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Sticking to the basics
by Patrick Lickiss

Clinical solution: Resuscitation at a nursing home

You arrive on scene to find staff performing CPR; did you get your priorities right?

By Patrick Lickiss

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.[1] 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. 

Treatment

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. 

Outcome

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. 

Works Cited

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.

Comments
The comments below are member-generated and do not necessarily reflect the opinions of EMS1.com 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.
Edward Herbert Edward Herbert Monday, June 02, 2014 4:32:06 PM A great many Extended Skilled Nursing Care Facilities call 911, or Medical Transport because the facility does not wish a death to be included in their facility statistics. Many times I went to Nursing Homes found a lifeless person, sometimes with a DNR, and the facility wanted us to transport. I arrived at a Nursing Home one time, and there was a Physician there watching the Staff do CPR for 30 minutes. We took over. Tubed the patient at which time projectile emesis flew out of the well placed Endotracheal Tube upon the first compression after the balloon was set. We proceeded to work the patient an additional 30 minutes, and the Doctor gave us a verbal order to transport. Working the patient all the way to the truck, the doors shut, and our Medical Control told us to call it, and we did,
Patricia A. Hill Patricia A. Hill Wednesday, June 04, 2014 4:17:50 PM Ed, I don't know what state you live in, but I worked28 years in nursing homes in MN and if a resident had a DNR order, we let them die with peace and dignity. I found that while working in a CCU in PA, that residents were the ones who wouldn't quit even if someone was in their 90s and contracted. It took our chaplain to make them stop.

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