Phase 1
Patient supine on bunk, eyes closed, no response to verbal stimuli
How does nursing establish control of medical care?
•Team Lead identifies self •delegates Airway/Med/Communicator/Documenter •announces ABC approach •requests crash bag/BVM/O₂/suction and monitor
RR 2–4 shallow; weak thready pulse; cool, pale skin, delayed cap refill
How are oxygen interventions being delivered?
•Begin with BVM ventilation with 100% O₂ (15 L/min) due to inadequate breaths •ensure tight mask seal •visible chest rise •suction as needed
RR 2–3; SpO₂ 72–80% RA; unresponsive; poor chest rise
What oxygen type is given?
BVM with reservoir at 15 L/min (100% O₂). NRB is not sufficient when respirations are inadequate.
What is Phase 4?
Reassessment & Medication Decisions
RR 10–12; improved chest rise; SpO₂ 92–94% with O₂
EMS arrives — What information must be communicated during handoff?
•Initial findings •timeline •vitals trends •interventions •medications/doses/times •response to therapy •suspected cause •current status •safety concerns •custody considerations
Patient supine on bunk, eyes closed, no response to verbal stimuli
What is your immediate assessment?
•Check responsiveness •airway patency •breathing (look–listen–feel) •carotid pulse •SpO₂ •quick skin check •obtain vitals and attach monitor.
RR 2–4 shallow; weak thready pulse; cool, pale skin, delayed cap refill
What are you concerned about?
•Impending respiratory arrest and severe hypoxia •risk of hypoxic brain injury •need for immediate ventilatory support
RR 2–3; SpO₂ 72–80% RA; unresponsive; poor chest rise.
What is the protocol related to medication given?
•Administer Narcan per standing orders x3 •reassess RR/mental status every 2–3 minutes •repeat dosing if indicated •maintain airway support regardless of medication until spontaneous ventilation is adequate
Respirations slightly improve; patient drowsy/minimally responsive; intermittent hypoventilation with head position changes.
What may happen again to the patient even with administered medication?
•Re-sedation/recurrence of respiratory depression (short-acting reversal vs long-acting depressant)
•airway obstruction with positional changes
•hypoxia recurrence
RR 10–12; improved chest rise; SpO₂ 92–94% with O₂
What documentation is required after transfer of care?
•Complete assessment •critical values •times of interventions •medication details •response notifications •SBAR provided •chain-of-custody •transport details.
Patient supine on bunk, eyes closed, no response to verbal stimuli
What must occur before medical care begins?
•Scene safety confirmed with custody •PPE on •secure space •remove hazards •assign roles •bring emergency equipment to bedside
Code Response Roles?
RR 2–3; SpO₂ 72–80% RA; unresponsive; poor chest rise
What interventions are initiated rapidly?
•start BVM with 100% O₂ •airway positioning (jaw thrust) •suction •attach monitor/SpO₂ •obtain IV/IO access •check blood glucose •prepare advanced airway support
Respirations slightly improve; patient drowsy/minimally responsive; intermittent hypoventilation with head position changes
What focused assessment guides further medication administration and what repeat medications are given if any?
•Reassess cause: medication history (opioids/benzos), glucose trend, tox exposure. •If signs of recurrent opioid toxicity—repeat naloxone per protocol if more needed obtain provider order. •If BG remains low—repeat dextrose. •Continue ventilatory support
RR 10–12; improved chest rise; SpO₂ 92–94% with O₂
What are your next required actions for the patient?
•Continue oxygen/ventilation as needed •maintain monitoring •secure IV •prepare for transport to higher level of care •ongoing neuro checks •repeat vitals •ensure airway equipment accompanies transport.
Patient supine on bunk, eyes closed, no response to verbal stimuli.
What are your priorities?
•Airway and breathing support first; •activate Rapid Response/EMS as indicated; •oxygenation/ventilation; •check blood glucose; •prepare for possible reversal meds per protocol •continuous monitoring.
RR 2–4 shallow; weak thready pulse; cool, pale skin, delayed cap refill
What condition is most likely?
•Acute respiratory failure with depressed level of consciousness; •differential includes CNS depression/overdose, •postictal state, •metabolic causes—treat airway first while investigating
RR 2–3; SpO₂ 72–80% RA; unresponsive; poor chest rise
What medication is indicated?
Dependent on findings: if suspected opioid toxicity with respiratory depression and pulse present, naloxone per protocol while continuing ventilation. If hypoglycemia, give IV dextrose. Do not delay ventilation for meds
Respirations slightly improve; patient drowsy/minimally responsive; intermittent hypoventilation with head position changes
What reassessments are required?
•Repeat ABCs •RR/quality •SpO₂ •mental status (GCS) •airway patency with position •lung sounds •vitals •blood glucose
RR 10–12; improved chest rise; SpO₂ 92–94% with O₂
SBAR?
S: Unresponsive patient with respiratory failure; ventilated with BVM; now RR 10–12, SpO₂ 93% on O₂.
B: Found supine, unresponsive at 1430; initial RR 2–3, SpO₂ 75%; pulse present; received [reversal/oxygen/ventilation].
A: Improving respirations; still drowsy; vitals trending up; airway still at risk.
R: Transport to ED; continue monitoring and airway support; consider advanced airway; repeat reassessments en route.