65 year old male, cardiac arrest at home, ambulance team achieved ROSC
His main diagnosis was an inferior stemi complicated by a few issues:
Simulation report 3/8/23
In situ sim ED JHC
Hi everyone,
Thank you so much for participating and helping in todays sim. I hope we all enjoyed the scenario.
In order to share our learning goals I have formulated a sim report.
Our case:
65 year old male, cardiac arrest at home, ambulance team achieved ROSC
His main diagnosis was an inferior stemi complicated by a few issues:
Airway and breathing issues:
- LMA in situ by ambulance crew, however still fairly low sats despite max o2 treatment
- Vomit in mouth, unprotected airway
- Crackles in chest, component of APO and/or aspiration
Circulation:
- Remains profoundly hypotensive and bradycardia
- Echo shows no valvulopathy or tamponade, mainly myocardial stunning
- Complete HB as a rhythm
The patient was stabilized by them team, intubated and transferred to the Cath lab
Learning goals:
- ETT placement in highly unstable patient
do not delay Intubation, prolonged hypoxemia increases lactic acidosis and decreases cardiac and peripheral perfusion
finding the right balance between BABC and ABC is the challenge in these unstable patients (see below)
- Before ETT placement is safe, treatment of shock is required with adrenaline increments/ infusion and Pacing (transdermal and transvenous).
There is fine time line to balance between right blood pressure and right time for ett placement. Team work required to keep eye on time, be aware whilst you are stabilizing the patient that he/she remains hypoxic.
- Choosing the right drugs for the rsi. Will the patient tolerate a cold intubation or require drugs?
If drugs are required small dose of Ketamine (max 0.5mg/kg) are recommended as deemed safest. Remember a highly unstable patient can deteriorate with any induction drug so be prepared.
https://litfl.com/intubation-hypotension-and-shock/
- A resuscitation is a dynamic event. If the patient initially seems to require drugs for an rsi by the time you choose to perform it the drugs might not be required. Always and constantly reassess.
- Finally, where does the patient receive reperfusion therapy?
Thrombolysis versus PCI unstable patients should receive PCI as first goal if available within 90 min post first medical contact
(even if thrombolysed patient often referred for rescue PCI)
Options in Joondalup are Cath lab SCGH and Cath lab JHC
The decision will be made by the Cardiology consultant, so for any unstable stemi ring the on call Cardiologist for JHC don’t only activate code stemi.
Cardiac Chest Pain Assessment and Management (C104.013)
Thank you again and please feel free to contact me under pelletieri@ramsayhealth.com.au if you have any other ideas or questions.
See you again for the next in situ sim,
Irene Pelletier
(FACEM)