Megacode 1 - Out-of-Hospital Unstable Bradycardia - Unstable Bradycardia > pVT > PEA > PCAC

Sep 23, 2026

Uploaded by Ezra

Out-of-hospital megacode scenario 1 focuses on managing an adult with syncope and unstable bradycardia progressing through pulseless ventricular tachycardia, pulseless electrical activity, and post–cardiac arrest care. Learners perform initial assessment, lead placement, monitoring, IV/oxygen setup, and atropine for symptomatic bradycardia while preparing transcutaneous pacing. The case then requires immediate pacing cessation, defibrillation, high-quality CPR, epinephrine and amiodarone delivery, and identification of reversible causes during PEA. After ROSC, participants transition to post–cardiac arrest care with ventilation effectiveness and targeted temperature management considerations.

LanguageEnglish

CategoryExam

FormatPDF

Pages12

Reading Time30 min

AccessFree to download

Adult Bradycardia Algorithm

Adult Cardiac Arrest Algorithm (pVT)

Adult Cardiac Arrest Algorithm (PEA)

Post–Cardiac Arrest Care Algorithm

Megacode Testing Checklist: Scenarios 1/3/8 Bradycardia → Pulseless VT → PEA → PCAC

Megacode 1—Out-of-Hospital Unstable Bradycardia (Unstable Bradycardia > pVT > PEA > PCAC) Lead-in: You are a paramedic treating a man who had a syncopal episode. Vital Signs Heart rate: Blood pressure: 78/42 mm Hg Respiratory rate: Spo2: Temperature: Weight: Age: 62 years | Initial Assessment
• The patient is conscious and alert.
What are your initial actions?
• His skin is pale, and he is diaphoretic.
• The patient is not following commands.
• There is no radial pulse, but the carotid pulse is weak and slow. | | --- | | Adult Bradycardia Algorithm
Instructor notes: The ECG monitor shows a sinus bradycardia with occasional PVC.
The student should follow the Adult Bradycardia Algorithm and be prepared toadminister a single dose of atropine while preparing for transcutaneous pacing. | | Adult Cardiac Arrest Algorithm (pVT)
Instructor notes: With the introduction of the pacing impulse, the ECG monitor displays VT. There is no pulse.
The student should immediately discontinue pacing and defibrillate the patient. The student will follow the VF/pVT pathway of the Adult Cardiac Arrest Algorithm. The student should assign team functions and monitor for high-quality CPR. The case should continue through safe defibrillation and administration of epinephrine and amiodarone. | | Adult Cardiac Arrest Algorithm (PEA)
Instructor notes: After the third shock, the patient develops an organized rhythm that is slow. There is no pulse. The patient is now in PEA. The student continues to monitor high-quality CPR and follows the PEA pathway of the Adult Cardiac Arrest Algorithm.
The student should consider reversible causes. | | Post–Cardiac Arrest Care Algorithm
Instructor notes: After ensuring effective ventilation, the student can now detect a carotid pulse. The patient has ROSC.
The student should initiate the Post–Cardiac Arrest Care Algorithm. | © 2020 American Heart Association Megacode Testing Checklist: Scenarios 1/3/8 Bradycardia → Pulseless VT → PEA → PCAC Student Name Date of Test | Critical Performance Steps | | | | | | Check
if done
correctly | | --- | --- | --- | --- | --- | --- | --- | | Team Leader | | | | | | | | Assigns team member roles | | | | | | | | Ensures high
quality CPR at all times | Compression rate
100-120/min
☐ | Compression
depth of ≥2 inches
☐ | Chest compression
fraction >80%
☐ | Chest recoil
(optional)
☐ | Ventilation
(optional)
☐ | | | Ensures that team members communicate well
Bradycardia Management | | | | | | | | Starts oxygen if needed, places monitor, starts IV | | | | | | | | Places monitor leads in proper position | | | | | | | | Recognizes symptomatic bradycardia | | | | | | | | Administers correct dose of atropine | | | | | | | | Prepares for second-line treatment | | | | | | | | Pulseless VT Management | | | | | | | | Recognizes pVT | | | | | | | | Clears before analyze and shock | | | | | | | | Immediately resumes CPR after shocks | | | | | | | | Appropriate airway management | | | | | | | | Appropriate cycles of drug–rhythm check/shock–CPR | | | | | | | | Administers appropriate drug(s) and doses | | | | | | | | PEA Management | | | | | | | | Recognizes PEA | | | | | | | | Verbalizes potential reversible causes of PEA (H’s and T’s) | | | | | | | | Administers appropriate drug(s) and doses | | | | | | | | Immediately resumes CPR after rhythm checks | | | | | | | | Post–Cardiac Arrest Care | | | | | | | | Identifies ROSC | | | | | | | | Ensures BP and 12-lead ECG are performed, O2 saturation is monitored, verbalizes need for endotracheal intubation and waveform capnography, and orders laboratory tests | | | | | | | | Considers targeted temperature management | | | | | | | STOP TEST | Test Results Circle PASS or NR to indicate pass or needs re

FAQs

What are the initial actions for an adult with unstable bradycardia after syncope?

Follow the adult bradycardia pathway: ensure monitoring and access (oxygen as needed, monitor placement, IV), assess pulses, recognize symptomatic bradycardia, and prepare for second-line therapy including atropine while getting ready for transcutaneous pacing.

How should the team manage pulseless VT after pacing is initiated?

When the ECG shows VT with no pulse, stop pacing and immediately defibrillate. Continue through the VF/pVT arrest pathway by assigning roles, monitoring and performing high-quality CPR, and continuing cycles of rhythm/drug/shock/CPR including epinephrine and amiodarone.

What changes when the rhythm becomes PEA and how does post–cardiac arrest care begin?

With PEA, continue high-quality CPR and follow the PEA pathway, considering reversible causes (H’s and T’s). After effective ventilation and identification of ROSC, initiate the post–cardiac arrest care algorithm, including ongoing monitoring and considering targeted temperature management.

Sep 23, 2026

Uploaded by Ezra