Shared gameplay
Extended’s 15 gameplay switches are under ACM Extended: Systems > Hardcore. Apply shared rules through Server or Mission settings. There is no current master Hardcore switch.
ACM EXTENDED / REFERENCE
Addon options
Find addon options by their in game names and compare normal and Hardcore behavior in ACM Extended 1.2.1.
01
Where to find an option
Open Options > Addon Options, choose the category in the table, then find the named option. Use the Server or Mission settings level for shared gameplay rules. Personal display preferences use your client settings. CBA shows when a value is forced by the mission or server.
The current build exposes switches for selected optional systems. Core circulation, respiratory and medication features do not each have an independent disable switch.
02
Hardcore settings
Each Hardcore option is independent. All 21 options below default to Off. Turning a Hardcore option off keeps its normal system available; the separate system-enable checkbox controls whether that optional system runs.
Personal wording
Clinical Descriptors is the 16th Extended option. It is a personal wording preference that cannot be forced by the mission or server.
Inherited ACM options
Five additional Hardcore options remain in their native ACM categories. Their current behavior is listed separately below.
Open an option to compare Off with On. Values are the current game defaults before mission tuning. Extended gameplay switches are evaluated live, but changing difficulty does not undo medication already delivered, remove established injury or instantly repair a casualty.
Medication delivery
[HARDCORE] MedicationsDefault: Off
Off
Normal medication physiology and the existing administration workflow remain active. The added rapid-push consequences and continuous one-handed IV/IO push session are disabled.
On
Enables rate-sensitive IV/IO pushes, the red Stop Push control, partial syringes and the corner syringe display. Closing or reopening menus leaves a running push uninterrupted. Fast administration can add temporary respiratory or circulatory depression; rapid rocuronium can establish blockade slightly sooner.
See push times, slow-push indications and the stop/restart walkthrough. Compound defaults use the slowest component. The selected time controls delivery, not a guarantee of safety; dose and the patient’s condition still matter.
[HARDCORE] Cardiac RhythmsDefault: Off
Off
Native ROSC checks still require adequate oxygenation and circulating volume and exclude tension chest problems. The additional Extended reversible-cause block is not applied.
On
During cardiac arrest, also blocks ROSC with core temperature below 30°C, modeled PaCO₂ at or above 85 mmHg, or a latched lidocaine-toxicity arrest. Relevant temperature/circulation systems must be active for their checks.
Correct the blocker before expecting ROSC. This option does not increase torsades frequency and does not turn off the circulation state of an already perfusing patient. Cardiac rhythm reference.
[HARDCORE] ShockDefault: Off
Off
The extra Hardcore pressor-debt accumulator is reset. Normal volume, resistance and medication physiology still operate.
On
Tracks pressor debt while pressor resistance support is above 0.5 and blood-volume deficit is at least 15% of the 6 L reference. Debt grows with the deficit and decays when pressor support stops.
Restore volume and reassess perfusion alongside pressure. The handler writes a debt value intended for acidosis, but the current circulation calculation does not read that value. A further acidosis penalty, shorter epinephrine duration or lower shock floor should not be assumed from this switch in this revision.
[HARDCORE] TransfusionDefault: Off
Off
Citrate-related calcium deficit begins beyond 2 L recorded transfused blood. The deficit coefficient is 0.22/L, the calcium floor is 0.45, and the maximum calcium-related bleeding multiplier is 1.4×. Cold-related clotting effects begin below 35°C, with a maximum multiplier of 1.6×.
On
Citrate deficit begins beyond 1 L, with a 0.30/L coefficient, a lower calcium floor of 0.30 and up to 1.9× calcium-related bleeding. Cold-related clotting effects begin below 36°C and can reach 2.1×. These are game-model coefficients.
Calcium replacement and temperature control become more consequential. The older tooltip also mentions mandatory Y tubing and a 250 mL saline bag, but the current prepared-set workflow does not make those requirements conditional on this switch. Y sets still require their own supplies and flushing steps in either mode. Fluids and blood reference.
Trauma and recovery
[HARDCORE] Junctional WoundsDefault: Off
Off
Extra junctional bleeding uses a 0.10 baseline coefficient. Direct pressure leaves 10% of that channel, packing alone leaves 50%, and packing plus pressure leaves 0% while held.
On
Baseline becomes 0.15. Direct pressure leaves 30%, packing alone 65%, and packing plus pressure 10%. The velocity-injury chance coefficient changes from 0.60 to 0.85; the avulsion coefficient changes from 0.15 to 0.30.
Requires Junctional Wounds enabled. Bleed/frequency sliders, injury eligibility and perfusion still affect the result, so these coefficients are not a fixed blood-loss rate or a chance for every hit. Finish the gauze and pressure-bandage treatment chain. Trauma reference.
[HARDCORE] Direct PressureDefault: Off
Off
Ordinary external limb bleeding is multiplied by 0.72 while held, a 28% reduction. Timed treatments performed one-handed while pressure continues take 1.6× their usual time.
On
Limb bleeding is multiplied by 0.80, a 20% reduction. Concurrent timed treatments take 2× their usual time.
Requires Direct Pressure enabled. These limb multipliers do not apply to the head or torso; the junctional channel has its own controls above. The current setting does not separately lengthen the clot-attempt interval despite the older tooltip’s “longer hold to clot” wording.
[HARDCORE] Chest Seal Mini-gameDefault: Off
Off
New penetrating chest injuries use the normal exit-wound coefficient, 0.60 by default.
On
Multiplies that coefficient by 1.15, giving 0.69 at the default. A newly processed penetrating injury is therefore more likely to generate an exit hole.
Requires Chest Seal Mini-game enabled. Existing holes and placed seals are retained. The initialized find radius remains 0.0075 of body height in both modes; the smaller Hardcore fallback is not used with the current defaults. Chest seal and breathing guide.
[HARDCORE] TBIDefault: Off
Off
The brain-injury model has its baseline compensation budget of 600 s. Stable mild/moderate acute burden can resolve when the model’s perfusion and respiratory conditions are met.
On
Shortens that compensation budget to 480 s. Sustained pressure or perfusion stress consumes the available reserve sooner.
Requires TBI model enabled. Injury severity already assigned to a patient is retained. This switch does not directly change the sodium ceiling or herniation-stage setting in this revision. Structural severity still determines the MAP/CPP requirements. TBI recovery and pressure reference.
[HARDCORE] ExtravasationDefault: Off
Off
Untreated lasting local injury starts when exposure reaches stage 2. The base recovery rate after exposure stops is 0.50 stage units/min.
On
The lasting-injury threshold moves to stage 1 and base recovery slows to 0.30 stage units/min.
Requires Extravasation / vesicant injury enabled. Stop further exposure, choose a suitable access site and use the coded matching reversal when available. Reversal, elevation and a wrapped bruise modify recovery; an untreated residual injury may persist. Vascular access reference.
[HARDCORE] HypothermiaDefault: Off
Off
An eligible, unwrapped patient can self-rewarm at 0.15°C/min once bleeding and perfusion conditions allow it. Self-recovery requires a temperature above 30°C.
On
Self-rewarming falls to 0.05°C/min and the self-recovery floor rises to 32°C. At or below that floor, spontaneous recovery is unavailable.
Requires Hypothermia model enabled. Arrange rewarming while correcting bleeding and perfusion. This controls spontaneous thermal recovery; the separate Rewarming option below controls HPMK completion feedback.
[HARDCORE] RewarmingDefault: Off
Off
The HPMK can write “Rewarmed to normothermia (HPMK)” when temperature reaches 36.9°C.
On
Suppresses that completion log. Assess the patient’s temperature rather than waiting for confirmation.
The current worker uses the same 0.6°C/min HPMK rate in both modes, reduced to 80% with the chest exposed. It requires a living, perfusing patient, HR at least 20 and MAP at least 60. The older tooltip’s slower-rewarming claim is not implemented by this switch.
Respiratory support and transport
[HARDCORE] NRB OxygenDefault: Off
Off
Refuses mask placement and displays an oxygen-source warning if the provider has no charged oxygen tank. Supplied flow is 15 L/min.
On
Allows placement without the oxygen-source warning. A mask with no supplied oxygen provides no oxygen support. Supplied flow rises to 25 L/min, consuming the tank faster.
In both modes, NRB oxygen benefit needs spontaneous breathing, a functioning airway and a perfusing pulse. Placing a mask does not ventilate an apneic patient. Airway and breathing reference.
[HARDCORE] Blast Lung / ARDSDefault: Off
Off
Progression to ARDS requires blast-lung severity at or above 0.85 for 60 s.
On
Lowers the threshold to 0.70 and the continuous exposure time to 40 s.
Requires [BETA] Blast lung / ARDS enabled. Once ARDS is established, the existing slower recovery and residual lung-injury floor still apply. Turning Hardcore off does not remove established ARDS. Blast injury reference.
[HARDCORE] VentilationDefault: Off
Off
The additional ventilator-induced lung-injury accumulator is disabled. Ventilation, oxygen delivery, airway problems and other lung injuries still affect the patient.
On
Delivered VTi above 8 mL/kg of the ventilator’s effective weight accumulates lung injury. Greater excess causes faster accumulation. Established injury reduces compliance and can add an oxygenation penalty.
Use the delivered VTi and the configured weight, then reassess pressures and oxygenation. Turning the option off prevents additional injury from this worker; it does not repair injury already present. Ventilator Settings & Tips.
[HARDCORE] Flight PhysiologyDefault: Off
Off
The maximum G-related resistance-drop coefficient is 28. Trapped gas expands or contracts with actual changes in cabin pressure.
On
Raises the maximum G-related resistance-drop coefficient to 40. Climbing or banking can therefore cause a larger pressure drop in a hypovolemic casualty.
Requires Flight physiology enabled. The old extra pneumothorax-growth coefficient is still assigned by the switch, but the current altitude worker uses cabin-pressure ratios instead; Hardcore does not add a separate gas-growth multiplier. Stabilize chest problems and perfusion before transport. Flight reference.
Personal wording
[HARDCORE] Clinical DescriptorsDefault: Off
Off
Uses the plain-language assessment and access-site names.
On
Uses clinical and anatomical wording, including named veins/IO locations, axillary or inguinal wounds, chest-seal counts and unilateral/bilateral decompression findings.
Personal setting; cannot be forced by the server or mission. Changes the next assessment, while previous log entries retain their wording. It changes presentation, not treatment effectiveness. Clinical descriptor reference.
Native ACM Hardcore settings
These five options also default to Off and use shared gameplay settings. Find each one in its own category below. For inherited settings, configure the scenario before launch; an existing injury flag or registered worker can outlive a mid-mission change.
[HARDCORE] Chest InjuriesDefault: Off
ACM: Breathing > Pneumothorax
Off
Extended’s shared pneumothorax model tracks air leaks, drainage and recovery.
On
This inherited switch does not add a separate permanent chest-injury state through Extended’s current PTX worker. The worker uses the same recovery model in both positions.
The native tooltip describes a lingering post-tension injury. Extended replaces that old progression path and clears the old residual flag when tension resolves. Follow the current pneumothorax recovery guide.
[HARDCORE] Hemothorax BleedingDefault: Off
ACM: Breathing > Pneumothorax
Off
Clot attempts occur on a randomly selected 10–20 s interval. The hemothorax bleeding state can clot down to zero when conditions allow.
On
Uses a 15–30 s interval and prevents untreated low-grade bleeding at state 1–2 from fully resolving by itself. Active TXA allows the clotting process to finish.
Stopping the bleeding source does not remove blood already accumulated in the chest. Drainage, respiratory support and resuscitation remain separate decisions. Platelet, pulse and perfusion gates still matter.
[HARDCORE] Post Cardiac Arrest ComplicationsDefault: Off
ACM: Circulation > Cardiac Arrest
Off
A successful ROSC does not set the native Hardcore post-arrest complication flag.
On
ROSC sets a persistent complication flag. After the first 45 s, native heart-rate targeting is reduced; when enabled at mission startup, the flagged patient also has a 1.4× ACE fatigue duty factor.
This affects care after ROSC. The separate Extended Cardiac Rhythms option controls additional eligibility checks before ROSC. Set this option before starting the scenario so its fatigue registration is present.
[HARDCORE] Internal BleedingDefault: Off
ACM: Damage > Internal Bleeding
Off
Normal internal-bleeding and coagulation calculations operate.
On
The option is exposed, but its additional Hardcore handler is commented out in the current blood-loss worker. No extra residual-bleeding behavior is enabled by this switch in this revision.
Internal bleeding still needs treatment and reassessment. Do not infer that it is absent, or that switching this option off heals an existing injury.
[HARDCORE] Complex FracturesDefault: Off
ACM: Disability > Fracture Management
Off
The fracture-severity system can produce mild/severe fractures without the Hardcore complex-fracture branch or its splint-no-effect flag.
On
High limb damage can produce a complex fracture. Complex fractures and some severe fractures can be marked as unresponsive to field splinting and need evacuation for definitive treatment.
Requires the Enable Fracture Severity option enabled. Pain control and stabilization remain useful, but a splint cannot be assumed to restore function. Existing complications are not erased by changing the option.
Medication timing and line flushing
[HARDCORE] Medications and Require saline flush after push are separate settings. The first controls the rate-sensitive medication behavior. The second holds selected IV/IO medication loads until a flush reaches the patient. A long incremental push is consolidated before flushing so its portions retain the intended accumulated dose and push time. Open the medication-push reference.
03
Circulation and medication
| Category / section | Option | Purpose |
|---|---|---|
ACM: Circulation > Cardiac Arrest | Rhythm Deterioration Multiplier | Scales the chance of pulseless VT deteriorating to VF and VF to asystole. Default 1.0. See the rhythm guide for the timing and CPR conditions. |
ACM: Circulation > Cardiac Arrest | Critical Damage Cardiac Arrest Chance | Changes arrest risk from critical injury. |
ACM: Circulation > CPR | CPR Effectiveness Multiplier | Changes CPR effectiveness; default 1.0. |
ACM Extended: Circulation > Medications | Require saline flush after push | Holds selected IV / IO medications pending a saline flush. |
ACM Extended: Circulation > Procedures | Allow Push Dose Epinephrine Action | Shows the dedicated push dose epinephrine action. |
ACM Extended: Circulation > Required Training | Dedicated Bolus Actions: Required Training | Minimum training for dedicated epinephrine and osmotherapy bolus actions. |
ACM Extended: Infusion & IV > Required Training | Patient Narc Box: Required Training | Minimum training for drawing medication at a patient. |
ACM Extended: Airway > Ketamine sedation | Ketamine: induction threshold | Adjusts induction sensitivity in the shared hypnosis model. Default 7. |
ACM Extended: Airway > Ketamine sedation | Ketamine: maintenance threshold | Adjusts how much ongoing hypnosis maintains drug caused unconsciousness. Default 1.2. |
ACM Extended: Airway > Rocuronium paralysis | Rocuronium: paralysis threshold | Active medication level required for paralysis. Default 0.5. |
ACM Extended: Airway > Rocuronium paralysis | Rocuronium: onset (seconds) | The option is visible, but the current paralysis check uses the medication curve and threshold without an additional delay from this slider. See the rocuronium card. |
04
Access and optional systems
| Category / section | Option | Purpose |
|---|---|---|
ACM Extended: Infusion & IV > Flow & drip | Default drop set (gtt/mL) | Sets the assumed drip chamber when the bag has none specified. |
ACM Extended: Infusion & IV > Flow & drip | Max drip rate (gtt/min) | Sets the maximum at a fully open roller clamp. |
ACM Extended: Infusion & IV > Flow & drip | Clamp response curve | Changes sensitivity across roller clamp travel. |
ACM Extended: Systems > Systems | Junctional Wounds | Enables junctional bleeding and its treatment chain. |
ACM Extended: Systems > Systems | Direct Pressure | Enables holding direct pressure. |
ACM Extended: Systems > Systems | Chest Seal Mini game | Enables interactive seal placement. |
ACM Extended: Systems > Systems | Hang Bag | Enables holding a bag higher for gravity assisted delivery. |
ACM Extended: Systems > Systems | Extravasation / vesicant injury | Enables tissue injury from medication leakage and local reversal treatments. |
ACM Extended: Systems > Systems | TBI model | Enables structural and acute brain injury, ICP, cerebral autoregulation, autonomic tone, herniation and osmotherapy. See the TBI reference for severity dependent recovery and perfusion requirements. |
ACM Extended: Systems > Systems | Flight physiology | Enables the modeled effects of altitude and flight. |
ACM Extended: Neuro & TBI > Procedures | Allow Osmotherapy Bolus Actions | Shows the dedicated hypertonic saline and mannitol pushes. |
ACM Extended: Neuro & TBI > Tuning | Sodium ceiling (mEq/L) | Stops further osmotherapy benefit at the sodium ceiling. |
ACM Extended: Trauma > Procedures | Allow Needle Decompression | Controls availability of the needle decompression procedure. |
05
Personal display and testing
| Category / section | Option | Purpose |
|---|---|---|
ACM Extended: Accessibility > Options | Group medical menu into dropdowns | Expands treatment groups in place. Grouped headings use left alignment. |
ACM Extended: Accessibility > Options | Use separate colors for medical menu sections | Optional section colors. Off by default; headings otherwise use cream text. |
ACM Extended: Accessibility > Options | Left align medical menu | Sets label alignment when the menu is flat. |
ACM Extended: Accessibility > Options | Colorblind mode / Colorblind correction strength | Adjusts procedural cue colors. |
ACM Extended: Accessibility > Options | BVM ventilation visual cue | Shows a visual cue when the BVM ventilation sound plays. |
ACM Extended: Debug > Overlay | Debug menu | Shows diagnostic information for scenario testing. |
For a useful test, record the shared addon settings, patient state and delivered medication dose. Change one setting at a time. Use the rhythm test notes and infusion reference to interpret the response.
Sources and revision
Reviewed against ACM Extended 1.2.1 development revision bc90fc7 on 14 September 2026. The comparisons above follow the active handlers where an older option tooltip describes different behavior.