Your patient is a 40-year-old man who was found unresponsive in the street. Paramedics have placed the patient on a backboard with cervical spine stabilization. An IV of normal saline is infusing when the patient arrives in the emergency department. You have a sufficient number of advanced life support personnel available to assist you and carry out your instructions. Emergency equipment, including a biphasic manual defibrillator, is available.
1. As you approach the patient, you see that he is supine on a backboard. His eyes are closed and his skin is pale. You observe blood dripping from the patient ’s right ear. What should be done next?
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2. The patient has occasional gasping breaths occurring at a rate of 4 breaths/min. There is no pulse. His skin is warm, pale, and moist. What should be done now?
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118 CHAPTER 4 Cardiac Arrest Rhythms
3. As the patient ’s chest is exposed to apply the combination pads, you observe multiple abrasions, a partial thickness laceration in the area of the right nipple, and what looks like footprints on the patient ’s chest and abdomen. What should be done next?
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4. The monitor reveals the following rhythm:
Identification _____________________________________
5. Information from the paramedics has been obtained and your physical examination findings are noted.
Signs/Symptoms: Possible assault by unknown persons with unknown weapons
A llergies: Unknown
Medications: Unknown
Past history: Unknown Last oral intake: Unknown
E vents prior: Found unresponsive in the street
Focused Physical Examination
Head/face: Blood dripping from right ear, bruising of left orbit, frontal bone contusion, left temporal area contusion; both pupils deviated to left side
Neck: Unremarkable
Thorax: Partial thickness laceration near right nipple; abrasions and footprints noted Abdomen: Markedly distended and firm; abrasions and footprints noted
Pelvis: Unremarkable Back: Unremarkable
Extremities: Multiple abrasions on upper extremities
You estimate the patient ’s weight to be 70 kg. What would you like to do next?
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6. Chest compressions are ongoing. An oral airway has been inserted and the patient is being ventilated with a BMD. What should be done next?
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(From Aehlert B: ECG study cards, St. Louis, 2004, Mosby.)
7. Although the monitor remains unchanged, a team member informs you that a weak pulse is present.
How would you like to proceed?
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8. The patient is unresponsive and there are no signs of spontaneous breathing. His heart rate is 125 beats/min and his blood pressure is 53/30 mm Hg. What should be done next?
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CHAPTER QUIZ ANSWERS True/False
1. T. When using handheld paddles, the use of gels, pastes, or pre-gelled defibrillation pads aids the passage of current at the interface between the defibrillator paddles/electrodes and the body surface.
Failure to use conductive material results in increased transthoracic impedance, a lack of penetration of current, and burns to the skin surface. Combination pads are pre-gelled and do not require the application of additional gel to the patient ’s chest.
OBJ: Explain defibrillation, its indications, proper pad or paddle placement, relevant precautions, and the steps required to perform this procedure with a manual defibrillator and an AED.
2. F. Epinephrine and vasopressin, which are vasopressors, have been shown to improve ROSC after administration during cardiac arrest. Because current evidence has revealed that the efficacy of these medications are similar and that there is no demonstrable benefit from administering both epineph-rine and vasopressin compared with epinephepineph-rine alone, vasopressin has been removed from the adult cardiac arrest algorithm (Link, et al., 2015).
OBJ: Given a patient situation, describe the ECG characteristics and initial emergency care for cardiac arrest rhythms, including mechanical, pharmacologic (ie, indications, contraindications, doses, and route of administration of applicable medications), and electrical therapy, where applicable.
3. F. Although there is inadequate evidence to support the routine use of lidocaine after cardiac arrest, the initiation or continuation of lidocaine may be considered immediately after a ROSC from car-diac arrest associated with pVT or VF (Link, et al., 2015).
OBJ: Discuss immediate post – cardiac arrest care upon ROSC.
4. T. For intubated patients, continuous EtCO2 monitoring should be used to monitor the quality of compressions during resuscitation efforts. Failure to achieve an EtCO2 of greater than 10 mm Hg immediately after intubation and after 20 minutes of CPR is associated with extremely poor chances for ROSC and survival (Link, et al., 2015). This finding, in combination with other factors, may be considered when deciding when to terminate resuscitation (Link, et al., 2015).
OBJ: Discuss the use of continuous EtCO2 monitoring during resuscitation efforts.
5. F. When a monophasic defibrillator is used for shockable cardiac arrest rhythms, the recommended energy dose is 360 J for all shocks (Link, et al., 2015).
OBJ: Identify the energy levels that are currently recommended, and indicate if the shock deliv-ered should be a synchronized or unsynchronized countershock, for pulseless monomorphic VT, PMVT, and VF.
6. T. Current guidelines state that it may be reasonable to administer epinephrine as soon as feasible after the onset of cardiac arrest associated with an initial nonshockable rhythm (Link, et al., 2015).
However, because optimal timing may vary based on patient factors and resuscitation conditions, there is insufficient evidence to make a recommendation as to the optimal timing of epinephrine, 120 CHAPTER 4 Cardiac Arrest Rhythms
particularly in relation to defibrillation, when cardiac arrest is associated with a shockable rhythm (Link, et al., 2015).
OBJ: Given a patient situation, describe the ECG characteristics and initial emergency care for cardiac arrest rhythms, including mechanical, pharmacologic (ie, indications, contraindications, doses, and routeof administration of applicablemedications), and electrical therapy, whereapplicable.
Multiple Choice
7. D. PEA is a clinical situation, not a specific dysrhythmia. PEA exists when organized electrical activity (other than VT) is observed on the cardiac monitor, but the patient is unresponsive, not breathing, and a pulse cannot be felt.
OBJ: Identify four cardiac rhythms that are associated with cardiac arrest.
8. C. Defibrillation is indicated in the management of pVT and VF. It is not indicated in the man-agement of PEA. Remember: defibrillation is performed to depolarize the myocardial cells at one time and provide an opportunity for one of the heart ’s natural pacemakers to take over. In PEA, an organized rhythm is present on the monitor. Thus pacemaker activity is already present but there is inadequate cardiac output and no pulse. PEA is not shocked because a shock could disrupt the orga-nized rhythm and cause chaos (ie, VF). Defibrillation is not indicated in asystole.
OBJ: Explain defibrillation, its indications, proper pad or paddle placement, relevant precautions, and the steps required to perform this procedure with a manual defibrillator and an AED.
9. D. When peripheral IV cannulation is unsuccessful or is taking too long, an IO infusion is an alternative method of gaining access to the vascular system and should be considered before considering placement of a central line. To improve flow rates during an IO infusion, the use of a pressure bag or infusion pump may be necessary. If IV or IO access cannot be achieved to give drugs during a cardiac arrest, the tracheal route can be used to give selected medications; how-ever, intravascular drug administration provides more predictable drug delivery and pharmacologic effect (Link, et al., 2015).
OBJ: Given a patient situation, describe the ECG characteristics and initial emergency care for cardiac arrest rhythms, including mechanical, pharmacologic (ie, indications, contraindications, doses, and route of administration of applicable medications), and electrical therapy, where applicable.
10. C. An IV bolus of epinephrine is indicated in cardiac arrest. Cardiac arrest rhythms include PEA, asystole, pVT, and VF. Epinephrine is not given as an IV bolus to patients who have a pulse.
Although epinephrine may be given to patients for symptomatic bradycardia, it is given as an IV infusion, not an IV bolus.
OBJ: Given a patient situation, describe the ECG characteristics and initial emergency care for cardiac arrest rhythms, including mechanical, pharmacologic (ie, indications, contraindications, doses, and route of administration of applicable medications), and electrical therapy, where applicable.
11. C. The primary survey focuses on BLS assessment and intervention. The secondary survey focuses on advanced life support assessment and interventions. Thus establishing vascular access is part of
“C” (ie, Circulation) in the secondary survey.
OBJ: List the purpose and components of the primary and secondary surveys.
12. B. The first medication used in the management of PEA is epinephrine. Amiodarone, atropine, and lidocaine are not indicated in the management of PEA.
OBJ: Given a patient situation, describe the ECG characteristics and initial emergency care for cardiac arrest rhythms, including mechanical, pharmacologic (ie, indications, contraindications, doses, and route of administration of applicable medications), and electrical therapy, where applicable.
13. D. The initial dose of lidocaine is 1 to 1.5 mg/kg IV push. Repeat doses of 0.5 to 0.75 mg/kg IV push may be given at 5- to 10-minute intervals, to a maximum dose of 3 mg/kg.
OBJ: Discuss immediate post – cardiac arrest care upon ROSC.
14. A. CPR and defibrillation are the most important treatments for the patient in cardiac arrest asso-ciated with pVT or VF. Insertion of advanced airways and administration of resuscitation medica-tions are of secondary importance. Although synchronized cardioversion may be used in the treatment of an unstable patient in monomorphic VT with a pulse, it is not indicated for pVT.
OBJ: Explain defibrillation, its indications, proper pad or paddle placement, relevant precautions, and the steps required to perform this procedure with a manual defibrillator and an AED.
15. C. Althoughan organizedrhythmis presenton themonitor, thepatienthas nopulse.Thisclinical situation is PEA. You should begin CPR immediately, ventilate the patient with a BMD, and give epinephrine 1 mg IV. Transcutaneous pacing, defibrillation, and atropine administration are not indicated for PEA.
OBJ: Given a patient situation, describe the ECG characteristics and initial emergency care for cardiac arrest rhythms, including mechanical, pharmacologic (ie, indications, contraindications, doses, and route of administration of applicable medications), and electrical therapy, where applicable.
Completion
16. Sinus rhythm to monomorphic VT
OBJ: Given a patient situation, describe the ECG characteristics and initial emergency care for cardiac arrest rhythms, including mechanical, pharmacologic (ie, indications, contraindications, doses, and route of administration of applicable medications), and electrical therapy, where applicable.
17. PMVT
OBJ: Given a patient situation, describe the ECG characteristics and initial emergency care for cardiac arrest rhythms, including mechanical, pharmacologic (ie, indications, contraindications, doses, and route of administration of applicable medications), and electrical therapy, where applicable.
18. Sinus rhythm with a run of monomorphic VT
OBJ: Given a patient situation, describe the ECG characteristics and initial emergency care for cardiac arrest rhythms, including mechanical, pharmacologic (ie, indications, contraindications, doses, and route of administration of applicable medications), and electrical therapy, where applicable.
19. Coarse VF
OBJ: Given a patient situation, describe the ECG characteristics and initial emergency care for cardiac arrest rhythms, including mechanical, pharmacologic (ie, indications, contraindications, doses, and route of administration of applicable medications), and electrical therapy, where applicable.
Matching 20. D 21. A 22. B 23. C
Short Answer
24. The purpose of defibrillation (ie, unsynchronized countershock) is to deliver a uniform electrical current of sufficient intensity to depolarize myocardial cells (including fibrillating cells) at the same time, briefly “stunning ” the heart. This provides an opportunity for the heart ’s natural pacemakers to resume normal activity. When the cells repolarize, the pacemaker with the highest degree of auto-maticity should assume responsibility for pacing the heart.
OBJ: Explain defibrillation, its indications, proper pad or paddle placement, relevant precautions, and the steps required to perform this procedure with a manual defibrillator and an AED.
122 CHAPTER 4 Cardiac Arrest Rhythms