team Leader: “I am going to establish IV line.
Nasal Cannula: 2 to 4 liters per unit Gathering supplies such as IV fluid, IV catheter,
Face Mask: 6 to 10 liters per unit IV tubing, tourniquet, tape, and antiseptic. Putting
NRM: 11 to 15 liters per unit gloves on. Connecting IV tubing to the bag.
Act as though you are doing what you are saying. Flushing. Choosing vein on the crook of the left
arm. Applying the tourniquet snugly 20-25 cm
Team Leader: “Gathering supplies. Nasal above insertion site. Feeling the vein. Disinfecting
Cannula is available. Connecting Nasal Cannula the insertion site with alcohol pad in the direction
tubing to the flow meter. Setting oxygen flow at of the venous flow. Skin has dried. Pulling skin
prescribed rate which is 2 to 4 liters per unit. taut to stabilize the vein. Inserting the catheter 15-
Placing the prongs into the patient’s nares. Fitting to-30-degree angle right on top of the vein. Bevel
the tubing around the patient’s ears.” up. Insertion done. Untying the tourniquet. Sliding
Team Leader: “Gathering supplies. Nasal the needle slightly. Backflow confirmed. Needle
Cannula is not available. Will use face mask out. Pressing a finger over the inserted catheter.
instead. Connecting tubing to the flow meter. Connecting tubing. Securing the catheter.
Setting oxygen flow at prescribed rate which is 6 to Loosening the clamp. Beginning infusion.”
10 liters per unit. Placing the mask over the
patient’s mouth and nose. Securing a firm seal.
NCMB 418 - RLE A.K.A
ADVANCED CARDIAC LIFE SUPPORT RETURN DEMONSTRATION
TREATMENT NOTE: Patient can be considered STABLE if the
BP is 90 and above. Check the cardiac monitor first.
Treatment will depend on what is flashed on the
cardiac monitor (Slow/Fast Cardiac Rate). Team Leader: “Patient’s BP is (state BP that you
see on the monitor). Patient is stable. Giving
Slow Rhythm: Sinus Bradycardia
physiologic treatment first which is Vagal
A: Atropine (1mg every 3-5 minutes) Maneuver Carotid Massage. Extending patient’s
T: ranscutaneous Pacing (Electric pulse) neck toward the opposite side. Ensuring there is
D: opamine Infusion (400mg + 250mL PNSS) no carotid bruit. (Place stethoscope on patient’s
E: pinephrine Infusion (1mg + 500mL PNSS) neck. Check for whooshing sound.) Applying firm
pressure on carotid sinus. (Count 1001-1009).
Carotid Massage done. Sir, can you cough?
(Patient cannot.)”
Team Leader: “I will proceed to pharmacologic
treatment. I am going to give 1st dose of Adenosine
Team Leader: “Based on the cardiac monitor, the
6mg rapid IV push followed by PNSS flush. If
patient is under Sinus Bradycardia. To increase
second dose is required, I will give Adenosine
heart rate, I am going to give 1mg of Atropine
12mg IV rapid push. Adenosine given.”
every 3 to 5 minutes as needed. Atropine given.”
Team Leader: “I will proceed to sedation. I am
If CI said, “Atropine ineffective. What are the
going to give 5mg of Diazepam. If unavailable, I
second-line drugs?”
can also use Demerol at 50mg.”
Team Leader: “If bradycardia is unresponsive to
Team Leader: “After sedating the patient, I will
Atropine, an equally effective alternative is
now proceed to synchronized cardioversion.
transcutaneous pacing with the use of beta-
Engaging synchronization mode. (Press sync
adrenergic agonists which are Epinephrine and
button). Initial recommended dose for narrow
Dopamine both used as infusions. 1mg of
regular rhythm is 50 to 100 joules; for narrow
Epinephrine is mixed with 500 mL PNSS with 2 to
irregular rhythm 120 to 200 joules. That being
10 mcg/min infusion rate. Dopamine is given 400
said, I will set the charge of defib at 50 joules.
mg mixed with 250 mL PNSS. Infusion rate for
Charge. (Press charge button.) Initiating shock in
Dopamine varies. Renal infusion rate is 1 to 3
3. 1 2 3. (Press shock button). Shock delivered.”
mcg/min while Cardiac infusion is 5 to 10
mcg/min.”
WIDE COMPLEX TACHYCARDIA
Fast Rhythm: Ventricular Tachycardia P: Amiodarone (150mg over 10 mins)
S: Sedate
NARROW COMPLEX TACHYCARDIA S: Synchronized Cardioversion
P: Vagal Maneuver (Carotid Massage + cough)
P: Adenosine (1st 6mg 2nd 12 mg)
S: Sedate
S: Synchronized Cardioversion
NOTE: Patient can be considered UNSTABLE if
the BP is below 90. Check the cardiac monitor first.
NCMB 418 - RLE A.K.A
ADVANCED CARDIAC LIFE SUPPORT RETURN DEMONSTRATION
Team Leader: “Patient’s BP is (state BP that you Team Leader: “Patient has gone into Vfib. (Name)
see on the monitor). Patient is unstable. I will give start the compressions! (Compressor will start the
Amiodarone 150 mg over 10 minutes. If VTACH 30:2 compressions right away). (Name) you’ll be
recurs, follow by maintenance infusion of on defibrillator! (Name) you’ll be recording!
1mg/min for the first 6 hours. Amiodarone given.” (Name) you’ll manage the airway! (Ambu bag)
(Name) establish an IV access.”
Team Leader: “I will proceed to sedation. I am
going to give 5mg of Diazepam. If unavailable, I POSITIONS:
can also use Demerol at 50mg.”
Team Leader: “After sedating the patient, I will
now proceed to synchronized cardioversion.
Engaging synchronization mode. (Press sync
button). Initial recommended dose for wide
regular rhythm is 100 joules; for wide irregular
rhythm give defib dose not synchronized. That
being said, I will set the charge of defib at 100
joules. Charge. (Press charge button.) Initiating
shock in 3. 1 2 3. (Press shock button). Shock
delivered.”
THE PATIENT IS STILL UNSTABLE.
Arrest: BLS Survey
30:2
Team Leader: “Patient is still unstable.
Proceeding to basic life support.”
BLS TAP AND SHOUT.
Team Leader: “Hey hey hey. Are you okay? Hey
hey hey. Are you alright? No response. (Push SHOCKABLE
button to call rescue team.) CODE BLUE! CODE VFIB/ PULSELESS VT
BLUE! Room 204! I’ll do high quality NON-SHOCKABLE
compression now.” ASYSTOLE/ PEA
Start 30 compressions 2 rescue breaths. At this point, compressor is doing the
PUSH HARD PUSH FAST. Complete chest recoil. compressions. Airway is giving rescue breaths
Interruption <10secs. Avoid excessive ventilation. through ambu bag. Defib activating the ECG
Simulator. IV/IO establishing IV access on crook of
CI will signal the rescue team to enter the scene. left arm. Observer take not of the time always and
medications given with dosage and infusion rate.
RESCUE TEAM ARRIVED.
Defib: “Charging at 360 joules. Stop touching the
patient. Is everybody clear? (CLEAR!) Shocking
in 3. 1 2 3. Shocking. Shock delivered.”
NCMB 418 - RLE A.K.A
ADVANCED CARDIAC LIFE SUPPORT RETURN DEMONSTRATION
Team Leader: “Continue high quality CPR.” 2 MINS 2ND CYCLE
IV/IO: “I have (IV/IO) access now.” Team Leader: “Okay. Let’s analyze. Switch roles.”
Team Leader: “Great. We’ll continue high quality Switch roles: Defib and Compressor. Start HQCPR.
CPR for2 minutes and evaluate the need for
CI will announce if “still in V-fib.”
additional defib. (Name of Observer) I’ll rely on
you to monitor the quality of the chest Team Leader: “Patient is in persistent Vfib. As per
compressions. (Name of IV/IO) If the arrest protocol, let’s shock again at 360 joules.”
persists, we’ll continue to drug therapy.”
Defib: “Charging at 360 joules. Stop touching the
2 MINS 1st CYCLE patient. Is everybody clear? (CLEAR!) Shocking
in 3. 1 2 3. Shocking. Shock delivered.”
Team Leader: “Okay. Let’s analyze. Switch roles.”
Team Leader: “Continue high quality CPR.”
Switch roles: Defib and Compressor. Start HQCPR.
Observer: “We can give the Amiodarone now.”
CI will announce if “still in V-fib.”
Team Leader: “Thanks, (Name of observer).
Team Leader: “Patient is still in V-fib. As per
(Name of IV/IO), please give 300 mg of
protocol, let’s shock again at 360 joules.”
Amiodarone.”
Defib: “Charging at 360 joules. Stop touching the
IV/IO: “Giving 300 mg of Amiodarone.
patient. Is everybody clear? (CLEAR!) Shocking
Amiodarone given and the (IV/IO) is flushed.”
in 3. 1 2 3. Shocking. Shock delivered.”
OBSERVER. Take note of the time each
Team Leader: “Continue high quality CPR.
medication is given.
(Name of IV/IO), please give 1mg of
Epinephrine.” Team Leader: “We’ve given 3 shocks. After the 2nd
shock we’ve given 1mg of Epinephrine. And we’ve
IV/IO: “Giving 1mg of Epinephrine and then
just administered 300 mg of Amiodarone. We’ll
saline flush. Epinephrine given.”
again administer Epinephrine. (Name of IV/IO),
OBSERVER. Take note of the time each please prepare 1 mg of Epinephrine.”
medication is given.
IV/IO: “Preparing 1 mg of Epinephrine.”
Team Leader: “Great. We’ve given 2 shocks and
Team Leader: “Let’s review any reversible causes
1mg of Epinephrine. The next medication to
considering the Hs and Ts.”
consider is Amiodarone. (Name of IV/IO), please
prepare 300 mg of Amiodarone.” IV/IO: “What about hypervolemia?”
IV/IO: “Preparing 300 mg of Amiodarone.” Team Leader: “That’s a good thought. We have
IV access established but no obvious signs of
Team Leader: “(Name of airway), are you getting
internal or external bleeding. Any other
good chest rise?”
suggestions?”
Airway: “Yes. I am being careful not to deliver
Defib: “What about hypoxia?”
ventilations too quickly or forcefully.”
Team Leader: “(Name of airway), is the airway
Team Leader: “Okay, great! Let’s continue there.”
still patent?”
Airway: “Still getting the chest rise.”
NCMB 418 - RLE A.K.A
ADVANCED CARDIAC LIFE SUPPORT RETURN DEMONSTRATION
Airway: “I don’t feel a pulse.”
2 MINS 3RD CYCLE Team Leader: “Continue chest compressions.
(Name of IV/IO). Let’s go ahead and give 150 mg
Team Leader: “Okay. Let’s analyze. Switch roles.”
of Amiodarone.”
Switch roles: Defib and Compressor. Start HQCPR.
IV/IO: “Giving 150 mg of Amiodarone.
CI will announce if status. Amiodarone given and the (IV/IO) is flushed.”
Team Leader: “Okay. The monitor shows (what is POST-ARREST: ROSC
the ECG reading). Do we have a pulse? (Airway
Team Leader: “Okay. Let’s analyze. Switch roles.”
check for pulse)”
Switch roles: Defib and Compressor. Start HQCPR.
NOTE:
CI will announce if status.
NON-SHOCKABLE
ASYSTOLE/ PEA Team Leader: “Okay. The monitor shows (what is
Class 1: HQCPR the ECG reading). Do we have a pulse? (Airway
Class 2: Epinephrine q3-5mins check for pulse).”
Airway: “I don’t feel a pulse.” Airway: “I can feel a rapid quick pulse.”
Team Leader: “Continue chest compressions. Team Leader: “Okay great. Let’s initiate
(Name of observer), how long has it been since the immediate post-cardiac arrest care. (Name of
last dose of epinephrine?” IV/IO), get BP, complete set of vital signs, pulse
ox, and GCS. (Name of Defib), let’s start a 12-lead
OBSERVER. Count how many minutes have ECG please. Can we check if this patient is
passed since your record of the last dose of Epi has breathing and responsive?”
been given.
Compressor: (Hold patient’s hands) “Ma’am/Sir,
Team Leader: “Okay, (Name of IV/IO). Let’s go can you squeeze my fingers? No eye opening. No
ahead and give 1 mg of Epinephrine.” verbal response. No motor response. Still
IV/IO: “Giving 1 mg of Epinephrine. Epinephrine unresponsive. GCS is 3.”
given and the (IV/IO) is flushed.”
OBSERVER. Take note of the time each
medication is given.
OBSERVER: “(Name of CURRENT compressor),
your compressions are slowing down. Can you
pick up the pace a bit?”
2 MINS 4TH CYCLE
Team Leader: “Okay. Let’s analyze. Switch roles.”
Switch roles: Defib and Compressor. Start HQCPR.
Team Leader: “Okay. The monitor shows (what is
the ECG reading). Do we have a pulse? (Airway
check for pulse)” Airway: Checking 4-point auscultation. “Still not
breathing.”
NCMB 418 - RLE A.K.A
ADVANCED CARDIAC LIFE SUPPORT RETURN DEMONSTRATION
Team Leader: “Okay let’s insert and advanced NOTES!!
airway and prepare for therapeutic hypothermia.”
IV/IO: “The patient’s BP is (check cardiac
monitor) with a heart rate of (check cardiac
monitor) in a rhythm of (what ECG reading).
Team Leader: “Okay the patient is hypotensive.
Let’s start with (computation: 30cc/kg) PNSS.
Since we started with hypothermia, let’s use cold
PNSS for the bolus at 4 degrees Celsius.”
Airway: “Starting intubation. Tilting the patient’s
head back. Inserting laryngoscope to mouth.
Raising epiglottis. Advancing tip of device into
larynx and then into trachea. Inflating balloon.
Removing laryngoscope. Tubes in.”
Team Leader: “Checking for patency.” (Do 5-
point auscultation. Normal: 4 positive sound 1
negative sound in the middle) Okay we’ve got good
breath sounds. PETCO Qualitative: Yellow.
Quantitative: 35 to 60. Let’s establish waveform
capnography. The o2 saturations is (check cardiac
monitor).”
Team Leader: “(Name of IV/IO), please insert
foley catheter before transferring the patient to
ICU.”