Megacode 1— Out-of-Hospital Unstable Bradycardia Megacode Testing Checklist: Scenarios 1/3/8

(Unstable Bradycardia > pVT > PEA > PCAC) Bradycardia → Pulseless VT → PEA → PCAC
Lead-in: You are a paramedic treating a man who had a syncopal episode. Student Name __________________________________________ Date of Test ___________________
Vital Signs
Check
Heart rate:
Critical Performance Steps if done
Blood pressure: 78/42 mm Hg correctly
Respiratory rate:
Spo2: Team Leader
Temperature:
Assigns team member roles
Weight:
Ensures high- Compression rate Compression Chest compression Chest recoil Ventilation
Age: 62 years 100-120/min depth of ≥2 inches fraction >80% (optional) (optional)
quality CPR at
Initial Assessment
all times ☐ ☐ ☐ ☐ ☐
• The patient is conscious and alert. Ensures that team members communicate well

What are your initial actions? Bradycardia Management

• His skin is pale, and he is diaphoretic. Starts oxygen if needed, places monitor, starts IV
• The patient is not following commands. Places monitor leads in proper position
• There is no radial pulse, but the carotid pulse is weak and slow. Recognizes symptomatic bradycardia
Administers correct dose of atropine
Adult Bradycardia Algorithm Prepares for second-line treatment
Instructor notes: The ECG monitor shows a sinus bradycardia with
Pulseless VT Management
occasional PVC.
Recognizes pVT
The student should follow the Adult Bradycardia Algorithm and be prepared to
Clears before analyze and shock
administer a single dose of atropine while preparing for transcutaneous pacing.
Immediately resumes CPR after shocks
Adult Cardiac Arrest Algorithm (pVT) Appropriate airway management
Appropriate cycles of drug–rhythm check/shock–CPR
Instructor notes: With the introduction of the pacing impulse, the ECG
Administers appropriate drug(s) and doses
monitor displays VT. There is no pulse.
The student should immediately discontinue pacing and defibrillate the patient. PEA Management
The student will follow the VF/pVT pathway of the Adult Cardiac Arrest Algorithm. Recognizes PEA
The student should assign team functions and monitor for high-quality CPR. Verbalizes potential reversible causes of PEA (H’s and T’s)
The case should continue through safe defibrillation and administration of Administers appropriate drug(s) and doses
epinephrine and amiodarone. Immediately resumes CPR after rhythm checks

Adult Cardiac Arrest Algorithm (PEA) Post–Cardiac Arrest Care

Identifies ROSC
Instructor notes: After the third shock, the patient develops an organized
Ensures BP and 12-lead ECG are performed, O2 saturation is monitored, verbalizes need for
rhythm that is slow. There is no pulse. The patient is now in PEA.
endotracheal intubation and waveform capnography, and orders laboratory tests
The student continues to monitor high-quality CPR and follows the PEA Considers targeted temperature management
pathway of the Adult Cardiac Arrest Algorithm.
STOP TEST
The student should consider reversible causes.
Test Results  Circle PASS or NR to indicate pass or needs remediation: PASS NR
Post–Cardiac Arrest Care Algorithm
Instructor notes: After ensuring effective ventilation, the student can now Instructor Initials _________ Instructor Number ___________________________ Date ____________________
detect a carotid pulse. The patient has ROSC.
Learning Station Competency
The student should initiate the Post–Cardiac Arrest Care Algorithm. ☐ Bradycardia ☐ Tachycardia ☐ Cardiac Arrest/Post–Cardiac Arrest Care ☐ Megacode Practice

© 2020 American Heart Association

Megacode 2—Out-of-Hospital Unstable Bradycardia Megacode Testing Checklist: Scenarios 2/5
(Unstable Bradycardia > VF > Asystole > PCAC) Bradycardia → VF → Asystole → PCAC
Lead-in: You are called to a restaurant for a man who suddenly became
unresponsive, vomited, and then stopped breathing. You have a 4-minute response Student Name __________________________________________ Date of Test ___________________
to the scene in your ALS ambulance.
Check
Vital Signs Critical Performance Steps if done
correctly
Heart rate: 44/min and very strong
Blood pressure: 84/50 mm Hg Team Leader
Respiratory rate: 3/min
Spo2: Assigns team member roles
Temperature: Ensures high- Compression rate Compression Chest compression Chest recoil Ventilation
Weight: quality CPR at 100-120/min depth of ≥2 inches fraction >80% (optional) (optional)
Age: all times ☐ ☐ ☐ ☐ ☐
Ensures that team members communicate well
Initial Assessment
• You arrive at the scene to find 3 firefighters assisting the patient. Bradycardia Management
• One is maintaining an open airway, another is suctioning the patient, and the Starts oxygen if needed, places monitor, starts IV
third is getting vital signs. Places monitor leads in proper position
• Witnesses state that the patient had a normal day but seemed irritated. Recognizes symptomatic bradycardia
Administers correct dose of atropine
Adult Bradycardia Algorithm
Prepares for second-line treatment
Instructor notes: The patient is in sinus bradycardia when the limb leads are
applied, and the 12-lead ECG is not suspicious for injury or ischemia. VF Management
An IV is being initiated when the patient has a 5-second episode of grand mal seizures Recognizes VF
and then remains unresponsive. Bag-mask ventilation is initiated with oxygen. Clears before analyze and shock
Shortly after that, the patient has no respirations and no pulse. The monitor shows VF. Immediately resumes CPR after shocks
Appropriate airway management
Adult Cardiac Arrest Algorithm (VF) Appropriate cycles of drug–rhythm check/shock–CPR
Instructor notes: Defibrillation is attempted, and then CPR is provided for Administers appropriate drug(s) and doses
2 minutes. During this time, his wife says that he is normally healthy and takes only Asystole Management
vitamin supplements but that he’s been under extreme stress at work lately.
Recognizes asystole
After the first 2 minutes of CPR, the rhythm is still VF. Another shock is given,
followed by more CPR . Epinephrine is given, and an advanced airway is placed, Verbalizes potential reversible causes of asystole (H’s and T’s)
with an ETCO2 reading of 22 mm Hg noted. Two minutes later, the rhythm is Administers appropriate drug(s) and doses
asystole, confirmed in 2 leads. Immediately resumes CPR after rhythm checks

Adult Cardiac Arrest Algorithm (Asystole) Post–Cardiac Arrest Care

Instructor notes: CPR continues, and treatable causes are considered. Identifies ROSC
Ensures BP and 12-lead ECG are performed, O2 saturation is monitored, verbalizes need for
After 2 minutes of CPR, the monitor shows a borderline wide-complex organized endotracheal intubation and waveform capnography, and orders laboratory tests
rhythm with a rate of 56/min, and there are pulses present.
Considers targeted temperature management
Post–Cardiac Arrest Care Algorithm STOP TEST
Instructor notes: Blood pressure is 180/108 mm Hg. The patient is still apneic
with a capnography reading of 50 mm Hg. Test Results  Circle PASS or NR to indicate pass or needs remediation: PASS NR
A finger-stick glucose reading (if asked for by Team Leader) is 187 mg/dL
Instructor Initials _________ Instructor Number ___________________________ Date ____________________
(10.4 mmol/L), and he remains unresponsive.
For transport considerations, the nearest emergency department is 4 minutes Learning Station Competency
from the scene, a comprehensive stroke center is 12 minutes from the scene, and a ☐ Bradycardia ☐ Tachycardia ☐ Cardiac Arrest/Post–Cardiac Arrest Care ☐ Megacode Practice
cardiac arrest receiving center is 16 minutes from the scene.
Megacode 3—Out-of-Hospital Unstable Bradycardia Megacode Testing Checklist: Scenarios 1/3/8
(Unstable Bradycardia > pVT > PEA > PCAC) Bradycardia → Pulseless VT → PEA → PCAC
Lead-in: Your ALS ambulance is dispatched to help an elderly man having chest pain. A
BLS engine is also responding. You arrive to find the firefighters placing a nonrebreathing Student Name __________________________________________ Date of Test ___________________
oxygen mask on the patient.
Vital Signs Check
Heart rate: Temperature: Critical Performance Steps if done
Blood pressure: 86/48 mm Hg by Doppler Weight: correctly
Respiratory rate: 18/min and nonlabored Age:
Spo2: Team Leader

Initial Assessment Assigns team member roles

• The patient is sitting with his back against a wall, alert and talking with firefighters. Ensures high- Compression rate Compression Chest compression Chest recoil Ventilation
quality CPR at 100-120/min depth of ≥2 inches fraction >80% (optional) (optional)
• He says his chest feels heavy and he might need to vomit; this started abruptly while
he waited in line at the bank.
• He has had cardiac problems in the past, and he received a heart transplant 2 years ago.
all times ☐ ☐ ☐ ☐ ☐
Ensures that team members communicate well
What are your initial actions?
Instructor notes: His pulse is slow and weak, and he is grossly diaphoretic and pale and Bradycardia Management
gray. The monitor displays a third-degree AV block with wider QRS complexes and a Starts oxygen if needed, places monitor, starts IV
rate of 32/min.
Places monitor leads in proper position
He takes multiple medications, but they are at his home. He is allergic to sulfa. The
12-lead ECG is suspicious for injury in leads II, III, and aVF, and lead V4R is flat. Recognizes symptomatic bradycardia
Administers correct dose of atropine
Adult Bradycardia Algorithm
Prepares for second-line treatment
Instructor notes: If students try to give atropine, it will have no effect because of
heart denervation. Pulseless VT Management
The transcutaneous pacemaker is applied, but before it acquires capture, the patient Recognizes pVT
becomes unresponsive, the rhythm changes to VT, and he becomes apneic. There is
no pulse. Clears before analyze and shock
Immediately resumes CPR after shocks
Adult Cardiac Arrest Algorithm (pVT) Appropriate airway management
Instructor notes: Defibrillation is attempted, and then high-quality CPR is given for Appropriate cycles of drug–rhythm check/shock–CPR
2 minutes, during which peripheral IVs are established in each arm. After 2 minutes, the Administers appropriate drug(s) and doses
rhythm is still VT.
Defibrillation is attempted again, with CPR and epinephrine administered. PEA Management
Bag-mask ventilation is performed without difficulty, so an advanced airway isn’t Recognizes PEA
necessary unless the Team Leader feels it’s indicated. Verbalizes potential reversible causes of PEA (H’s and T’s)
After 2 minutes, the rhythm is sinus bradycardia with marginally wide QRS complexes.
A pulse is not present. Administers appropriate drug(s) and doses
Immediately resumes CPR after rhythm checks
Adult Cardiac Arrest Algorithm (PEA)
Post–Cardiac Arrest Care
Instructor notes: CPR is continued, an advanced airway is now placed, and
capnography is connected, with a reading of 22 mm Hg. Identifies ROSC
After 2 minutes of CPR, the rhythm is nearly the same, and the QRS complexes aren’t as Ensures BP and 12-lead ECG are performed, O2 saturation is monitored, verbalizes need for
wide, but the rate is the same. endotracheal intubation and waveform capnography, and orders laboratory tests
A carotid pulse is present, but a radial pulse can’t be felt. The ETCO2 reading is now Considers targeted temperature management
48 mm Hg.
STOP TEST
Post–Cardiac Arrest Care Algorithm
Instructor notes: The patient will bat his eyes to loud voices, and he begins breathing at Test Results  Circle PASS or NR to indicate pass or needs remediation: PASS NR
8 breaths per minute. His blood pressure by Doppler is 68/40 mm Hg.
The Team Leader should consider dopamine infusion for blood pressure support and/or Instructor Initials _________ Instructor Number ___________________________ Date ____________________
epinephrine infusion to support perfusion.
Learning Station Competency
The closest emergency department is 3 minutes from the scene, and a STEMI receiving
center is 12 minutes from the scene. ☐ Bradycardia ☐ Tachycardia ☐ Cardiac Arrest/Post–Cardiac Arrest Care ☐ Megacode Practice
Megacode 4—Out-of-Hospital Unstable Ventricular Tachycardia Megacode Testing Checklist: Scenarios 4/7/10
(Unstable Tachycardia > VF > PEA > PCAC) Tachycardia → VF → PEA → PCAC
Lead-in: Your ALS ambulance is dispatched to a car that has pulled to the side of the
highway. The caller was driving the patient to an appointment, but she was sick and Student Name __________________________________________ Date of Test ___________________
needed to stop. She reports shortness of breath and weakness.
Vital Signs Check
Heart rate: 150/min Temperature: Critical Performance Steps if done
Blood pressure: 84/54 mm Hg Weight: correctly
Respiratory rate: 20/min with mildly labored breathing Age: 65 years
Spo2: 94% on 15 L/min of oxygen Team Leader
Initial Assessment Assigns team member roles
• Your unit arrives to the scene to find the patient in the passenger seat of an SUV, Ensures high- Compression rate Compression Chest compression Chest recoil Ventilation
awake and talking in 2- to 3-word sentences. quality CPR at 100-120/min depth of ≥2 inches fraction >80% (optional) (optional)
• Her lungs have fine crackles in both bases.
• There are palpable carotid and radial pulses.
all times ☐ ☐ ☐ ☐ ☐
Ensures that team members communicate well
What are your initial actions?
Tachycardia Management
Adult Tachycardia With a Pulse Algorithm
Instructor notes: The student’s partner attaches the cardiac monitor, and the initial Starts oxygen if needed, places monitor, starts IV
rhythm is monomorphic wide-complex tachycardia. Places monitor leads in proper position
Due to the overall patient condition, the Team Leader should consider cardioversion. Recognizes unstable tachycardia
A peripheral IV is attempted without success. Cardioversion is performed without a Recognizes symptoms due to tachycardia
change in condition.
While the student prepares to increase the energy to cardiovert again, the patient’s head Performs immediate synchronized cardioversion
slumps, and she stops breathing. The monitor now shows VF. VF Management
Adult Cardiac Arrest Algorithm (VF) Recognizes VF
Instructor notes: The patient is rapidly moved from the car to the stretcher. CPR is Clears before analyze and shock
initiated, defibrillation is quickly delivered, and CPR is continued. Immediately resumes CPR after shocks
The stretcher (with CPR in progress) is moved to the ambulance to access equipment. Appropriate airway management
During CPR, an IO access is achieved, and bag-mask ventilation is performed with Appropriate cycles of drug–rhythm check/shock–CPR
mild difficulty.
Administers appropriate drug(s) and doses
After 2 minutes, the rhythm is still VF, defibrillation is performed, and CPR continues.
Epinephrine is given, and an advanced airway is placed, with a capnography reading of PEA Management
25 mm Hg. Recognizes PEA
After 2 minutes, the rhythm is an organized wide-complex rhythm at a rate of 70/min,
but no pulses are present. Verbalizes potential reversible causes of PEA (H’s and T’s)
Administers appropriate drug(s) and doses
Adult Cardiac Arrest Algorithm (PEA) Immediately resumes CPR after rhythm checks
Instructor notes: CPR is continued, and capnography readings continue to hover
between 22 and 27 mm Hg during CPR. Post–Cardiac Arrest Care
Treatable causes are considered, and the person driving the vehicle states, “I was taking Identifies ROSC
her to dialysis because she missed her appointment 2 days ago.” Ensures BP and 12-lead ECG are performed, O2 saturation is monitored, verbalizes need for
Calcium chloride or gluconate and sodium bicarbonate should be considered for this endotracheal intubation and waveform capnography, and orders laboratory tests
patient to offset hyperkalemia. Considers targeted temperature management
After this, at the next rhythm check, the monitor shows a marginally wide-complex
rhythm, with severely peaked T waves, and a rate of 100/min. The patient now has a STOP TEST
pulse at the carotid.
Test Results  Circle PASS or NR to indicate pass or needs remediation: PASS NR
Post–Cardiac Arrest Care Algorithm
Instructor notes: The patient is starting to have spontaneous respirations (disorganized) Instructor Initials _________ Instructor Number ___________________________ Date ____________________
with a capnography reading of 60 mm Hg and Spo2 of 100% with oxygen. Her blood pressure
is 94/56 mm Hg. A finger-stick glucose reading of 330 mg/dL (18.3 mmol/L) is obtained. Learning Station Competency
The nearest emergency department is 7 minutes away; a tertiary care center is ☐ Bradycardia ☐ Tachycardia ☐ Cardiac Arrest/Post–Cardiac Arrest Care ☐ Megacode Practice
14 minutes away.
Megacode 5—Emergency Department Unstable Bradycardia Megacode Testing Checklist: Scenarios 2/5
(Unstable Bradycardia > VF > Asystole > PCAC) Bradycardia → VF → Asystole → PCAC
Lead-in: You are working in the emergency department when paramedics bring in a
drowsy man. They are concerned about a drug overdose. Student Name __________________________________________ Date of Test ___________________

Vital Signs Check

Heart rate: Temperature: Critical Performance Steps if done
Blood pressure: Weight: correctly
Respiratory rate: Age: 28 years
Spo2: Team Leader
Assigns team member roles
Initial Assessment Compression rate Compression Chest compression Chest recoil Ventilation
Ensures high-
• Paramedics say that the patient has a history of depression and also takes quality CPR at 100-120/min depth of ≥2 inches fraction >80% (optional) (optional)
diltiazem for an unknown reason.
• A family member on scene said that the patient has had a very low mood lately
all times ☐ ☐ ☐ ☐ ☐
Ensures that team members communicate well
and threatened suicide earlier in the day.
• An empty bottle of diltiazem was found beside the patient when the Bradycardia Management
paramedics arrived. Starts oxygen if needed, places monitor, starts IV
What are your initial actions? Places monitor leads in proper position
• Assessing the patient on the paramedic stretcher, you find the patient very Recognizes symptomatic bradycardia
drowsy and slurring his words. Administers correct dose of atropine
• You cannot get any useful information from the patient on his history. Prepares for second-line treatment
Adult Bradycardia Algorithm VF Management
Instructor notes: His vital signs include heart rate 30/min, respiratory rate Recognizes VF
16/min, blood pressure 80/48 mm Hg, Spo2 98% on 3 L by nasal prongs, Clears before analyze and shock
temperature 36.5°C, and blood glucose 195 mg/dL (10.8 mmol/L). Immediately resumes CPR after shocks
A rhythm strip shows wide QRS ventricular escape rhythm at 30, with a long QT. Appropriate airway management
His heart rate continues to drop, and then the patient suddenly becomes Appropriate cycles of drug–rhythm check/shock–CPR
unresponsive and loses his pulse. The monitor shows VF. Administers appropriate drug(s) and doses
Asystole Management
Adult Cardiac Arrest Algorithm (VF)
Recognizes asystole
Instructor notes: Students should follow the VF pathway of the Adult Cardiac
Arrest Algorithm. Verbalizes potential reversible causes of asystole (H’s and T’s)
Advanced students may consider discussing intravenous lipid emulsion therapy Administers appropriate drug(s) and doses
and extracorporeal CPR. Immediately resumes CPR after rhythm checks
Post–Cardiac Arrest Care
Adult Cardiac Arrest Algorithm (Asystole)
Identifies ROSC
Instructor notes: After the second shock, the patient’s rhythm changes to asystole.
Ensures BP and 12-lead ECG are performed, O2 saturation is monitored, verbalizes need for
The student should follow the asystole pathway of the Adult Cardiac Arrest Algorithm endotracheal intubation and waveform capnography, and orders laboratory tests
with special attention given to high-quality CPR and good team communication. Considers targeted temperature management
Post–Cardiac Arrest Care Algorithm STOP TEST
Instructor notes: After several rounds of CPR and ACLS, the patient has ROSC.
The rhythm on the monitor is a ventricular escape bradycardia with hypotension.
Test Results  Circle PASS or NR to indicate pass or needs remediation: PASS NR
The student should consider the toxicological aspects of the case as well as the Instructor Initials _________ Instructor Number ___________________________ Date ____________________
differential diagnosis.
A discussion around the treatment of calcium channel blocker overdose and Learning Station Competency
available treatment options may be included for advanced learners. ☐ Bradycardia ☐ Tachycardia ☐ Cardiac Arrest/Post–Cardiac Arrest Care ☐ Megacode Practice
Megacode 6—In-Hospital Unstable Bradycardia Megacode Testing Checklist: Scenarios 6/11
(Unstable Bradycardia > VF > PEA > PCAC) Bradycardia → VF → PEA → PCAC
Lead-in: A man admitted to the hospital with pneumonia has chest pain on the second
day of his hospital course. You are called to evaluate him. Student Name __________________________________________ Date of Test ___________________
Vital Signs
Check
Heart rate: Temperature:
Blood pressure: Weight:
Critical Performance Steps if done
correctly
Respiratory rate: Age: 58 years
Spo2: Team Leader
Initial Assessment Assigns team member roles
What are your initial actions? Ensures high- Compression rate Compression Chest compression Chest recoil Ventilation
quality CPR at 100-120/min depth of ≥2 inches fraction >80% (optional) (optional)
Adult Bradycardia Algorithm
Instructor notes: The patient’s vital signs are heart rate 35/min, respiratory rate 18/min,
all times ☐ ☐ ☐ ☐ ☐
and blood pressure 88/49 mm Hg. Ensures that team members communicate well
The monitor shows a third-degree heart block. The initial dose of atropine will not Bradycardia Management
have much effect, and pacing should be initiated. Starts oxygen if needed, places monitor, starts IV
With pacing, the patient’s blood pressure will also improve such that the patient can now
Places monitor leads in proper position
go to the cardiac cath lab.
Recognizes symptomatic bradycardia
Adult Cardiac Arrest Algorithm (VF) Administers correct dose of atropine
Instructor notes: Just after completing cardiac catheterization (with findings of 100% Prepares for second-line treatment
right coronary artery occlusion), the patient will develop VF.
The patient will be refractory to at least 3 shocks, thus allowing the student to progress VF Management
through the algorithm. Chest compressions should be initiated with high-quality CPR Recognizes VF
and the airway managed initially with bag-mask ventilation and, ultimately, probably Clears before analyze and shock
intubation and epinephrine/amiodarone. Immediately resumes CPR after shocks
Errors would be to provide epinephrine before at least 2 shocks. After the third shock, Appropriate airway management
the patient will go into a sinus tachycardia with no pulse (PEA).
Appropriate cycles of drug–rhythm check/shock–CPR
Of note, if the student chose to relook at the coronary arteries, this would be an Administers appropriate drug(s) and doses
appropriate step and they would be patent (ie, the underlying cause could be arterial
reocclusion, but this advanced reasoning is beyond the expectations of the scenario). PEA Management
Adult Cardiac Arrest Algorithm (PEA) Recognizes PEA
Instructor notes: The patient is now in PEA. The student continues to monitor high- Verbalizes potential reversible causes of PEA (H’s and T’s)
quality CPR, and epinephrine should be provided. Administers appropriate drug(s) and doses
After a dose of epinephrine, the student will notice that the continuous ETCO2 rises Immediately resumes CPR after rhythm checks
to 40 mm Hg. The student should recognize that ROSC is likely and stop CPR, even
if the full 2 minutes is not performed, because the ETCO2 is indicating ROSC (a good Post–Cardiac Arrest Care
opportunity for this teaching point). Identifies ROSC
Underlying causes during this event that could be considered include cardiac Ensures BP and 12-lead ECG are performed, O2 saturation is monitored, verbalizes need for
tamponade, and, if an ultrasound is performed, there would be no fluid present. endotracheal intubation and waveform capnography, and orders laboratory tests
Considers targeted temperature management
Post–Cardiac Arrest Care Algorithm
Instructor notes: After the student recognizes ROSC (ETCO2 rises to 40 mm Hg) and STOP TEST
checks a pulse, the patient will be found to be hemodynamically unstable, with heart rate
110/min and blood pressure 70/30 mm Hg. Test Results  Circle PASS or NR to indicate pass or needs remediation: PASS NR
The student should ask for the vital signs, not state them. The patient should receive
a fluid bolus, and a vasopressor infusion should be initiated (blood pressure will not Instructor Initials _________ Instructor Number ___________________________ Date ____________________
improve with fluids alone). Learning Station Competency
The patient will not follow commands and is a candidate for targeted ☐ Bradycardia ☐ Tachycardia ☐ Cardiac Arrest/Post–Cardiac Arrest Care ☐ Megacode Practice
temperature management.
Megacode 7—In-Hospital Unstable Ventricular Tachycardia Megacode Testing Checklist: Scenarios 4/7/10
(Unstable Tachycardia > VF > PEA > PCAC) Tachycardia → VF → PEA → PCAC
Lead-in: You are a healthcare provider caring for a patient who was admitted for chest
pain, and you rule out myocardial infarction. He was diagnosed with stable angina 10 years Student Name __________________________________________ Date of Test ___________________
ago, but over the past few months, his pain has been increasing in duration and intensity.
Check
Vital Signs Critical Performance Steps if done
Heart rate: 82/min Temperature: correctly
Blood pressure: 124/74 mm Hg Weight:
Respiratory rate: 16/min Age: Team Leader
Spo2: 98%
Assigns team member roles
Initial Assessment Ensures high- Compression rate Compression Chest compression Chest recoil Ventilation
quality CPR at 100-120/min depth of ≥2 inches fraction >80% (optional) (optional)
What are your initial actions?
Instructor notes: At the change of shift, the patient denied chest pain. The student all times ☐ ☐ ☐ ☐ ☐
leaves the room and is soon called back by the patient’s son. Ensures that team members communicate well
The student enters the room and assesses that the patient is clutching his chest, stating
he has chest pain, and displaying diaphoresis. His vital signs are now heart rate 160/min, Tachycardia Management
respiratory rate 22/min, blood pressure 156/92 mm Hg, and Spo2 93%. Starts oxygen if needed, places monitor, starts IV
His bedside monitor shows a monomorphic, wide, and rapid rhythm, which is Places monitor leads in proper position
different from previously recorded rhythms. The patient may have an acute coronary
syndrome. Because of the patient’s history, the student will initially focus on the Recognizes unstable tachycardia
tachycardia rhythm. Recognizes symptoms due to tachycardia
The student will question the patient on his current symptoms and ensure IV line Performs immediate synchronized cardioversion
patency and cardiac monitoring. Nitroglycerin may be initiated as long as the blood
pressure is greater than 90 mm Hg systolic and the patient continues to have chest pain.
VF Management
Administration of aspirin is appropriate as long as the patient is responsive. Recognizes VF
Clears before analyze and shock
Adult Tachycardia With a Pulse Algorithm Immediately resumes CPR after shocks
Instructor notes: The symptoms of the patient’s tachycardia require management and Appropriate airway management
treatment. The student can differentiate that the patient is in VT and is symptomatic. The
Appropriate cycles of drug–rhythm check/shock–CPR
treatment for this is immediate cardioversion, and drug therapy should not delay
the cardioversion. Administers appropriate drug(s) and doses
PEA Management
Adult Cardiac Arrest Algorithm (VF)
Instructor notes: Upon delivery of the cardioversion shock, the patient develops Recognizes PEA
a different rhythm, which is identified as VF. Now, the student will follow the VF/pVT Verbalizes potential reversible causes of PEA (H’s and T’s)
pathway of the Adult Cardiac Arrest Algorithm. Administers appropriate drug(s) and doses
The Team Leader assigns team functions and monitors for high-quality CPR. The case Immediately resumes CPR after rhythm checks
continues through safe defibrillation, administering a vasopressor, and considering an
antiarrhythmic drug. Post–Cardiac Arrest Care
Identifies ROSC
Adult Cardiac Arrest Algorithm (PEA)
Ensures BP and 12-lead ECG are performed, O2 saturation is monitored, verbalizes need for
Instructor notes: Despite the student’s actions, the patient is now showing second- endotracheal intubation and waveform capnography, and orders laboratory tests
degree AV block on the monitor with no pulse (PEA).
Considers targeted temperature management
The Team Leader should continue to monitor high-quality CPR and follow the PEA
pathway of the Adult Cardiac Arrest Algorithm. STOP TEST
The patient may be in cardiogenic shock, so the student must be able to differentiate
and discuss potential causes of PEA. Test Results  Circle PASS or NR to indicate pass or needs remediation: PASS NR

Post–Cardiac Arrest Care Algorithm Instructor Initials _________ Instructor Number ___________________________ Date ____________________
Instructor notes: The team continues high-quality chest compressions, and the patient
Learning Station Competency
has ROSC. At this point, you should initiate the Post–Cardiac Arrest Care Algorithm.
☐ Bradycardia ☐ Tachycardia ☐ Cardiac Arrest/Post–Cardiac Arrest Care ☐ Megacode Practice
Megacode 8—In-Hospital Unstable Bradycardia Megacode Testing Checklist: Scenarios 1/3/8
(Unstable Bradycardia > pVT > PEA > PCAC) Bradycardia → Pulseless VT → PEA → PCAC
Lead-in: A man who was admitted to the hospital with palpitations now reports chest
discomfort, and you are called to evaluate him. Student Name __________________________________________ Date of Test ___________________
Vital Signs
Check
Heart rate: 50/min
Blood pressure: 150/70 mm Hg
Critical Performance Steps if done
correctly
Respiratory rate: 24/min
Spo2: 90% on room air Team Leader
Temperature:
Weight: Assigns team member roles
Age: 72 years Compression rate Compression Chest compression Chest recoil Ventilation
Ensures high-
quality CPR at 100-120/min depth of ≥2 inches fraction >80% (optional) (optional)
Initial Assessment
What are your initial actions?
all times ☐ ☐ ☐ ☐ ☐
Ensures that team members communicate well
• A 12-lead ECG reveals an acute inferior STEMI.
Bradycardia Management
Adult Bradycardia Algorithm
Starts oxygen if needed, places monitor, starts IV
Instructor notes: The patient has a STEMI, bradycardia, and hypoxia. The patient
should be placed on supplemental oxygen because of the hypoxia, the cath lab should Places monitor leads in proper position
be activated, and aspirin should be given. Recognizes symptomatic bradycardia
The patient’s heart rate is 50/min and the monitor shows sinus bradycardia. Because Administers correct dose of atropine
the blood pressure is stable, no intervention is necessary. Prepares for second-line treatment
If the student chooses to give atropine, the side effects of this drug in acute myocardial
infarction (when not clinically indicated) can be discussed. Pulseless VT Management
Other interventions, such as anticoagulation, could be considered while preparing for the cath Recognizes pVT
lab, although nitroglycerin should be avoided because of the inferior myocardial infarction. Clears before analyze and shock
Immediately resumes CPR after shocks
Adult Cardiac Arrest Algorithm (pVT)
Appropriate airway management
Instructor notes: While waiting to go to the cath lab, the patient becomes
Appropriate cycles of drug–rhythm check/shock–CPR
unresponsive, is pulseless, and has VT on the monitor.
Administers appropriate drug(s) and doses
One correct action would be immediate defibrillation (one could also have done
precordial thump as a witnessed event) simultaneously with good CPR. PEA Management
VT will persist despite a defibrillation attempt, and the patient will need high-quality CPR, Recognizes PEA
bag-mask ventilation with or without intubation, and reevaluation of the rhythm after
2 minutes of CPR. Verbalizes potential reversible causes of PEA (H’s and T’s)
After a second defibrillation attempt, the patient’s rhythm will change to PEA. Administers appropriate drug(s) and doses
Immediately resumes CPR after rhythm checks
Adult Cardiac Arrest Algorithm (PEA)
Post–Cardiac Arrest Care
Instructor notes: After epinephrine is given for PEA, the rhythm will go back to VF.
Identifies ROSC
After another defibrillation attempt, the ETCO2 will rise to 40 mm Hg after about 1 minute
of CPR. Ensures BP and 12-lead ECG are performed, O2 saturation is monitored, verbalizes need for
endotracheal intubation and waveform capnography, and orders laboratory tests
The student should recognize that ROSC is obtained, and CPR should be stopped rather
than continue for an additional minute. Considers targeted temperature management
STOP TEST
Post–Cardiac Arrest Care Algorithm
Instructor notes: After ROSC, the patient should have his vital signs checked (heart Test Results  Circle PASS or NR to indicate pass or needs remediation: PASS NR
rate 108/min, blood pressure 80/60 mm Hg, Spo2 95%).
He should be given a fluid bolus for hypotension and rapidly transported to the cath lab Instructor Initials _________ Instructor Number ___________________________ Date ____________________
for revascularization.
He is unresponsive, so plans can be made to initiate targeted temperature management, Learning Station Competency
ideally simultaneously with revascularization in the cath lab. ☐ Bradycardia ☐ Tachycardia ☐ Cardiac Arrest/Post–Cardiac Arrest Care ☐ Megacode Practice
Megacode 9—In-Hospital Stable Tachycardia (SVT) Megacode Testing Checklist: Scenario 9
(Stable Tachycardia > PEA > VF > PCAC) Tachycardia → PEA → VF → PCAC
Lead-in: A woman with a history of lupus and asthma was admitted with pneumonia.
She is doing well initially but develops tachycardia while receiving albuterol for ongoing Student Name __________________________________________ Date of Test ___________________
wheezing.
Check
Vital Signs
Heart rate: 160/min, and the monitor shows SVT Temperature: Critical Performance Steps if done
correctly
Blood pressure: 140/70 mm Hg Weight:
Respiratory rate: Age: 42 years
Spo2: Team Leader
Assigns team member roles
Initial Assessment Compression rate Compression Chest compression Chest recoil Ventilation
Ensures high-
What are your initial actions? quality CPR at 100-120/min depth of ≥2 inches fraction >80% (optional) (optional)

Adult Tachycardia With a Pulse Algorithm all times ☐ ☐ ☐ ☐ ☐

Instructor notes: If the student gives adenosine in this scenario, the rhythm will Ensures that team members communicate well
change from SVT to sinus, but the patient will progress to severe respiratory distress Tachycardia Management
with marked wheezing. Adenosine is relatively contraindicated in asthma exacerbation
because of the effects on the adenosine receptors, and it will worsen the underlying Starts oxygen if needed, places monitor, starts IV
asthma exacerbation, leading to respiratory distress. If the student recognizes this and Places monitor leads in proper position
chooses an alternative for SVT, that should be positively noted, but for the scenario, the
patient will progress to respiratory failure anyway. Recognizes tachycardia (specific diagnosis)
The patient is in profound respiratory distress with wheezing and will be refractory to Recognizes no symptoms due to tachycardia
any attempts at albuterol. The patient will clearly either need immediate intubation or her Considers appropriate initial drug therapy
condition will progress to complete respiratory failure requiring bag-mask ventilation.
After intubation, the patient’s condition will progress to PEA. The student should PEA Management
recognize this by evaluating for pulse and blood pressure after the intubation. Also, the Recognizes PEA
PEA theoretically could be caused or contributed to by excessive ventilation (ie, auto-
Verbalizes potential reversible causes of PEA (H’s and T’s)
PEEP) immediately after intubation.
Administers appropriate drug(s) and doses
Adult Cardiac Arrest Algorithm (PEA) Immediately resumes CPR after rhythm check and pulse checks
Instructor notes: The patient is in PEA after intubation with contributions from auto- VF Management
PEEP given the severe asthma. The ventilation rate should be low, and the student
should consider disconnecting the bag to allow full exhalation. Recognizes VF
After the student attends to the ventilation rate and provision of epinephrine, the patient Clears before analyze and shock
will have a rhythm change to VF. Immediately resumes CPR after shocks
Adult Cardiac Arrest Algorithm (VF) Appropriate airway management
Instructor notes: The patient is in VF, and immediate defibrillation is required. After Appropriate cycles of drug–rhythm check/shock–CPR
attempting defibrillation, chest compressions can be initiated. After about 1 minute of Administers appropriate drug(s) and doses
chest compressions, ETCO2 will rise from 12 mm Hg to 38 mm Hg.
Post–Cardiac Arrest Care
The student should recognize ROSC, discontinue CPR, confirm pulse and blood pressure,
and move to the Post–Cardiac Arrest Care Algorithm. Identifies ROSC
Ensures BP and 12-lead ECG are performed, O2 saturation is monitored, verbalizes need for
Post–Cardiac Arrest Care Algorithm endotracheal intubation and waveform capnography, and orders laboratory tests
Instructor notes: After ROSC, the patient will have substantial auto-PEEP, and one Considers targeted temperature management
immediate strategy will need to be avoiding excessive ventilation. The blood pressure will be
relatively low (89/70 mm Hg) but responsive to fluids, and vasopressors are not necessarily STOP TEST
needed, although they could be prepared in case the patient’s condition worsens.
Because the causes of arrest are pneumonia and asthma, there should not be Test Results  Circle PASS or NR to indicate pass or needs remediation: PASS NR
consideration for cardiac catheterization (if performed, a 12-lead ECG will show sinus
tachycardia at rate of 110/min but otherwise normal). Instructor Initials _________ Instructor Number ___________________________ Date ____________________
The patient will not be following commands and thus would be a candidate for targeted
temperature management. Oxygenation will be marginal, so the principle of avoiding Learning Station Competency
hypoxia (as opposed to hyperoxia) will be in play. ☐ Bradycardia ☐ Tachycardia ☐ Cardiac Arrest/Post–Cardiac Arrest Care ☐ Megacode Practice
Megacode 10—In-Hospital Unstable Ventricular Tachycardia Megacode Testing Checklist: Scenarios 4/7/10
(Unstable Tachycardia > VF > PEA > PCAC) Tachycardia → VF → PEA → PCAC
Lead-in: You are working in the cardiac care unit of your hospital. A woman who
Student Name __________________________________________ Date of Test ___________________
underwent PCI 3 hours ago is reporting heavy central chest pressure and nausea.
Vital Signs Check
Heart rate: 130/min Temperature: 37°C Critical Performance Steps if done
correctly
Blood pressure: 72/40 mm Hg Weight:
Respiratory rate: 20/min Age: 51 years
Team Leader
Spo2:
Assigns team member roles
Initial Assessment Ensures high- Compression rate Compression Chest compression Chest recoil Ventilation
What are your initial actions? quality CPR at 100-120/min depth of ≥2 inches fraction >80% (optional) (optional)
• On initial assessment, the patient reports feeling light-headed and nauseated, all times ☐ ☐ ☐ ☐ ☐
with severe central crushing chest pain. Ensures that team members communicate well
• She appears drowsy, pale, and diaphoretic. The Spo2 monitor is not showing a
waveform and giving no reading. Tachycardia Management
• The rhythm strip shows a regular wide-complex tachycardia at 130/min. Starts oxygen if needed, places monitor, starts IV
Places monitor leads in proper position
Adult Tachycardia With a Pulse Algorithm
Recognizes unstable tachycardia
Instructor notes: A 12-lead ECG shows VT at 130/min. A previous ECG done
before the procedure shows a normal sinus tachycardia with narrow complex. Recognizes symptoms due to tachycardia
The goals of this section will be for the student to recognize unstable VT and Performs immediate synchronized cardioversion
follow the algorithm, assess ABCs, provide supplemental O2, ensure adequate IV VF Management
access, discuss the pros and cons of analgesia and sedation, demonstrate safe Recognizes VF
synchronized cardioversion, and consider treatment for acute ischemia and acute
Clears before analyze and shock
coronary syndromes in this setting.
Immediately resumes CPR after shocks
Adult Cardiac Arrest Algorithm (VF) Appropriate airway management
Instructor notes: After 2 failed synchronized cardioversions, the patient loses Appropriate cycles of drug–rhythm check/shock–CPR
pulses and becomes apneic and unresponsive. The monitor shows VF. Administers appropriate drug(s) and doses
Focus on safe defibrillation, high-quality compressions, and a consideration of PEA Management
differential diagnoses. Recognizes PEA
Adult Cardiac Arrest Algorithm (PEA) Verbalizes potential reversible causes of PEA (H’s and T’s)
Instructor notes: After the second defibrillation attempt, the patient’s rhythm Administers appropriate drug(s) and doses
changes to a wide-complex regular rhythm (with P waves) at 70/min. The patient Immediately resumes CPR after rhythm checks
still has no pulses.
Post–Cardiac Arrest Care
The student should follow the PEA pathway of the Adult Cardiac Arrest Algorithm.
Identifies ROSC
Students should focus on high-quality chest compressions and may consider
Ensures BP and 12-lead ECG are performed, O2 saturation is monitored, verbalizes need for
advanced airway and underlying causes, including pulmonary embolism and endotracheal intubation and waveform capnography, and orders laboratory tests
myocardial infarction hemorrhage, among other things.
Considers targeted temperature management
Post–Cardiac Arrest Care Algorithm STOP TEST
Instructor notes: The team continues high-quality chest compressions, the
patient has ROSC, and the team initiates the Post–Cardiac Arrest Care Algorithm. Test Results  Circle PASS or NR to indicate pass or needs remediation: PASS NR
The students may consider myocardial ischemia and involvement of the
interventional cardiologist (question acute stent obstruction). Instructor Initials _________ Instructor Number ___________________________ Date ____________________
If the patient cannot follow commands, targeted temperature management should Learning Station Competency
be started. ☐ Bradycardia ☐ Tachycardia ☐ Cardiac Arrest/Post–Cardiac Arrest Care ☐ Megacode Practice
Megacode 11—In-Hospital Colonoscopy Suite Unstable Bradycardia Megacode Testing Checklist: Scenarios 6/11
(Unstable Bradycardia > VF > PEA > PCAC)
Bradycardia → VF → PEA → PCAC
Lead-in: A patient is undergoing his initial colon screening. Fifteen minutes into the procedure,
under conscious sedation, the patient’s respiratory rate drops to 4 and ETCO2 is 55 mm Hg. Student Name __________________________________________ Date of Test ___________________
Vital Signs
Heart rate: Check
Blood pressure: Critical Performance Steps if done
Respiratory rate: correctly
Spo2:
Temperature: Team Leader
Weight:
Age: 51 years Assigns team member roles
Ensures high- Compression rate Compression Chest compression Chest recoil Ventilation
Initial Assessment quality CPR at 100-120/min depth of ≥2 inches fraction >80% (optional) (optional)
What are your initial actions?
• This healthy man with a family history of colon cancer (maternal grandfather and uncle) is
all times ☐ ☐ ☐ ☐ ☐
undergoing an initial screening colonoscopy. Ensures that team members communicate well
• He has no significant past medical history except daily alcohol use (3 to 4 drinks per day). Bradycardia Management
• The patient had received a combination of fentanyl and midazolam for conscious sedation.
• It is noted that as the ETCO2 rises, the patient becomes less arousable and then apneic. Starts oxygen if needed, places monitor, starts IV
• The Code Team is activated. Places monitor leads in proper position
What are the next steps?
Recognizes symptomatic bradycardia
Instructor notes: IV reversal agents are ordered. Bag-mask ventilation is initiated. His vital signs
are heart rate 30/min, respiratory rate 3/min, blood pressure 70/P mm Hg, and Spo2 82% on Administers correct dose of atropine
4 L/min via nasal cannula. Prepares for second-line treatment
Students should recognize the impending respiratory failure and consider reversal agents.
The patient is placed on 100% oxygen, and flumazenil and naloxone are provided with improved VF Management
oxygen saturations, but there is no change in respiratory rate. A supraglottic airway is placed. Recognizes VF
Adult Bradycardia Algorithm Clears before analyze and shock
Instructor notes: The patient’s respiratory status has been stabilized. Immediately resumes CPR after shocks
The student should note the abnormal heart rate and hypotension. The bradycardia is slow and Appropriate airway management
narrow complex without ST changes. The patient is unstable and given IV atropine (0.5 mg)
twice without change in heart rate or blood pressure. Appropriate cycles of drug–rhythm check/shock–CPR
While the dopamine infusion is being prepared, the patient becomes unresponsive. Administers appropriate drug(s) and doses
What is the next action? PEA Management
Adult Cardiac Arrest Algorithm (VF) Recognizes PEA
Instructor notes: The monitor demonstrates VF.
Verbalizes potential reversible causes of PEA (H’s and T’s)
What is the action?
Instructor notes: The patient has no pulse. CPR is started. The VF/pVT pathway should be Administers appropriate drug(s) and doses
followed. Shocks are delivered. Epinephrine and amiodarone are given. Immediately resumes CPR after rhythm checks
An advanced airway is placed. A rhythm check shows SVT. No pulse or spontaneous respirations
are confirmed. Post–Cardiac Arrest Care
Adult Cardiac Arrest Algorithm (PEA) Identifies ROSC
Instructor notes: CPR is continued. Bag-mask ventilation at 100% is continued. A second dose Ensures BP and 12-lead ECG are performed, O2 saturation is monitored, verbalizes need for
of epinephrine is given with no change in condition. endotracheal intubation and waveform capnography, and orders laboratory tests
During the rhythm check, the monitor reveals a narrow-complex tachycardia and no pulse. The Considers targeted temperature management
PEA pathway of the Adult Cardiac Arrest Algorithm is followed.
Post–Cardiac Arrest Care Algorithm STOP TEST
Instructor notes: The team continues high-quality chest compressions, the patient has ROSC,
and the team initiates the Post–Cardiac Arrest Care Algorithm. Test Results  Circle PASS or NR to indicate pass or needs remediation: PASS NR
Instructor Initials _________ Instructor Number ___________________________ Date ____________________
Learning Station Competency
☐ Bradycardia ☐ Tachycardia ☐ Cardiac Arrest/Post–Cardiac Arrest Care ☐ Megacode Practice
Megacode 12—In-Hospital Surgical Waiting Room Unstable Megacode Testing Checklist: Scenario 12
Bradycardia (Unstable Bradycardia > VF > Asystole/PEA > PCAC) Bradycardia → VF → Asystole/PEA → PCAC
Lead-in: A woman sits in the surgical waiting room, awaiting news about her
husband’s surgery, when she suddenly becomes light-headed and dizzy and Student Name __________________________________________ Date of Test ___________________
nearly passes out.
Check
Vital Signs Critical Performance Steps if done
Heart rate: Temperature: correctly
Blood pressure: Weight:
Respiratory rate: Age: 67 years Team Leader
Spo2: Assigns team member roles
Ensures high- Compression rate Compression Chest compression Chest recoil Ventilation
Initial Assessment 100-120/min depth of ≥2 inches fraction >80% (optional) (optional)
quality CPR at
• The patient has a past medical history of breast cancer (in remission) and diabetes.
• She is lying on the floor.
all times ☐ ☐ ☐ ☐ ☐
Ensures that team members communicate well
• You respond as a member of the medical emergency team that was activated.
What are your initial steps? Bradycardia Management
Instructor notes: She admits that she forgot to eat breakfast today. The rest of Starts oxygen if needed, places monitor, starts IV
the team arrives. Her vital signs are heart rate 28/min, respiratory rate 18/min, blood Places monitor leads in proper position
pressure 68/P mm Hg, 96% Spo2 on room air, and blood sugar 90 mg/dL (5 mmol/L). Recognizes symptomatic bradycardia
The patient is moved to a stretcher. Administers correct dose of atropine
The monitor shows a second-degree type II AV block. Prepares for second-line treatment
Adult Bradycardia Algorithm VF Management
Instructor notes: The student should note the abnormal heart rate and Recognizes VF
hypotension. The bradycardia is narrow complex without ST changes. Clears before analyze and shock
The patient is unstable and given IV atropine (0.5 mg) twice without a change in Immediately resumes CPR after shocks
heart rate or blood pressure. Appropriate airway management
What is the next action? Appropriate cycles of drug–rhythm check/shock–CPR
The patient is wheeled urgently to the hospital emergency department. Administers appropriate drug(s) and doses

Adult Cardiac Arrest Algorithm (VF) Asystole and PEA Management

Instructor notes: The monitor demonstrates VF. Recognizes asystole and PEA
What is the action? Verbalizes potential reversible causes of asystole and PEA (H’s and T’s)
The patient has no pulse. CPR is started. Administers appropriate drug(s) and doses
The student should follow the VF/pVT pathway. Shocks are delivered twice, and Immediately resumes CPR after rhythm checks
epinephrine and amiodarone are given. An advanced airway is placed. Post–Cardiac Arrest Care
A monitor check demonstrates asystole. No pulse or spontaneous respirations Identifies ROSC
are confirmed.
Ensures BP and 12-lead ECG are performed, O2 saturation is monitored, verbalizes need for
Adult Cardiac Arrest Algorithm (Asystole and PEA) endotracheal intubation and waveform capnography, and orders laboratory tests
Considers targeted temperature management
Instructor notes: CPR is continued. Bag-mask ventilation with 100% oxygen is
continued. Epinephrine is given (third dose). There is no change in her condition. STOP TEST
During the rhythm check, the monitor reveals a narrow-complex tachycardia
with no pulse. The PEA pathway of the Adult Cardiac Arrest Algorithm is followed. Test Results  Circle PASS or NR to indicate pass or needs remediation: PASS NR

Post–Cardiac Arrest Care Algorithm Instructor Initials _________ Instructor Number ___________________________ Date ____________________
Instructor notes: The team continues high-quality chest compressions, the Learning Station Competency
patient has ROSC, and the team initiates the Post–Cardiac Arrest Care Algorithm.
☐ Bradycardia ☐ Tachycardia ☐ Cardiac Arrest/Post–Cardiac Arrest Care ☐ Megacode Practice