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In this case, you're presented with a 56-year-old man who arrived in the emergency department complaining of moderate to severe chest pain and discomfort. He also has some weakness and shortness of breath, and he has had it for the last four hours. As of the last one to two hours, the pain has intensified and it's now radiating up into the neck and jaw and down the left arm. When you ask him to describe the discomfort on a scale from one to 10, the patient states the pain is currently a number 9 and he feels as though he's going to be sick and vomit. The patient care assistant is directed by the nurse to go get an emesis basin, and while the nurse keeps typing in the notes, you continue to ask the gentleman more questions. But he stops responding and appears unconscious. The scene is safe, your personal protection is in place, now let's get started. It's at this time you would want someone to tap and shout and find out if the patient is now fully unresponsive. The patient is indeed unresponsive, so you'll want to call a code or ask for additional help, depending on your area of practice. The code is called, and in this situation, the team is now on their way. Now we want to assess for a carotid pulse as we begin gathering appropriate equipment that may already be in the room. As we check for a carotid pulse and breathing, we find no pulse and the patient is indeed not breathing. It's at this time that we would want to place a CPR board under the patient, or if they're on a hospital bed with a CPR button, activate it so that the bed will deflate and make the surface rigid, if this hasn't already been done. Now it's at this time that CPR will be initiated. As additional assistance or the code team arrives, we are able to direct each of the team members to their respective roles or assign them their roles if they are all equally trained. Now as the team leader begins to take the leadership role, they direct the recorder to please record times, treatments, and any of the associated notes that are important to that protocol. A compressor will be assigned along with a monitor defibrillator team member. A reminder is given to do CPR at 30 compressions and at 2 to 2.4 inches deep with a rate between 100-120 compressions per minute. Remember, high quality CPR is the top priority in advanced cardiac life support. Now the airway person is also assigned and directions to prepare to ventilate are given. The team leader should remember to give clear directions to the other team members like: "Please prepare a basic airway adjunct and ventilate with 100% oxygen delivered via bag valve mask at 12 breaths per minute." Now is a good time to begin thinking about an advanced airway, especially if the airway is compromised or if oxygenation with a basic airway is not sufficient. In order to obtain near 100% oxygenation, we need to turn the oxygen flow regulator to 15 liters per minute and allow the bag valve mask reservoir to fill prior to ventilations being given. During CPR, the monitor defib team member is preparing the patient for defibrillation. The ECG monitor and defib pads are placed appropriately, and as soon as they're ready, the team leader should give the direction to pause CPR in order to check. The leader asks everyone to stand clear while analyzing the rhythm. We see that the patient is in V-Fib. CPR is continued while the automated biphasic defibrillator charges. Or if the defibrillator is manual, the shock will be given at 360 joules. Once fully charged, the monitor defibrillator will call out, "Everyone clear! Shocking on 3, 1, 2, 3" and pushes the shock button. CPR should continue immediately as we prepare to deliver medication. IV or IO are both acceptable, but, at this time, we're going to try an IV and only move to the IO if we're unable to obtain a patent IV for effective medication and fluid delivery. As an important note to remember, in a team situation, many skills will happen simultaneously. When V-fib is recognized, epinephrine will be the first drug given as soon as possible. Okay, we now have a patent IV of normal saline via 18 gauge in the left antecubital. At this time, the recorder states, "It's been about two minutes." The leader should switch between the CPR compressor and the monitor/defibrillator so as to have a fresh compressor. This switch should occur every two minutes or at least when you recognize insufficient compressions due to fatigue if sooner than the two minutes. As the compressor calls out the last compressions, "28, 29, 30," that's when we should switch. Two ventilations should be delivered and the monitor defibrillator switches spots with the compressor, readies their hands in the appropriate position on the chest and begins effective compressions immediately after the last ventilation. We should now deliver our first medication. The team leader calls out a drug order for "1mg Epinephrine 1:10,000 IV push" and then "flushed with 20 ccs of normal saline." The IV medication team member calls back the same order: "1mg Epinephrine 1:10,000 given. IV push flushed with 20ml of normal saline." You could say, "That's correct, so now we can continue." CPR continues again for two more minutes. And at the end of that cycle, the team leader calls out, "Stop compressions." The leader checks the ECG and sees that the patient is still in ventricular fibrillation. It's at this time that the team leader calls out for another automated shock to be delivered, or if manual, another 360 joules shock. At the end of the CPR cycle, the defibrillator calls out, "Everyone stand clear, shocking on 3, 1, 2, 3!" The shock is delivered and CPR is continued. So at this time, an advanced airway is considered in order to secure the airway, give synchronous compressions with rescue breaths, and be able to monitor capnography. The team leader requests an advanced airway using an endotracheal tube. It's measured, and a number 6 ET is used with a stylet. The endotracheal tube balloon is inflated after the tube is passed between the vocal cords and lung sounds are auscultated between the left and the right lobes and we also check if we have any air sounds in the stomach. If there are no stomach sounds and we have good breath sound bilaterally, you know the ET tube is in the correct location. Now the recorder states, "We're at four minutes." The team leader calls out for everyone to stand clear so that the rhythm can be checked and announces that the compressors should switch positions again. The team leader states that the patient appears to still be in ventricular fibrillation, so let's go ahead and prepare for the third automated shock, or the next 360 joules shock if manually delivered. Once again, the defibrillator tells the team and leader, "Shocking at 360 joules. Everyone stand clear. Shocking on 3, 1, 2, 3!" The leader now says to continue CPR. The team leader will now direct the next medication to be given IV push which will be amiodarone at 300mg. The assistant should repeat, "I'll give 300mg of amiodarone IV push followed by 20ccs of normal saline." After they flush it and confirm the medication is given, the scenario continues until all treatment options are exhausted and all possible causes are ruled out. Now it's important to remember that a second dose of amiodarone may be given for persistent V-Fib at half the initial dose, which would be 150mg after two minutes of CPR and another shock that does not convert the rhythm. In addition, epi may be given every three to five minutes and can be staggered between the shocks and the CPR.
In this lesson, we're going to let you play the role of team leader during a cardiac emergency – pulseless arrest VFib. From start to finish, you'll be in charge of assessing the patient and providing therapy and treatment recommendations.
In this scenario, you've been presented with a 56-year-old male patient who arrived at the ER complaining of moderate to severe chest pains and discomfort. He also has some weakness and shortness of breath. And symptoms have been ongoing for about 4 hours.
Over the last 2 hours, his pain has intensified and is now radiating up into his neck, jaw, and down his left arm. When you ask him to assess his level of pain from 1 to 10, he says it's currently a 9.
He also mentions that he's beginning to feel nauseous and may even vomit. As you continue to ask him more questions, he suddenly stops responding and now appears unconscious.
Your initial assessment recap:
Let's assume the scene is safe and your personal protective equipment is in place. You begin by instructing a team member to perform a tap and shout sequence to confirm the patient's unresponsiveness. And he remains unconscious and unresponsive.
At this point, you call in a code or ask for additional help depending on you and your team's experience and level of expertise. Help is on the way.
Your team checks for a carotid pulse and signs of normal breathing as you all begin gathering the appropriate equipment, which may or may not already be in the room. Your team finds no pulse and no signs of breathing.
Someone in the team either places a CPR board under the patient or if he's on a hospital bed with a CPR button, you activate it at this time. Doing so will deflate the bed and create a hard surface, which will aid CPR efforts.
Now is the time when you'll take a leadership role and assign team member roles. You begin by directing the recorder to record all times, treatments, and any other associated and relevant notes for that protocol.
You assign a compressor and a monitor/defibrillator and remind the team that high-quality CPR must be given – 30 compressions at 2 to 2.4 inches deep and at a rate of 100 to 120 compressions per minute followed by 2 rescue breaths.
Pro Tip #1: It's important for everyone on your team to remember that high-quality CPR has risen to the top of importance even in ACLS, so you communicate this to everyone on your team.
You assign an airway person and directions to begin ventilations. An example of exactly how you might do this, especially if you're not used to being team leader is: Please prepared a basic airway adjunct and ventilate with 100 percent oxygen delivered via bag valve mask at 12 breaths per minute.
Pro Tip #2: Now is a good time to begin thinking about advanced airways if protecting the patient's airway is important or if oxygenation with basic airways is insufficient.
In order to obtain 100 percent oxygenation, you need to turn the oxygen regulator to 15 liters per minute and allow the bag valve mask reservoir to fill prior to giving ventilations.
During CPR, the monitor/defibrillator team member is preparing the patient for rapid defibrillation – the ECG monitor and defibrillator pads are placed on the patient appropriately and as soon as ready, you'll give directions to your team to pause CPR to check the patient's underlying rhythm.
You tell everyone, stand clear while the rhythm is analyzed. It indicated that the patient is in VFib.
CPR is continued while the automated defibrillator charges (or if the defibrillator is manual, shocks will be delivered at 360 joules.)
Once the defibrillator is fully charged, the monitor/defibrillator team member calls out, everyone stand clear; shocking on 3; 1-2-3. The monitor/defibrillator person then pushes the shock button.
CPR resumes and you prepare the team for medications delivery.
Pro Tip #3: While both IV and IO are acceptable, try IV first and only move to IO if you're unable to obtain patient IV access for effective medication and fluid delivery.
Your team is able to get patent IV access via an 18 gauge in the left antecubital and start the patient on normal saline. The recorder team member states, It's been 2 minutes.
You instruct the compressor and monitor/defibrillator to switch positions to have a fresh compressor at all times. This switch should occur at least every 2 minutes or sooner if you recognize insufficient compressions due to fatigue.
As the compressor calls out the last few compressions – 28, 29, 30 – that's when the switch occurs. After 2 ventilations are delivered, the monitor/defibrillator switches positions with the compressor and readies his or her hands in the appropriate chest position, then begins effective chest compressions immediately after the last ventilation.
Now is the time for the first medication delivery. You call out the drug order for 1mg of 1:10,000 concentration of epi via IV push flushed with 20cc of normal saline and wait for the IV/medication team member to repeat the order back to you, which they do. You verify the repeated order by saying, That's correct.
CPR resumes for 2 more minutes. At the end of that cycle, you call out, Stop compressions, and allow the ECG to check the patient's rhythm. You find that the patient is still in VFib, so you call out for another shock to be delivered.
At this time, you decide to secure an advanced airway to maintain the airway, give synchronous compressions with rescue breaths, and have the ability to monitor capnography.
As the team leader, you request an advanced airway using an endotracheal tube. Someone on the team measures for it and inserts a #6 endotracheal tube with a stylet. The ET tube balloon is inflated after it passes between the left and right lobes. You also check the patient's stomach for any air sounds.
Pro Tip #4: If you cannot detect any stomach air sounds and there are good breath sounds bilaterally, you know that the ET tube is in the correct spot.
The recorder calls out, We're at 4 minutes.
You instruct the rest of the team to stand clear of the patient while his rhythm is checked and then announce another switch for the compressor and monitor/defibrillator team members. The patient is still in VFib, so you prepare the team for a third shock.
You instruct everyone to continue CPR and also direct the medication team member to prepare the next round of medication – amiodarone at 300mg followed by 20cc of normal saline. The medications team member repeats the order and you confirm it's correct.
A second dose of amiodarone may be given for persistent VFib, which is half the initial dose, or 150mg, and administered after 2 more minutes of CPR and another shock if the rhythm has not converted. Alternatively, epi can be given every 3 to 5 minutes instead and staggered between shocks and CPR.
This scenario continues until all treatment options have been exhausted and all possible causes have been ruled out.