So we’re gonna run through the scenario demonstration to help prepare you to be able
to pass the scenario test.
But first, let’s setup the scenario situation.
In this case, let’s pretend.
Okay, you’re presented with a 56 year old man who arrived in the emergency department
complaining of moderate to severe chest pain and discomfort.
They’ve also got some weakness and shortness of breath, and they’ve had it for the last
4 hours.
Now as of the last 1 to 2 hours, their pain has really intensified and it’s now radiating
up into their neck and jaw and down their left arm.
When you ask them to describe the discomfort on a scale from 1 to 10, the patient states
the pain is currently a number 9 and they feel as though they’re probably going to
get sick and vomit.
The patient care assistant is directed by the nurse to go get an emesis basin while
the nurse keeps typing in the notes.
And as you continue to ask the gentleman more questions, they stop responding and appear
unconscious.
The scene is safe, your personal protection is in place, now let’s get started.
Now, so, this is when you would want someone to Tap and Shout and find out if the patient
is now fully unresponsive.
It’s at this time they are unresponsive, so you want to call a code or ask for additional
help depending on your area of practice.
The code is called, in this situation, and the team is 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 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.
And 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.
Now a compressor will be assigned along with a monitor defibrillator team member.
And a reminder to give CPR at 30 compressions, 2-2.4 inches deep and at a rate between 100-120
compressions per minute is definitely important to be communicated.
Remember, high quality CPR has risen to the top of importance even in advanced cardiac
life support.
Now the airway person is also assigned and directions to prepare to ventilate are given.
You know, one way that might be an example of how you might direct this, especially if
a person is not used to doing it is, give them some specifics 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 advanced airway if protecting the airway is
important or if oxygenation with basic airway is not sufficient.
Now in order to obtain that 100% oxygenation we need to turn the oxygen regulator to 15
liters per minute and allow the BVM reservoir to fill prior to ventilations being given.
During CPR, the monitor defib team member is preparing the patient for rapid defibrillation.
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 to check while we check the underlying dysrhythmia.
It’s at this time that the leader calls 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 defibrillator is manual, the shock will be then 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.
It’s at this time we’ll continue giving CPR and now 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.
Okay, so we’ve got the patent IV of normal saline via 18 gauge in the left antecubital.
At this time, the recorder states, “it’s been about 2 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 that 2 minutes.
As the compressor calls out the last compressions, “28...29..30…” that’s when we 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.
It’s at this time that our first drug should now be given.
The team leader calls out a drug order for “1mg Epinephrine 1:10,000 IV push” and
then “flushed with 20 cc’s 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.”
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!”
CPR is continued.
And it’s at this time that 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
chords and lung sounds are auscultated between the left and the right lobes and then we also
check the stomach to see if we have any air sounds in the stomach.
Now, if you don’t have any stomach sounds, and we have good breath sounds bilaterally,
you know the ET tube is in the right spot, so we’re good to go.
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 300 mg of amiodarone IV push followed by 20 cc
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 2 minutes of CPR and another
shock that does not convert the rhythm.
In addition, epi may be given every 3-5 minutes and can be staggered between the shocks and
the CPR.