Note: Your progress in watching these videos WILL NOT be tracked. These training videos are the same videos you will experience when you take the full ProACLS program. You may begin the training for free at any time to start officially tracking your progress toward your certificate of completion.
In this lesson, we're going to let you play the role of team leader during a cardiac emergency – pulseless arrest VFib. From start to finish, you'll be in charge of assessing the patient and providing therapy and treatment recommendations.
In this scenario, you've been presented with a 56-year-old male patient who arrived at the ER complaining of moderate to severe chest pains and discomfort. He also has some weakness and shortness of breath. And symptoms have been ongoing for about 4 hours.
Over the last 2 hours, his pain has intensified and is now radiating up into his neck, jaw, and down his left arm. When you ask him to assess his level of pain from 1 to 10, he says it's currently a 9.
He also mentions that he's beginning to feel nauseous and may even vomit. As you continue to ask him more questions, he suddenly stops responding and now appears unconscious.
Your initial assessment recap:
- 56-year-old male
- Severe chest pain
- Radiating into jaw, neck, left arm
- Pain currently at 9/10
- Now appears unconscious
Let's assume the scene is safe and your personal protective equipment is in place. You begin by instructing a team member to perform a tap and shout sequence to confirm the patient's unresponsiveness. And he remains unconscious and unresponsive.
At this point, you call in a code or ask for additional help depending on you and your team's experience and level of expertise. Help is on the way.
Your team checks for a carotid pulse and signs of normal breathing as you all begin gathering the appropriate equipment, which may or may not already be in the room. Your team finds no pulse and no signs of breathing.
Someone in the team either places a CPR board under the patient or if he's on a hospital bed with a CPR button, you activate it at this time. Doing so will deflate the bed and create a hard surface, which will aid CPR efforts.
Now is the time when you'll take a leadership role and assign team member roles. You begin by directing the recorder to record all times, treatments, and any other associated and relevant notes for that protocol.
You assign a compressor and a monitor/defibrillator and remind the team that high-quality CPR must be given – 30 compressions at 2 to 2.4 inches deep and at a rate of 100 to 120 compressions per minute followed by 2 rescue breaths.
Pro Tip #1: It's important for everyone on your team to remember that high-quality CPR has risen to the top of importance even in ACLS, so you communicate this to everyone on your team.
You assign an airway person and directions to begin ventilations. An example of exactly how you might do this, especially if you're not used to being team leader is: Please prepared a basic airway adjunct and ventilate with 100 percent oxygen delivered via bag valve mask at 12 breaths per minute.
Pro Tip #2: Now is a good time to begin thinking about advanced airways if protecting the patient's airway is important or if oxygenation with basic airways is insufficient.
In order to obtain 100 percent oxygenation, you need to turn the oxygen regulator to 15 liters per minute and allow the bag valve mask reservoir to fill prior to giving ventilations.
During CPR, the monitor/defibrillator team member is preparing the patient for rapid defibrillation – the ECG monitor and defibrillator pads are placed on the patient appropriately and as soon as ready, you'll give directions to your team to pause CPR to check the patient's underlying rhythm.
You tell everyone, stand clear while the rhythm is analyzed. It indicated that the patient is in VFib.
CPR is continued while the automated defibrillator charges (or if the defibrillator is manual, shocks will be delivered at 360 joules.)
Once the defibrillator is fully charged, the monitor/defibrillator team member calls out, everyone stand clear; shocking on 3; 1-2-3. The monitor/defibrillator person then pushes the shock button.
CPR resumes and you prepare the team for medications delivery.
Pro Tip #3: While both IV and IO are acceptable, try IV first and only move to IO if you're unable to obtain patient IV access for effective medication and fluid delivery.
Your team is able to get patent IV access via an 18 gauge in the left antecubital and start the patient on normal saline. The recorder team member states, It's been 2 minutes.
You instruct the compressor and monitor/defibrillator to switch positions to have a fresh compressor at all times. This switch should occur at least every 2 minutes or sooner if you recognize insufficient compressions due to fatigue.
As the compressor calls out the last few compressions – 28, 29, 30 – that's when the switch occurs. After 2 ventilations are delivered, the monitor/defibrillator switches positions with the compressor and readies his or her hands in the appropriate chest position, then begins effective chest compressions immediately after the last ventilation.
Now is the time for the first medication delivery. You call out the drug order for 1mg of 1:10,000 concentration of epi via IV push flushed with 20cc of normal saline and wait for the IV/medication team member to repeat the order back to you, which they do. You verify the repeated order by saying, That's correct.
CPR resumes for 2 more minutes. At the end of that cycle, you call out, Stop compressions, and allow the ECG to check the patient's rhythm. You find that the patient is still in VFib, so you call out for another shock to be delivered.
At this time, you decide to secure an advanced airway to maintain the airway, give synchronous compressions with rescue breaths, and have the ability to monitor capnography.
As the team leader, you request an advanced airway using an endotracheal tube. Someone on the team measures for it and inserts a #6 endotracheal tube with a stylet. The ET tube balloon is inflated after it passes between the left and right lobes. You also check the patient's stomach for any air sounds.
Pro Tip #4: If you cannot detect any stomach air sounds and there are good breath sounds bilaterally, you know that the ET tube is in the correct spot.
The recorder calls out, We're at 4 minutes.
You instruct the rest of the team to stand clear of the patient while his rhythm is checked and then announce another switch for the compressor and monitor/defibrillator team members. The patient is still in VFib, so you prepare the team for a third shock.
You instruct everyone to continue CPR and also direct the medication team member to prepare the next round of medication – amiodarone at 300mg followed by 20cc of normal saline. The medications team member repeats the order and you confirm it's correct.
A second dose of amiodarone may be given for persistent VFib, which is half the initial dose, or 150mg, and administered after 2 more minutes of CPR and another shock if the rhythm has not converted. Alternatively, epi can be given every 3 to 5 minutes instead and staggered between shocks and CPR.
This scenario continues until all treatment options have been exhausted and all possible causes have been ruled out.
