# Situation: A 64-year-old man on a medical ward is eating lunch in bed when he suddenly grasps his throat. He has no pacemaker and no do-not-resuscitate order. The unit's adult choking protocol calls for cycles of 5 back blows and 5 abdominal thrusts for severe airway obstruction in a responsive adult. The code team arrives and attaches the monitor. At the first rhythm check, the monitor shows an organized narrow-complex rhythm at 50/min, and no carotid pulse is felt. An intravenous (IV) line is in place. Which order should the nurse expect next?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630238  
> language: ko  
> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A 64-year-old man on a medical ward is eating lunch in bed when he suddenly grasps his throat. He has no pacemaker and no do-not-resuscitate order. The unit's adult choking protocol calls for cycles of 5 back blows and 5 abdominal thrusts for severe airway obstruction in a responsive adult.

The code team arrives and attaches the monitor. At the first rhythm check, the monitor shows an organized narrow-complex rhythm at 50/min, and no carotid pulse is felt. An intravenous (IV) line is in place. Which order should the nurse expect next?

## 보기

1. Adrenaline 1 mg intravenously now and every 3–5 minutes **✔ 정답**
2. Atropine 1 mg intravenously for the slow rate, then compressions
3. Amiodarone 300 mg intravenous push, then resume compressions
4. Defibrillation at 200 joules, then resume compressions

**정답: 1**

## 해설

An organized rhythm without a pulse is pulseless electrical activity, a nonshockable rhythm. Management is cardiopulmonary resuscitation (CPR) with adrenaline 1 mg IV as soon as feasible, repeated every 3–5 minutes, while reversible causes such as hypoxia are sought. Shocks and antiarrhythmics are for ventricular fibrillation or pulseless ventricular tachycardia.

## 심화 해설

Clinical situation

A witnessed collapse during a meal, followed by an organized narrow-complex rhythm at 50/min with no palpable carotid pulse, describes pulseless electrical activity (PEA). PEA is a nonshockable rhythm, so defibrillation and antiarrhythmic drugs are not the immediate priority. The correct next step is high-quality cardiopulmonary resuscitation with adrenaline 1 mg IV as soon as vascular access is available, repeated every 3–5 minutes.

Why adrenaline, and why early

In PEA, the heart still generates electrical activity, but mechanical contraction is insufficient to produce a pulse. Adrenaline is the first-line vasopressor because its alpha-adrenergic effect raises coronary perfusion pressure and cerebral perfusion pressure during chest compressions. Higher coronary perfusion pressure is the key determinant of return of spontaneous circulation in nonshockable arrest. The guideline-based interval of every 3–5 minutes balances the need for repeated alpha-adrenergic support against the risk of excessive beta-adrenergic stimulation, which can increase myocardial oxygen demand and worsen post-resuscitation dysfunction.

Key point! In PEA and asystole, adrenaline is the only drug with a strong recommendation for routine use. Antiarrhythmics such as amiodarone are reserved for shockable rhythms, and atropine is no longer recommended for routine cardiac arrest management.

Timing matters in nonshockable arrest

The study by Chacko and colleagues examined in-hospital cardiac arrest with nonshockable rhythms and found that delays in the first adrenaline dose were common when administration depended on physician authorization. Empowering nurses to give the first adrenaline dose reduced the time to drug delivery in nonshockable arrest. This supports the expectation that the nurse should anticipate and prepare adrenaline immediately rather than waiting for a physician to personally push the drug. In a monitored setting with an IV line already in place, the nurse can draw up and administer the first dose as part of the resuscitation team response.

Why the other options are incorrect

| Option | Why it is not the next step |
| --- | --- |
| Atropine 1 mg IV | Atropine is not recommended for routine cardiac arrest. Bradycardia without a pulse is PEA, not symptomatic bradycardia; the treatment is CPR and adrenaline, not vagolytic therapy. |
| Amiodarone 300 mg IV | Amiodarone is indicated for refractory ventricular fibrillation or pulseless ventricular tachycardia, which are shockable rhythms. PEA is nonshockable and does not respond to antiarrhythmic therapy. |
| Defibrillation 200 J | Defibrillation is only for shockable rhythms. Delivering a shock to PEA interrupts compressions without addressing the underlying perfusion problem and can worsen outcomes. |

Linking the rhythm to the choking context

The initial event was a sudden airway obstruction while eating. Even after the obstruction is relieved, the patient may remain in PEA because of hypoxia—one of the reversible causes of PEA. The management of PEA always includes searching for and treating reversible causes, but this does not delay the first dose of adrenaline. Hypoxia, hypovolemia, hydrogen ion excess, hypo-/hyperkalemia, hypothermia, tension pneumothorax, tamponade, toxins, and thrombosis are the classic reversible causes to consider during the resuscitation.

Drug administration route and dose

Intravenous access is preferred for drug delivery during cardiac arrest. The dose of adrenaline is 1 mg of the 1:10,000 concentration, given as a rapid bolus followed by a 20 mL fluid flush to ensure the drug reaches the central circulation. The dose is repeated every 3–5 minutes while the arrest continues. If IV access is not available, the intraosseous route is an acceptable alternative; endotracheal administration is no longer recommended as a first choice.

Watch out! Do not confuse the cardiac arrest adrenaline dose (1 mg IV every 3–5 minutes) with the anaphylaxis dose (0.3–0.5 mg IM of 1:1,000 concentration). The concentration, route, and dose are different, and mixing them is a serious medication error.

What the nurse should do next

The nurse should anticipate the order for adrenaline 1 mg IV now, prepare the medication immediately, and administer it while high-quality chest compressions continue. Compressions should be interrupted as little as possible, and the adrenaline should be given during a brief pause only if necessary. After administration, compressions resume immediately, and the rhythm and pulse are reassessed after 2 minutes of CPR. The search for reversible causes—especially hypoxia in this choking scenario—continues in parallel with drug administration.

## 임상 시나리오

PEA Arrest ManagementOrganized rhythm without a pulse is nonshockable
An organized narrow-complex rhythm at 50/min with no palpable carotid pulse is pulseless electrical activity, a nonshockable arrest rhythm. Immediate management is high-quality CPR with adrenaline 1 mg IV as soon as access is available, repeated every 3–5 minutes.

Adrenaline's alpha-adrenergic effect raises coronary and cerebral perfusion pressure during chest compressions, which is the key determinant of return of spontaneous circulation in nonshockable arrest.

CautionDo not defibrillate PEA and do not give amiodarone or atropine routinely. Shocks and antiarrhythmics are reserved for shockable rhythms such as ventricular fibrillation or pulseless ventricular tachycardia.

## 핵심 개념

- **Pulseless electrical activity (PEA)** — An organized cardiac rhythm on the monitor without a palpable pulse, reflecting electrical activity without effective mechanical contraction.
- **Nonshockable rhythm** — Cardiac arrest rhythms (asystole and PEA) that do not respond to defibrillation and are managed with CPR and adrenaline.
- **Adrenaline** — First-line vasopressor in cardiac arrest; alpha-adrenergic effects increase coronary and cerebral perfusion pressure during CPR.
- **Coronary perfusion pressure** — The pressure gradient driving blood flow to the myocardium during CPR; a key determinant of return of spontaneous circulation.
- **Shockable rhythm** — Ventricular fibrillation and pulseless ventricular tachycardia, which are treated with defibrillation and antiarrhythmics.

## 같은 주제 문제

- [Situation: A 58-year-old man with severe community-acquired pneumonia is intubated in the …](https://mymerci.kr/pages/nclex_q.php?qn_id=630016)
- [Situation: A 58-year-old man with severe community-acquired pneumonia is intubated in the …](https://mymerci.kr/pages/nclex_q.php?qn_id=630017)
- [Situation: A 58-year-old man with severe community-acquired pneumonia is intubated in the …](https://mymerci.kr/pages/nclex_q.php?qn_id=630018)
- [Situation: A 58-year-old man with severe community-acquired pneumonia is intubated in the …](https://mymerci.kr/pages/nclex_q.php?qn_id=630019)
- [Situation: A 62-year-old man arrives at the emergency department of a provincial hospital …](https://mymerci.kr/pages/nclex_q.php?qn_id=630020)
- [Situation: A 62-year-old man arrives at the emergency department of a provincial hospital …](https://mymerci.kr/pages/nclex_q.php?qn_id=630021)
- [Situation: A 62-year-old man arrives at the emergency department of a provincial hospital …](https://mymerci.kr/pages/nclex_q.php?qn_id=630022)
- [Situation: A 70-year-old woman with rheumatic heart disease is in the coronary care unit. …](https://mymerci.kr/pages/nclex_q.php?qn_id=630023)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._