03.03 Cardiopulmonary Arrest

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Hello everyone and welcome to our lesson on cardiopulmonary arrest in the emergency department. This is going to be a short lesson as i am sure you all know how to do CPR by now. We just wanted to go over what happens in the ED setting.

Things are a little different in the ED. The fact is, we never work alone. We know the members of our team, and we all know what our job is. When we all do it right, good things can happen for our patients. 

The basics are still the basics. We love our algorithms in the ED. They lay out exactly how to treat our patients. For these patients, remember your BLS and ACLS. The basics still apply, even in the ED. 

There are 4 rhythms that can cause cardiac arrest, hopefully you know them already, but just in case, they are: V-fib, V-Tach, PEA, and asystole. When it comes to defibrillation, we can hit the v-tach or v-fib, but nothing is going to happen if we try that on PEA of asystole. You can't shock a heart that has no electricity in it. We can, however, do compressions on all of these situations, and you absolutely should!

One of the most important things in the ED is to know who you are working with, In a true code situation, the best team members go exactly where they are needed, know what each person's job is as well as their own, and sometimes, doesn't even have to talk because each member can anticipate what the next move is and execute it without hesitation. That is a strong ED team. Hopefully during your career you will have the opportunity to be a member of a team like that and you will know just what im talking about. 

So the assessment here you guys know. First determine if the patient is truly unresponsive. And trust me, start doing chest compressions on someone who is still responsive, and they will let you know how much they dont like that.

We want to check for breathing, and you know, we look listen and feel. Check that chest rise and fall, listen for the breath and get close so you can feel it.

We then want to make sure they have a pulse… or not. Do not check a radial pulse and start coding someone. You need to assess the carotid of femoral pulse, one of the central pulses. If that missing, start compressions.

We also want to get them on the monitor ASAP. Its the only way to truly determine what rhythm we are dealing with and if we can deliver a shock. Please don't forget that step. 

So first things first. No breathing, no pulse, we start compressions. As we are doing that, someone will secure the airway, usually with rapid sequence intubation (and don't worry there is another lesson here on NRSNG all about RSI). Once the airway is secure, we have to breathe for them,. That can be with an ambu bag or by placing the patient on the ventilator. We then need IV access. Get 2 large bore peripheral lines, an intraosseous line, or a central line. Nurse everywhere can get the peripheral line. IOs are a little more restricted so check with your facility. It is a recognized skill by the emergency nurses association but many facilities are not yet letting ED nurses do it. An usually the doc will try to insert a central line. If its a teaching hospital, this will probably be the first year guy..

If the rhythm is right, we want to defibrillate. And during all of this, once access is obtained, we are pushing our medication. Many of it is timed and follows the algorhythms. It is very important during all this that there is a recorder, someone writing down everything being done and keeping time for everything. 

A big factor during cardiopulmonary arrest is trying to figure out why the heart is in a fatal dysrhythmia and how we can correct it. A very common mnemonic we use is the H’s and T’s These are all things we try to address and correct if we can.

The H’s, hypoxia, well we should be breathing for them. Hypovolemia, give em fluids. Acidosis, correct the pH, maybe some sodium bicarb. Hypothermia, warm them up, and hypo or hyperkalemia, well treat whichever one they have. 

And the T’s - Toxins...this can be poison or recreational drug overdose. Remember, narcan is your friend, and kind of a miracle drug. Tamponade, is the heart being crushed, get your doc that pericardiocentesis needle and watch them work. Tension pneumo, needle decompression (again a nursing skill) or a chest tube (not a nursing skill). And thrombosis. If we thing a clot is causing all the trouble we might use fibrinolytic, but that's usually the last resort in a code like this.

We have to know our rhythms and what we can defibrillate. Perfusion is key, get on those chest compressions and do not stop unless the doc says so, or your doing a pulse check. It also would help if you know your ACLS pharmacology. Know the drugs and be able to anticipate what the next medication will be. 

A few key points. We have to recognize our rhythms. There is a big difference between PEA and sinus an we need to know it. Always start compressions when there is no pulse, it's the best thing to keep that blood flowing and getting oxygen to the brain. Remember your steps and follow your algorithms. Know your drugs and when they need to be used. And know your role, Are you the med nurse, the access nurse, the recorder. It helps not only to know your role, but the role of your teammates. 

Thanks for joining us for this quick lesson, be sure to check out all of our emergency medicine lectures and as always, HAPPY NURSING!!!

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