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Sticking to the basics
by Patrick Lickiss

Clinical scenario: Resuscitation at a nursing home

You arrive on scene to find staff performing CPR; what are your priorities during this resuscitation?

By Patrick Lickiss

Post your assessment in the comment section below, and the person with the best answer will receive one of our exclusive EMS1 Challenge Coins!


At 0700 hours just after completing shift change, you are dispatched to a skilled nursing facility in a rural part of your district for a report of a 75-year-old resident with shortness of breath.

The update you receive while en route indicates that the patient has a low pulse oximetry reading. You arrive on scene and are advised by dispatch that the ALS ambulance is approximately 15 minutes away. 

You are buzzed in the front door by a staff member and led through the common area to the patient’s room. When you walk through the door you find staff performing CPR on a patient lying in bed. The patient has an OPA in place and is being ventilated with a BVM hooked up to high-flow O2. A staff member arrives behind you with the facility’s AED. 

As your crew takes over compressions and ventilations, the staff member hooks up the AED. The unit analyzes and does not advise a shock. With CPR continuing, you begin to ask staff about the patient. 

She has a history of CHF and diabetes and was admitted to the skilled nursing facility two weeks ago for rehabilitation following a stroke. Her therapy has been going well. At 0645 today, she rang her call button and reported to staff that she was feeling like she could not catch her breath.

While your crew continues CPR, ask yourself:

  • What are your priorities during this resuscitation and why?
  • What are some potential causes of the patient’s cardiac arrest?
  • Are any of those causes correctable during the resuscitation?

About the author

An EMS practitioner for nearly 15 years, Patrick Lickiss is currently located in Grand Rapids, MI. He is interested in education and research and hopes to further the expansion of evidence-based practice in EMS. He is also an avid homebrewer and runner.
The comments below are member-generated and do not necessarily reflect the opinions of or its staff. If you cannot see comments, try disabling privacy and ad blocking plugins in your browser. All comments must comply with our Member Commenting Policy.
Ashley Pendarvis Ashley Pendarvis Thursday, May 22, 2014 4:57:09 PM Since she is being ventilated, I would check for a pulse myself since the AED had advise no shock. I would then secure an airway by intubation. The pt is likely to be having a exacerbation of CHF. Lung sounds prior to intubation would also confirm that. I would also check a sugar level especially since she's a known diabetic.
Saoirse Kane Saoirse Kane Thursday, May 22, 2014 5:24:32 PM Put her on the floor for cpr! The bed is too soft!
Carol Knapp Mahnke Carol Knapp Mahnke Friday, May 23, 2014 5:45:12 AM Check for pulse, and position backboard (or something hard and flat) beneath her. Continue CPR, but ask how long staff has been giving her CPR. Make sure she is positioned well to breathe as that may have been part of the problem in the first place. Try AED again. Check blood sugar.
John MacMillan John MacMillan Saturday, May 24, 2014 4:14:49 PM Well first since she is in a nursing home first priority would be to see if they have any advanced directives(DNR, MOLST). Then provide care as needed as far as CPR and ACLS guidelines
Dave Kinder Dave Kinder Saturday, May 24, 2014 4:17:39 PM Any DNR papers? How long on CPR? 20 minutes and contact medical control if no ROSC to consider cease of CPR.
John Hansen John Hansen Saturday, May 24, 2014 4:25:41 PM First is high quality CPR on a hard surface, During resuscitation check medical history and for DNR's. ACLS with rapid transport. I'm thinking PE or CHF.
Darlene DeVeny Darlene DeVeny Saturday, May 24, 2014 4:30:34 PM Priorities would be high quality cpr and ventilation. Check blood glucose to see if blood sugar is low for possible reason for the arrest. Also check lung sounds since patient has a history of CHF; possible embolism in the lungs from being bed bound the two weeks for rehab after a CVA. Assuming this is a basic unit response since ALS is 15 minutes out; if have abilty to start a line or not to correct H's and T's. I am going with a basic unit and continue high quality CPR until ALS arrives then gi e them the report and assist them with continuing CPR and transporting.
Jeffrey Frank Jeffrey Frank Saturday, May 24, 2014 4:32:24 PM Well since it said ALS is 15 minutes away im going to assume this is a BLS ambulance and since the nursing home staff started CPR im going to assume there is no DNR or POLST. So im going to quickly update dispatch/ALS that this is now a cardiac arrest call then start with the basics. Check pulse, confirm that you are getting chest rise and fall with BVM. continue cpr as needed. Check blood sugar. Check for pain medications and give IN narcan as appropriate.
Robin Sykes Robin Sykes Saturday, May 24, 2014 4:41:16 PM well regardless of what the facility is doing i would assume that she is not a DNR or the staff would know that and not have started CPR( and if i dont see a DNR i work the code!). than i would do my usual assessment (ABCs)starting with airway, make sure you have chest rise and fall, (maybe drop a combi-tube) check O2 sats. check pulse since no shock advised. place the pt. on a hard service and if nessasary continue CPR. than try the AED again to see if shock advised. get the pt on the cto ready for transfer when ALS does arrive.( regardless as a BLS crew i could do nothing for the diabetes or to fix the CHF so just make sure air is going in and out!)
Mindy Hopkins Mindy Hopkins Saturday, May 24, 2014 4:56:08 PM Continue with CPR. Check glueclose. Maintain airway if possable get an i.v. started. try to stabilize and package and go. And try to get a medic en route to the hospital to meet us.
Rob Clendening Rob Clendening Saturday, May 24, 2014 5:04:50 PM Priority is high quality CPR. I'm going to pay special attention to make sure airway is open. I have a high suspicion for dysphagia due to the recent stroke. That could have caused the difficulty breathing and eventually the arrest. There is no info given, but I would also try to determine if any medications could have been messed up to cause depressed breathing. Rapid transport of course, but not waiting on scene for ALS. Intercept en route if possible
David Austin Walters David Austin Walters Saturday, May 24, 2014 5:05:34 PM 1st. Double check DNR status. 2nd reassess patients condition. Is she still pulse less, apneic and unresponsive. If so continue high quality CPR while switching rescuers every 2 mins for fatigue along with reanalyze of AED. Check quality of compressions by check for a pulse. Check blood sugar to make sure she's not hypoglycemic. With HX of CHF, patient could have developed " flash" CHF. Obtained last HX of meds administered like LASIK. If true BLS unit only thing can be done is CPR. If equipped with EMT-I then possibly admin D-50 for blood sugar and or LASIK for fluid if needed. Along with appropriate advanced airway if needed.
Donna Baer Donna Baer Saturday, May 24, 2014 5:21:09 PM Priorities during resuscitation are effective compressions and ventilations--with OPA in place is she getting air? If not, reposition (Need to reposition anyway to either put on h ard flat surface or put back board beneath). Effective compressions with recoil are essential. If still not getting effective air exchange, combitube needed to attempt to get air moving but not at expense of effective CPR. Causes for cardiac arrest include blood clot especially since in recovery from an initial stroke and diabetes increases chances as well. Pulmonary embolus also a possibility. Since no shock is advised As basic responder, I can't address the clot but with effective compressions and air flow I can preserve her chances until ALS unit arrives.
Jen Turner Jen Turner Saturday, May 24, 2014 5:30:46 PM Very first thing I would do is make sure.the patient didn't have a pulse, because I have walked into plenty of nursing homes doing cpr on peoole that are alive. Then, I would put the pt on the floor, and do effective CPR, assuming that the pt is dead. I would continue having ventilated while I gained IV access and continue drug therapy per acls protocol. I would check.blood.glucose and administer D50 if indicated. Recheck rhythm and continue with resus as indicated by pt respinse. Check for nitro or duragesic patches, establish advanced airway with end tidal co2. Narcan coyld be a possibility, if she's diabetic and a renal patient, calicum chloride, sodium bicarb to reverse acidosis, have fluids running wide open to take care of hypovolemia, all the while continuing CPR and watching for spikes in ETCO2 which may indicate ROSC. If all this fails and pt does not respond, call med control and see what they say.
Casey Moyes Casey Moyes Saturday, May 24, 2014 5:30:53 PM Priorities would be scene safety, PPE, high quality cpr with minimal interruptions, assure that your ventilations are adequate and continuing to analyze the rhythm. Check 5 h's and 5 t's and especially obtain blood glucose level. 2. Potential causes would be but not limited to flash pulmonary edema, MI, hypoglycemia and acute CVA. 3. Yes. PPV can reduce pulmonary edema, dextrose 50% can treat hypoglycemia, defirilation can vf or vt if they went into that rhythm.
Zachary Dussault Zachary Dussault Saturday, May 24, 2014 5:36:17 PM Knowing SNFs in my area I wouldn't be surprised if the pt actually had a pulse.
Cynthia Navis Cynthia Navis Saturday, May 24, 2014 5:38:08 PM Check for rigor.
Jose Ortiz Jose Ortiz Saturday, May 24, 2014 5:42:47 PM priority during cpr compressions are effective and that they maintain blood flow, we have several potential causes and that Pt has hx. chf and diabetes can be checked at 6 H and 6 t. Securing the airway and check fluid retention in the body as the pte had poor oxygenation
Chris Thomas Chris Thomas Saturday, May 24, 2014 6:01:18 PM It says pt is having cpr in bed. Check DNR status, Move pt to the floor, check for pulse, if still pnb continue cpr, check blood sugar, perform effective CPR for 2 minutes, ALS is 15 minutes away I'm guessing I'm a BLS rig. If I am at a higher level follow protocols for PNB pt. Start line, flow NS tko and continue with CPR until ALS UNIT arrives onscene.
Mari Warner Mari Warner Saturday, May 24, 2014 6:06:09 PM Make sure ALS is enroute. Continue CPR. Place an advanced airway. Start an iv. Chances are this started as a PE. Follow the CPR guidelines. Transport as soon as possible. If a DNR is found call for medical direction before stopping CPR.
Colleen Marie Colleen Marie Saturday, May 24, 2014 6:27:46 PM Priorities: scene safety (have unnessecary people removed to make way for ALS crew), BSI (patient likely to vomit due to CPR), high quality CPR (good compressions, good rate, complete chest recoil), adequate ventilations (can use pulse ox to assist, goal being 99%) with good chest rise and equality. I would update the incoming unit that we have a full arrest. As a BLS truck, this and checking a glucose and recent meds (opioids) are about all I could do. It's the crux of good ALS care anyway. Potential causes are PE/MI (assuming ischemic vs hemorrhagic CVA), CHF exacerbation, sudden cardiac death, hypoglycemia, opioid overdose. As a BLS truck, I could correct opioid OD if Narcan is available and hypoglycemia if Glucagon is available.
Heidi M Fischer Heidi M Fischer Saturday, May 24, 2014 6:29:08 PM Being a nursing home I would check for DNR, not assuming that it has been done as people don't always act rationally in an emergency and I would want to make sure that the patient's wishes are respected. Inspect airway for obstruction - due to the CVA she could have aspirated, or her CHF puts her risk for APO so there could be secretions. Clear airway if necessary, triple airway manoeuvre. Ensure good rise and fall of chest with BVM. Place patient on floor for effective CPR as this is not possible on a bouncy mattress. Considering the H's and T's: 1) hypoxia: going on the patient's medical hx one of the potential dx I would be suspecting is APO due to her CHF (aspiration could also cause this as a non-cardiac cause) and her respiratory distress prompting the initial call for emergency services, which progressed rapidly to cardiac arrest. In BLS I cannot treat this with drugs but I can assure good air entry with the BVM and high flow oxygen to correct hypoxia. 2) Hypoglycaemia: is no longer part of the 4 H's but would still need to be considered due to the patient's hx of diabetes. Take a BSL and correct with glucose if indicated. 3) hypo / hyperkalaemia: again a risk factor, especially if the diabetes is not well controlled or the patient is dehydrated due to difficulty swallowing. Can't do much about this in BLS except ensure good CPR. 4) thrombus: the patient has a hx of CVA so is at high risk of thrombus. PE is a possibility due to sudden onset of respiratory distress progressing rapidly. An AMI could also cause the respiratory symptoms and lead to cardiac arrest. Again not reversible with BLS except ensuring good CPR. 5) toxins: what are the patient's allergies? What medications is she on? There is a slight possibility that her respiratory distress could have been caused by an allergic reaction, leading to airway obstruction, hypoxia and subsequent cardiac arrest. As the BLS crew I would ensure good quality CPR with effective ventilations and obtaining a thorough history to assist the ACLS crew with rapid decision making when they arrive.
James E Glass James E Glass Saturday, May 24, 2014 6:52:32 PM DO what the dr orders say in the chart
Ryan Falkey Ryan Falkey Saturday, May 24, 2014 7:03:43 PM First priority is BSI is the scene safe, it needs to be confirmed that the patient doesn't have a DNR, next is to pull the patient to the floor and get them on a backboard, (a squishy bed is not the place to be doing CPR) making sure the patient really has no pulse. Make sure your doing good CPR and getting full chest recoil. Check the patients throat the best you can to make sure their are no obstructions that you can see. Make sure the BVM is actually getting air in their lungs (listen, feel and see if any of their color has returned). Have the suction near by incase they vomit. Find out the down time of the patient and if it was witnessed with immediate CPR. Then load and start going to the nearest hospital and attempt to meet ALS along the way. There is no reason to stay on scene if you are working this patient (unless you are a first response agency then you just continue CPR until the ambulance arrives). Cause may be a complication from the stroke, their heart finally failed due to the CHF, could be they have gotten low with their sugars but their isn't anything a bls crew can do for that being they are unconscious so I would waste my time checking. Good CPR and ventilation is the thing that would save this persons life at a BLS level. As basic techs we can open the airway if that was closed off and that could correct itself otherwise their isn't anything we can correct. We need to preform good CPR and begin immediate transport of the patient to the closest hospital trying to meet with ALS or if we are first responders making sure we have the patient packaged and ready to go when the ambulance arrives giving them all the information we have gathered and assisting them in whatever way they need.
Dale Miller Miller Dale Miller Miller Saturday, May 24, 2014 9:57:48 PM first is the pt a full code or DNR second is get the pt to the floor you can not do proper compressions in a bed next advise incoming unit of the code so they can bring proper equipment in as for causes most likely is the CHF history
Judy Eskin Jackson Judy Eskin Jackson Sunday, May 25, 2014 5:29:20 AM Check for a DNR, if none, place pt onto bb, turn on the AED and follow prompts. Find out if she is compliant with her meds. Rule outs would be check pt sugar and check to make sure her false teeth are not obstructing her airway, Listen to lung sounds during BVM for fluid since she has CHF. Drop a King when possible with positive pressure ventilation . High quality CPR, PUSHING HARD AND FAST.... Have nurse get medical history and records ready to roll when ALS arrives.
Doug Hawkins Doug Hawkins Sunday, May 25, 2014 6:09:37 AM Prioritize quality CPR and make sure to place a tube, combi or king (basic in MI) get lung sounds could be collapsed due to pressure from fluid.Maintain the airway. Have staff or your partner get glucose reading since it could be hyper or hypo glycemia. As basic could not rectify as unconscious patient (our scope of practice). Make als use diesel treatment.
Lisa McFerren Lisa McFerren Sunday, May 25, 2014 9:33:39 PM 1. Does she have a DNR? if so where is it? 2. ABC's, pt hx, meds, when administered last. Trend. 3. as BLS, CPR, ventilate, and wait to transfer care to ALS (if there is no DNR) (* note, I worked at an assisted living facility and most of the staff had no training or clue about DNR"s and starting CPR- really, palm to forehead- really)
Nathan Scott Koistinen Nathan Scott Koistinen Tuesday, May 27, 2014 12:49:20 AM priorities to the call would be bsi, ventilation, and compressions. chf is the most likely cause to this call as she has a history of heart problems. i dont see stroke or diabetes being contributing factors at this time. as resuscitation attempts continue we cannot correct any problems other than delivering high O2. aed advises no shock so it would be appropriate to check for pulse no more than 10 seconds. patient undergoing cpr is unresponsive so nitro or aspirin is not a viable option. main priority is to give patient enough time for als to arrive, deliver care, and transport.
Patrick Dunaway Patrick Dunaway Thursday, June 05, 2014 3:17:54 PM Take the patient off the bed and put her on the floor. Then start CPR.

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