Prehospital Resuscitation for the 21 st Century Simulation Case VF/Asystole Case History 1 (hypovolemic cardiac arrest secondary to massive upper GI bleed) 56 year-old male patient who fainted in the presence of family members 20 minutes ago home has a pulse of 130 and regular and a BP of 80/60. Upon being placed on the stretcher, the patient collapses into unconsciousness. Key Findings and ECG (Simulation Setting) ECG: Course VF Flat neck veins History of esophageal varices End tidal CO 2 20 Patient was vomiting bright red blood History of esophageal varices Expected Actions and Related Findings The Team Leader should direct the routine aspects of a code including; Appropriate assessment of the patient 30:2 with bag mask, CC CPR following insertion of advanced or alternative device Basic and advanced airway management with minimal interruption of compression 2 inch compression at 100 per minute Shock 150-200 j (post shock asystole) Administration of vasopressors (1 mg. epinephrine or 40 U. of vasopressin IV/IO) Exploration of the H s and T s and identify hypovolemic etiology Identifies history and physical findings suggesting hypovolemia o Alcoholic o History of esophageal varicies o Vomited earlier today (did not see) Good CPR, fluid challenge Progress during intra-cardiac arrest period
Drop End Tidal CO2 to 15 if CPR is poor If fluid bolus given, evolve to Sinus tachycardia at 140 (BP 70/50) Expect second fluid bolus. Flat neck veins End tidal CO 2 25 following intubation Post Resuscitation: End tidal CO 2 45 mm Hg Palpable pulse and sinus tachycardia 120/minute Blood pressure 100/40 Patient remains unresponsive and in respiratory arrest Continue ventilation at a rate of 5-6 breaths per minute Continue fluid resuscitation as needed Oxygen Sat 90% (adjust oxygen to titrate to 94-96%) Administer fluid to achieve MAP close to 100 mm/hg (no significant response) Consider vasopressor infusion (i.e. Epinephrine Dopamine, Norepinephrine) Begin therapeutic hypothermia protocol (IV Fluids, Arctic Sun)
Prehospital Resuscitation for the 21 st Century Simulation Case VF/PEA Case History 2 (cardiac arrest secondary to hyperkalemia) You arrive at the home of a 48 year-old male patient who collapsed in the presence of family members 10 minutes ago in the living room. A family member is present. Key History, Physical Findings, and ECG (Simulation Setting) ECG: Course VF Brachiobasilic fistula is noted in the left forearm History of renal failure Missed dialysis treatment today Expected Actions and Related Findings Appropriate assessment of the patient Basic and advanced airway management Minimally interrupted chest compressions Establishment of IV access Shock at 150-200j, (shock into Wide complex tachycardia, with peaked T waves PEA) Administration of vasopressors (1 mg. epinephrine or 40 U. of vasopressin IV/IO) Exploration of the H s and T s Identifies history and physical findings indicating hyperkalemia o Calcium Chloride 10% (100 mg/ml) o Sodium Bicarbonate 0.5-1 meq/kg IV o 25 gms/50 ml dextrose IV over 20-30 minutes Post Resuscitation: End tidal CO 2 40 mm Hg Palpable pulse and sinus tachycardia 130/minute Blood pressure 80/40 Patient remains unresponsive and in respiratory arrest Oxygen Sat 90% (adjust oxygen to titrate to 94-96%) Continue ventilation at a rate of 5-6 breaths per minute Administer fluid to achieve MAP above 90 mm/hg (no significant response) Consider Dopamine infusion of 10 mcg/kg/min-if Systolic B/P < 90 mmhg Begin therapeutic hypothermia protocol (IV Fluids, Arctic Sun)
Prehospital Resuscitation for the 21 st Century Simulation Case VF/PEA Case History 3 (cardiac arrest secondary to Tension Pneumothorax) You respond to a 66 year-old male patient complaining of pleuritic retrosternal chest pain, shortness of breath, anxiety and weakness. Suddenly he appears to be unconscious. Key History, Physical Findings, and ECG (Simulation Setting) Not responsive VF COPD Expected Actions and Related Findings Appropriate assessment of the patient Basic and advanced airway management Minimally interrupted chest compressions Establishment of IV access Shocked into PEA 120 Sinus tachycardia Administration of vasopressors (1 mg. epinephrine or 40 U. of vasopressin IV/IO) Exploration of the H s and T s Identifies history and physical findings indicating tension pneumothorax Needle decompression Post Resuscitation: End tidal CO 2 40 mm Hg Palpable pulse and sinus tachycardia 130/minute Blood pressure 100/60 Patient remains in respiratory arrest Continue ventilation at a rate of 5-6 breaths per minute
History of Bleeding Ultrasound Collapsed IVC History of Submersion Core Body Temperature Fluid, blood Internal cooling Prolonged Arrest, ABG Salicylate OD Renal History, Dialysis Blood Test, ECG Changes Cyanosis, ABG Check Oxygen/Ventilation History, Smells, Physical Findings, Smoke Inhalation Trauma, Recent Cardiac Surgery, Ultrasound Breath Sounds, Neck Veins Ultrasound History Chest Pain Prior to Collapse, 12 lead History Chest Pain, Ultrasound Dilated R. Ventricle Bicarbonate Pharmacology Treatment Assure adequate Ventilation/Oxygen Supportive care Antidote if available Pericardiocentesis Needle decompress. Chest tube Catherization Lab Thrombolytics