Out-Of-Hospital – NurseCheung.com https://nursecheung.com From "You're Not Good Enough" To "Look At Me Now!" Wed, 06 Dec 2023 15:11:37 +0000 en-US hourly 1 https://wordpress.org/?v=6.5.5 https://2hya11.p3cdn1.secureserver.net/wp-content/uploads/2023/01/nurse-cheung-logo-Logo-1000-×-1000-px-2-150x150.png Out-Of-Hospital – NurseCheung.com https://nursecheung.com 32 32 Out-Of-Hospital ACLS Airway Management Megacode: The Best Strategies for Saving Lives https://nursecheung.com/aclsmegacode-ooh-airwaymanagement/ Sat, 07 Jan 2023 17:14:33 +0000 https://nursecheung.com/out-of-hospital-acls-airway-management-megacode-the-best-strategies-for-saving-lives/

Table of Contents

Adult Out-Of-Hospital Respiratory Arrest Megacode Scenario

The following is a scenario in which you would use the out-of-hospital adult respiratory arrest Megacode:

You are a paramedic and arrive on the scene for a woman having an asthma attack at home.

Demonstrate what you would do next

Initial Impression

The woman is conscious and reports difficulty breathing during her evening meal. The woman begins to have respiratory distress and a decrease in mental status.

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

Airway: The airway is starting to swell. The flow through the trachea is impaired.

Breathing: Oxygenation is showing less than 50% on room air. Agonal gasps are noted.

Circulation: Blood pressure is 60/38, heart rate is 120/min, and the pulse is present but weak.

Disability: Decrease in mental status. Responsive to verbal stimulation.

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 woman becomes unresponsive.

What are your next actions?

  1. Check responsiveness: Tap the shoulders and shout, “Are you okay?” There is no response.
  2. Activate the emergency response system. You direct the second rescuer to activate the emergency response system and get an AED.
  3. Check for breathing: Look for visible chest rising and falling. No breathing present.
  4. 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?

  1. Pulse is present so we will not begin CPR starting with compressions.
  2. The decision between oropharyngeal or nasopharyngeal airway can be difficult, but there are a few things to consider when making the decision.
  3. Oropharyngeal airways are inserted into the mouth, and nasopharyngeal airways are inserted into the nose. Oropharyngeal airways are more likely to be successful the first time, but nasopharyngeal airways are less likely to cause vomiting.
  4. Administer oxygen. Oxygen saturation is less than 50%. 
  5. 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).
 

The woman is stable and oxygen saturation is rising. What are your next steps?

Secondary Survey (SAMPLE)

Signs and Symptoms: Signs and symptoms are improving; however, swelling is still present.

Allergies: The woman’s friend states she has an allergy to peanuts.

Medications: Albuterol inhaler and an epinephrine pen

Past Medical History: Asthma

Last Meal, Liquid Consumed: Last meal and liquid consumed during the asthma attack. This ordered Chinese takeout Pai Thai.

Events: No events lead up to the asthma attack.

What are your text interventions?

  • Epinephrine
  • Diphenhydramine
  • Albuterol
  • Vital signs monitoring
  • Monitor for any changes
 
 

You will begin the transfer to the nearest hospital. Your scenario has concluded.

]]> Out-Of-Hospital ACLS Unstable Bradycardia Megacode: How to Respond in an Emergency Situation https://nursecheung.com/alcsmegacode-ooh-unstablebradycardia/ Sat, 07 Jan 2023 17:14:28 +0000 https://nursecheung.com/out-of-hospital-acls-unstable-bradycardia-megacode-how-to-respond-in-an-emergency-situation/

In this blog post, we will discuss how to respond to an out-of-hospital 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 Out-Of-Hospital Unstable Bradycardia Megacode Scenario

The following is a scenario in which you would use the out-of-hospital adult unstable bradycardia Megacode:

You are a paramedic responding to a call of a person with altered mental status.

Demonstrate what you would do next upon arrival

Initial Impression

The 60-year-old male person is sitting upright on a couch. He is disoriented, pale, and diaphoretic.

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 86% on room air. You provide oxygen 4LNC.

Circulation: Blood pressure is 80/68, heart rate is 40/min, a rhythm check shows third-degree heart block, and the pulse is present but weak.

Disability: Decrease in mental status. Responsive to painful stimulation.

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 man becomes unresponsive.

What are your next actions?

  1. Check responsiveness: Tap the shoulders and shout, “Are you okay?” There is no response.
  2. Activate the emergency response system. You direct the second rescuer to activate the emergency response system and get an AED.
  3. Check for breathing: Look for visible chest rising and falling. Breathing is present but weak.
  4. 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?

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

Unstable Bradycardia Algorithm

Identify and Treat the Underlying Cause

  1. Maintain patent airway, assist with breathing if necessary – Airway is patent and breathing is spontaneous
  2. Oxygen (if hypoxemic) – person is on 4LNC upon Primary Assessment
  3. Cardiac monitor, blood pressure, oximetry – Third Degree Heart Block, BP 80/68, 98% on 4LNC
  4. IV Access – 20 gauge in the right antecubital
  5. 12-Lead ECG if available and doesn’t delay therapy – Not readily available
  6. 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? – Wife states the man experienced chest pain prior to becoming unresponsive – YES
  • 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
 
 

You will begin the transfer to the nearest hospital. Your scenario has concluded.

]]> Out-Of-Hospital ACLS Unstable Tachycardia Megacode: The Most Effective Strategies https://nursecheung.com/aclsmegacode-ooh-unstabletachycardia/ Sat, 07 Jan 2023 17:14:22 +0000 https://nursecheung.com/out-of-hospital-acls-unstable-tachycardia-megacode-the-most-effective-strategies/

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 Out-Of-Hospital Unstable Tachycardia Megacode Scenario

The following is a scenario in which you would use the out-of-hospital adult unstable tachycardia megacode:

You are working on an advanced life support ambulance and are dispatched to a person who doesn’t feel right.

Demonstrate what you would do next upon arrival

Initial Impression

The person is a 58-year-old female lying down in the front doorway of her home. She is anxious, pale, and dizzy.

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

Airway: The airway is patent but is experiencing mild respiratory distress. The flow through the trachea is not impaired.

Breathing: Oxygenation is showing 92% on room air. You provide oxygen 2LNC.

Circulation: Blood pressure is 92/60, heart rate is not being captured on the monitor, the rhythm check shows monomorphic wide complex ventricular 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. The woman’s son states he helped her to the doorway to get some cold air. He denies any falls or injuries.

What are your next actions?

  1. Check responsiveness: Tap the shoulders and shout, “Are you okay?” The woman responds but is weak.
  2. Activate the emergency response system. You direct the second rescuer to activate the emergency response system and get an AED.
  3. Check for breathing: Look for visible chest rising and falling. Breathing is rapid and present.
  4. 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

  1. Maintain patent airway, assist with breathing if necessary – Airway is patent and breathing is spontaneous
  2. Oxygen (if hypoxemic) – The woman is on 2LNC upon Primary Assessment
  3. Cardiac monitor, blood pressure, oximetry – monomorphic wide complex ventricular tachycardia, BP 92/60, 96% on 2LNC
  4. IV Access – 20 gauge in the right antecubital
  5. 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, woman states chest discomfort
  • 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?

  • Synchornized Cardioversion – Consider sedation
 

If synchronized cardioversion is not effective or contraindicated:

  • Amiodarone IV Drip: 1-4 mg/min
  • Procainamide 20-50 mg/min until the arrhythmia is suppressed, hypotension ensues, QRS duration increases. There is a maintenance infusion dose.
  • Sotalol 100 mg (1.5 mg/kg) over 5 minutes. Avoid if QT is prolonged.
 

Outcomes

Two attempts at synchronized cardioversion were performed unsuccessfully. No change in rhythm was noted.

Amiodarone infusion started. After 5 minutes, another attempt at synchronized cardioversion was attempted and successful.

Rhythm is now normal sinus rhythm at 80 bpm.

 

You will begin the transfer to the nearest hospital. Your scenario has concluded.

]]> Out-Of-Hospital ACLS Cardiac Arrest Megacode: The Most Effective Strategies https://nursecheung.com/aclemegacode-ooh-cardiacarrest/ Sat, 07 Jan 2023 17:14:16 +0000 https://nursecheung.com/out-of-hospital-acls-cardiac-arrest-megacode-the-most-effective-strategies/

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 complex ACLS algorithms providers will encounter is cardiac arrest. We will cover both shockable and unshockable rhythms.

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

Adult Out-Of-Hospital Cardiac Arrest Megacode Scenario

The following is a scenario in which you would use the out-of-hospital adult cardiac arrest megacode:

You are working as a paramedic responding to an altered mental status call. Upon arrival, you hear a person screaming loudly attempting to wake up a middle-aged man.

Demonstrate what you would do next upon arrival

Initial Impression

The person is a 60-year-old male lying down on the floor in the living room of their home. He is agonal breathing and not responsive.

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

Airway: The airway is patent but agonal breathing 3 breaths per minute is noted upon assessment. The flow through the trachea is not impaired.

Breathing: Oxygenation is showing 60% on room air. You provide oxygen via a bag valve mask.

Circulation: Blood pressure is 60/40, heart rate is not being captured on the monitor, the rhythm check is not being captured on the monitor, and the pulse is present but very weak.

Disability: The man is responsive to painful stimuli only.

Exposure: No obvious signs of trauma, bleeding, burns, markings, or medical alert bracelet. The man’s wife states he had been burping more than normal and was complaining of indigestion.

What are your next actions?

  1. Check responsiveness: Tap the shoulders and shout, “Are you okay?” The man does not respond.
  2. Activate the emergency response system. You direct the second rescuer to activate the emergency response system and get an AED.
  3. Check for breathing: Look for visible chest rising and falling. Breathing is no longer spontaneous.
  4. 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 no longer present.
 

What are your next actions?

Pulse and breathing are no longer present so we will begin CPR starting with compressions.

Cardiac Arrest Algorithm

Adult Compressions

Perform High-Quality Compressions

  • Hands should be placed on the lower half of the sternum
  • 30 compressions at a rate of 100 to 120 compressions per minute
  • Compresses at least 2 inches (5 cm)
  • Complete chest recoil after each compression
 

Adult Rescue Breaths

Give 2 breaths with a barrier device

  • Each breath should be given over 1 second
  • Visible chest rise and fall with each breath
  • resume compressions in less than 10 seconds
 

You will need to perform one to two rounds of high-quality CPR.

Automated External Defibrillator (AED)

  1. Turn on the AED and follow the prompts
  2. Correctly attached pads and plug-in connector. Remove any barriers including medication patches, water, or clothing.
  3. Clear for AED analysis. Stop chest compressions. Call out “stand clear.”
  4. Push the analyze button and allow time for analysis.
  5. Deliver shock if recommended by AED.
 

The AED does not advise a shock. This means the man is either in asystole or pulseless electrical activity.

What are your next steps?

Resume CPR immediately!

Interventions

What interventions could you perform next?

  • IV/IO Access
  • Epinephrine 1 mg every 3 to 5 minutes.
  • Placement of advanced airway
 

H's and T's

It is important to consider your H’s and T’s for these rhythms and treat accordingly.

H’s and T’s are mnemonics for the major causes of arrest:

  • Hypovolemia
  • Hypoxia
  • Hydrogen ions (acidosis)
  • Hyperkalemia or hypokalemia
  • Hypothermia
  • Tamponade (cardiac, tension)
  • Toxins
  • Tension pneumothorax
  • Thrombosis (coronary, pulmonary) – may most likely be the cause
 

Outcomes

Two attempts at delivering a shock were not advised. The man received 3 doses of epinephrine. Upon the third attempt, a deliverable shock was advised.

The team continued high-quality chest compressions and ROSC was achieved.

 

You will begin the transfer to the nearest hospital. Your scenario has concluded.

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