The Megacode Mambo: What Changing ACLS Protocols Mean for You

The Megacode Mambo: What Changing ACLS Protocols Mean for You


I used to work as an electrocardiogram technician in a nuclear stress lab. We administered exercise and chemical myocardial perfusion studies in a new outpatient clinic located within a large community hospital. The more tests we did over our first few years, the more nervous those of us in the stress lab became. After thousands of tests, we still hadn’t had it yet–the code blue we knew was statistically coming.

Sure enough, one spring day a patient went down in pulseless ventricular tachycardia while on the treadmill. It would have been manageable, except for one thing: down the hall in an exam room another patient was coding at the exact same time. Talk about a mess–the code team was completely confused about where to respond, and the clinic crash cart was set up for only one code. We had extra vials of most medications (albeit all on the one cart), but only one AED, one oxygen tank, and one suction unit.

After that near debacle (both patients were resuscitated successfully), I made it my personal mission to beef up the crash cart, and went from being BLS CPR certified to ACLS certified. I survived the megacode — the code blue simulation final exam in which anything and everything is thrown at you — because I was quick to identify arrhythmias.

I met with a PharmD who worked in the ICU and CCU to make sure we had adequate supplies of all the necessary drugs on the crash cart, as well as easy-to-use cards for resuscitation and intervention protocols. While meeting, we talked about better use of compounding to make the stress lab run more efficiently, set up an adenosine test protocol to replace dipyridamole, and made sure we had the proper delivery systems for all the medications we administered. Just an hour or so with a knowledgeable pharmacist changed a lot of our lab operation for the better, for both staff and patients.

A Brief History of Advanced Cardiac Life Support

While chest compressions and rescue breathing have literally been around for centuries, an integrated approach to codes with intubation and pharmaceutical intervention is quite new. As the methodology for handling pulseless non-breathers became more complex, a set of national algorithms that became Advanced Cardiac Life Support was developed.

If you’ve ever participated in a code before, you know how chaotic, confusing, and stressful they can be. Having a branching yes/no protocol makes managing the situation much easier. While cardiac arrest and stroke are two of the more common ACLS algorithms, there are other standards for handling breathing and arrhythmia emergencies.

The first ACLS protocols were published in 1974 as a  joint project of the American Heart Association and the National Research Council. Updates have occurred approximately every 5-8 years since then. The early years of ACLS were focused on CPR until 1986, a landmark year, when real algorithms (versus suggestions) were implemented, which emphasized defibrillation, intravenous access, and the administration of drugs.

1992 and 2000 put more stress on airway management, while 2005 made the algorithms easier to memorize. 2010 saw the return of focus to CPR, but this time with alterations driven by evidence-based medicine.

How ACLS Changes Affect You

When they are first released, changes to the ACLS algorithms send everyone scrambling to update their CPR courses, pharmacy stock, and flash cards. Of course, it is necessary to get everyone on the same page to make codes run smoothly and correctly. A well-run code blue is a team effort between physicians (or PAs/NPs), nurses, pharmacists, respiratory therapists, and cardiac or EKG techs.

The drugs and resuscitation steps will always change as new evidence is released and we learn more about successful care of patients. However, there are certain elements of efficient code management that remain for all the roles listed above, regardless of which ACLS version you are employing:

  • Know your cardiac arrhythmias inside and out. If you understand the cellular and electrophysiological causes of each arrhythmia, the drugs used to treat them make more sense. While CPR will always be part of code algorithms, the pharmacological management is nearly always driven by underlying arrhythmias, and those arrhythmias demand pharmaceutical intervention.
  • Focusing on improving IV access back in 1986 was a good idea. Without a patent IV, delivery of most drugs is impossible. Don’t be afraid to call in anesthesia, the PICC nurse — whomever your institution’s  venous access magician is — early in the code process if it looks like the IV will a problem. I worked a code with a patient who flatlined after being given dipyridamole during her stress test. (She had a long first degree AV block and should never have received dipy in the first place, as it lengthens conduction time through the AV node, but the physician in this case was insistent on performing the test this way.) There she was, all vasodilated with no vitals and guess what? Her IV blew. Her flaccid veins made it all the more difficult for the nurse to get a new line started. Which brings me to the next point…
  • Get as efficient as possible when it comes to thinking on your feet. In the situation described above, we were so busy trying to establish a new IV line, we weren’t looking at the big picture. What the patient needed first and foremost was to receive aminophylline, the vasoconstricting reversing agent for the dipyridamole. Yes, the patient needed an IV, and that was the conventional way to deliver the aminophylline. But we also could have drawn it out of the bag with a syringe and mainlined it in her jugular, then perfused it with chest compressions. That would have likely made it easier to get an IV going. It’s a bit of a MacGyver move, but when a patient is clinically dead, sometimes those are the best solutions. Anticipate complicated scenarios, run tabletop simulations, and always debrief codes to learn for the next one.
  • Work out vague areas in protocols ahead of time. For example, there is currently no specific place in the pulseless V-tach algorithm for the administration of amiodarone. Decide in advance where you will plan on giving it, such as after the second defibrillator shock in anticipation of a third shock.
  • Always treat the patient, not just the numbers. Infamous trick questions on the megacode test involve elevating the heart rates of patients with “normal” rates who are experiencing relative bradycardia, because they are in septic shock or normally have a rate over 100 beats per minute. These questions aren’t just intended to trip you up, but to make you examine whether a patient is symptomatic or unstable, even with vital signs in normal ranges.
  • Pharmacy personnel and everyone involved in running codes should work as a team in advance to make sure drugs are adequately supplied and equipment is well-stocked. Anticipate needing extra of some drugs. I’ve seen amiodarone vials shatter on the floor, for example, because the nurse trying to work with it had no idea that it was as slippery as dish soap.

Patients, at least in our lifetimes, will always code, and there will always be ACLS guidelines to govern the management of their cases. With good planning in advance and attention to detail, your patients can have the best outcomes possible, and you and your colleagues will know you have done the best for them.

For information about compounding medications for cardiac intervention or resuscitation, contact Pharmaceutica North America. We are your resource for drugs recommended in the AHA ACLS guidelines, and for many more to improve the lives of your patients.



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