Clinical solution: Resuscitation at a nursing home
You arrive on scene to find staff performing CPR; did you get your priorities right?
First of all, thanks to everyone who wrote in mentioning high-quality CPR. That was definitely the focus of this scenario. This month's coin goes to Chad Lawton, who not only identified the need for high quality resuscitation, but also reviewed many of the particular items that make up "high-quality CPR".
As a side note, there was some interesting discussion in the Facebook comments about DNRs. One thing to keep in mind is that DNR rules vary from state to state. Please make sure that you're familiar with the exact regulations where you work. The goal of a DNR is to honor a patient's end of life wishes but these forms have to meet specific local requirements to be valid.
Cardiac arrest care has become increasingly focused on basic resuscitation. High quality CPR has been shown to directly impact patient outcomes.
In the past, a “positive” outcome from the EMS perspective for a cardiac arrest patient was the Return of Spontaneous Circulation (ROSC). Recently, however, the goal of resuscitation has shifted to emphasize whether or not the patient is ultimately discharged from the hospital alive, and what extent of neurologic function they maintain.
The goal now is that a patient suffering an out-of-hospital cardiac arrest not only achieves ROSC but is able to return to her family and function to fulfill her own daily needs.
This renewed focus on high quality CPR puts bystanders and BLS and MFR first response agencies in a position of being some of the most important participants in a resuscitation. Starting CPR quickly and ensuring good habits from the beginning of the call increases the patient’s chance of survival both in the field and in the hospital by maintaining the heart’s ability to circulate oxygenated blood to the brain. Additionally, performing high quality CPR can be tiring. It is extremely important to change compressors every two minute to ensure that high quality compressions continue.
After confirming that the patient has a clear airway and that she is easily ventilated with a BVM, you take the metronome and stopwatch out of your clipboard. The metronome is set at 100 beats per minute and the firefighter providing compressions begins to use the beat to keep time. With the stopwatch running, you advise the crew when to switch compressors and when to stop for AED analysis of the rhythm.
After approximately four minutes, the AED advises that the patient is in a shockable rhythm. While the unit charges, compressions continue. Once the AED is charged you advise everyone to clear the patient. CPR begins immediately after the AED fires. After three more defibrillations, the patient regains pulses. As ALS arrives, you find that the patient has begun breathing on her own.
The ALS unit stabilizes the patient and performs a 12-lead ECG which finds an Inferior STEMI. As you assist with packaging the patient for transport, the lead paramedic sends the ECG to the hospital and calls in a report.
The patient is intubated en-route to the hospital and taken directly to the cardiac cath lab. During her procedure a stent is placed. The patient regains consciousness and is extubated three days later. Following several weeks in cardiac rehabilitation she is able to return home to her family with no neurologic deficits.
1. Berg, Robert A., Robin Hemphill, Benjamin S. Abella, Tom P. Aufderheide, Diana M. Cave, Mary Fran Hazinski, E. Brooke Lerner, Thomas D. Rea, Michael R. Sayre, and Robert A. Swor. "2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science Part 5: Adult Basic Life Support." Circulation 122(2010): 5685-5705. Web. 30 Mar. 2014.
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