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. After checking the monitor, we see that the
arrhythmia is still persistent V-Fib and 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!” The team leader looks at ECG after the shock
is delivered, to see that the patient is still in ventricular fibrillation. 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!” Monitor is checked after the shock and the
patient ECG is still in V-fib. 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.
