ACLS Symptomatic Bradycardia Progressing to PEA

Initial Presentation:

A 45-year-old male in the hospital develops symptomatic bradycardia, with a heart rate of 30 bpm and signs of poor perfusion, including cold extremities and hypotension. Despite initial interventions, the patient’s condition worsens, and he progresses to pulseless electrical activity (PEA). The medical team works rapidly to address the evolving crisis.

What is the foundational first step in any emergency scenario?

A 45-year-old male presents with fatigue, lightheadedness, and bradycardia at 30 beats per minute. What is your first step?

Administer atropine 1 mg IV

Assess airway, breathing, and circulation.

Defibrillate the patient

Prepare for transcutaneous pacing

What is the first-line drug for bradycardia per ACLS guidelines?

The patient shows signs of poor perfusion (altered mental status, hypotension). What is your next step?

Administer epinephrine 1 mg IV.

Initiate transcutaneous pacing.

Start a dopamine infusion.

Administer atropine 0.5 mg IV.

What intervention follows atropine in symptomatic bradycardia?

Atropine is administered, but the heart rate remains unchanged. What is your next step?

Administer a second dose of atropine.

Initiate transcutaneous pacing.

Start a norepinephrine infusion.

Administer epinephrine 1 mg IV.

How can you ensure patient comfort during pacing?

The patient develops severe chest pain during transcutaneous pacing. What should you do next?

Increase the current without sedation.

Administer analgesia and sedation.

Reduce the pacing rate to below 30 bpm.

Stop pacing immediately.

What is the immediate priority for non-shockable rhythms?

The patient progresses to pulseless electrical activity (PEA). What is your first step?

Perform synchronized cardioversion.

Start high-quality CPR.

Administer epinephrine 1 mg IV.

Intubate the patient immediately.

What is the recommended medication for non-shockable rhythms?

What medication is recommended during CPR for PEA?

Administer amiodarone 300 mg IV.

Administer atropine 0.5 mg IV.

Start a dopamine infusion.

Administer epinephrine 1 mg IV/IO every 3-5 minutes.

What are the most common H's and T's in ACLS?

The team evaluates for reversible causes of PEA. Which is the most likely reversible cause in this patient?

Tension pneumothorax.

Hyperkalemia.

Toxins.

Hypoxia.

What is the first-line agent for hypotension post-ROSC?

ROSC is achieved. BP is 85/50 mmHg, and the patient remains intubated. What is your next step?

Administer atropine IV.

Perform synchronized cardioversion.

Administer amiodarone.

Start a norepinephrine infusion to support BP.

What SpO2 range minimizes hypoxia and hyperoxia?

Post-ROSC, what is your oxygenation goal for the patient?

100%

94-99%

88-92%

90-94%

What improves recovery for comatose patients after cardiac arrest?

The patient remains comatose post-ROSC. What is the next step to improve neurological outcomes?

Initiate targeted temperature management (32-36°C).

Administer dopamine infusion.

Perform synchronized cardioversion.

Administer high-dose steroids.

ACLS Practice Megacodes