Pulseless Arrest V-fib Teaching

In this case, you're presented with a 56-year-old man who arrived in the emergency department complaining of moderate to severe chest pain and discomfort. He also has some weakness and shortness of breath, and he has had it for the last four hours. As of the last one to two hours, the pain has intensified and it's now radiating up into the neck and jaw and down the left arm. When you ask him to describe the discomfort on a scale from one to 10, the patient states the pain is currently a number 9 and he feels as though he's going to be sick and vomit. The patient care assistant is directed by the nurse to go get an emesis basin, and while the nurse keeps typing in the notes, you continue to ask the gentleman more questions. But he stops responding and appears unconscious. The scene is safe, your personal protection is in place, now let's get started. It's at this time you would want someone to tap and shout and find out if the patient is now fully unresponsive. The patient is indeed unresponsive, so you'll want to call a code or ask for additional help, depending on your area of practice. The code is called, and in this situation, the team is now 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 indeed 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. 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. A compressor will be assigned along with a monitor defibrillator team member. A reminder is given to do CPR at 30 compressions and at 2 to 2.4 inches deep with a rate between 100-120 compressions per minute. Remember, high quality CPR is the top priority in advanced cardiac life support. Now the airway person is also assigned and directions to prepare to ventilate are given. The team leader should remember to give clear directions to the other team members 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 an advanced airway, especially if the airway is compromised or if oxygenation with a basic airway is not sufficient. In order to obtain near 100% oxygenation, we need to turn the oxygen flow regulator to 15 liters per minute and allow the bag valve mask reservoir to fill prior to ventilations being given. During CPR, the monitor defib team member is preparing the patient for defibrillation. The 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 in order to check. The leader asks 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 the defibrillator is manual, the shock will be 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. CPR should continue immediately as we 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. As an important note to remember, in a team situation, many skills will happen simultaneously. When V-fib is recognized, epinephrine will be the first drug given as soon as possible. Okay, we now have a patent IV of normal saline via 18 gauge in the left antecubital. At this time, the recorder states, "It's been about two 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 the two minutes. As the compressor calls out the last compressions, "28, 29, 30," that's when we should 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. We should now deliver our first medication. The team leader calls out a drug order for "1mg Epinephrine 1:10,000 IV push" and then "flushed with 20 ccs of 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." You could say, "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 shock is delivered and CPR is continued. So at this time, 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 cords and lung sounds are auscultated between the left and the right lobes and we also check if we have any air sounds in the stomach. If there are no stomach sounds and we have good breath sound bilaterally, you know the ET tube is in the correct location. 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!" The 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 300mg of amiodarone IV push followed by 20ccs 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 two minutes of CPR and another shock that does not convert the rhythm. In addition, epi may be given every three to five minutes and can be staggered between the shocks and the CPR.