Sim Lab 1 - VTach Arrest to PEA arrest to ROSC

Patient with PMH unknown to you is found unresponsive on a medical floor in the hospital.

  1. check pulse and responsiveness simultaneously.
  2. pulse is absent: begin chest compressions and simultaneously place defibrillation pads and turn on the monitor
  3. once connected, pause compressions for a rhythm and pulse check
  4. VTach is seen on the monitor: begin charging monitor to 120J, 150J, or 200J (depending on body habitus of patient and team leader's judgement), resume compressions while charging.
  5. Once charged, pause compressions deliver shock and then immediately resume chest compressions. Timekeeper should begin a 2 minute countdown
  6. draw up 1 mg 1:10,000 epinephrine and have it ready to infuse at the 2 minute mark
  7. At the 2 minute mark pause compressions for a rhythm and pulse check. PEA was seen on the monitor. Resume chest compressions, push epi. Start the second 2 minute countdown.
  8. Team leader should be considering H's and T's to determine why pt. is in PEA.
  9. Person on airway claims the patient is difficult to bag, this is highly suspicious for a pneumothorax. Have person give 4 quick breaths and listen to the apex and bases bilaterally. Breath sounds were absent on the right.
  10. Perform finger thoracostomy at 5th ICS. (evidence supports going straight to finger thoracostomy over needle decompression, due to high failure rate of needle decompression to relieve pneumothorax).
  11. Resume compressions until the 2 minute mark.
  12. At 2 minutes pause compressions for a pulse and rhythm check.
  13. Monitor shows NSR, begin ROSC care:
    1. assess mental status and obtain vital signs.
    2. patient is found to be unresponsive and had the following VS: HR 102, BP 60/10, RR 0, 100%
    3. patient is hypotensive and altered post-rosc, start 2L NSS wide open and begin hypothermia protocol. Continue ventillations via BVM, do not intubate until patient has SBP >90 or a MAP >65
    4. NSS improves BP to 96/58 after ~10 minutes. Perform endotracheal intubation.
    5. Obtain CXR to confirm tube placement. Place NG or OG tube. Start anti-arrhythmic drip due to fact that patient was initially in VT. Obtain 12-lead ECG, POC glucose, draw CBC, CMP, ABG, VBG, troponin. Consider starting sedation drip if patient's mental status begins to increase.
    6. Consult cardiology/ICU.
  14. High five your team members and go back to work.