Summary of Approach to Megacode

In a megacode evaluation, you need to demonstrate proficiency in assessment and management of

• the live patient: establish responsiveness / pulse, then assess whether patient is stable or unstable (see "The Live Patient" in this blog)
• the arrested patient
• the resuscitated patient

The priorities are:

• assess the patient clinically
• assess the rhythm
• apply the algorithm according to findings in 1 and 2

In the live patient, you need to establish the following:

1. stable or unstable? 

• responsive?
• short of breath? 
• hypoxic or showing evidence of LVF? 
• hypotensive?
• ischaemic chest pain?

      2. What rhythm is on the monitor?

• fast or slow?
• regular or irregular?
• narrow QRS or broad QRS (>0.12s)
• are normal p waves present?
• is there a p before every QRS and a QRS after every p?
• what is the PR interval like (normal length, always the same, etc)

Remember the aide memoire VOMIT SAMPLE.....

·       VITALS: BP, RR, Pulse, Temperature

·       OXYGEN: titrate to SpO₂ 94%

·       MONITOR: 3-lead ECG to see rhythm

·       IV: intravenous access; send bloods

·       TWELVE LEAD ECG and Targeted examination: CVS, lungs, oedema

·       SYMPTOMS: Chest pain? Shortness of breath? Palpitations? Etc.

·       ALLERGIES

·       MEDICATIONS

·       PAST HISTORY

·       LAST MEAL

·       EVENTS leading to presentation

      Apply the algorithm according to whether the patient has a stable or unstable tachycardia, or stable or unstable bradycardia.  In general, stable patients are treated with drugs, [unstable patients are treated with electricity (pacing for bradycardias, synchronised cardioversion for tachcardias) 

Arrested patient: General Principles

In the arrested patient consider whether the rhythm is shockable or non-shockable

Shock the shockables once defibrillator available then every 2 minutes while rhythm persists

Epinephrine is used in all arrest rhythms 

Amiodarone is only used with shockable rhythms

Initial management: ABCD of team management

Assign tasks to team

Brief the team

Check the team are performing well

Draw and give drugs

Ongoing management: consider the Hs and Ts

 Post-Resuscitation ABCDEFGH

• AIRWAY: open airway, consider intubation and EtCO2 monitoring
• Breathing: support respirations 1 every 6 sec, support oxygenation
• Circulation: pulse present - how is BP? If systolic BP remains below 90mmHg give IV fluids, consider pressor infusion
• Differentials: reconsider Hs and Ts, do post arrest ECG, portable CXR and bloods
• Environment: where does the patient have to go? PCI if ECG abnormal, HDU if intubated, monitored bed if not intubated
• Family, Foley, File: communicate with family, insert foley catheter for bladder emptying, monitoring perfusion, and obtaining urine specimen for toxins; check file for contributory past history and drug treatments
• Glucose, God, Gratitude, Gastric: check blood glucose, consider pastoral care, thank and debrief team, and insert NG tube if patient unconscious...useful for gastric decompression and for administration of certain drugs eg dual antiplatelet therapy before PCI
• Hypothermia: consider targeted temperature management post arrest if patient remains unresponsive. Cool to between 32 to 36 deg C