Management of Cardiopulmonary Arrest on an Orthopedic Unit: A Simulated Clinical Experience

QUESTION

This simulated clinical experience focuses on a patient on an Orthopedic Unit who has had back surgery. On his second postoperative day he is ambulating to the bathroom unassisted when the nurse hears a loud crashing noise coming from his room. On arrival, the nurse finds the patient lying on the floor in cardiopulmonary arrest.

Interventions based on current BLS with AED guidelines for ventricular fibrillation and tachycardia should be undertaken and the patient will survive and be transferred to the Intensive Care Unit.

History/Information:

This patient is a 60-year-old male who is a patient on the Orthopedic Unit, recovering from an anterior-posterior inter-body fusion of L4-L5 performed two days ago. He has had an uneventful recovery. He is eating a full liquid diet, has no signs of infection at his surgical site, and is ambulating independently in his room.

His saline lock became dislodged during the night and was not restarted. Prior to his surgery, his only significant health problems were hypertension, hypercholesterolemia, diabetes mellitus type II, and obesity. The hypertension and diabetes are well controlled by his medication. He does not smoke, drink, or use illicit drugs. He is married and has two adult children who live locally.

While you have been caring for the patient today, his pain has been well controlled. He is currently eating lunch so you are at the nurse’s station charting. Several minutes later, you hear a loud crashing noise from his room. Upon entering, you find his lunch tray scattered on the floor and the patient lying face down.

Post-Op Healthcare Provider’s Orders:

Ambulate as tolerated, at least four times a day

Full liquid diet, advance as tolerated

Metoprolol 100mg PO daily

Simvastatin 40mg PO daily at bedtime

Oxycodone 5mg/acetaminophen 325mg PO every 4 hours as needed for pain

Docusate Sodium 100 mg PO daily

MOM 30 mL PO daily prn

May shower

Change dressing daily

1. What risk factors predispose this patient to sudden cardiac arrest?
2. What assessment findings establish that a patient is in cardiopulmonary arrest?

3. Discuss the steps of basic life support and explain why each is necessary in the established

order. [Please review the current BLS guidelines].

4. Describe these rhythms and explain what is happening to the heart and cardiac output:

a. Ventricular tachycardia

b. Ventricular fibrillation

5. What immediate steps must be taken if the patient has ventricular fibrillation?

6. Describe the safety measures that need to be taken when a patient is defibrillated and explain why they are necessary.

7. Discuss the progression of defibrillation if the patient does not respond to the first attempt.

8. Identify common medications used to treat ventricular fibrillation.

9. Discuss the interaction between the cardiovascular medications and defibrillation. Why are they often necessary in tandem?

10. If the patient’s family were present at the time of the cardiac arrest should they be allowed to remain present during the code?

11. As an LVN who is IV certified what is your responsibility in a code situation?

ANSWER

 Management of Cardiopulmonary Arrest on an Orthopedic Unit: A Simulated Clinical Experience

Introduction

This essay focuses on a simulated clinical experience involving a patient on an Orthopedic Unit who experiences a sudden cardiac arrest. The scenario presents a patient recovering from back surgery who unexpectedly collapses. The essay addresses various aspects of the situation, including the risk factors predisposing the patient to cardiac arrest, assessment findings indicating cardiopulmonary arrest, steps of basic life support (BLS) based on current guidelines, description of ventricular tachycardia and ventricular fibrillation, immediate actions for ventricular fibrillation, safety measures during defibrillation, medication used to treat ventricular fibrillation, the interaction between cardiovascular medications and defibrillation, the presence of family during the code, and the responsibilities of an LVN (Licensed Vocational Nurse) who is IV certified in a code situation.

Risk Factors Predisposing the Patient to Sudden Cardiac Arrest

The patient in this scenario possesses several risk factors for sudden cardiac arrest, including:

History of hypertension, hypercholesterolemia, diabetes mellitus type II, and obesity: These conditions increase the risk of cardiovascular events and cardiac arrhythmias.
Recent anterior-posterior inter-body fusion surgery: The stress of surgery and anesthesia can affect cardiac function and trigger arrhythmias.

 Assessment Findings of Cardiopulmonary Arrest

The assessment findings that establish a patient is in cardiopulmonary arrest include:

Absence of pulse: The absence of palpable pulse indicates circulatory arrest.
Unresponsiveness: The patient does not respond to stimuli or attempts at stimulation.
Absent or inadequate breathing: The patient shows no signs of spontaneous or effective breathing.

 Steps of Basic Life Support (BLS)

The steps of BLS are essential in the established order to maximize the chances of patient survival. Based on current BLS guidelines, the steps include:

Recognition and activation of the emergency response system: Promptly recognizing cardiac arrest and activating the code team or emergency medical services (EMS) to ensure a coordinated response.
Early cardiopulmonary resuscitation (CPR): Initiating chest compressions to maintain blood flow and oxygen delivery to vital organs.
Rapid defibrillation: Promptly delivering an electric shock (defibrillation) to treat shockable rhythms such as ventricular fibrillation and ventricular tachycardia.
Basic airway management and ventilation: Ensuring open airway, providing rescue breaths, and maintaining oxygenation.
Administration of medications: Administering appropriate medications, such as epinephrine, to support circulation and restore cardiac activity.
Advanced cardiac life support (ACLS): Implementing advanced interventions, including advanced airway management, continuous monitoring, and further pharmacological interventions, based on ACLS protocols.

Description of Rhythms: Ventricular Tachycardia and Ventricular Fibrillation

Ventricular tachycardia: Ventricular tachycardia is a rapid heart rhythm originating in the ventricles. The heart rate exceeds 100 beats per minute, compromising effective pumping and reducing cardiac output.
Ventricular fibrillation: Ventricular fibrillation is a chaotic, disorganized rhythm in which the ventricles quiver or fibrillate instead of contracting effectively. This results in the absence of coordinated pumping and the absence of a pulse.

Immediate Steps for Ventricular Fibrillation

Immediate steps for ventricular fibrillation include:

Call for help and activate the code team.
Ensure the safety of the environment and confirm the absence of anyone in contact with the patient or surrounding area.
Retrieve and apply an automated external defibrillator (AED) to deliver an electric shock and attempt to restore a normal cardiac rhythm.

Safety Measures During Defibrillation

During defibrillation, the following safety measures are necessary:

Ensure everyone is clear of the patient and the bed to prevent accidental shock.
Confirm proper electrode pad placement and adhere to the manufacturer’s instructions.
Verify that no fluids or flammable materials are in contact with the patient or the bed.

Progression of Defibrillation if the Patient Does Not Respond:

If the patient does not respond to the first attempt at defibrillation, the code team will continue CPR for a specified duration or a specific number of cycles before reattempting defibrillation. This cycle of CPR and defibrillation will be repeated as per ACLS guidelines.

Common Medications Used to Treat Ventricular Fibrillation

Medications commonly used to treat ventricular fibrillation include:

Epinephrine: Enhances cardiac contractility and promotes vasoconstriction to maintain perfusion.
bAmiodarone or lidocaine: Antiarrhythmic medications used to restore normal heart rhythm.

Interaction Between Cardiovascular Medications and Defibrillation

Cardiovascular medications, such as beta-blockers or calcium channel blockers, can impact the effectiveness of defibrillation. These medications may affect the heart’s response to electric shocks and require higher energy levels for successful defibrillation. Therefore, it is essential to consider the patient’s medication history when managing ventricular fibrillation.

Presence of Family During the Code

The decision to allow family members to remain present during the code is situational and depends on the healthcare facility’s policies and the family’s preferences. Allowing family presence can offer emotional support, foster trust, and enable them to witness resuscitation efforts. However, it is crucial to consider the potential impact on family members who may experience distress witnessing the resuscitation process.

Responsibilities of an LVN Who Is IV Certified in a Code Situation

In a code situation, an LVN who is IV certified may have responsibilities that include:

Assisting with CPR: Participating in chest compressions as part of the CPR team.
Preparing and administering medications: Assisting with medication preparation and administration under the direction of the code team leader.
Documenting interventions and patient responses: Accurately documenting the sequence of events, medications given, and patient’s response during the code.

Conclusion

Managing cardiopulmonary arrest requires prompt recognition, adherence to BLS guidelines, and appropriate interventions. The simulated clinical experience highlighted the importance of risk assessment, rapid response, defibrillation, and pharmacological interventions. Understanding the steps of BLS, the nature of ventricular tachycardia and fibrillation, and the safety measures during defibrillation are crucial for healthcare professionals. Additionally, considering the presence of family during the code and recognizing the responsibilities of an LVN who is IV certified contribute to effective code management and patient outcomes.