Case Study“Physician to the Resuscitation Bay Stat!” Upon arriving to the bay, you find EMS performing CPR on a patient. EMS gives the report that they were called out for a 69-year-old female complaining of general illness and dizziness. When they arrived, the patient was in no distress and was stable en route. Just prior to pulling into the ED, she became unresponsive, pulseless, and apneic. Show
Objectives:Upon completion of this self-study module, you should be able to:
IntroductionEmergency Medicine physicians must be adept at dealing with life threatening emergencies. Cardiac arrest claims over 350,000 lives a year and the majority of these events occur outside the hospital. Early initiation of cardiopulmonary resuscitation (CPR) and advanced cardiopulmonary life support (ACLS) has been shown to improve the mortality following cardiac arrest. As you walk into the resuscitation bay, what initial steps should be taken to evaluate and manage this cardiac arrest victim?
BLS Primary SurveyThis basic approach to life support stresses early CPR and early defibrillation. The goal is to support or restore effective oxygenation, ventilation, and circulation until return of spontaneous circulation or until ACLS interventions can be initiated. These actions have been shown to significantly improve the chance of survival and neurologic outcome. As each step is assessed the appropriate critical action should be performed before proceeding to the next assessment step. Remember assess, then perform the appropriate action. The BLS approach to cardiac arrest can be best remembered by using the acronym ABCD: Airway, Breathing, Circulation, and Defibrillation. Infants and children generally go into cardiac arrest due primarily to airway issues. Adults go into cardiac arrest typically due to cardiac issues, therefore BLS in adults recommends checking for circulation and potential for defibrillation prior to evaluating the airway and breathing.
Regardless of the technique employed, adequacy of ventilation can be assessed by inspecting the chest for equal rise and fall and auscultating the chest for adequate aeration. Epigastric sounds and abdominal distention suggest gastric insufflations and poor ventilation. ACLS Secondary SurveyThe ACLS secondary survey involves more advanced, invasive techniques. It is critical to consider the differential diagnoses to appropriately identify and treat the underlying cause of cardiac arrest.
Differential Diagnosis for Cardiac ArrestConsider, identify, and treat potential reversible causes, commonly referred to as the “H’s and T’s”:
While there are recommendations to use the above pneumonic of recalling the H’s and T’s, there are alternative methods to approach the differential diagnosis of a patient in cardiac arrest. One example is to use the rhythm strip to determine if the QRS complex is wide or narrow.
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