Float Nurse

Ah, Bravo! Bull! The crowd roars! The bull goes, he comes, He comes and strikes again! Shaking his dart-stabbed neck, Full of fury, he runs! The arena is full of blood! They save themselves, they pass the gates It is your turn now. Let’s go! En guard! Let’s go! Let’s go! Ah! Toreador, en guard! Toreador, Toreador! And dream away, yes, dream in combat, That a black eye is watching you, And that love awaits you, Toreador, Love awaits you! Escamillo's Aria from Bizet's Carmen 1805:  A 50 year old man is brought in by EMS with complaints of difficulty breathing and generalized weakness.   He has a history of cardiomyopathy with EF 15%, CHF, ascites, and diabetes.    1815:  He is placed on the monitor and oxygen is continued at 4L/min via mask.   His initial oxygen saturations are 96%.   An IV is established, a 20 gauge in the right AC, and labs are obtained”  TNI, BNP, Chemistries, CBC, DDi...

“All their life in this world and all their adventures had only been the cover and the title page: now at last they were beginning Chapter One of the Great Story which no one on earth has read: which goes on for ever: in which every chapter is better than the one before.” ― C.S. Lewis, The Last Battle A 65 year old that got choked while eating and developed a complete airway obstruction.  EMS was dispatched to the scene.   BLS and ACLS measures with placement of an advanced airway were initiated at the scene.  Twenty minutes have elapsed since the patient collapsed.  CPR is in progress when the patient arrives.    Initial Rhythm with CPR in Progress CPR Rhythm Epinephrine Given During Compressions CPR Rhythm Rhythm Check PEA Rhythm Epinephrine Given During Cardiac Compressions CPR in Progress Rhythm Check Epinephrine Given During Cardiac Compressions Rhyth...

Near, far, wherever you are  I believe that the heart does go on…  09:53  Placed on monitor Initial rhythm 09:55 CPR Unsuccessful IV access attempt Unsuccessful IV access attempt CPR Rhythm 10:00 CPR Intubated 7.5 ET tube.  Tube placement confirmed CPR Rhythm 10:02 Epinephrine 2mg via ET tube Successful IO placement in right tibia CPR in progress CPR Rhythm 10:05 Vasopressin 40 units IO CPR in progress CPR Rhythm Check 10:09 Epinephrine 1mg IO NS fluid bolus started CPR Rhythm 10:11 Sodium Bicarbonate IO CPR in progress Adequate ventilations CPR Rhythm Check 10:15 Epinephrine 1mg IO CPR in progress CPR Rhythm 10:19 Epinephrine 1mg IO CPR in progress CPR Rhythm Check 10:24 Epinephrine 1mg IO CPR in progress CPR Rhythm 10:27  Epinephrine 1mg IO Continued CPR Final rhythm 10:28  Code ended Once more you open th...

Pediatric PEA E valuate Reversible Causes ·          Hypoxia ·          Hypovolemia ·          Hyper/hypokalemia ·          Hypothermia ·          Tension pneumothorax ·          Tamponade ·          Thromboembolism ·          Tables/toxins ·          Trauma Note:   Management of PEA is exactly the same as for asystole. Interventions for specific causes of PEA may lead to successful resuscitation. Appropriate measures may include a rapid fluid bolus for potential hypovolemia (20 mL/kg normal saline or lactated Ringer’s administered IV or IO), needle decompression for suspected tension pneumothorax, vent...

Pediatric PEA Length based color-coded tape. Medication Dose Calculation ·          Use the child’s weight if it is known ·          If the child’s weight is unknown, it is reasonable to use a body length tape ·          No data regarding the safety or efficacy of adjusting the doses for obese patients IV Access ·          Peripheral IV ·          Central line ·          Intraosseous ·           Endo tratracheal Peripheral IVs ·           Placement may be difficult in a critically ill child ·           Central venous placement requires procedure can be time consuming Central IV Drug Delivery ...

Pediatric PEA Secondary Survey ·          Intubate ·          Oxygenate ·          IV access ·          Treat reversible causes Note: Once the patient is intubated, continue CPR with asynchronous ventilations and chest compressions. Formula for Estimating Endotracheal tube size:  Uncuffed ET tube:  mm ID = (age in years/4) + 4 Cuffed ET tube:  mm ID = (age in years/4) + 3.5 Confirm ET tube placement n   Direct cord visualization n   End-tidal CO2 monitor n   Purple- problem n   Yellow- yes n   Tan- think about it n   Bilateral breath sounds n   CXR n   Continuous waveform capnography Note:  Continuous quantitative waveform capnography is now recommended for intubated patients throughout the periarrest period as a means of bot...

Pediatric PEA Rhythms Idioventricular rhythm Sinus bradycardia Sinus tachycardia with inverted T waves Agonal Rhythm PEA mnemonic:  Keep them ALIVE A ssess ABCs L isten for pulse using doppler I nitiate CPR V asoconstrictors E valuate reversable causes A ssess ABCs- Primary Survey ·          Assess responsiveness and pulse ·          Active EMS system ·          Call for defibrillator/monitor Note:  If a rhythm is present on the monitor but the pulse is absent (eg,PEA), CPR should be started immediately, beginning with chest compressions, and should continue for 2 minutes before the rhythm check is repeated. L isten for Pulse Using Doppler ·          A doppler will help distinguish between a pulseless state and profoundly weak cardiac contractions with...