Emergency Department – NurseCheung.com

Emergency Department ACLS Airway Management Megacode: The Best Strategies for Saving Lives

Nurse Cheung — Sat, 07 Jan 2023 17:14:31 +0000

The Airway Management section of the AHA Emergency Department (ED) ACLS algorithm is one of the most important, and it can be difficult to know what to do when someone is choking or has another airway emergency.

We will provide you with a step-by-step guide on how to manage an airway emergency, as well as some tips for avoiding common mistakes.

In this blog post, we will discuss the best strategies for saving lives in the Emergency Department setting.

Adult ED Respiratory Arrest Megacode Scenario

The following is a scenario in which you would use the ED adult respiratory arrest Megacode:

You are working the day shift in an emergency department. You are asked to see a new patient in your bay. A bystander called 911 after finding a man unconscious in a ditch.

Demonstrate what you would do next

Initial Impression

The man is unconscious with mildly cyanotic lips. The paramedics placed a nasopharyngeal airway and have been trying to ventilate but have had difficulty. The paramedics also noted that there were drug paraphernalia on the scene and an empty syringe.

Primary Assessment Survey (A, B, C, D, E)

Airway: There is a nasopharyngeal airway present. It is being ventilated by paramedics on arrival and taken over by respiratory. The flow through the trachea is impaired by the tongue.

Breathing: Oxygenation is showing 75% with bag valve mask ventilation. The man has no spontaneous breaths.

Circulation: Blood pressure is 100/60, heart rate is 140/min, the rhythm is narrow-complex rapid tachycardia, and the pulse is present but weak.

Disability: Unresponsive to any stimuli. Pupils are dilated bilaterally at 7 mm (commonly misused drugs that dilate pupils are amphetamines, bath salts, benzodiazepines, cocaine, crystal meth, ecstasy, LSD)

Exposure: Numerous track marks are located on the man’s arms.

Change in Condition

After assessment of the initial impression and primary assessment, the man’s oxygen continues to decline and his heart rate increases.

What are your next actions?

Check responsiveness: Tap the shoulders and shout, “Are you okay?” Found unresponsive during the primary survey, move on to the next step.
Activate the emergency response system. Shout for backup and announce what room you are in.
Check for breathing: Look for visible chest rising and falling. No spontaneous breathing was present.
Check for a pulse: Place your fingers on the inside of the patient’s neck, just below the angle of the jaw. You will palpate the carotid pulse for no more than 10 seconds. Pulse is present but weak.

What are your next actions?

Pulse is present so we will not begin CPR starting with compressions.
The nasopharyngeal airway is not working effectively. It may be time to switch to endotracheal intubation.
Administer oxygen. After endotracheal intubation, the oxygen saturation is 99% with positive color changes on the CO2 Detector. Waveform capnography is the gold standard.
Perform bag-mask ventilation for 1 minute effectively at the proper rate (1 breath every 6 seconds), speed (over 1 second), and volume (about half a bag) until the ventilator arrives.

The man is stable and oxygen saturation is normal. What are your next steps?

Secondary Survey (SAMPLE)

Signs and Symptoms: Signs and symptoms are improving, heart rate has decreased to 90 bpm normal sinus rhythm; however, no spontaneous breathing is noted.

Allergies: Unknown if there are any allergies.

Medications: Unknown if there are any medications.

Past Medical History: Unknown if there is any past medical history.

Last Meal, Liquid Consumed: Unknown when the last meal and liquid were consumed.

Events: No events were noted outside of what was discussed with the paramedic team.

What are your text interventions?

Drug urinalysis
Labs
Fluids
Naloxone trial with escalating doses
Transfer to a higher level of care – Intensive Care Unit

You will begin the transfer to the unit. Your scenario has concluded.

Emergency Department ACLS Unstable Bradycardia Megacode: How to Respond in an Emergency Situation

Nurse Cheung — Sat, 07 Jan 2023 17:14:26 +0000

In this blog post, we will discuss how to respond to an emergency department ACLS unstable bradycardia megacode. This is a serious emergency situation that requires quick action.

If you are not familiar with the megacode, don’t worry! We will go over the steps that you need to take in order to provide lifesaving care for the patient.

Adult Emergency Department Unstable Bradycardia Megacode Scenario

The following is a scenario in which you would use the ED adult unstable bradycardia Megacode:

You are a healthcare provider working in the emergency department. You are assessing a woman with a history of syncopal episodes. She is present in the ED as she feels she is going to have another syncopal episode.

Demonstrate what you would do next

Initial Impression

The 75-year-old female is sitting upright on a stretcher. She is feeling dizzy, light-headed, weak, and faint. There are no complaints of chest pain, dyspnea, or palpitations. Overall she has been healthy with no recent changes to her medications.

Primary Assessment Survey (A, B, C, D, E)

Airway: The airway is patent. The flow through the trachea is not impaired.

Breathing: Oxygenation is showing 98% on room air.

Circulation: Blood pressure is 76/50, heart rate is 30/min, a rhythm check shows second-degree heart block Type II, and the pulse is present but weak.

Disability: The patient is oriented but drowsy. Overall alert, but responsive to verbal stimuli at times.

Exposure: No obvious signs of trauma, bleeding, burns, markings, or medical alert bracelet.

Change in Condition

After assessment of the initial impression and primary assessment, the patient’s mental status starts to deteriorate and the monitor shows a third-degree AV block.

What are your next actions?

Check responsiveness: Tap the shoulders and shout, “Are you okay?” There is a slight response.
Activate the emergency response system. Shout for backup and announce what room you are in.
Check for breathing: Look for visible chest rising and falling. Breathing is present but weak.
Check for a pulse: Place your fingers on the inside of the patient’s neck, just below the angle of the jaw. You will palpate the carotid pulse for no more than 10 seconds. Pulse is present but weak.

What are your next actions?

Pulse and breathing is present so we will not begin CPR starting with compressions.

Unstable Bradycardia Algorithm

Identify and Treat the Underlying Cause

Maintain patent airway, assist with breathing if necessary – Airway is patent and breathing is spontaneous
Oxygen (if hypoxemic) – The patient is not hypoxemic at this time and does not require oxygen.
Cardiac monitor, blood pressure, oximetry – Third Degree Heart Block, BP 76/50, 98% on room air
IV Access – 20 gauge in the left and right antecubital
12-Lead ECG if available and doesn’t delay therapy – Not readily available
Consider hypoxic and toxicologic causes – Myocardial Ischemia/infarction, calcium-channel blockers, beta-blockers, digoxin, hypoxia, hyperkalemia

Persistent Bradyarrhthmia Causing

Hypotension? – YES
Acutely altered mental status? – YES
Signs of shock (low blood pressure, altered mental status, cold moist skin, weak or rapid pulse, rapid breathing, decreased urine output) – YES
Ischemic chest discomfort? – Unknown at this time but declined on previous assessment
Acute heart failure (heavy breathing, suffocating sensation, struggle to breathe while lying down, tight chest, arrhythmia, cough, fluid retention, loss of consciousness)? – YES

Interventions

What interventions could you perform next?

Atropine 1mg bolus – relatively contraindicated in high-degree blocks

If atropine is not effective or contraindicated:

Transcutaneous pacing – YES
Dopamine
Epinephrine
Labs – electrolytes and cardiac biomarkers
Urinalysis
Fluids
Chest x-ray
Cardiac Consultation
Transfer to a higher level of care

You will begin the transfer to a higher level of care. Your scenario has concluded.

Emergency Department ACLS Unstable Tachycardia Megacode: The Most Effective Strategies

Nurse Cheung — Sat, 07 Jan 2023 17:14:20 +0000

ACLS or Advanced Cardiac Life Support is a set of clinical guidelines that are used to treat cardiac arrest and other life-threatening medical emergencies.

One of the most common arrhythmias that ACLS providers will encounter is unstable tachycardia.

In this blog post, we will discuss the most effective strategies for managing unstable tachycardia using the ACLS megacode.

Adult Emergency Department Unstable Tachycardia Megacode Scenario

The following is a scenario in which you would use the emergency department adult unstable tachycardia megacode:

You are working in the emergency department and are assessing a woman who has had multiple reports of syncopal episodes and palpitations.

Demonstrate what you would do next upon arrival

Initial Impression

The patient is a 32-year-old female lying down on the stretcher. She is anxious, pale, weak, and dizzy. She states these episodes have happened over the last few years but have become more frequent recently.

Primary Assessment Survey (A, B, C, D, E)

Airway: The airway is patent. The flow through the trachea is not impaired.

Breathing: Oxygenation is showing 96% on room air.

Circulation: Blood pressure is 84/60, heart rate is 160 bpm, the rhythm check shows narrow complex supraventricular tachycardia and the pulse is present.

Disability: The woman is alert but anxious and diaphoretic.

Exposure: No obvious signs of trauma, bleeding, burns, markings, or medical alert bracelet.

Change in Condition

After assessment of the initial impression and primary assessment, the patient’s palpitations become worse and she is short of breath.

What are your next actions?

Check responsiveness: Tap the shoulders and shout, “Are you okay?” The woman responds but is becoming increasingly weak.
Activate the emergency response system. Shout for backup and announce what room you are in.
Check for breathing: Look for visible chest rising and falling. Breathing is rapid and present.
Check for a pulse: Place your fingers on the inside of the patient’s neck, just below the angle of the jaw. You will palpate the carotid pulse for no more than 10 seconds. Pulse is present but fast.

What are your next actions?

Pulse and breathing are present so we will not begin CPR starting with compressions.

Unstable Tachycardia Algorithm

Identify and Treat the Underlying Cause

Maintain patent airway, assist with breathing if necessary – Airway is patent and breathing is spontaneous
Oxygen (if hypoxemic) – The woman is on 4LNC upon Primary Assessment
Cardiac monitor, blood pressure, oximetry – narrow complex supraventricular tachycardia, BP 84/60, 94% on 4LNC
IV Access – 20 gauge in the right and left antecubital
12-Lead ECG if available and doesn’t delay therapy – Not readily available

Persistent Tachyarrhythmia Causing

Hypotension? – YES
Acutely altered mental status? – NO
Signs of shock (low blood pressure, altered mental status, cold moist skin, weak or rapid pulse, rapid breathing, decreased urine output) – YES
Ischemic chest discomfort? – YES, the patient states chest discomfort from palpitations
Acute heart failure (heavy breathing, suffocating sensation, struggle to breathe while lying down, tight chest, arrhythmia, cough, fluid retention, loss of consciousness)? – YES

Interventions

What interventions could you perform next?

Synchronized Cardioversion – Consider sedation

If synchronized cardioversion is not effective or contraindicated:

Adenosine IV – First dose 6mg rapid IV push followed by NS flush, Second dose 12 mg if required

Outcomes

Two attempts at synchronized cardioversion were performed successfully.

Rhythm is now normal sinus rhythm at 80 bpm.

Next steps for this patient:

Labs – electrolytes and cardiac biomarkers
Fluids
Chest x-ray
Cardiac Consultation
Transfer to a higher level of care

You will begin the transfer to a higher level of care. Your scenario has concluded.