Advanced Cardiovascular Life Support Case Scenarios

Transcription

1 Advanced Cardiovascular Life Support Case Scenarios

2 ACLS Respiratory Arrest Case Out-of-Hospital Scenario You are a paramedic and respond to the scene of a possible cardiac arrest. A young man lies motionless on the pavement. He is having a few agonal gasps but otherwise appears lifeless. Bystanders report that he just collapsed. The scene appears safe. No one has started CPR. The man otherwise appears healthy and is in casual, clean attire. There are no indications of trauma. He has stopped breathing as you approach and he is cyanotic. What are your actions? You perform an initial assessment and determine that a pulse is present. After interventions and with bag-mask ventilation, vital signs are BP 100/60, HR 110, and RR 0 (spontaneous). Cyanosis improves with ventilation. He remains unresponsive. You transport with appropriate ventilations and monitoring. ACLS Respiratory Arrest Case Out-of-Hospital Scenario You are a paramedic and respond to the scene of a possible cardiac arrest. An elderly woman lies motionless on her sofa. She is having a few agonal gasps but otherwise appears lifeless and is cyanotic. Her family reports that she complained of a headache and then gradually lost consciousness. Respirations became slow. The scene appears safe. No one has started CPR. The woman otherwise appears healthy and is in bedclothes. There are no indications of trauma. She gasps and stops breathing as you approach. She is deeply cyanotic. What are your actions? The student performs initial assessment and determines that a pulse is present. After interventions and ventilation with a bag-mask, vital signs are BP 100/60, HR 110, and RR 0 (spontaneous). Cyanosis improves with ventilation. She remains unresponsive. You transport with appropriate ventilations and monitoring.

3 ACLS Respiratory Arrest Case In-Hospital Scenario You are a nurse and respond to a call bell. In the room the patient s daughter says her mother stopped talking and breathing. She has been well for several days following knee replacement. She lies on her side motionless, and she is not breathing. She has not been on a cardiac monitor. What are your actions? The student performs initial assessment and determines that a pulse is present. After interventions and ventilation with bag-mask, vital signs are BP 100/60, HR 110, and RR 0 (spontaneous). Cyanosis improves with ventilation. She remains unresponsive. The code team and attending physician arrive. ACLS Respiratory Arrest Case In-Hospital Scenario You are a radiology technician and respond to a call for help from your coworker. She is preparing a patient for a contrast CT scan of the chest for pulmonary embolism but has not injected contrast. Her patient has suddenly stopped breathing. She lies on her side motionless, and she is not breathing. The cardiac monitor shows artifact. What are your actions? The student performs initial assessment and determines that a weak pulse is present. After interventions and ventilation with a bag-mask, vital signs are BP 90/60, HR 120, and RR 0 (spontaneous). Cyanosis continues with oxygen. She remains unresponsive. The code team and attending physician arrive.

4 ACLS VF CPR/AED Case Out-of-Hospital Scenario You are standing in line boarding your flight at the airport. A man running for your flight with his luggage slows and collapses. Other passengers stand motionless and shocked. He is lifeless and unresponsive. He has a few agonal gasps. What do you do? After application of an AED, shocks, and continued CPR, he begins to move and complains of a squeezing chest pain and shortness of breath. Airport EMS arrives and administers oxygen. ACLS VF CPR/AED Case Out-of-Hospital Scenario You are attending a meeting in a high-rise office building. There is an emergency call that an employee has collapsed in the exercise facility one floor above. You arrive and find club members looking panicked and confused. No CPR has been started. A fit and healthy man is lifeless and unresponsive. No one has started CPR. What do you do? After application of an AED, shocks, and continued CPR, he does not respond. You hear EMS sirens.

5 ACLS VF CPR/AED Case In-Hospital Scenario You are a nurse and exit the elevator on the second floor. In the surgical waiting area a woman lies on the floor unresponsive. You know an AED is one hall down. A janitor appears and looks puzzled. What do you do? After application of an AED, shocks, and continued CPR, the hospital Code Team arrives. ACLS VF CPR/AED Case In-Hospital Scenario You are walking by the hospital admissions. A man appears and says he is having chest pressure and wants to be admitted. He suddenly collapses. You know an AED is outside in the lobby. What do you do? After application of an AED, shocks, and continued CPR, he begins to move. The first members of the Code Team arrive.

6 ACLS VF/Pulseless VT Case Out-of-Hospital Scenario You are an airport paramedic and respond to an AED alarm on Concourse B. Bystanders report that a man collapsed while running for a flight with his luggage. An AED is attached, and CPR is in progress. He is cyanotic and unresponsive. The AED operator reports that the machine has shocked twice. What are your actions? Your team takes over and a cardiac monitor is placed. A rhythm check finds ventricular fibrillation (show ECG strip). What are your actions? ACLS VF/Pulseless VT Case Out-of-Hospital Scenario You are a paramedic. You arrive on scene and bystanders are performing CPR on a woman. They report that she suddenly collapsed. She was standing in line to pay for merchandise, and she appeared well. She is cyanotic and unresponsive. What are your actions? Your team takes over and a cardiac monitor is placed. A rhythm check finds ventricular fibrillation (show ECG strip). What are your actions?

7 ACLS VF/Pulseless VT Case In-Hospital Scenario You respond to a cardiac arrest in the ED registration area. A patient, brought by car, collapsed while complaining of chest pain. The triage personnel have initiated CPR. He is cyanotic and unresponsive. A cardiac monitor is attached and displays VF (show ECG strip). What are your actions? You have given a shock and resumed CPR. What are your next actions? After a rhythm check, VF persists. What do you do? ACLS VF/Pulseless VT Case In-Hospital Scenario You respond to a cardiac arrest in the hospital admission area. A patient collapsed while giving registration information. She had been referred for elective cardiac catheterization. Hospital admissions personnel initiated CPR and called a code. She is cyanotic and unresponsive. A cardiac monitor is attached and displays VF (show ECG strip). Your cardiac arrest team has arrived on location. What are your actions? You have given a shock and resumed CPR. What are your next actions? After a rhythm check, VF persists. What do you do?

8 ACLS PEA Case Out-of-Hospital Scenario You are a paramedic and respond to a cardiac arrest call. On your arrival the daughter of an elderly man reports that he has been having abdominal pain and has just returned from the doctor s office. He collapsed and became unresponsive. He is unresponsive. EMTs have performed the Primary ABCDs and CPR is in progress. What are your actions? You attach a cardiac monitor. A rhythm check finds a narrow-complex rapid tachycardia (show ECG strip). What are your actions? A repeat rhythm check is unchanged and no pulse is present. The daughter shows you an office discharge paper with the diagnosis anemia and peptic ulcer disease. There is also a prescription for ulcer medication. What are your next actions? ACLS PEA Case Out-of-Hospital Scenario You are a paramedic and respond to a cardiac arrest call. On your arrival, a young woman has collapsed and CPR is in progress. She is unresponsive. EMTs have performed the Primary ABCDs and CPR is in progress. What are your actions? You attach a cardiac monitor. A rhythm check finds a narrow-complex rapid tachycardia (show ECG strip). There is still no pulse or spontaneous respirations. What are your actions? A repeat rhythm check is unchanged and no pulse is present. The patient s husband says she had recently complained of abdominal pain and was running fevers. What are your next actions?

9 ACLS PEA Case In-Hospital Scenario You are a nurse and respond to a call for help from a radiology technician. She was preparing a patient for a contrast CT scan of the chest for pulmonary embolism. Her patient suddenly stopped breathing. The patient lies on her side motionless and is not breathing. The cardiac monitor shows artifact. What are your actions? You perform an initial assessment and determine that no pulse is present. After initiation of CPR and bag-mask ventilation, the cardiac monitor shows a narrow-complex tachycardia at 120/min. What are your initial actions? After administration of epinephrine and then vasopressin, there is no change in rhythm. What now do you consider? (H s & T s if not already addressed; rate slows, then agonal then consider code termination.) ACLS PEA Case In-Hospital Scenario You are a physician and respond to an in-hospital cardiac arrest. You find CPR in progress by nursing staff. They report that a patient was admitted for observation following a motor vehicle collision and planned surgery for treatment of an open leg fracture. He was the unbelted driver of a car. Members of the Code Team have arrived and CPR is in progress. The Primary ABCDs are reported as completed. Now what are your actions? You have confirmed high-quality CPR and assigned team member functions. After administration of epinephrine and then vasopressin, there is no change in rhythm. What do you consider now? (H s & T s if not already addressed; rate slows, then agonal then consider code termination.)

10 ACLS Asystole Case Out-of-Hospital Scenario You are paramedic and arrive on scene. Bystanders are performing CPR on a man. They report that he suddenly collapsed. He was standing in line to pay for merchandise, and he appeared well. He is cyanotic and unresponsive. What are your actions? Your team takes over and a cardiac monitor is placed. A rhythm check finds asystole (show ECG strip). What are your actions? ACLS Asystole Case Out-of-Hospital Scenario You are an airport medic and respond to an AED alarm on Concourse B. Bystanders report that a woman collapsed while running for a flight with her luggage. An AED is attached and CPR is in progress. She is unresponsive. The AED operator reports that the machine has shocked 2 times. What are your actions? Your team takes over and a cardiac monitor is placed. A rhythm check finds asystole (show ECG strip). What are your actions?

11 ACLS Asystole Case In-Hospital Scenario You are a nursing supervisor and code team leader on night shift. You respond to a code on the general medical floor. A patient was found unresponsive. Personnel initiated CPR and called a code. You find a woman in cardiac arrest with CPR in progress. She is unresponsive. A cardiac monitor is attached and displays asystole (show ECG strip). Your code team has arrived on location. What do you do? You have performed the secondary ABCDs and given initial drug therapy. The floor nursing staff informs you that the patient has cancer, and a family member on the phone informs them that the patient desires no lifeprolonging measures. An admission DNR has not yet been signed by the attending physician. After a rhythm check, your team reports asystole. What are your next actions? (This should be modified based on your hospital policies if necessary.) ACLS Asystole Case In-Hospital Scenario You are a hospital intensivist and respond to a cardiac arrest in the hospital admission area. A patient collapsed while giving registration information. He had been referred for elective cardiac catheterization. Hospital admissions personnel initiated CPR and called a code. He is unresponsive. A cardiac monitor is attached and displays asystole (show ECG strip). Your cardiac arrest team has arrived on location. What are your actions? You have given a shock and resumed CPR. What are your next actions? After a rhythm check, you again find asystole. What do you do?

12 ACLS Bradycardia Case Out-of-Hospital Scenario You are a paramedic and respond to a call for dizziness. On your arrival, an elderly patient is sitting in a convenience store surrounded by the owner and patrons. He says he is dizzy and weak. Then he becomes poorly responsive but regains consciousness within a few seconds. You complete the Primary and Secondary ABCDs. A cardiac monitor is attached and shows that a slow rhythm is present. Vital signs are BP 90/60, HR 38, and RR 16. The rhythm is sinus bradycardia (show ECG strip). What are your next actions? After initial treatment he is conscious and alert. Color is improved. He denies dizziness. Repeat vital signs are BP 104/64, HR 48, and RR 16. Your colleague requests additional orders for the heart rate of 48. What are your actions? ACLS Bradycardia Case Out-of-Hospital Scenario You are a paramedic and respond to a call for cardiac arrest. On your arrival an elderly patient is on the floor at home. The patient s husband says she clutched her chest and collapsed. No CPR is in progress. What are your actions? You perform the Primary ABCDs and find that she is breathing and has a weak but palpable pulse. You perform the secondary ABCDs. A cardiac monitor is attached and shows second-degree AV block type II (Mobitz II) (show ECG strip). An IV is initiated. What are your actions? After initial therapy with atropine, the patient remains unresponsive. Vital signs are BP 70/palp, HR 26, and RR 8. What are your next actions? After additional atropine and preparation for pacing, she is conscious and alert. She is slightly dizzy but otherwise has no complaints. Repeat vital signs are BP 96/70, HR 48, and RR 12. Your colleague requests additional orders for the heart rate of 48. What are your actions?

13 ACLS Bradycardia Case In-Hospital Scenario You are a physician evaluating a patient. An elderly man was brought from triage complaining of dizziness. He tells you that symptoms began about an hour ago. He is lying on the stretcher and says he is dizzy and weak. Then he becomes poorly responsive but regains consciousness within a few seconds. This recurs several times while a monitor is being placed. What are your actions? You complete the Primary and Secondary ABCDs. A cardiac monitor is now attached and shows that a slow rhythm is present. Vital signs are BP 90/60, HR 38, and RR 16. The rhythm is sinus bradycardia (show ECG strip). What are your next actions? After initial treatment with atropine, he is conscious and alert. Color is improved. He denies dizziness. Repeat vital signs are BP 104/64, HR 48, and RR 16. The nurse requests additional orders for the heart rate of 48. What are your actions?

14 ACLS Bradycardia Case In-Hospital Scenario You are a physician evaluating a patient brought by EMS. They report finding an elderly patient on the floor at home. The patient s husband says she clutched her chest and collapsed. After initial therapy with atropine, she improved and had stable vital signs. She was transported to your ED. Now she complains of dizziness again, and her heart rate drops to 28. A monitor strip shows second-degree type II AV block (Mobitz II). A pacer is not immediately available. What do you do? After initial therapy with atropine, the patient is conscious but confused. Vital signs are BP 70/palp, HR 40, and RR 8. The monitor shows third-degree AV block (show ECG strip). What are your next actions? Pacing fails to capture, and she remains poorly responsive with an unchanged heart rate. She moans with each pacer stimulus. Repeat vital signs are BP 96/ 70, HR 28, and RR 6. What are your actions? After epinephrine is initiated and titrated to 4 μg/min, she is responsive and has no specific complaints. Repeat vital signs are BP 96/70, HR 48, and RR 10. The nurse requests additional orders for the heart rate of 48. What are your actions?

15 ACLS Unstable Tachycardia Case Out-of-Hospital Scenario You are a paramedic. You arrive on scene and find a 55-year-old man who is complaining of palpitations and chest discomfort. He has a past history of intermittent palpitations and takes a medication for this. Today his palpitations persisted, and he developed chest pressure and lightheadedness after 1 hour. His coworkers phoned 911. An EMT has completed the primary ABCDs. He is receiving oxygen at 4 L/min. What are your actions? You complete the Secondary ABCDs. He has severe 9/10 chest discomfort now. He is pale and diaphoretic. A cardiac monitor is attached and finds a rapid irregular rhythm. Vital signs are BP 80/60, HR 178, and RR 28. The rhythm is atrial fibrillation (show ECG strip). What are your next actions? An IV was started during your assessment. Your partner asks if he should give IV adenosine for rate control. What are your actions? ACLS Unstable Tachycardia Case Out-of-Hospital Scenario You are a paramedic transporting a 55-year-old man. His chest discomfort had resolved after 2 sublingual nitroglycerin tablets. Now he has recurrent discomfort 8/10 and feels as if he is going to pass out. He is pale and diaphoretic. On oxygen at 4 L/min, his O 2 saturation has decreased to 86%. A weak pulse is present and blood pressure palpable at 100 mm Hg systolic. The monitor shows a regular wide-complex tachycardia at 170/min. What are your next actions? Following synchronized cardioversion, he now has a regular narrow-complex tachycardia at 118/min (show sinus tachycardia). His chest discomfort is gone. Vital signs are BP 110/60, HR 118, and RR 16. Your partner asks if he should deliver another shock. What are your next actions?

16 ACLS Unstable Tachycardia Case In-Hospital Scenario You are a nurse on a monitored unit. A 55 year-old man is recovering from an anterior MI following fibrinolysis in the ED. The monitor alarms and you see a tachycardia. You go to the room. What are your initial actions? You complete the Primary and Secondary ABCDs. You start oxygen at 4 L/min and confirm that his IV is patent. He is pale and diaphoretic He has severe 9/10 chest discomfort. Vital signs are BP 80/60, HR 178, and RR 28. The rhythm is atrial fibrillation (show ECG strip). What are your next actions? You have successfully performed synchronized cardioversion. He is now in sinus tachycardia at 128/min. His chest discomfort persists. Blood pressure is 124/86 mm Hg. A member of your team asks if another shock should be given. What are you next actions? A 12-lead ECG shows sinus tachycardia with new STsegment elevation. What are your actions? ACLS Unstable Tachycardia Case In-Hospital Scenario In the emergency department you are evaluating a 26-year-old woman. She was born with heart abnormalities and has chronic palpitations. A corrective surgical procedure was performed as a child. She has passed out once in her life. Today her palpitations did not stop, and she came to the ED. During your assessment she develops lightheadedness and feels short of breath. She starts to become confused, disoriented, and diaphoretic. The monitor shows a rapid narrow-complex tachycardia at 230/min. A faint pulse is present, and her blood pressure is 60 mm Hg palpable. What are your next actions?

17 ACLS Stable Tachycardia Case Out-of-Hospital Scenario You are a paramedic. You arrive on scene and find a 47-year-old female who is complaining of palpitations. She tells you she has had a history of recurrent rapid heart rates. These have always been brief but have persisted today. Her coworkers insisted on phoning 911. What are your initial actions? You complete the Primary and Secondary ABCDs. As a monitor is placed, you start oxygen at 4 L/min and initiate an IV. You determine that she has no chest pain, shortness of breath, or dizziness. Other than apprehension, she is asymptomatic. Her blood pressure is 110/70 and heart rate 170. The monitor shows a tachycardia at 210/min. What are your next actions? You determine that the rhythm is a regular narrow-complex tachycardia. A Valsalva maneuver does not terminate the rhythm. You have given adenosine 6 mg rapid IV push. The patient has not converted. What are your next actions? After adenosine 12 mg rapid IV push, she converts to sinus tachycardia. You have obtained a 12-lead ECG postconversion and are transporting to the ED. ACLS Stable Tachycardia Case Out-of-Hospital Scenario You are a paramedic and arrive on scene. A 35-year-old male is complaining of palpitations. He tells you he has had a history of recurrent rapid heart rates. Today symptoms persisted and coworkers phoned 911. They tell you he is having a heart attack. What are your initial actions? You complete the Primary and Secondary ABCDs. As a monitor is placed, you start oxygen at 4 L/min and initiate an IV. You determine that he has no chest pain, shortness of breath, or dizziness. Other than apprehension, he is asymptomatic. His blood pressure is 110/70 and heart rate 180. The monitor shows a tachycardia at 180/min. What are your next actions? You determine that the rhythm is an irregular wide-complex tachycardia. What are your next actions? You determine that the patient is asymptomatic with stable vital signs and transport him to the ED for expert consultation.

18 ACLS Stable Tachycardia Case In-Hospital Scenario You are in the emergency department and are evaluating a 47-year-old female who presented complaining of palpitations. She tells you she has had a history of recurrent fast heart rates, but several episodes today brought her to the ED. While you are doing her examination, she suddenly complains of palpitations, and you see a rapid tachycardia on the cardiac monitor. What are your initial actions? Your staff has administered oxygen at 4 L/min and initiated an IV. You determine that she has no chest pain, shortness of breath, or dizziness. Other than apprehension, she remains asymptomatic except for palpitations. Her blood pressure is 110/70 and heart rate is 170. The monitor shows a tachycardia 170/min (show ECG strip or describe). What are your next actions? You determine that the rhythm is a regular narrow-complex tachycardia. A Valsalva maneuver and carotid sinus massage do not terminate the rhythm. You have given adenosine 6 mg rapid IV push. The patient has not converted. What are your next actions? After 12 mg adenosine rapid IV push, she converts to sinus tachycardia. You have obtained a 12-lead ECG postconversion and now consult cardiology.

19 ACLS Stable Tachycardia Case In-Hospital Scenario A 35-year-old male arrives in the ED complaining of palpitations. He tells you he has had a history of recurrent fast heart rates. He has been having palpitations for several days. Today symptoms were worse and coworkers phoned 911. He thinks he is having a heart attack. What are your initial actions? You complete the Primary and Secondary ABCDs. As a monitor is placed, staff start oxygen at 4 L/min and initiate an IV on your orders. You determine that he has no chest pain, shortness of breath, or dizziness. Other than apprehension, he is asymptomatic. His blood pressure is 110/70 and heart rate 180. The monitor shows a tachycardia at 180/min. What are your next actions? You determine that the rhythm is an irregular wide-complex tachycardia. What are your next actions?