Case 1: Respiratory Arrest With a Pulse

PRIMARY ABCD SURVEY

 

•   Assesses responsiveness

•   Calls for help

•   Calls for defibrillator/monitor

•   Opens airway

•   Determines breathing

•   Provides first rescue breaths through pocket face mask

•   Checks pulse (present)

•   Starts rescue breathing at 1 breath every 5 seconds

•   Omits “hunt” for shockable rhythm (pulse present)

 

SECONDARY ABCD SURVEY

 

 

•   Prepares to achieve advanced airway control

•   Uses laryngoscope and TT correctly

•   Performs tracheal intubation effectively and safely

—                 Within 30 seconds

—                 Recognizes when taking too long

—                 Knows to try another airway method if unsuccessful or taking too long

•   Confirms tube placement with these techniques

—                 Visualizes tube passing through the vocal cords and entering the trachea

—                 Uses end-tidal CO₂ device (qualitative or quantitative)

—                 Performs 5-point auscultation

—                 Looks for chest expansion, rising 02 saturation levels, vapors in tube

—                 Uses EDD: squeeze/hold bulb => attach to TT => release => time

•   Secures tube in place: uses commercial holder, knows a taping technique

•   Checks clinical responses to confirm effective oxygenation and ventilation

•   Establishes IV access to circulation

•   Starts rhythm monitoring

•   Administers rhythm-appropriate medications

•   Considers likely causes of problem; develops a differential diagnosis

  

Case 2: VF/Pulseless VT—Single Rescuer With CPR and AED

GAINS EARLY ACCESS

•   Directs someone to call 911 and get the AED

•   Provides medical support, not leadership, as PAD responders arrive

•   Helps gain access to patient to evaluate

•   Directs other passengers as needed

 

CONDUCTS PRIMARY ABCD SURVEY

•   Assesses responsiveness

•   Calls for help

•   Calls for AED

•   Starts ABCs of CPA (uses pocket face mask from AED case)

 

STARTS AED PROTOCOL WHEN DEVICE IS AVAILABLE

•   POWERS ON AED

•   Attaches pads to cable, pads to chest, cable to AED

•   Clears victim of all contact and movement

•   Starts analyze mode

•   Shocks if AED advises “shock indicated”

 

MAINTAINS RESUSCITATION EFFORT; REMAINS ON TASK

•   Follows AED directions for each shock/analyze step

•   After 3 analyze/shock cycles gives 1 minute of CPA

•   Follows defibrillation safety steps

•   Maintains airway, rescue breathing

•   Reassesses for pulse, breathing

•   If pulse is present, checks BP and respirations

•   Responds appropriately to positive or negative pulse, BP, and ventilations

•   Responds appropriately to refibrillation

•   Transfers care to higher-level professionals; gives brief report

 

Case 3: Mega-VF: Refractory VF/VT

PRIMARY ABCD SURVEY

•   Assesses responsiveness

•   Calls for help

•   Calls for AED

•   Starts ABCs of CPR (uses pocket face mask)

•   Attaches AED, quick-look paddles, or ECG monitor

•   Recognizes ECG rhythms of VF and pulseless VT

•   Delivers countershocks safely, effectively, and at correct energy levels

 

SECONDARY ABCD SURVEY

 

•   Prepares to achieve advanced airway control

•   Selects and prepares the LMA

•   Inserts LMA effectively and safely

—                 Within 30 seconds

—                 Recognizes when taking too long

—                 Knows to try another airway method if unsuccessful or taking too long

•   Confirms LMA placement with these techniques

—                 Uses end-tidal CO₂ device (qualitative or quantitative)

—                 Performs 5-point auscultation

—                 Looks for chest expansion, rising 02 saturation levels, vapors in tube

•   Secures tube in place: uses commercial holder, knows a taping technique

•   Checks clinical responses to confirm effective oxygenation and ventilation

•   Establishes IV access to circulation in correct location, with correct technique

•   If using LMA, does riot consider drug administration through LMA

•   Considers tracheal drug route if using TI and IV access is unavailable

•   Selects adrenergic agent; gives at proper dose and intervals (gives more defibrillatory shocks after adrenergic agent but before antiarrhythmics)

•   Rechecks rhythm; makes proper identification; defibrillates if indicated

•   Determines the VF pattern: persistent or recurrent?

•   Considers antiarrhythmics; chooses proper agent, dose, and sequence

•   Considers likely causes of problem; develops differential diagnosis

•   Acts on differential diagnosis when reasonable

 

 

Case 4: Pulseless Electrical Activity

PRIMARY ABCD SURVEY

 

•   Assesses responsiveness

•   Calls for help

•   Calls for defibrillator/monitor

•   Starts ABCs of CPR (uses pocket face mask)

•   Attaches quick-look paddles or ECG monitor

•   Recognizes ECG rhythm is not VF; shock not indicated

•   Moves at once to Secondary ABCD Survey

 

SECONDARY ABCD SURVEY

 

•   Prepares to achieve advanced airway control

•   Selects and prepares the Combitube

•   Inserts Combitube effectively and safely

—                 Within 30 seconds

—                 Recognizes when taking too long

—                 Knows to try another airway method if unsuccessful or taking too long

•   Confirms Combitube placement (while inflating obturator or tracheal tube cuffs

through proper ports) using these techniques

—                 Uses end-tidal CO₂ device (qualitative or quantitative)

—                 Performs 5-point auscultation

—                 Looks for chest expansion, rising 02 saturation levels

•   Secures Combitube in place per manufacturer’s instructions

•   Checks clinical responses to confirm effective oxygenation and ventilation

•   Establishes IV access to circulation in correct location, with correct technique

•   Starts rhythm monitoring; examines rhythm; makes proper identification

•   Gives epinephrine as adrenergic agent; gives proper dose in proper sequence (1 mg IV push, repeat every 3 to 5 minutes)

•   Gives atropine 1 mg IV (if PEA rate is slow)

•   Assesses for occult blood flow (“pseudo-EMD”)

•   Explicitly begins to consider differential diagnosis for PEA (possible reversible causes)

•   Can state a preplanned review for reversible causes using mnemonic (e.g., 5 H’s and 5 Ts)

•   Thinks of a specific cause; looks for indications of that cause

•   Acts upon differential diagnosis when reasonable

•   Reassesses patient frequently; troubleshoots problems

 

 

Case 5: Asystole

PRIMARY ABCD SURVEY

 

•   Assesses responsiveness; calls for help

•   Calls for defibrillator/monitor

•   Starts ABCs of CPA (uses pocket face mask)

•   Performs rapid scene survey, looking for evidence that personnel should not attempt resuscitation (e.g., DNAR order, signs of death)

•   Attaches quick-look paddles or ECG monitor

•   Recognizes ECG rhythm is not VF; shock not indicated

•   Recognizes “fiat line” is not the same as “asystole”; performs asystole protocol

—                 Monitor POWER ON

—                 Cables connected

—                 Lead selection not on “paddles” if using leads

—                 “Gain” turned up to maximum

•   Checks for VF masquerading as asystole (“occult VP)

—                 Switch lead II to Ill and aVF if monitor has lead select switch

—                 Paddles to right angles

 

SECONDARY ABCD SURVEY

 

•   Prepares to achieve advanced airway control

•   Inserts oropharyngeal airway correctly; calls for cricoid pressure

•   Applies pocket face mask with effective fit; gives 2 ventilations every 15

compressions; uses at least 2 seconds to complete full squeeze of bag

—                 Looks for good chest expansion, rising 02 saturation levels

—                 Performs 5-point auscultation

—                 Given vomiting scenario, calls for and uses suction devices

•   Checks clinical responses to confirm effective oxygenation and ventilation

•   Establishes IV access to circulation in correct location with correct technique

•   Starts rhythm monitoring; examines rhythm; makes proper identification

•   Gives drugs appropriate for asystole; uses proper dose and sequence (epinephrine 1 mg IV push, repeat every 3 to 5 minutes; atropine 1 mg IV, repeat every 3 to 5 minutes, up to a total dose of 0.04 mg/kg)

•   Considers TCP; if TCP can be used, starts at once

•   Considers differential diagnosis: are reversible causes present?

•   Knows reversible causes to consider; uses mnemonic (e.g., 5 H’s and 51’s)

•   Looks for specific causes; if causes detected, treats appropriately

 

IF ASYSTOLE PERSISTS

 

•   Asks “Should resuscitative efforts stop?” Considers

—                 Quality of resuscitation

—                 All appropriate ACLS interventions given?

—                 Any atypical clinical features (hypothermia, drug overdose)?

—                 Family members present? Offer chance to be with patient at end?

—                 Given circumstances, is stopping efforts appropriate?

 

 

Case 6: Acute Coronary Syndromes

PRIMARY ABCD SURVEY

•   Assesses responsiveness (responsive)

•   Assesses airway (open), breathing (yes, but adequate? compromised?)

•   Assesses circulation (pulse present, but adequate? compromised?)

•   Calls for defibrillator/monitor (not indicated)

PERFORMS IMMEDIATE ASSESSMENTS IN <10 MINUTES

•   Measures vital signs (T—HR—BP—R—0₂ Sat)

•   Starts 0₂—IV—fluids—monitor

•   Obtains 12-lead ECG (rapid physician review)

•   Performs targeted history, physical exam: eligible for fibrinolytic therapy?

•   Obtains initial serum cardiac markers, electrolytes, coagulation studies

•   Reviews portable chest x-ray (<30 minutes)

•   Starts serial pain scale estimates

PERFORMS IMMEDIATE GENERAL TREATMENT (MONA GREETS ALL PATIENTS)

•   Oxygen 4 11mm

•   Aspirin 160 to 325 mg

•   Nitroglycerin SL or spray

•   Morphine sulfate IV (if pain not relieved by nitroglycerin)

ASSESSES 12-LEAD ECG IN <10 MINUTES AFTER ARRIVAL

•   Recognizes ST elevation or new or presumably new LBBB

•   Recognizes ST depression or dynamic T-wave inversion

•   Recognizes nondiagnostic ECG: no changes in ST segment or I waves

•   Classifies patient into 1 of the 3 algorithm branches (see Ischemic Chest Pain Algorithm, 2000 ECC Handbook, page 29)

12-LEAD ECG (OK to use AHA posters and code cart laminates)

•   Can use 12-lead ECG to locate injured area of myocardium

•   Can identify most likely occluded coronary artery

STARTS ADJUNCTIVE TREATMENTS (knows to start adjunctive treatments soon after

identifying ST elevations strongly suspicious for acute myocardial injury)

•  B-Adrenoreceptor blockers

•  Nitroglycerin IV

•  Heparin IV

•   ACE Inhibitors (after 6 hours or when stable)

SELECTS REPERFUSION STRATEGY if time from symptom onset <12 hours

•   Fibrinolytic therapy?

•   Primary PCI angioplasty ± stent?

 

IF FIBRINOLYTIC THERAPY SELECTED

•   Can list 5 contraindications to use of fibrinolytic agents

 

EXTRA CREDIT

For patients with ST depression strongly suspicious for ischemia, can list 5

recommended adjunctive agents to consider

•   Heparin (UFH, LMWH)

•   Aspirin

•   Glycoprotein llb/Illa receptor inhibitors

•   Nitroglycerin

•   B-Adrenergic receptor blockers

 

Case 7: Bradycardias

PRIMARY ABCD SURVEY

 

•   Assesses responsiveness (responsive)

•   Assesses Airway (open), Breathing (yes, but adequate? compromised?)

•   Assesses Circulation (pulse present but adequate? compromised?)

•   Determines if defibrillator/monitor is available (not indicated)

 

SECONDARY ABCD SURVEY

 

•   Assesses need for secondary ABCD interventions (invasive airway management needed?)

•   Oxygen—lV access—monitor—fluids

•   Measures vital signs; attaches pulse oximeter; monitors BP

•   Obtains and reviews 12-lead ECG

•   Obtains and reviews portable chest x-ray

•   Performs rapid, problem-focused history and physical exam focused on determining “symptomatic” or “unstable” bradycardia

•   Recognizes signs and symptoms of hemodynamic compromise that are due to the slow heart rate

•   Considers possible causes (differential diagnosis)

 

SERIOUS SIGNS OR SYMPTOMS? DUE TO BRADYCARDIA?

 

If yes to both, selects treatment from these medications in this sequence:

•   Atropine

•   TCP

•   Dopamine

•   Epinephrine

•   Isoproterenol

 

TRANSCUTANEOUS PACING (UNDERSTANDS INDICATIONS FOR TCP)

 

•   Knows how to set up and attach TCP effectively and safely when indicated

•   Initiates pacing by selecting rate and current

•   Can recognize ineffective and effective pacing spikes; understands increasing current until “captured” complex appears on monitor

 

RECOGNIZES CRITICAL BRADYCARDIAS AND WHY THEY ARE SIGNIFICANT

 

•   Second-degree AV block

—                 Type I

—                 Type II

•   Third-degree AV block

 

RECOGNIZES INDICATIONS FOR TRANSVENOUS PACING

 

  

Case 8: Unstable Tachycardia/Electrical Cardioversion

PRIMARY ABCD SURVEY

 

•   Assesses responsiveness (responsive)

•   Assesses Airway (open), Breathing (yes, but adequate? compromised?)

•   Assesses Circulation (pulse present but adequate? compromised?)

•   Determines if defibrillator/monitor is available (not indicated at first)

 

 

SECONDARY ABCD SURVEY

 

•   Assesses need for secondary ABCD actions (advanced airway adjuncts needed?)

•   Oxygen—lV access—monitor—fluids

•   Obtains vital signs; attaches pulse oximeter; monitors BP

•   Obtains and reviews 12-lead ECG

•   Performs rapid, problem-focused history and physical exam directed toward the following critical decision: is this a “symptomatic/unstable” tachycardia?

•   Recognizes when rapid heart rate is causing hemodynamic compromise

•   Thinks differential diagnosis: reversible condition causing rapid heart rate?

 

SERIOUS SIGNS OR SYMPTOMS? DUE TO TACHYCARDIA?

If yes to both, knows to prepare for Immediate cardioversion

Can describe critical preparation steps needed before cardioversion

•   Oxygen—IV--monitor—fluids—0₂ saturation monitor—suction device

•   Intubation tube and supplies

•   Medications: sedatives, analgesics

•   Knows rapid infusion of antiarrhythmic is acceptable

 

POST-CARDIOVERSION ACTIONS

•   Recognizes a stable, converted rhythm

•   Reassesses cardiovascular status with vital signs and responsiveness

•   Recognizes possibility of change from tachycardia to VF

•   Recognizes possibility of change from converted rhythm to VF

•   Changes to unsynchronized mode if post-cardioversion rhythm is VF

•   Monitors post resuscitation condition

•   Provides appropriate antiarrhythmic therapy

 

Case 9: Stable Tachycardia

PRIMARY ABCD SURVEY

•   Assesses responsiveness (responsive)

•   Assesses Airway (open), Breathing (yes, but adequate? compromised?)

•   Assesses Circulation (pulse present but adequate? compromised?)

•   Determines if defibrillator/monitor is available (not indicated at first)

SECONDARY ABCD SURVEY

•   Assesses need for secondary ABCD interventions (advanced airway adjuncts needed?)

•   Starts/calls for oxygen—lV access—monitor—fluids

•   Obtains vital signs; attaches pulse oximeter; monitors BP

•   Obtains and reviews 12-lead ECG, rhythm tracing

•   Performs problem-focused history and physical exam; attempts to answer

critical questions:

—                Is patient stable or unstable?

—                 Are there serious signs or symptoms? due to the tachycardia?

—                 Does patient have underlying/chronic impaired cardiac function?

—                 Considers reversible causes of rapid heart rate (differential diagnosis)

 

STARTS SYSTEMATIC APPROACH TO DIAGNOSIS AND TREATMENT

•   Sorts patients into 1 of 4 tachycardia types (see Tachycardia Overview Algorithm, 2000 ECC Handbook, Figure 7, page 15)

 

1, Atrial fibrillatlon/atrlal flutter

—                 Knows clinical features to evaluate (unstable? cardiac function? WPW? duration >48 hours?)

—                 Knows major treatment focus (cardiovert if unstable; control rate; convert rhythm; anticoagulate if indicated)

—                 Uses atrial fibrillation/flutter tables (pages 16-17) to select reasonable treatment

2. Narrow-complex tachycardias (Figures 7 and 8, pages 15 and 18)

—                 Attempts to establish a specific diagnosis

—                 Attempts vagal maneuvers; attempts conversion with adenosine

—                 Subclassifies narrow rhythms as ectopic AT, multifocal AT, or PSVT

—                 Knows re-entry tachycardias respond better to cardioversion

—                 Knows automatic focus tachycardias respond better to blocking agents

—                 Further treats according to heart function and Narrow-Complex Tachycardia Algorithm (Figure 8)

—                 Attends to issues of impaired heart vs. normal cardiac function

3. Stable wide-complex tachycardia of unknown type

—                 Attempts to establish a specific diagnosis

—                 Subclassifies as WCT-unknown type, stable wide-complex VT, or SVT

—                 If WCT-unknown type, considers cardiac function; selects treatment per Tachycardia Overview Algorithm (Figure 7)

—                 If confirmed SVT, goes to Narrow-Complex Tachycardia Algorithm (Figure 8)

—                 If confirmed stable VT, goes to Stable Ventricular Tachycardia Algorithm (Figure 9, page 19)

4. Stable ventricular tachycardia: monomorphic or polymorphic (Figure 9)

—                 Considers cardiac function as impaired or normal

—                 Considers if prolonged QT interval is present; if yes, old or new?

—                 Follows algorithm recommendations after above considerations

 

 

Case 10: Acute Ischemic Stroke

PREHOSPITAL

 

ASSESSMENTS AND ACTIONS

•   Recognizes stroke signs (e.g., poor speech, weak arms or hands, facial droop)

•   Performs Primary and Secondary ABCD Surveys as necessary

•   Describes 3 review features of Cincinnati Prehospital Stroke Scale

•   Describes 6 review features of Los Angeles Prehospital Stroke Screen

•   Tries to determine time of onset of stroke symptoms

•   Checks serum glucose

•   Notifies ED that stroke victim is en route

 

EMERGENCY DEPARTMENT

 

Initiates IMMEDIATE GENERAL ASSESSMENTS <10 MINUTES AFTER ARRIVAL

 

•   Repeats Primary and Secondary ABCD Surveys as necessary

•   Assesses vital signs (T—HR—BP—R—0₂ sat)

•   Starts 02—I V—fluids—monitor

•   Checks blood sugar if not already done; treats if indicated

•   Sends blood for CBC, electrolytes, coagulation studies

•   Obtains 12-lead ECG; reviews rapidly for arrhythmias or “3 l’s”

•   Performs general neurologic screening assessment

•   Reviews eligibility for fibrinolytic therapy

•   Alerts stroke team: neurologist, radiologist, CT technician

 

INNITIAES IMMEDIATE NEUROLOGIC ASSESSMENT <25 MINUTES AFTER ARRIVAL

•   Reviews patient history

•   Establishes time of onset (onset to start of fibrinolytics must be <3 hours)

•   Performs physical exam

•   Performs neurologic exam

—                 Determines level of consciousness: Glasgow Coma Scale

—                 Checks for severity: NIH Stroke Scale or Hunt and Hess Scale

•   Orders urgent noncontrast CT scan (arrival-to—CT scan goal: <25 minutes)

•   Reads CT scan (door-to—CT read goal: <45 minutes)

•   Performs lateral cervical spine x-ray (if patient is comatose or has a history of trauma)

 

RESPONDS APPROPRIATELY TO CT SCAN RESULT