Quiz 7
It is a cold winter day with the temperature staying around zero throughout most of the day. You are on-call today with just another two hours left on your last shift for this tour. You and your partner are ready to go home and go to bed for some real uninterrupted sleep. You have had some very long days recently and you are ready for your four days off to recharge your batteries. You and your partner have both been working EMS for six years and your EMR student is new, with only seven calls as of today under her belt. You admire her dedication and honesty, which are just two of the requirements of being in the health care industry.
You are called to respond to a cardiac arrest about 12 kilometres out of town at a local dairy farm. They state a 22-year-old male has collapsed after shoveling grain in a grain bin. There does not appear to be any extraction or hazardous information in your initial 9-1-1 call. The local police and your second unit will also be dispatched immediately. Bystander CPR is apparently in progress by family members. Your second unit is a BLS unit and will meet you on scene within about two to three minutes after your arrival. You are about to perform your first code with the new CPR standards under the recently changed BLS and ALS guidelines.
You know that the new standards recommend drastic but warranted changes. The main changes are based on performing better BLS and there is not as much push to initiate ALS immediately as in the past recommendations. One of the examples you can vividly recall is that we need to perform “harder and faster chest compressions.” This change was just one recommendation from the recent research by the American Heart Association (AHA) into what changes are needed to make an improvement in the overall success by providers of CPR, BLS and ACLS. We know that the best outcomes come now from good CPR with minimal interruptions. The main emphases are to get the chest compressions started immediately and ensure the pauses and interruptions in performing any BLS or ALS skills are minimal.
The importance of intubating is reduced now, to be done after good BLS with a BVM and an OPA or NPA initially. We know now from past retrospective observations that there is important time being lost during BLS or ALS procedures while we intubate, evaluate rhythms and debate if the pulse is present or not. We are loosing too much valuable time, with nobody doing any chest compressions, and the outcomes are worsened as a result. The emphasis is to perform better chest compressions and do not worry as much about ventilating as there seems to be minimal or decreased importance in ventilation in most of the cases. That is the case in a majority of the events, unless the arrest was caused initially by an asphyxia cause that initiated the cardiac arrest. We know in a cardiac arrest caused by an airway problem it must be fixed immediately by performing airway or breathing interventions in order to have any chance of a successful resuscitation. Remember “good BLS” is more important than “adequate or less than adequate ALS”.
We know from the most recent literature that we also need to perform BLS and ALS longer, especially for pediatric patients, as we may have inadvertently stopped prematurely. If we increase the “code” longer, to 30 to 40 minutes in children, we might see an increased discharge rate of anywhere from 25 to 50 per cent, which is very significant. The following recommendation or suggestion was that we should consider termination of effort after 20 minutes of good ALS. You know now that on this call we might need to perform CPR a little longer due to longer transport times, perform better chest compressions with fewer interruptions, change the personnel who are performing compressions every two minutes and ensure we only interrupt the first couple of minutes of CPR for essential ventilation pauses.
On arrival you see a male laying beside a grain bin with the police already on scene with bystander CPR in progress. The patient looks to be a “giant of a man,” about 180 to 190 cm tall and weighing about 130 kg. His family states to you he has a history of diabetes and hypertension. You initiate your efforts with your team members. You know today that time itself is against you.
Vital Signs
• Temperature 35.9° C
• Respirations absent
• Pulse is also absent
• SpO2 is not reading
• Glucose is 6.9 mmol/l
• Pupils are dilated and fixed
References.
Currents in Emergency Cardiovascular Care. Volume 16 Number 4 Winter 2005 – 2006 American Heart Association.
About the Author.
Dale Bayliss is an experienced Advanced Care Paramedic and Registered Nurse living in Camrose, Alberta. Dale is an instructor with the University of Alberta, Augustana Faculty’s Paramedic Program. He also works part time as an Emergency Nurse at the University of Alberta Hospital in Edmonton and works casual as a Paramedic with Peace Hills EMS in Wetaskiwin, Alta. and with Beaver EMS in Tofield, Alta.
Please keep in mind the answers to these questions are to industry standards and may not necessarily be correct according to local protocol. If there is any discrepancy between these answers and local protocol, please follow the protocol for your area as set out by your Medical Director.
Canadian Emergency News and the authors of this quiz grant permission for readers to copy it for personal and departmental educational purposes. All other reproduction and re-publication without written consent is prohibited.
- What findings at this scene would stop your resuscitation efforts immediately upon arrival?
- The new BLS standards state we only check for breathing for no more than:
- The new standards state if the patient needs rescue breathing from a BLS approach the “two ventilations” are provided with a pocket mask or a BVM. The rescuer must:
- If the patient is not breathing after the breathing assessment is performed we give:
- On this patient in cardiac arrest we know now that we need to do 30 chest compressions at a rate of about 100 per minute then ventilate two times. The ventilations need to:
- You know this is a medical patient with no signs and no history of cervical trauma. You ask your student to grab the spine board. You will also get the EMR to apply the cervical collar as your work on performing chest compressions. You know that the airway is best secured in a medical patient by applying these devices to:
- You are just about to finish two minutes of chest compressions and your partner is ready to provide the required ventilations. You know that after the thirtieth chest compression you will need to:
- The most common rhythm noticed after shocking a non-witnessed ventricular fibrillation patient would be:
- We know our chances of having a heart attack come from looking at past statistics. Risk factors are rated as controllable or non-controllable components. Uncontrollable risk factors that might make this patient more susceptible to cardiac complications or acute coronary syndromes would be:
- You apply the AED and it states that no shock is advised. We know that the rhythm is likely not:
- What is the likely cause of this patient having persistent ventricular fibrillation despite your first shock from your AED?
- What is the likely cause of the patient to have a Sp02 that will not register on our initial arrival?
- The initial treatment for this patient would require you to perform certain skills in a rapid manner. Your partner initiates chest compressions. You would first want to ___________ then ______________ as a BLS provider.
- Your patient has had two sets of 30:2 (compressions/ventilations) and on your next pulse check you feel a faint pulse at about 60/minute. You would now:
- The patient’s family would like to accompany you to the local emergency department. You say:
- This patient will be transported rapidly to the closest hospital which is familiar with ACLS. They will expect you to perform a (an) ______________ prior to arrival.
- The pulse remains weak at the radial with only a 76/36 obtained after the transport is initiated. The heart rate is 64 and slightly irregular with occasional PVCs. The most appropriate therapy would be:
- You have decided to assist ventilations post-arrest at:
- The patient still has multiple PVCs that are about 20 or more per minute. The best way to stop PVCs in all patients is by administering:
- This patient has not responded to any stimulation. His GCS is 3/15. What medication can be considered prior to the intubation in this case for two different reasons?
- You have intubated the patient and you notice the patient’s Sp02 is dropping rapidly and the heart rate is decreasing rapidly. You would expect:
- Your partner extubates and you assist with ventilations with supplemental oxygen for several minutes and then you re-intubate the patient. You now have a positive end tidal C02,, there is misting within the endotracheal tube, and the patient’s Sp02 is registering and climbing slowly. If the heart rate stays low after you correct the airway complication you can:
- The most likely cause of this patient arresting en route after you have had a spontaneous return of a pulse would be:
- Your patient starts to breathe en route to the local hospital with four to six ventilations/minute and there are attempts to move his hands towards the endotracheal tube. You would likely now administer:
- Upon arrival at the local ER the physician would likely order:
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