Resuscitation Rumble
Give tHree poTential reversable causes of cardiac arrest.
Reversible Causes: H’s & T’s
H’s:
Hypovolemia
Hypoxia
Hydrogen ion (acidosis)
Hypo-/hyperkalemia
Hypothermia
T’s:
Tension Pneumothorax
Tamponade, cardiac
Toxins
Thrombosis, pulmonary
Thrombosis, coronary
What to do if ACT is too high to remove:
1. venous sheath
2. arterial sheath
1. venous- may start 10cc/hour TKO line to maintain patency
2. arterial- attach arterial pressure tubing to maintain patency
* always start be verifying the patency of the line by aspirating 5-10cc of blood from the sheath sidearm before hooking up NEW tubing
When connecting the NG tube to suction, is suction continuous or intermittent?
intermittent
Your patient had an unwitnessed fall in the bathroom.
- how often should you perform vital signs?
- how long do you perform neuro checks post fall?
- obtain vital signs every 15 minutes for 1 hour, then every hour for 3 hours
- obtain neuro checks for 5 hours post fall
*neuro checks should include LOC, orientation level, cognition, speech, neglect, pupil assessment, motor function/sensation, neuro symptoms
What is next for this patient? What are you concerned about?
- EKG shows concern for STEMI. Patient should go to cath lab!
- CO2 elevated on VBG. consider starting patient on bipap
CPR Ratios & Quality- Compression to breath:
Without an airway
With airway
Compression depth
Compression frequency (bpm)
Compression to breath ratio:
No airway- 30:2
Advanced Airway- 1 breath Q 6 seconds with cont. chest compressions
Depth:
3. At least 2 inches
BPM:
4. 100-120/min
Apply firm 3 finger pressure above and medial to the puncture site where the sheath enters the skin
How often should gastric volume residuals be checked with an enteral NG/OG?
follow the policy! Q4 hours or before intermittent feedings
Mrs.Amiodarone is a 75 y.o female. She was admitted to CSD for treatment of a PE and is on a heparin drip. PMH includes hypertension and hemodialysis M/W/F. Vitals have been stable, she is A&O x2. She has been on oxygen overnight. She is independent at home and wears glasses.
- what are her biggest risks for injury?
- what are her biggest risks for fall?
- risks for injury: anticoagulant use, poor bone health due to dialysis and post-menopausal female
- risks for fall: IV-line, oxygen, cognition
Mr.J was stented in cath lab and weaned to 3L NC. He is appropriate to be recovered in CSD. What are some things that should be done upon admission?
- follow-up EKG
- BMP&Mag/CBC/consider a f/u troponin
- initial assessment
- site checks
- admission charting
Your patient’s monitor is alarming with this rhythm. You enter patient room and confirm unresponsive without pulse.
As first responder, next step?
What is another time-sensitive intervention to expect?
Call Code/Begin CPR
Bring stat stand to bedside, place/connect pads, & perform defibrillation
Name 4 complications after sheath removal
-Bleeding or hematoma: if noted, hold pressure for the entire prescribed time determined by the french size of the sheath. If new hematoma forms, apply direct occlusive pressure 3 fingers over site for min. 10 min and page interventional fellow.
- Retroperitoneal (RP) bleed: signs include flank tenderness/discoloration, tachycardia, hypotension. if you suspect this, page the team, draw a cbc/type&screen and have fluids ready if necessary.
- Sheath fractured during removal: stay with patient and monitor for signs of embolus. page MD and prepare pt to go to IR for extraction.
- Vagal response with bradycardia and hypotension: prepare to administer 0.5mg of atropine. consider calling RRT if not resolved. hook up patient to crash cart and pads.
What is the max amount of saline that can be used to inflate a rectal tube balloon? Does every rectal tube require this amount?
Max amount could be 45mL and amount can be different with each rectal tube.
Inflate balloon with NO MORE THAN 45mL of saline
The ‘signal’ indicator will pop when balloon space is sufficiently filled with saline
Your patient that is BMAT level 3 wants to ambulate to the bathroom. List some ways you should prepare the patient's room environment for safe ambulation.
- bed lowered to appropriate height and breaks locked
- clear pathways (tripping hazards, barriers)
- recliner/chair/bed/commode in optiminal position/location and breaks locked
- move lines to side of bed that patient will mobilize towards
- appropriate assistance device in close proximity
- confirm gait belt is in room/utilize when ambulating
- bed/chair alarm
The cath lab used Mr.J's Right femoral artery for access. They removed the arterial sheath prior to transferring to CSD. During your site check you palpate a small mass under the skin and new bruising. What are your next steps?
Apply direct occlusive pressure using 2-3 fingers over the site for a minimum of 10 minutes and page the interventional fellow.
Name:
2 shockable rhythms
2 non-shockable rhythms
Shockable:
VF
pVT
Non-shockable:
Asystole
PEA
How to determine length of manual pressure hold following:
1. venous sheath removal
2. arterial sheath removal
1. venous- 2x the venous french size
2. arterial- 3x the french size. first 1/3 of time should be occlusive pressure in which the second nurse cannot palpate pulses. if no bleeding occurs, the RN holding pressure will slowly ease up pressure during last 2/3 of the time.
T or F: A rectal tube requires a physician order
How do you properly position a patient's rectal tube during a turn?
T = Yes, a rectal tube requires a physician order
Examples of other devices that require a provider order:
Bair hugger
Chest tube
Hyper/hypothermia blanket (cooling blanket)
Mr.Apple was admitted to CSD overnight and has not yet gotten out of bed. He would now like to ambulate to the bathroom. He states that he walks "just fine" at home. You perform a BMAT 2.0 assessment and note the following: he is able to sit upright unsupported and point toes x3. He is then able to his shift weight forward but was not able to fully rise and stand upright.
What BMAT 2.0 level is Mr.Apple? What equipment should be used?
BMAT level 3!
Mr.apple passed level 2 but was unable to stand upright to pass level 3.
equipment: Gait belt and sit to stand/assistive device
An hour has gone by, and you notice that Mr.J’s O2 sat on the monitor is 87% with 3 ***. He is currently on 3L NC.
You head into the room to assess him and notice he is slumped over and appears to be sleeping. When you attempt to wake up Mr.J, he is arousable but he appears newly lethargic and is in/out of sleep. He is now satting 85%. What is your first action?
- Increase O2 L
- page the providers
- continue to assess neuro/LOC
- consider drawing a VBG to assess CO2 levels
You vented patient’s monitor is beeping with this rhythm.
You enter patient room and confirm unresponsive without pulse. As first responder, next step?
Which drug/dose do you expect to be administered? & how often?
Call Code/Begin CPR
Epi 1mg Q 3-5 min
Management of non-shockable rhythms focuses on:
High quality CPR c pulse checks Q2min
Administering IV Epi 1mg Q 3-5 min
Addressing reversible causes
You are performing admission charting for your post-TAVR patient when they suddenly stop responding to you. What are your next steps?
1. check for a pulse (how long?)
2. begin CPR/ACLS protocol and call a code
BONUS! Correctly attach the defibrillator leads and pads to the patient, assess the rhythm and charge to 200J if indicated.
You are caring for a post TAVR patient who has completed bedrest and would now like to get up. You complete a BMAT 2.0 and as you are walking to the bathroom with the patient they begin to slur their words and you see that their mouth is now drooping to one side. What is happening? What are your next steps?
The patient is likely having a stroke. Yell for help, guide the patient to safe place to sit or get back to bed and call a stroke code.
TAVR patients are at risk for stroke following the procedure! Be diligent when performing neuro checks.
After increasing Mr.J’s nasal cannula to 6L, he is satting 88% and has increased work of breathing. The CO2 on the VBG you sent is 63. He also has only urinated 50cc since giving a bumex push 3 hours ago. What are your concerns? What is your next step?
- maxxed on NC, still below O2 goal
- elevated CO2
- lack of urine output
*call RRT to initiate bipap and initiate ICU transfer as patients cannot be initiated on bipap in CSD.