Megacode PEA Part 3

Secondary Survey

·         Intubate and secure airway device.

·         Oxygenate with 100% O₂.

·         IV access

Note: Given the potential association of PEA with hypoxemia, placement of an advanced airway is theoretically more important than during VF/pulseless VT and might be necessary to achieve adequate oxygenation or ventilation.

Methods of Confirming ET tube Placement

·         Direct cord visualization

·         End-tidal CO2 monitor

Yellow- yes, tube is correctly placed

Tan- think about it

Purple- problem with tube placement

·         Bilateral breath sounds

·         CXR

·         Continuous waveform capnography

Note:  Continuous waveform capnography is recommended in addition to clinical assessment as the most reliable method of confirming and monitoring correct placement of an endotracheal tube (Class I, LOE A). Providers should observe a persistent capnographic waveform with ventilation to confirm and monitor endotracheal tube placement in the field, in the transport vehicle, on arrival at the hospital, and after any patient transfer to reduce the risk of unrecognized tube misplacement or displacement

Continuous Waveform Capnography

·         Persistently low PETCO2 values (<10 mm Hg) during CPR in intubated patients suggest that ROSC is unlikely

·         If PETCO2 is <10 mm Hg, it is reasonable to consider trying to improve CPR quality by optimizing chest compression parameters

Note:  Although a PETCO2 value of <10 mm Hg in intubated patients indicates that cardiac output is inadequate to achieve ROSC, a specific target PETCO2 value that optimizes the chance of ROSC has not been established. Monitoring PETCO2 trends during CPR has the potential to guide individual optimization of compression depth and rate and to detect fatigue in the provider performing compressions.

3:25 PM.   CPR is in progress with adequate positive pressure ventilations.   The MD ordered another dose of epinephrine to be given.   Although vasoconstrictors will sometimes improve the cardiac output, they do not treat the underlying cause of the problem.   Medications will give you some extra time but it is most important that the underlying cause of the problem be established.   What would be some potential problems  (Hs&Ts)  associated with an older adult with endstage kidney disease who is receiving hemodialysis?

 There was no response to the epinephrine and a rhythm check show the patient to be in asystole.   As you observe the monitor during compression you can often see if the patient develops an organized rhythm.  The complexes will appear between the compressions.   The usual response to a dose of epinephrine is a wide complex tachycardia and the patient will often have a bounding pulse.   Some people want to treat the rhythm as VT and defibrillate it.   But more often than not, it is a response to the epinephrine and the rhythm will begin to slow down as the epinephrine wears off.