week
CASE
You have been dispatched code 1 (the most urgent response) to a residence of a 74‐year‐old male who has woken with chest pain and collapsed.
Pre‐arrival information
The male is unconscious and not breathing effectively. CPR instructions are being given over the phone to a female on scene.
Windscreen report
The house is low set and appears to be neat, nil signs of any danger. You can see through the window that the patient is in the bedroom on the bed, with CPR being performed by a neighbour.
Entering the property
You are met at the door by an elderly woman, visibly distressed. She states that the patient is in the bedroom with the neighbour, also stating that he woke up and did not look well and collapsed onto the bed. You walk through the large, spacious lounge room into a small, cramped bedroom where the patient is located.
On arrival with the patient
The male patient is lying on the bed with a neighbour performing ineffective CPR. The patient is in his pyjamas, but his exposed limbs look grey in colour. You notice some saliva coming out of his mouth and he is not responding to the CPR being provided.
Patient assessment triangle
General appearance
The patient is unresponsive, lying across the bed.
Circulation to the skin
Grey in colour and is the same temperature as the bedroom.
Work of breathing
The patient took an agonal breath as you walked in the room, but no other breaths have been noted.
SYSTEMATIC APPROACH
Danger
Nil.
Response
No response.
Airway
Some saliva noted in the airway.
Breathing
One deep breath on arrival, no more breaths witnessed.
Circulation
No pulse.
Disability
GCS 3/15.
Exposure
Nil signs of trauma, The patient has central cyanosis.
Case history
The partner states that the patient slept in this morning and when he awoke he screamed that he had the worst chest pain he has ever experienced, then he went to get out of bed and groaned and collapsed onto the bed. He was unresponsive, so the partner screamed out and the neighbour heard and came to help. When they rang the ambulance the dispatcher asked them to commence CPR. The partner stated that she could not do such a task, but the neighbour had begun CPR when the ambulance arrived.
TASK
Look through the information provided in this case study and highlight all of the information that might concern you as a paramedic.
1 Given the chain of survival, high‐quality compressions are urgently required for this patient. What is your next move? Consider what you have just walked through.Moving the patient to the spacious lounge room you have just walked through is ideal. This will provide a better working area and ensure that good‐quality uninterrupted compressions can be achieved.
2 You have moved the patient out to the lounge room to a large area. Your partner is a qualified advanced care paramedic. What are the first steps you are going to take with this patient?If there are no signs of life, e.g. no pulse, or no normal breathing, chest compressions need to be started and continued while the patient’s chest is exposed by removing his pyjama top (cutting it off). The defibrillation pads can then be attached to the patient.
Case Progression
An automatic rhythm check is immediately performed and the patient is found to be in ventricular tachycardia (VT), so a direct current countershock (DCCS) is advised and delivered.
Vital signs
Defibrillation pads: ventricular tachycardia at a rate of 180 bpm
RR: 0
BP: unrecordable
SPO2: unrecordable
Blood glucose: 5.1 mmol/L
GCS: 3/15
Pupils: fixed, 3 mm
Colour/appearance: grey
Respiratory effort/rhythm: no effort, irregular
Pulses: absent
Head to toe: reveals nil obvious injuries, deformities, scarring and nil medical alerts
1 The person performing chest compressions asks you where their hands should be positioned on the patient’s chest and how to best perform compressions. What would you say?Kneel down to the side of the patient. Place the heel of your hand in the centre of the patient’s chest this should be on the lower half of the sternum, roughly between the nipples (ANZCOR, 2016). Ensure that it is not placed over ribs or the upper abdomen. Their other hand is then placed on top of this hand and the fingers may be interlocked. Keep your arms straight and position yourself vertically above the patient’s
