CASE STUDY 1-1
While walking through a visitor waiting area you observe a middle-aged male slumped over, blue and apparently not breathing. You pick up the nearby house phone and call a “Code Blue” and immediately go to the victim, carefully sliding him onto the floor while protecting his c-spine. There is no response to your actions. You begin quality CPR by placing your hands between the victim’s nipples and compress at a depth of at least 2 inches; not to exceed 2.4 inches, using a rate of at least 100 compressions per minute. (push hard and fast; be sure there is full chest recoil; avoid over-ventilation.) The first arriving responder has a bag-valve-mask device and immediately begins administering 2 ventilations after each set of 30 compressions.
Shortly thereafter, the arrest team arrives and defibrillator patches are placed on the patient’s chest and the monitor shows ventricular fibrillation. While charging the defibrillator, a cuffed endotracheal tube is inserted without causing significant interruption to ongoing CPR.
After announcing your intention to deliver a shock, you scan to make sure all team members no longer have contact with the patient. You deliver a bi-phasic shock. (If the defibrillator was an older non-biphasic model, the energy would be set for 360 joules.) After delivery of the shock, the ECG screen shows continued ventricular fibrillation. Pulse check reports continue to be negative. Quality CPR continues and IV access is established without significant interruption to the ongoing CPR. 10 ml of 1:10,000 (1 mg) of epinephrine is administered IV followed by a 10 ml bolus of IV fluid and circulated for 3 minutes. A second biphasic shock is administered resulting in a tachy sinus rhythm. A pulse is palpated.
The patient is transported to the emergency department for stabilization and further care. You later learn that he was taken to the cardiac cath lab and received angioplasty and a stent. His condition is reportedly good.
CASE STUDY 1-2
A 47- year-old, 100 kg male has been transported by EMS to your department with signs and symptoms suggestive of cardiac ischemia. Low flow oxygen, IV and ECG monitoring have been established. The patient suddenly grabs his chest; his eyes roll back and he arrests. His ECG shows:
Defibrillation paddles are placed properly on the patient’s chest after applying conductive gel. An initial biphasic shock of 200 joules is administered after announcing the shock and visually scanning to assure no one is in contact with the patient. Upon delivery of the shock, the patient takes a sudden deep breath, and you observe the following change on the ECG monitor:
As the patient’s color begins to improve, he suddenly collapses again. This is what is observed on the ECG monitor:
The patient is shocked again using the same biphasic 200 joules with the following result:
Lidocaine 100 mg is administered by bolus and a 4 mg/min continuous infusion is initiated. The patient is transported immediately to the cardiac cath lab for angiography and likely percutaneous coronary intervention.