Simulation 15: 51 Year-Old Woman Undergoing Resuscitation

Simulation 15: 51 Year-Old Woman Undergoing Resuscitation Flow Chart Flow Chart Opening Scenario Section 1 Type: DM Arrive after 5-6 min in-progress resuscitation 51 YO female; no pulse or BP, just received 2 nd shock, ECG rhythm V-fib Nurse starts IV, anesthesiologist takes lead; recommend: continue CPR, epinephrine every 3-5 min, bolus amiodarone, advanced airway, waveform capnography Section 2 Type: IG After CPR cycle + 3 rd shock patient intubated with capnography assess: pulse weak, rapid/thready, BP - 63/40, ECG - VTach, SpO2 86%, CO2 trend rising to 35 mm Hg Section 3 Type: DM Section 4 Type IG Recommend synchronous cardioversion @ 100 Joules After cardioversion assess: pulse - 40/min, BP - 68/42, ECG - sinus bradycardia, SpO2-89%, patient exhibits intermittent gasping Section 5 Type: DM Section 6 Type: DM Section 7 Type: DM Recommend administering a 0.5 bolus of atropine sulfate After atropine, pulse & BP, no respirations, SpO2 98% (100% O2) recommend mechanical ventilation, vasopressor (dopamine or norepi), hypothermia, 12-lead ECG, A-line, CXR, urine output + creatinine, ABG + lactate + potassium Pt weighs 175 lbs - recommend ventilator settings: VC,AC; 600 ml VT; rate 12/min; titrate FIO2 to SpO2 94-96%; 5 cm H2O PEEP End

Opening Scenario (Links to Section 1) As the lead RT of the Code Blue team, you arrive at the scene of a resuscitation effort on a 51 year-old woman, in progress for about 5-6 minutes. During hand-off, a staff therapist reports to you that the patient has no palpable pulse or blood pressure and just received her 2 nd biphasic 200 Joule unsynchronized shock. The ECG monitor displays the following rhythm: (Click the Start button below when ready to begin) Illegal to Duplicate or Distribute without Permission 2

Decision-Making Section (Multi-Select) Simulation Section #: 1 Links from: Opening scenario Links to Section#: 2 The team nurse establishes an intravenous line just as an anesthesiologist arrives and takes command of the situation. You would now recommend: (SELECT AS MANY as you consider indicated in this Section, then click on the Go To Next Section button below to proceed to the next Section.) Action/Recommendation Pushing 50 ml NaHCO3 via IV Continuing CPR for another cycle, then re-shocking patient if VF persists Administering a 300 mg bolus of amiodarone (Cordarone) Immediately re-shocking the patient @ 360 Joules Inserting an advanced airway and initiating capnography Inserting an intraosseous line Response to Selection Physician disagrees - - consider other Physician agrees - - consider other Physician agrees - - consider other Physician disagrees - - consider other Physician agrees - - consider other Physician disagrees - - consider other Administering 1 mg IV epinephrine Physician agrees - - consider other every 3-5 minutes Discontinuing the resuscitation effort Physician disagrees - - consider other Perfect Score: 8 Minimum Pass Score: 5 Response Score -3 Illegal to Duplicate or Distribute without Permission 3

Information-Gathering Section Simulation Section #: 2 Links from Section #: 1 Links to Section #: 3 The patient is now intubated, connected to a capnography and being manually ventilated at a rate of 10/minute. After 2 more minutes of CPR and a 3 rd shock, you would assess which of the following? (SELECT AS MANY as you consider indicated in this Section, then click on the Go To Next Section button below to proceed to the next Section.) Requested Information Response Data Response Score Carotid pulse (no compressions) Weak, rapid, thready Pupillary response Dilated, responsive to light -1 End-tidal PCO2 trend Pop-up below SpO2 86% +1 Capillary refill 4 seconds 0 Spontaneous respirations Intermittent gasping 0 ECG rhythm Pop-up below Blood pressure (no compressions) 63/40 mm Hg Perfect Score: 9 Minimum Pass Score: 6 ECG pop-up (wide, regular ventricular tachycardia) Capnogram pop-up (trend showing rise in CO2 associated with restoration of circulation) Illegal to Duplicate or Distribute without Permission 4

Decision-Making Section Simulation Section #: 3 Links from Section #: 2 Links to Section #: 4 You would now recommend: (CHOOSE ONLY ONE unless you are directed to Make another. ) Action/Recommendation Response to Selection Response Link to Score Section Reintubating the patient to ensure Physician disagrees - make another -3 proper tube placement Administering a 0.5 mg bolus of Physician disagrees - make another -3 atropine sulfate Repeating defibrillation @ 200 Physician disagrees - make another Joules Getting a STAT X-ray to confirm ET tube placement Physician disagrees - make another Applying synchronous cardioversion @ 100 Joules Done 4 Perfect Score: 2 Minimum Pass Score: 2 Illegal to Duplicate or Distribute without Permission 5

Information-Gathering Section Simulation Section #: 4 Links from Section #: 3 Links to Section #: 5 After cardioversion, you would assess which of the following? (SELECT AS MANY as you consider indicated in this Section, then click on the Go To Next Section button below to proceed to the next Section.) Requested Information Actual Data Response Score Pulse Palpable at 40/min Pupillary response Equal and reactive to light 0 Heart sounds Muffled -1 SpO2 89% +1 Arterial blood gas Physician disagrees -1 Spontaneous respirations Intermittent gasping +1 ECG rhythm Pop-up below Blood pressure 68/42 mm Hg Perfect Score: 8 Minimum Pass Score: 7 ECG Pop-up (sinus bradycardia) Illegal to Duplicate or Distribute without Permission 6

Decision-Making Section Simulation Section #: 5 Links from Section #: 4 Links to Section #: 6 You would now recommend: (CHOOSE ONLY ONE unless you are directed to Make another. ) Action/Recommendation Response to Selection Response Link to Score Section Administering an IV bolus of Physician disagrees - make another -3 propranolol (Inderal) Applying synchronous Physician disagrees - make another cardioversion @ 200 Joules Initiating transvenous pacing Physician disagrees - make another -1 Administering a 0.5 mg bolus of Done 6 atropine sulfate Applying carotid sinus massage Physician disagrees - make another Perfect Score: 2 Minimum Pass Score: 1 Illegal to Duplicate or Distribute without Permission 7

Decision-Making Section (Multi-Select) Simulation Section #: 6 Links from Section #: 5 Links to Section #: 7 After atropine is administered, the patient's heart rate increases to 64/min and blood pressure rises to 78/53 mm Hg. Because there are no respirations evident, you continue to manually ventilate the patient with 100% O2 (SpO2 = 98%). Which of the following would you recommend at this time? (SELECT AS MANY as you consider indicated in this Section, then click on the Go To Next Section button below to proceed to the next Section) Action/Recommendation Response to Selection Initiating mechanical ventilation Physician agrees - consider other Initiating a cisatracurium (Nimbex) Physician disagrees - consider other IV infusion Hyperventilating the patient Physician disagrees - consider other Administering a vasopressor, e.g., Physician agrees - consider other dopamine or norepinephrine Considering therapeutic hypothermia Physician agrees - consider other Obtaining a 12-lead ECG Physician agrees - consider other Inserting an A-line to monitor blood Physician agrees - consider other pressure Obtaining a chest X-ray Physician agrees - consider other Measuring urine output and creatinine Physician agrees - consider other Measuring blood gases, lactate and K+ Physician agrees - consider other Perfect Score: 12 Minimum Pass Score: 8 Response Score +1 +1 +1 +1 Illegal to Duplicate or Distribute without Permission 8

Decision-Making Section Simulation Section #: 7 Links from Section #: 6 Links to Section #: END You and the team transfer the patient to ICU, where a ventilator has been setup and a bedside monitor with capnograph readied. The nurse indicates that the patient weighs about 175 pounds. Which of the following would you recommend as the initial settings for mechanical ventilation? (CHOOSE ONLY ONE unless you are directed to Make another. ) Action/Recommendation Mode = VC,A/C; VT = 600 ml; rate 12/min; FIO2 titrated to achieve SpO2 94-96%; 5 cm H2O PEEP Mode = VC/AC; VT = 800 ml; rate 15/min titrated to end-tidal CO2 25-30 mm Hg; 100% O2; 5 cm H2O PEEP Mode = APRV; high/low P = 30/5 cm H2O; I-time=3 sec; E-time=2 sec; 100% O2 Mode = VC,SIMV; VT = 600 ml; rate 4/min; 100 % O2; 5 cm H2O PEEP Mode = VC,A/C; VT = 350 ml; rate 20/min; FIO2 titrated to achieve SpO2 94-96%; 8 cm H2O PEEP Response Link to Response to Selection Score Section Physician agrees END Physician disagrees make another Physician disagrees make another Physician disagrees make another Physician disagrees make another Perfect Score: 2 Minimum Pass Score: 2 Illegal to Duplicate or Distribute without Permission 9

RTBoardReview Simulation 35 15 Year-Old Woman Undergoing Resuscitation Condition/Diagnosis: ACLS Protocols V-Fib, Cardioversion, Post-Resuscitation Care Simulation Scoring Individual Response Scoring (Used for All RTBoardReview Simulations) Score Meaning Essential/optimum to identifying or resolving problem +1 Likely helpful in identifying or resolving problem 0 Neither helpful nor harmful in identifying or resolving problem -1 Unnecessary or potentially harmful in identifying or resolving problem Wastes critical time in identifying problem or causes direct harm to patient -3 Results in life-threatening harm to patient Summary Scoring of Simulation 15 Section IG Max IG Min DM Max DM Min 1 8 5 2 9 6 3 2 2 4 8 7 5 2 1 6 12 8 7 2 2 TOTALS 17 13 26 18 MPL% 76% 69% Cut Score = IG Min + DM Min = 13 + 18 = 31 MPL% = Minimum Pass Level as a percent = (Min/Max) x 100 IG and DM MPL% vary by problem; typically ranges are 77-81% for IG and 60-70% for DM If the IG or DM raw score is negative (e.g., ) then the reported % score = 0 The Cut Score for a problem is the sum of IG Min + DM min To pass a problem, the sum of one s IG + DM raw scores must be the Cut Score Illegal to Duplicate or Distribute without Permission 10

RTBoardReview Simulation 15 51 Year-Old Woman Undergoing Resuscitation Condition/Diagnosis: ACLS Protocols V-Fib, Cardioversion, Post-Resuscitation Care Take-Home Points This problem follows current American Heart Association (AHA) algorithms on Adult Cardiac Arrest, Tachycardia with a Pulse, Bradycardia with a Pulse and Immediate Post-Cardiac Arrest Care, as reproduced below. Adult Cardiac Arrest Illegal to Duplicate or Distribute without Permission 11

For CPR follow C-A-B (Chest compressions, Airway, Breathing); for adult arrest: 1. Check the patient for responsiveness and no breathing. 2. Call for help and get a defibrillator/aed 3. Check the pulse (max 10 seconds) 4. Give 30 compressions (within 10 seconds of recognizing arrest) 5. Open the airway and give 2 breaths 6. Resume compressions/breaths at 30:2 ratio (1 or 2 rescuers) Consider inserting an LMA or ET tube after 2 CPR cycles; once inserted provide o 10 breaths/min, about 1 second per breath o No need to synchronize with chest compressions o Judge effectiveness by observing visible chest rise Recommend 1 mg epinephrine every 3-5 minutes Start capnography as soon as the arrest patient has advanced airway in place; use to o Confirm ET tube placement o Monitor CPR quality and detect return of spontaneous circulation (ROSC) Initially defibrillate VF at 12000 Joules biphasic (360 Joules if monophasic) Use cardioversion (synchronized) at initial energies of 100 J to treat adult monomorphic ventricular tachycardia; if there is no response increase the dose in a stepwise fashion ROSC is indicated by palpable pulse/bp, increase in expired CO2 to normal levels, and/or spontaneous arterial pressure waveform (with A-line in place) Illegal to Duplicate or Distribute without Permission 12

For the treatment of symptomatic bradycardia, recommend a positive chronotropic drug such as atropine (0.5 mg every 3-5 min) + dopamine and epinephrine for hypotension Illegal to Duplicate or Distribute without Permission 13

For post-cardiac arrest care o Maintain SpO2 94% o Consider advanced airway and capnography (if not instituted previously) o Do not hyperventilate o Recommend treating hypotension with vasopressors (epinephrine, dopamine, norepinephrine) o Consider targeted temperature management (TTM) via therapeutic hypothermia (36 C likely as effective as 33 C) o If MI suspected as cause, recommend coronary reperfusion Illegal to Duplicate or Distribute without Permission 14

Follow-up Resources Useful Web Links: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation Quality. Circulation. 2015;132:S414-S435, https://circ.ahajournals.org/content/132/18_suppl_2/s414.full.pdf 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 7: Adult Advanced Cardiovascular Life Support. Circulation. 2015;132:S444-S464. https://circ.ahajournals.org/content/132/18_suppl_2/s444.full.pdf Bon, C. (2015). Cardiopulmonary resuscitation (CPR). Medscape/E-Medicine. Available at: http://emedicine.medscape.com/article/1344081-overview Shah, S. (2014). Defibrillation and cardioversion. Medscape/E-Medicine. Available at: http://emedicine.medscape.com/article/80564-overview Illegal to Duplicate or Distribute without Permission 15