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In this scenario, we have a 42-year-old male involved in an accident where they fell out of a tree stand while hunting. The patient believed that he fell nearly 12 feet to the ground and thought that he landed on a tree stump. After walking back to his house, he began to develop difficulty breathing with an increased chest discomfort. Now, while interviewing the patient, he states that he's developing more trouble breathing and he's starting to feel lightheaded. He's placed on O2 by nasal cannula at four liters and his vital signs are taken. The BP is 98 over 68, his pulses are 112 and tachycardic, respirations are 20 and shallow. The patient becomes less coherent and actually stops responding altogether. The team leader directs an assistant to check for responsiveness using the tap and shout. The patient does not respond to the taps and shout, so the code team is called. Now, we want to assess for a carotid pulse and for breathing. As we check, we find no pulse and the patient is not breathing. It's at this time that we would wanna place a CPR board under the patient, or if it's a hospital bed with a CPR button, activate it so the bed will deflate and make the surface rigid if it's not already so. Now CPR should be initiated at 30 compressions to two rescue breaths at two to 2.4 inches deep at rate of between 100 to 120 compressions per minute. As additional assistance or the code team arrives, the team leader begins to direct each member in their roles. The compressor continues compressions while respiratory would begin with a basic airway, giving two breaths after every 30 compressions with a bag valve mask delivering 15 liters of oxygen. The recorder would be directed to record times, treatments given and any associated notes per protocol. As compressions are being given, the defibrillator person will be directed to attach defib pads in preparation to view the initial arrhythmia and shock, if needed. When the defib pads are on, the leader calls to everyone to stand clear while we analyze the rhythm. The ECG shows that what looks to be a slow, normal sinus rhythm. The leader should call for respiratory to check for the pulse. If respiratory can't do that, you can ask your compressor or another assistant to check for a pulse as well. We find that there is no pulse, so we know that this is PEA. The leader directs the team to give high-quality CPR and calls for an IV to be started with an 18-gauge needle, starting normal saline at a TKO. The recorder now says, "About two minutes of CPR have gone by." It's at this time that the compressor should switch with the monitor/defibrillator person. Now would be a good time to do a quick look at the monitor to see if there are any changes. This should take any longer than 10 seconds to determine if a shock is needed or, in this case, if CPR should be resumed. Now, in our scenario, the team leader sees what looks like a slow, normal sinus rhythm and asks again for a pulse check. There is still no pulse, so the patient is still in PEA. The leader tells the compressor to continue with CPR and calls for the first medication. 1mg Epinephrine at one to 10,000 delivered IV push and flushed with 20 cc of normal saline. Remember that flushing the line ensures that the medication gets to the central circulatory system, which is what needs to happen for the medication to be effective. Remember, CPR should continue and should not be stopped for the delivery of medications. Now the leader tells respiratory to get an advanced airway in place and monitor capnography. The team leader requests an endotracheal tube. The patient is measured at a number seven, and it's placed with a stylet. The ET balloon is inflated after the tube is passed between the vocal cords of the patient, and the lung sounds are auscultated at both upper lobes, and then over the stomach for tube placement accuracy. Lung sounds are equal bilaterally with good chest rise and fall, and there are no sounds over the stomach. The tube placement is accurate. When the tube is in place and capnography is attached, the leader will take a look to see the effectiveness of the compressions and breaths. In our scenario, the CPR quality looks great. Now the recorder states that it's been four minutes. The compressor will change. The second dose of epinephrine is given and flushed with 20 cc of normal saline. Remember, the leader should encourage the CPR compressor when compressions are looking good, or make suggestions to improve the quality of CPR throughout the code. Now is a good time to ask the team to help in considering why this patient may have gone into PEA. To do this, we should consider the reversible H's and T's. For the H's, this includes Hypovolemia, Hypoxia, Hydrogen Ion, which means Acidosis, Hypo or Hyperkalemia. And for the T's, we have Tension Pneumothorax, Cardiac Tamponade, Toxins, Cardiac Thrombosis or Coronary Thrombosis. Now, because we don't know if the patient actually is suffering from something from the long fall, or is having something other than trauma, we may wanna consider the effects of chest or head trauma when he said he fell on the tree stump. The ACLS team could be questioned in order to have help in determining the possible correctable causes of the PEA in this scenario. An example of this would be suggesting that a tension pneumothorax may be the culprit, except for the fact that we have good, equal lung sounds. We also have great compliance when we're giving those ventilations, which tells us it's probably not a tension pneumo. Another suggestion is that the chest trauma, or the blunt force to the chest, may be causing the PEA from cardiac tamponade. Now, this is reasonable, and it's a good suggestion. All measures for correcting such an injury should be expedited. Now, after all of the reversible causes are eliminated and the patient is still in arrest, the team leader may actually consider stopping resuscitation, especially if the ETCO2 is less than 10 after 20 minutes of high-quality CPR and all the treatments have been exhausted. Now, in many cases, the PEA deteriorates into an asystole over time. Remember, it's never easy to call a code. You know everybody's invested a ton of time and a ton of effort, and we want this patient to survive. But after a long period of working a person, and they begin to show deterioration and they're not responding to the treatments, it's very unfortunate, but this may have to be part of the next step in concluding this scenario.
In this lesson, we're going to let you play the role of team leader during another cardiac emergency – pulseless electrical activity (PEA). 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 42-year-old male patient who fell out of a tree stand while hunting. He fell about 12 feet and may have landed on a tree stump. He walked back to his house and shortly after began to develop breathing difficulty and chest discomfort.
While interviewing the patient, he tells you that his breathing is getting more labored and he's feeling lightheaded.
Your initial assessment recap:
You place the patient on O2 via nasal cannula at 4 liters and his vital signs are taken:
The patient begins to become less coherent and stops responding to your questions.
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.
Your team checks for a carotid pulse and signs of normal breathing as you all begin gathering the appropriate equipment. 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.
CPR has been initiated – 30 compressions at a depth of 2 to 2.4 inches deep at a rate between 100 and 120 compressions per minute and followed by 2 rescue breaths.
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 an airway person and directions to begin with a basic airway providing breaths using a bag valve mask at 15 liters of oxygen at cycles of 30 compressions to 2 rescue breaths.
While compressions are being given, you direct the monitor/defibrillator team member to attach the defibrillator pads to get the patient's initial rhythm and shock him if needed. As soon as the pads are on, you 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 shows what looks like a slow normal sinus rhythm. You call for the airway manager to check again for a pulse, or the compressor if the airway manager is busy.
No pulse can be found, and you determine that the patient is in PEA. You direct the team to continue performing high-quality CPR and call for an IV to be established with an 18-gauge needle, start him on normal saline, and prepare to give medications.
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.
You take a quick look at the monitor – no longer than 10 seconds – to see if a shock needs to be given or CPR resumed. In this scenario, you still see what looks like a slow normal sinus rhythm and ask again for a pulse check. There is still no pulse; the patient is still in PEA.
You direct the compressor to continue performing CPR and call 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.
Pro Tip #1: Remember, flushing the line ensures that the medication gets into the central circulatory system more effectively. Also important to remember, CPR does not stop for the delivery of medications.
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 #7 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.
Remember, 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 chest is also showing signs of good chest rise and fall, which also indicates the tube placement was accurate.
When the ET tube is in place and capnography is attached, you look to see if compressions and rescue breaths are effective, and CPR quality looks great.
The recorder calls out, We're at 4 minutes.
The compressor and monitor/defibrillator team member switch again after the second dose of epi is given and flushed with 20cc of normal saline.
Pro Tip #2: As team leader, part of your duties is to either encourage the CPR compressor when compressions are good or make suggestions to improve quality if they are not.
You decide that now is a good time to ask the team for feedback to help determine why the patient is in PEA. You do this by considering the reversible H's and T's:
Since you're not sure if the trauma/fall is to blame for the PEA, or if something else is, you're open to suggestions from the team. The team considers the effects of the head and/or chest trauma from the fall and someone suggests tension pneumothorax could be the cause.
You think about this but eventually dismiss it – the patient has good equal lung sounds and has great compliance when giving ventilations, which indicates it's probably not tension pneumothorax.
Another member of the team suggests that chest trauma may be causing the PEA due to cardiac tamponade:
This sounds like a good suggestion and all measures for correcting it are expedited.
However, what if all reversible causes have been eliminated and the patient remains in cardiac arrest? As team leader, you may reach a point when a decision to stop resuscitation may have to be made, especially if EtCO2 is less than 10 after 20 minutes of high-quality CPR and all treatment options have been exhausted.
In many cases, PEA will deteriorate into asystole over time. It's never easy to call it quits. Everyone has invested a lot of effort and time and everyone on the team wants to see the patient survive.
However, if nothing is working and the patient's condition isn't improving or is deteriorating further, you may have to make the hard decision to conclude the resuscitation attempt.