Arctickat Posted September 13, 2013 Share Posted September 13, 2013 So, you're dispatched to intercept a BLS ambulance service enroute with a patient having chest pain. 1 minute into your response you're told the patient is in cardiac arrest and CPR is in progress. 14 minutes later you intercept the BLS ambulance and get into the back with the EMT, ECG is hooked up, OPA is in place and the EMT is doing 1 person CPR with the BVM.... Link to comment Share on other sites More sharing options...
paramedicmike Posted September 13, 2013 Share Posted September 13, 2013 So essentially the patient hasn't been getting any effective CPR for 14 minutes. Stop the ambulance to allow for effective compressions to start. Switch out the person doing compressions as the guy who was in the back is more than likely exhausted from attempting to compress in a moving ambulance. What's the HPI for the patient? What interventions aside from what's been stated has been done? Is it an AED/monitor? Shocks delivered? What does the EKG show? Get a line started and wait for answers to the above. Glad you're back, Kat. Link to comment Share on other sites More sharing options...
Just Plain Ruff Posted September 13, 2013 Share Posted September 13, 2013 14 minutes of less than effective CPR means a less than effective outcome. But let's get the ball or code rolling. Link to comment Share on other sites More sharing options...
DartmouthDave Posted September 13, 2013 Share Posted September 13, 2013 Hello, As noted above. I would get a report and assess the patient. Cheers Link to comment Share on other sites More sharing options...
Arctickat Posted September 13, 2013 Author Share Posted September 13, 2013 Patient was working in a field and started having chest pain, he called 911 and during the call the 911 operator lost contact with him for about 2 minutes. The BLS crew were given incorrect directions and the BLS response ended up being 25 min. He was Alert and Orientated when BLS arrived and began transport. During transport he had a seizure which preceded the cardiac arrest. He has a history of 4 previous heart attacks and his wife says he has been planning to see the doctor about an infection in his foot. There is only room for you and the EMT in the ambulance and their cot won't fit in your unit. There is an AED in the ambulance with the 3 lead electrodes applied, but no therapy electrodes.The defib is a brand you're unfamiliar with, but it clearly shows VFib. Thanks Mike. I was never really away. Link to comment Share on other sites More sharing options...
paramedicmike Posted September 13, 2013 Share Posted September 13, 2013 We're hanging out for a few minutes at least. Grab my stuff from my vehicle (Ambulance? Chase car?) so I have stuff I'm familiar with. Let's get some solid CPR going for at least a couple of minutes. Secure the line. Give the first round of drugs and some fluid. Get the monitor hooked up with pads applied. Might as well expose the patient completely since we're in the ambulance. The foot infection may be a red herring but it might be worth looking at since he could be septic as a cause of his arrest. Still VF after a few minutes of CPR? Clear! Link to comment Share on other sites More sharing options...
Arctickat Posted September 13, 2013 Author Share Posted September 13, 2013 (edited) Would you take the time to switch the monitor over to yours or would you relieve the exhausted EMT and do CPR while he locates and places the pads for defib? The monitor also has the BP cuff and SpO2 connected. Edited September 13, 2013 by Arctickat Link to comment Share on other sites More sharing options...
triemal04 Posted September 14, 2013 Share Posted September 14, 2013 What is the setting where the 2 units are stopped? Is it in a turnout or other area where there is room to SAFELY operate outside the vehicles? (preferably shielded by the 2 rigs) If so, remove the patient and work the arrest outside. This will allow all 4 set's of hands (or at least 3 if you keep 1 person as a spotter for oncoming traffic) to work the resuscitation. If not and you have a larger ambulance, transfer the patient to your gurney and move to your rig for the same reasons. If that is the case, shock the patient (with your monitor to minimize hands off time) then take over compressions while your gurney is prepped. Switch rigs as quickly as possible, and then start a full resuscitation; IV access with a 500ml bolus to start, intubation (without interrupting compressions) followed by waveform capnography, epinephrine, the antiarrhythmic of your choice, and more CPR. Basically, start a standard CPR. The seizure was most likely a vf seizure, but not neccasarily. Take a look at the foot and the rest of the body for any discoloration or abnormalities. He was working in the field, so...what's the ambient temp like? How long had he been working? Known meds? Allergies? (both environmental and to meds) Lung sounds? That'll do for a start. If you truly can't move the patient and really can only fit 2 people in the back then you're pretty much screwed if the patient stays in cardiac arrest. Defibrillate the patient, trade out the first EMT for the driver and secure the airway ASAP. If it's really that cramped intubation may not be possible, so use a SGA if you have to. (having some type of advanced airway in place will make it much easier to ventilate the patient in a cramped setting and if someone can reach through from the front to work the BVM it'll be so much better) You'll have to manage the BVM in between starting a line (go for the EJ), switching monitors, pushing meds, etc etc. Not the best situation, but not the end of the world. Swap the person on compression every 2 minutes and go with what was done in the second paragraph. Link to comment Share on other sites More sharing options...
Arctickat Posted September 14, 2013 Author Share Posted September 14, 2013 (edited) Okay, I misspoke, there is room for 1 more to get in and operate the BVM at the head. The Defib pads are placed and the first shock delivered. Pt converts to a 10 bmp Sinus brady on the monitor with no detectable pulse. Edited September 14, 2013 by Arctickat Link to comment Share on other sites More sharing options...
chbare Posted September 14, 2013 Share Posted September 14, 2013 Switch out and do two minutes of solid chest compressions then reassess. I can worry about monitor switching later. Link to comment Share on other sites More sharing options...
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