In this demonstration 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 tree stump.
After walking back to his house, he began to develop difficulty breathing
with increased chest discomfort.
While interviewing the patient, he states that he’s developing more trouble breathing
and feels light headed.
He is placed on O2 by nasal cannula at 4 liters and his vital signs are taken.
The BP is 98/68, pulse is 112 and tachycardic, respirations are 20 and shallow.
The patient becomes less coherent and stops responding to questions.
The team leader directs an assistant to check for responsiveness using a tap and shout.
The patient does not respond to the taps and shouts 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 want to 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
is rigid if it’s not already so.
Now, CPR should be initiated at 30 compressions to 2 breaths at 2-2.4 inches deep at 100-120
compressions per minute.
As additional assistance or the code team arrives, we are able to direct each of the
team members to their respective roles.
The team leader begins to direct each member in their roles.
Respiratory would begin with a basic airway, giving breaths with a BVM at 15 liters of
oxygen at cycles of 30 compressions to 2 breaths.
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 what looks like 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 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 keep giving high quality CPR and calls for an IV to be
started with an 18 gauge needle, starting normal saline, and we need this to establish
the ability to give medications.
The recorder now says, about 2 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 no longer than 10 seconds to determine if a shock is needed or, in this
case, if CPR should be resumed.
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 its’ first medication.
1mg Ephinephrine 1:10,000 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 always a good thing we we’re trying to have an effect with that medication.
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 7 ET and it’s placed with a stylet.
The ET balloon is inflated after the tube is passed between the vocal chords of the
patient, and 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 with no sounds in 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 4 minutes.
So compressor will change then after 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 is in 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 Hyper-kalemia.
Tension Pneumothorax is when we start getting into the T’s.
Then we have 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 want to consider the effects
of that chest or head trauma when he said he fell on that 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.
Maybe an example of this would be we could suggest that a tension pneumothorax may be
the culprit, except for the fact that we have equal and good lung sounds.
We also have great compliance when 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
PEA from cardiac tamponade.
Now this is a reasonable, and it’s a good suggestion, and all measures for correcting
such an injury are expedited.
If, after all of the reversible causes are eliminated, and the patient is still in arrest,
the team leader may consider stopping resuscitation.
Especially if the ETCO2 is less than 10 after 20 minutes of high quality CPR and all treatments
have been exhausted.
Now in many cases, the PEA deteriorates into asystole over time.
Now remember, it’s never easy to call a code.
You know, everybody has 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, unfortunately this may have to be part of the next steps
in concluding this scenario.