Now, in this demonstration we have a 30 year old female who was found unconscious
in her office by co-workers.
Witnesses report that she was emotionally distraught and
she may have had a problem with chronic illness and use of different pain pills.
The patient appears cyanotic and seems to be unresponsive.
So first, the team leader directs an assistant to check for responsiveness using a tap and
shout.
The patient does not respond to taps and shouts and it’s at this time that you would want
to call a code or ask for additional help depending on your area of practice.
The code is called and the team is on their way.
Now, we want to assess for a carotid pulse and for breathing as we begin gathering appropriate
equipment that may already be in the room or close by.
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
it’s in a hospital bed with a CPR button, activate it so that the bed will deflate and
make the surface as rigid as possible.
It’s at this time that CPR is 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 be assigned roles if all are equally trained.
As the team leader begins to take the leadership role, they direct to the recorder to please
record times, treatments given and any associated notes per protocol.
A compressor will be assigned along with a monitor defibrillator.
A reminder to give CPR at 30 compressions at 2-2.4 inches deep and at a rate of between
100-120 compressions per minute is communicated.
The airway person is also assigned and directions to prepare to ventilate are given.
“Please prepare a basic airway adjunct and ventilate with 100% oxygen delivered via bag
valve mask at 12 breaths per minute,” is a good example of how that may sound.
Now is a good time to begin thinking about an advanced airway if protecting the airway
or if oxygenation with a basic airway is insufficient.
To obtain 100% oxygenation we will turn the oxygen regulator at 15 liters per minute and
allow the bag valve mask reservoir to fill prior to ventilations being delivered.
At this time, the leader calls everyone to stand clear while analyzing the rhythm.
We then see that the patient is in what looks to be asystole.
In this case, it’s important that we double check some easy things to correct with this
type of EKG rhythm.
First, are all the leads on correctly and attached with good contact?
Is there sufficient power to the ECG?
Is the amplitude setting correct so as to determine asystole vs. fine V-Fib?
If all these are answered yes and working properly, the team leader may continue.
At this time the team leader states, “let’s keep giving high quality CPR.”
Because there isn’t a shockable rhythm now, we move to the IV access or an IO access in
order to begin medication and fluid therapy.
In our scenario, an 18 gauge antecubital IV is established.
At this time, the team leader should call for 1mg Epinephrine 1:10,000 to be delivered
IV push and then flushed with 20 cc of normal saline.
This ensures that the medication is in the central circulatory system.
Remember, CPR should still be in progress and should not be stopped for the delivery
of medications.
After CPR has been in progress for some time, the recorder says, “about 2 minutes has
gone by.”
It’s at this time that the compressor should be switched with the monitor/defibrillator.
Now would be a good time to do a quick look at the monitor for changes.
This should not take any longer than 10 seconds before the shock is delivered or CPR is resumed
if there is no change in the rhythm.
The team leader states, “it appears the patient is still in asystole, so let’s continue
with CPR.”
Now is a good time to consider an advanced airway.
The team leader states, “Let’s prepare for intubation and attach capnography.”
The team leader requests an advanced airway using an endotracheal tube.
It’s measured at a number 7 ET and is placed with a stylet.
The ET balloon is inflated after tube is passed between the vocal chords of the patient and
lung sounds are auscultated for ET tube placement accuracy.
Both upper lobes, and over the stomach is checked to ensure that the tube is in the
trachea and not in the esophagus.
Tube placement is accurate and lung sounds are equal and good bilaterally.
Air in the stomach sounds are negative.
The team leader states, “CPR quality looks good.
Let’s ensure we’re monitoring capnography.”
As CPR has been in progress for a while, the recorder states that it’s been about 4 minutes
since epi was first given.
The team leader should now call for a second dose of epi 1 mg 1:10,000 IV push flushed
with 20 cc normal saline.
Remember to change compressors every two minutes or upon noticeable fatigue to ensure adequate
CPR compressions throughout the whole code.
Encourage the CPR compressor that compressions are looking good or make any suggestions to
improve quality throughout.
Once initial treatments have been started, it is important to ask the team to help in
considering why this patient went into asystole.
To do this we should consider the reversible H’s and T’s.
These include Hypovolemia, Hypoxia, Hydrogen Ion (which is Acidosis), Hypo or Hyper-kalemia,
Tension Pneumothorax, Cardiac Tamponade, Toxins, Cardiac or Coronary Thrombosis.
Now remember, it’s important to remember that as healthcare professionals, we cannot
know when a person may experience a survival that goes against all scientific reason, and
so we should regularly rescue with great enthusiasm.
But, it’s also important to note, that many studies have shown that asystole represents
what is termed to be final rhythm.
In other words, cardiac function and electrical activity have diminished over time until there
is no perceivable electric or mechanical activity and the patient biologically or is permanently
dead.
Unless there are special circumstances like hypothermia or drug overdose, prolonged resuscitation
efforts beyond 20 minutes are usually unnecessary and futile.
The team leader may consider stopping resuscitation if ETCO2 is less than 10 after 20 minutes
of high quality CPR and all treatments have been exhausted.