hi sharon okay no worries yep just to let you know that today we have the lovely and gareth
they're going to be your helpers so you need some help you can call them yep sure
they are very capable and competent but luckily she gets even clearer okay yeah
great so jen i'm going to give you a scenario and ask you to please repeat it back to me
all right so you've been called in to assess the gentleman who has got a one-hour history
of some chest pain that is radiating through to his left arm uh he's a 58 year old man and
he's got a history of ischemic heart disease he looks quite unwell and pale and sweaty
and i'd like you to please come and assess him and then allocate your table sure and what's his name
sharon his name is george so george 58 year old mel who's got a one-hour history of central chest
pain radiation radiating down his left arm with the background of cardiac disease and he's unwell
and needs assessing correcting sure quite different okay so walk into the room and look for
danger and i'll just say hi george how you going oh hi how are you yeah good thanks how you feeling
okay we'll have a look at that for you so he's airways okay he's talking to me
i might need to come back but at the moment i'm happy so i'm just
gonna have a listen to your chest so what's his respiratory rate sharon
okay and i'll just auscultate his chest
clear chest is clear and palpate his trick here is that midline
and is he making much respiratory effort and i'll just pop his sap probe on his finger which
hopefully i've got one here okay just going to pop this on your finger and check his sets what's
so set's a 97 so i think i'll leave oxygen for now okay so i'm going to pop some monitoring on
as well i might pop the pads on at this stage to get a heart rate and also check his blood pressure
can i get a blood pressure
okay just going to monitor your heart there so i've got a blood pressure 110 on 60.
heart rate's 111 looks okay but tachycardic has he got a line in
sharon he doesn't have any access i might get some help actually because i'd like to
get a 12 lead ecg as well so i might call sophie and garrus just checking his cap refill
sorry two seconds hi sophie so this is george he's got some chest pain he's got a history of cardiac
disease he's not feeling that well at the moment can you please put in a line and take some bloods
and do a fbc UEC and we'll do a ck and troponin and also check her blood sugar and i might get
gareth is gareth can you get the ecg machine and do 12 lead for me gareth so circulation i might
move on to disability so we'll check the blood sugar and how you feeling at the moment george
okay so we might need to give him some um gtn for that you said his blood pressure was 110.
okay so we might just give you a tablet or spray under your tongue for your chest pain
is he on aspirin uh he's not okay and he has so we might also gareth um would you mind getting um
some aspirin ordered okay great yep okay so um so i'm on d so he's uh he's an avp who is an a at the
moment and we've checked his blood sugar is there any medication on his chart that's new or okay so
we just have a little look at him maybe i'm gareth if you can just have a look at his calves mommy
check there's no swelling and we'll just check there's no bleeding anywhere or over his signs
okay
george can you open your eyes he's not responding is he
making any respiratory effort can't feel a pulse okay sophie can you start cpr please at steady
steady compressions cheapest can you call a code gareth and then manage the airway
okay actually i might get you to put the pads on actually for me so pads are on pads are on yup
okay so he's arrested we've called for help we've got cpr going we'll do a rhythm check
i'm going to come down here so continue compressions oxygen charging 200 joules
it's a shockable rhythm can you please shock it gareth 200 jewels delivering a shark shot
and we'll restart cpr please and we'll get some more help hopefully so that we can
swap over regularly so we're going to do two minutes of cpr 30 compressions to two breaths
and if we've got someone on airway we might put in a um a supraglottic device because it will mean
we can do continuous compressions so establish resuscitation don't need to give any drugs so
we need to think about reversible causes i think the most likely thing is from thrombosis so you
might have had an ami could have had a pe though so they my most likely causes but thinking about
toxins you said he hadn't started on any new drugs we don't think he's taking anything um gareth when
we next do the the breasts can we have a quick listen to make sure that we've got equal air entry
so uh charles just trying to exclude attention in the thorax i checked the joker before
it's midline uh so toxins tension temp cardiac tamponade we might need to get an echo to
determine that and we can call for one of those so that we can check and then we'll just go through
the hs so hypoxia he starts with 97 you said he was a bit uh maybe short bit short of breath but
sure okay so not too worried about that and we're managing the airway is that going okay
yep so we're managing the airway i don't think it's hypoxia and um we could do a blood gas
now so i can check his electrolytes so i want to see what his k's doing so we'll send that option
yeah so it could be a hypo hyperkalemia or other electrolyte disorders and check his acidosis as
blood gas status as well so hypovolemia hemorrhage there's no signs of any bleeding or anything like
that and a temperature check i forgot to do that before okay so i think it's most likely it's
coronary thrombosis but we just need to sure so can we do another rhythm check please gareth yep
so continue compressions oxygen is away all for your top middle and bottom charging 200 joules
that's a shockable rhythm gareth can you deliver a shot please
okay and we need to give one milligram of adrenaline please iv and then um continue cpr
it's a milligram of adrenaline given we probably need a bit more help but so we've given one
milligram of adrenaline we're doing good cpr we're managing the airway i've sort of been through the
reversible causes i mean we could give some fluid but i'm not sure that it's really necessary but
we could maybe give 250 mls it's probably not going to hurt okay so can we do another rhythm
check please okay so compressions continue everyone else stand clear i'm charging to 200
jewels that's a shockable rhythm sophie can you shock that please
so that's our third shock so we also need to give amiodarone 300 milligrams now
we'll give that over three minutes in 30 mils of dextrose and continue cpr
okay so um so we're in bf we think it's a thrombosis we've gone through all the
other reversible causes did we get the gas back
so there's nothing really to change there so we just need to keep doing effective cpr
and we gave adrenaline on the second shock sophie so
we can probably draw up another one milligram ready in case we need it at the next rhythm check
sure so can sophie can you do another rhythm check please and gareth once we've done the
rhythm check can you unless we need to do something different restart cpr straight
away okay so compressions continue everyone else stand clear i'm charging 200 views
so it's vf can you shop please sophie yep and we recommend cpr ideally i'd like to swap but we
haven't got enough help okay so we're continuing cpr okay can you please do another rhythm
check sophie and be ready to um recommend cpr afterwards gareth if need be okay so compressions
so can you please disarm it's an unshockable rhythm gareth can you please check a pulse
okay so that's good so let's go into a reassessment stage now so
um airway is still got the lma in is he trying to wake up at all sharon
okay so let's get the set we got sets of 96. so if you're happy to keep managing
the airway and finish supplementary breaths please give them but we've got
a set of 96 sophie can i get you to have another listen yeah an auscultate so um
he's making respiratory effort we've got good sets trachea probably hasn't moved since last time
so we move on to circulation and get a blood pressure please and it's got st elevation there
on the monitor so let's get a 12 lead ecg and cool cardiology which probably could have done
that earlier but call them urgently i think he might need to go to the cath lab potentially
he's got blood pressure piles just recheck his cap refill yeah and we'll just keep maintenance
iv fluids we won't fill him too much at the moment so e george any eye opening
so he's uh v or p so he's a p or a u sorry is that poo sure okay and we'll recheck the blood sugar
and um follow up the bloods and then we'll just check we haven't caused any damage
while we've been doing cpo can we please also organize a chest x-ray and we'll probably start
preparing to transfer him so let's get all our emergency equipment set up so we've got
airway management drugs the d-fib oxygen and get the team so that we can transport him to
potentially cath lab potentially icu depends on what cardiologists say thank you
sure
it's a bit nerves oh thank god for that phew that's a relief thanks you