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Transcript of Adv Acls Casestudies
Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case Studies
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. 2
Case 1
3 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Scenario
Your patient is a 42-year-old woman who was pulled out of a backyard swimming pool. It is a warm July day. The time is 1523.
You have four other advanced life support (ALS) personnel available to assist you.
Emergency equipment is immediately available.
The scene is safe to enter.
4 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 1
You are putting on personal protective equipment as you approach the patient
What are the general impression ABCs?
5 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
General Impression ABCs
Appearance
Mental status, muscle tone, and body position
(Work of) Breathing
Body position, visible movement of chest and abdomen, ventilatory rate, ventilatory effort, and audible airway sounds
Circulation
Skin color
6 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
General Impression: Decision
On the basis of your general impression, decide if the patient is sick (unstable) or not sick (stable).
7 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 1
Your patient is a 42-year-old woman who was pulled out of a backyard swimming pool.
It is a warm July day.
The time is 1523.
8 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 1
You see a woman supine on a stretcher.
Her eyes are closed, and her hair and clothing are wet.
You see no signs of breathing.
Her skin looks pale.
9 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 1
What memory aid can you use to evaluate the patient’s level of responsiveness?
10 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Assess Responsiveness
A = Alert
V = Responds to Verbal stimuli
P = Responds to Painful stimuli
U = Unresponsive
11 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 1
The patient is unresponsive.
What should be done next?
12 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Primary Survey
Perform a primary survey that starts with the assessment of the patient’s airway: A = Airway B = Breathing C = Circulation D = Defibrillation/disability E = Exposure
13 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 1
How will you open the patient’s airway?
14 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Airway
Unresponsive patient
Use the head tilt–chin lift maneuver to open the airway if no trauma is present.
Use a jaw-thrust without head-tilt maneuver if there is known or suspected trauma.
15 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 1
You see a small amount of pink fluid in the patient’s mouth.
What should be done now?
16 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 1
What is the maximum length of time for a suctioning attempt?
17 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 1
The patient’s airway is clear.
What should be done now?
18 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 1
The patient is not breathing.
How should you proceed?
19 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 1
Size and insert an oral airway. Begin positive pressure ventilation. Continue the primary survey.
20 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 1
How will you determine the properly sized oral airway for this patient?
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. 21
Oral Airway: Sizing
22 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 1
Name two possible complications of oral airway insertion.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. 23
Oral Airway: Complications
Too long Too short
24 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 1
Describe two methods for the insertion of an oral airway in the adult patient.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. 25
Oral Airway: Insertion
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. 26
Oral Airway: Insertion
27 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 1
An oral airway has been inserted.
The patient is still not breathing.
Should a nasal cannula be considered at this point?
28 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 1
When the use of a nasal cannula is indicated, what liter flow is recommended for use with this device?
What is the approximate oxygen concentration that can be delivered with a nasal cannula?
29 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Nasal Cannula
0.25 to 8 L/min flow
Oxygen concentration of approximately 22% to 45% (actual amount of inspired oxygen depends on ventilatory rate and depth)
30 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 1
Should a simple face mask be considered at this point?
31 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 1
When the use of a simple face mask is indicated, what liter flow is recommended for use with this device?
What is the approximate oxygen concentration that can be delivered with a simple face mask?
32 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Simple Face Mask
5 to 10 L/min flow
Inspired oxygen concentration of approximately 35% to 60%
The patient’s actual inspired oxygen concentration will vary, because the amount of air that mixes with supplemental oxygen is dependent on the patient’s inspiratory flow rate.
33 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 1
What percentage of oxygen can be delivered with a bag-mask device?
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. 34
Bag-Mask Ventilation
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. 35
Bag-Mask Ventilation
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. 36
Bag-Mask Ventilation
37 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 1
What are the most frequent problems associated with bag-mask ventilation?
38 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 1
An oral airway has been inserted, and the patient is being ventilated with a bag-mask device.
You see gentle chest rise with bagging.
At what rate should this patient be ventilated?
39 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 1
The patient is being ventilated as instructed.
What should be done now?
40 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 1
Although it is difficult to feel, a slow carotid pulse is present. You estimate the rate to be about 40 beats/min.
The patient’s skin is cool, pale, and wet.
What should be done now?
41 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 1
The patient remains unresponsive and apneic.
Breath sounds with bag-mask ventilation are clear and equal.
The patient’s heart rate is 44 beats/min.
Her blood pressure is 86/54 mm Hg.
42 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 1
The patient has been placed on the cardiac monitor. What is the rhythm?
What should be done now?
43 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
SAMPLE HistorySigns/symptoms Submersion incident
Allergies None
Medications Unknown
Past medical history Depression
Last oral intake Unknown
Events prior The patient was retrieved from the swimming pool by her husband. He estimates that she was in the water for less than 10 minutes.
What should be done now? What should be done now?
44 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Physical Examination Findings
Head, ears, eyes, nose, and throat
Pink fluid initially present in the mouth (cleared with suctioning)
Neck Trachea midline, no jugular venous distention
Chest Breath sounds clear and equal with bag-mask ventilation
Abdomen No abnormalities noted
Pelvis No abnormalities noted
Extremities No abnormalities noted
Posterior body Unremarkable
45 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 1
A tracheal tube has been inserted and the cuff inflated.
An IV has been established with normal saline.
What methods can be used to verify the proper placement of the tracheal tube?
46 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Confirming Tube Placement Visualizing the passage of the tracheal tube between
the vocal cords Auscultating the presence of bilateral breath sounds Confirming the absence of sounds over the epigastrium
during ventilation Adequate chest rise with each ventilation Absence of vocal sounds after tracheal tube placement End-tidal carbon dioxide measurement (waveform
capnography is preferred) Verification with an esophageal detector device Chest radiography
47 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 1
Describe how you will auscultate the patient’s chest to confirm tracheal tube placement.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. 48
Confirming Tube Placement
49 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 1
There are no sounds heard over the epigastrium.
Breath sounds are diminished on the left side of the chest with bag-mask ventilation. They are clearly heard on the right.
What should be done now?
50 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 1
On the basis of these findings, you should suspect a right primary bronchus intubation.
Ask the airway team member to deflate the cuff, pull back slightly on the tracheal tube, re-inflate the cuff, and reassess the patient’s breath sounds.
51 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 1
Breath sounds with bag-mask ventilation now reveal clear and equal breath sounds.
What would you like to do now?
52 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 1
Capnography confirms the presence of CO2. The tracheal tube has been secured.
What should be done now?
53 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 1
The patient is attempting to breathe spontaneously at a rate of 6 to 8 breaths/min.
Her vital signs are now as follows: Blood pressure: 112/74 mm Hg Pulse: 75 beats/min, strong and regular Ventilatory rate: 10 breaths/min via bag-mask
device SpO2: 97% with bagging
54 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 1
What is the rhythm on the cardiac monitor?
What should be done now?
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. 55
Case 2
56 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Scenario
Your patient is a 52-year-old woman who was found unresponsive on her kitchen floor by a neighbor. The time is 1442.
You have four other ALS personnel available to assist you.
Emergency equipment is immediately available.
57 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
General Impression
A woman is supine on a stretcher.
Her eyes are closed.
You do not see any signs of breathing.
Her skin is pale, and her lips are blue.
What would you like to do now?
58 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 2
The patient is unresponsive.
How would you like to proceed?
59 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 2
The patient is not breathing.
What would you like to do now?
60 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 2
There is no pulse.
You note that the patient’s skin is cool, pale, and dry.
How would you like to proceed?
61 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 2
Compressions are being performed as requested.
How would you like to proceed?
62 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 2
The patient’s airway is clear.
What should be done now?
63 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 2
An oral airway has been inserted.
The patient is being ventilated with a bag-mask device. You see gentle chest rise with bagging.
What would you like to do next?
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. 64
Case 2
The AED pads are in place on the patient’s chest.
The power to the AED is on.
How do you want to proceed?
65 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 2
While waiting for the machine to analyze the patient’s rhythm, should you ask your assistants to insert an advanced airway or start an IV?
Why or why not?
66 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 2
The AED advises a shock.
What do you want to do now?
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. 67
Case 2
Everyone is clear of the patient.
The defibrillation team member has delivered the shock.
What should be done now?
68 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 2
The AED states, “No shock advised.”
How would you like to proceed?
69 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 2
A strong carotid pulse is present.
The patient is waking up and breathing on her own at a rate of about 12 breaths/min.
What should be done now?
70 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 2
The patient’s heart rate is strong and regular at a rate of 80 beats/min.
Ventilations are occurring at a rate of 12 breaths/min.
The patient’s blood pressure is 98/60 mm Hg.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. 71
SAMPLE History
(History obtained from neighbor)
Signs/symptoms Found unresponsive by neighbor
Allergies Unknown
Medications Azithromycin (Zithromax), alendronate (Fosamax)
Past medical history “Intestinal problems”
Last oral intake Unknown
Events prior Found unresponsive on the kitchen floor by a neighbor who had last spoken to the patient about 25 minutes prior
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. 72
Physical Examination Findings
Head, ears, eyes, nose, and throat
Cyanosis of lips noted on initial examination
Neck Trachea midline, no jugular venous distention
Chest Breath sounds clear and equal with positive pressure ventilation
Abdomen No abnormalities noted
Pelvis No abnormalities noted
Extremities No abnormalities noted
Posterior body No abnormalities noted
73 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 2
What should be done now?
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. 74
Case 3
75 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Scenario
Your patient is a 58-year-old man who collapsed while having lunch.
The patient was helped to the floor by his coworkers.
It has been 5 minutes since the patient collapsed.
You have five other ALS personnel available to assist you.
Emergency equipment, including a biphasic manual defibrillator, is immediately available.
76 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
General Impression
The patient’s eyes are closed.
He does not appear to be breathing.
His skin looks very pale.
What should be done now?
77 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 3
You have determined that the patient is unresponsive and not breathing.
What should be done now?
78 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 3
There is no pulse.
The patient’s skin is cool, pale, and dry.
What should be done now?
79 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 3
Compressions are being performed as requested.
How would you like to proceed?
80 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 3
The patient’s airway is clear.
What should be done now?
81 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 3
An oral airway has been inserted. The patient is being ventilated with a bag-
mask device. You see gentle chest rise with bagging. Breath sounds are clear and equal with positive
pressure ventilation. Combination pads are in place on the
patient’s chest.
What should be done now?
82 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 3
A biphasic defibrillator is within arm’s reach.
What is the rhythm on the cardiac monitor?
How do you want to proceed?
83 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 3
Will you be performing synchronized cardioversion or defibrillating this patient?
84 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 3
What initial medications do you want the IV team member to prepare?
85 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 3
What energy setting will you use for your initial shock?
86 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 3
The shock is delivered.
What would you like to do next?
87 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 3
An IV has been started with normal saline in the patient’s left antecubital vein.
Epinephrine has been given intravenously.
What would you like to do next?
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. 88
SAMPLE History
(History obtained from the patient’s wife)
Signs/symptoms Collapsed about 15 minutes ago
Allergies Codeine, penicillin
Medications Divalproex sodium (Depakote)
Past medical history Epilepsy, substance abuse
Last oral intake Unknown
Events prior Sudden collapse
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. 89
Physical Examination Findings
Head, ears, eyes, nose, and throat
No abnormalities noted
Neck Trachea midline, no jugular venous distention
Chest Breath sounds clear and equal with positive pressure ventilation
Abdomen No abnormalities notedPelvis No abnormalities notedExtremities No abnormalities notedPosterior body No abnormalities noted
90 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 3
You observe the following rhythm on the cardiac monitor.
How do you want to proceed?
91 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 3
The IV team member requests clarification regarding the amiodarone order. What dosage should be administered at this time?
92 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 3
Amiodarone has been given as instructed.
The patient’s cardiac rhythm remains unchanged, and CPR is ongoing.
What would you like to do now?
93 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 3
The shock has been delivered. A team member calls your attention to a
rhythm change on the cardiac monitor. What is the rhythm?
What should be done now?
94 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 3
The patient is unresponsive but breathing shallowly at a rate of approximately 4 breaths/min.
A strong pulse is present at a rate of approximately 80 beats/min.
His blood pressure is 88/62 mm Hg.
His color is improving.
How do you want to proceed?
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. 95
Case 4
96 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Scenario
Your patient is a 24-year-old man who was found unresponsive in his home by his girlfriend.
She told law enforcement personnel that he was fine about 15 minutes ago and then she heard a gunshot.
The time is 1415.
You have four other ALS personnel available to assist you.
Emergency equipment is immediately available.
97 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
General Impression
You see a young man supine on a stretcher. He is unaware of your approach. There is no obvious rise and fall of his chest. His skin is pale. You observe minimal bleeding from a chest
wound on the patient’s right sternum. What would you like to do now?
98 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 4
The patient is unresponsive.
What should be done now?
99 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 4
The patient is not breathing.
What would you like to do now?
100 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 4
There is no pulse.
The patient’s skin is cool, pale, and dry.
What should be done now?
101 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 4
Compressions are being performed as requested.
How would you like to proceed?
102 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 4
The patient’s airway is clear.
What should be done now?
103 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 4
An oral airway has been inserted. Two-person bag-mask ventilation is being
performed. You see gentle chest rise with bagging. Breath sounds are clear and equal with positive
pressure ventilation.
Combination pads are in place on the patient’s chest.
A biphasic defibrillator is within arm’s reach. What should be done now?
104 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 4
What is the rhythm on the cardiac monitor?
How do you want to proceed?
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. 105
SAMPLE History
Signs/symptoms Found unresponsive by girlfriend after she heard a gunshot; minimal bleeding from chest wound on right sternum
Allergies None
Medications None
Past medical history None
Last oral intake Lunch 2 hours ago
Events prior Last seen 15 minutes ago; law-enforcement personnel report that the patient shot himself in the chest with a .45-caliber gun; an estimated 1 to 2 L of blood have been lost at the scene
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. 106
Physical Examination Findings
Head, ears, eyes, nose, and throat
No abnormalities noted
Neck Trachea midline, jugular veins flatChest Gunshot wound present on the right
of the sternum; breath sounds diminished on the left with positive pressure ventilation
Abdomen No abnormalities notedPelvis No abnormalities notedExtremities No abnormalities notedPosterior body Large exit wound lateral to the left
scapula
107 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 4
What should be done next?
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. 108
Case 4
The airway team member has successfully inserted a Combitube.
The IV team member has successfully placed an IV in the right antecubital vein.
109 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 4
Waveform capnography confirms the proper placement of the Combitube.
How would you like to proceed?
110 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 4
The Combitube has been secured.
The IV fluid bolus that you ordered is infusing, and 1 mg of 1:10,000 epinephrine has been given.
CPR is ongoing, and the rhythm on the cardiac monitor is unchanged.
Does the placement of an advanced airway necessitate any changes in bag-mask ventilation?
111 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 4
After 40 minutes of high-quality CPR, the rhythm on the cardiac monitor is unchanged.
Epinephrine has been given every 3 to 5 minutes, and one dose of vasopressin was administered.
What would you like to do now?
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. 112
Case 5
113 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Scenario
Your patient is a 53-year-old woman who has been found unresponsive by her husband.
The time is 1700.
You have five other ALS personnel available to assist you.
Emergency equipment is immediately available.
114 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
General Impression
You see a middle-aged woman lying supine on a stretcher.
You estimate that the patient weighs approximately 100 kg.
Her eyes are closed, and you do not observe any rise and fall of her chest.
She is blue from her chest up.
What should be done now?
115 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 5
The patient is unresponsive.
How would you like to proceed?
116 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 5
The patient is not breathing.
What would you like to do now?
117 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 5
There is no pulse.
The patient’s skin is cool, pale, and dry.
What should be done now?
118 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 5
Compressions are being performed, and combination pads have been applied to the patient’s chest.
How would you like to proceed?
119 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 5
The patient’s airway is clear.
What should be done now?
120 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 5
An oral airway has been inserted. Two-person bag-mask ventilation is being
performed. You see gentle chest rise with bagging. Breath sounds are clear and equal with positive
pressure ventilation. The defibrillator that you requested is within
arm’s reach. What would you like to do next?
121 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 5
You see this rhythm on the cardiac monitor. What is the rhythm?
What should be done now?
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. 122
SAMPLE HistorySigns/symptoms Unresponsive, apneic, pulseless
Allergies Unknown
Medications Unknown
Past medical history Unknown
Last oral intake Unknown
Events prior According to the patient’s husband, the patient told her daughter that she was not feeling well and went to take a nap in the bedroom about 2 hours ago. The husband went to awaken his wife for dinner but could not arouse her. He reports that his wife has had no recent surgery or trauma. They returned from a 6-day stay in Mexico yesterday.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. 123
Physical Examination Findings
Head, ears, eyes, nose, and throat
Upper body blue
Neck Trachea midline, no jugular venous distention
Chest Breath sounds clear and equal with positive pressure ventilation; blue from the chest up
Abdomen No abnormalities noted
Pelvis No abnormalities noted
Extremities No abnormalities noted
Posterior body No abnormalities noted
124 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 5
What should be done next?
125 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 5
The airway team member has successfully inserted a tracheal tube.
The IV team member has successfully placed an IV in the left antecubital vein, and epinephrine was administered as ordered.
What should be done now?
126 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 5
The proper placement of the tracheal tube has been confirmed with an esophageal detector and waveform capnography.
A cardiology consult has been ordered.
How would you like to proceed?
127 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 5
The tracheal tube has been secured.
What would you like to do next?
128 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 5
High-quality CPR is continuing.
The patient’s cardiac rhythm is unchanged.
How would you like to proceed?
129 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 5
Epinephrine is being given intravenously as instructed.
What memory aids can be used to help recall the possible reversible causes of cardiac arrest?
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. 130
PATCH-4-MD
Pulmonary embolism
Acidosis
Tension pneumothorax
Cardiac tamponade
Hypovolemia
Hypoxia
Heat/cold (hyperthermia/hypothermia)
Hypokalemia/hyperkalemia (and other electrolytes)
Myocardial infarction
Drug overdose/accident
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. 131
The Five Hs and Five Ts
1. Hypovolemia
2. Hypoxia
3. Hypothermia
4. Hypokalemia/
hyperkalemia
5. Hydrogen ions (acidosis)
1. Tamponade, cardiac
2. Tension pneumothorax
3. Thrombosis: lungs
4. Thrombosis: heart
5. Tablets/toxins: drug overdose
132 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 5
On the basis of the information available to you, what possible causes of this patient’s cardiac arrest have you considered?
133 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 5
You observe a change on the cardiac monitor. What is the rhythm?
Does the change in the patient’s cardiac rhythm necessitate any changes in the management of the patient at this time?
134 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 5
High-quality CPR is ongoing.
There is gentle chest rise with bagging.
Breath sounds are clear and equal bilaterally with positive pressure ventilation.
135 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 5
Forty-five minutes have now elapsed since resuscitation efforts began.
So far, 8 mg of epinephrine have been given in 1-mg doses.
The patient’s ECG rhythm and condition remain unchanged.
136 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Case 5
What should be done now?
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. 137
Case 6
138 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Scenario
Your patient is a 52-year-old man who is complaining of shortness of breath and substernal chest discomfort.
The time is 0719.
You have five other ALS personnel available to assist you.
Emergency equipment is immediately available.
139 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
General Impression
You see a 52-year-old anxious-looking man sitting in a chair.
His breathing does not appear to be labored.
His skin is pink.
140 Copyright © 2012 by Mosby, an imprint of Elsevier Inc.
Primary Survey
Airway: clear; patient states that he is short of breath and has severe chest discomfort
Breathing: 22 breaths/min, unlabored Patient completes sentences without hesitation
Circulation Radial and carotid pulses strong and regular Heart rate of approximately 60 beats/min Warm, pink, and moist skin
What should be done now?
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. 141
SAMPLE History Signs/symptoms Shortness of breath and substernal chest discomfort
OPQRST Symptoms began at rest; patient describes his chest discomfort as “pressure” with radiation down his left arm and rates his discomfort at 10/10; the symptoms have been present for about 1 hour
Allergies None
Medications Nitroglycerin, chlorzoxazone (Parafon Forte), imipramine (Tofranil), alprazolam (Xanax), hydrochlorothiazide (Hydrodiuril)
Past medical history
Depression, hypertension, angina pectoris; patient is 5’9” and weighs 190 pounds
Last oral intake Dinner last evening
Events prior The patient states that he was watching the morning news on television when his symptoms began; he denies nausea, vomiting, and dizziness
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Physical Examination Findings
Head, ears, eyes, nose, and throat
No abnormalities noted
Neck Trachea midline, no jugular venous distention
Chest Breath sounds clear bilaterally
Abdomen No abnormalities noted
Pelvis No abnormalities noted
Extremities No abnormalities noted
Posterior body No abnormalities noted
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Case 6
Blood pressure: 127/88 mm Hg
Heart rate: 58 beats/min
Ventilations: 22 breaths/min
SpO2: 98% (nasal cannula at 4 L/min O2)
How would you like to proceed?
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Case 6
An IV has been started.
Aspirin has been given.
The patient still rates his discomfort at 10/10.
A 12-lead ECG has been obtained as ordered.
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Case 6 Are there any significant findings on this 12-lead
ECG?
I Lateral aVR ------------ V1 Septum V4 Anterior
II Inferior aVL Lateral V2 Septum V5 Lateral
III Inferior aVF Inferior V3 Anterior V6 Lateral
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Case 6
What would you like to do next?
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Case 6
The loading dose of clopidogrel was given as instructed.
The patient rated his chest discomfort as 10/10 after the first dose of NTG. The patient’s blood pressure remained stable, and
a second NTG dose was given. The patient’s discomfort was subsequently noted as 8/10.
A third dose of NTG was given, with no change in the patient’s rating of his discomfort (i.e., 8/10).
How would you like to proceed?
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Case 6
What would you like to do next?
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Case 6
The patient’s blood pressure is now 131/91 mm Hg, his heart rate is 66 beats/min, and his ventilatory rate is 18 breaths/min.
After two doses of IV morphine, the patient rates his discomfort as 0/10.
What should be done now?
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Case 7
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Scenario
Your patient is a 76-year-old woman who is complaining of dizziness. The time is 1121.
You have five other ALS personnel available to assist you.
Emergency equipment is immediately available.
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General Impression
You see an ill-appearing woman lying on a stretcher.
Her eyes are closed.
You can see equal rise and fall of her chest.
Her skin is pale.
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Primary Survey
Airway: “I feel dizzy”
Breathing: 18 breaths/min, unlabored
Circulation Carotid pulse weak but regular Heart rate of approximately 30 beats/min Cool, pale, and dry skin
Defibrillation: biphasic defibrillator available
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Case 7
What would you like to do now?
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Case 7
Blood pressure: 64/42 mm Hg
Heart rate: approximately 30 beats/min
Ventilations: 18 breaths/min
Breath sounds clear and equal
SpO2: 90% on room air
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SAMPLE History
Signs/symptoms Sudden onset of severe dizziness
Allergies None
Medications Furosemide (Lasix), aspirin, olanzapine (Zyprexa), pantoprazole (Protonix), paroxetine (Paxil)
Past medical history Arthritis, osteoporosis, heart failure, schizophrenia, gastroesophageal reflux disease, depression
Last oral intake Breakfast 3 hours ago
Events prior Sudden onset of dizziness; symptoms started approximately 30 minutes ago while at rest
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Physical Examination Findings
Head, ears, eyes, nose, and throat
No abnormalities noted
Neck Trachea midline, no jugular venous distention
Chest Breath sounds clear bilaterally
Abdomen No abnormalities noted
Pelvis No abnormalities noted
Extremities No abnormalities noted
Posterior body No abnormalities noted
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Case 7
The patient has been placed on the cardiac monitor.
What is the rhythm?
How would you like to proceed?
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Case 7
The patient has been placed on O2, and an IV has been started.
A 12-lead ECG has been ordered.
Your defibrillator has transcutaneous pacing capability.
How would you like to proceed?
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Case 7
Atropine has been given as ordered.
Laboratory work and a chest radiograph have been ordered.
A cardiology consult has been ordered.
A reperfusion checklist has been started.
What would you like to do next?
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Case 7
The patient’s heart rate has increased to 48 beats/min (i.e., junctional rhythm).
The patient’s blood pressure is now 74/53 mm Hg, and her ventilatory rate is 16 breaths/min.
What should be done now?
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Case 7 A second dose of atropine has been given as
ordered.
The patient’s blood pressure is now 110/66 mm Hg, her heart rate is 80 beats/min, and her ventilatory rate is 16 breaths/min.
Her skin is now warm, pink, and dry.
The patient states that she is feeling much better.
What would you like to do next?
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Case 8
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Scenario
Your patient is a 37-year-old man who states that he was awakened by “heart palpitations.”
The time is 0023.
You have five other ALS personnel to assist you.
Emergency equipment is immediately available.
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General Impression
You see a man supine on a stretcher.
He is awake, and his skin looks very pale.
You can see the rise and fall of his chest.
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Primary Survey Airway: clear
Breathing: 16 breaths/min
Circulation
Unable to feel radial pulse
Weak carotid pulse present
Heart rate of approximately 150 beats/min
Cool, pale, and moist skin
Defibrillation: biphasic machine available
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Case 8
What would you like to do next?
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Case 8
The patient’s blood pressure is 50/24 mm Hg, his heart rate is 150 beats/min, and his ventilatory rate is 16 breaths/min.
Breath sounds are clear and equal.
The patient’s SpO2 is 88% on room air.
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SAMPLE History
Signs/symptoms Heart palpitations
Allergies Codeine, sulfa
Medications Albuterol (Proventil), ipratropium (Atrovent)
Past medical history Asthma
Last oral intake Dinner at 1800
Events prior Awakened from sleep by “heart palpitations”; symptoms present for 1.5 hours
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Physical Examination Findings
Head, ears, eyes, nose, and throat
No abnormalities noted
Neck Trachea midline, no jugular venous distention
Chest Breath sounds clear bilaterally
Abdomen No abnormalities noted
Pelvis No abnormalities noted
Extremities No abnormalities noted
Posterior body No abnormalities noted
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Case 8
The patient has been placed on the cardiac monitor.
What is the rhythm? Is the patient stable or unstable?
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Case 8
What would you like to do now?
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Case 8
An IV has been started.
A 12-lead ECG has been ordered.
Midazolam has been given as instructed.
The cardiologist is en route.
Will you be performing synchronized cardioversion or defibrillation?
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Case 8
A biphasic manual defibrillator is available.
What initial energy setting will you use?
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Case 8
A synchronized shock was delivered using 100 joules.
You see the following rhythm on the monitor. What is the rhythm?
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Case 8
What would you like to do next?
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Case 8
Strong carotid and radial pulses are present.
The patient’s ventilatory rate is 14 breaths/min.
Breath sounds are clear and equal.
The patient’s blood pressure is BP 108/88 mm Hg, and his SpO2 is 99%.
The cardiologist is here.
What should be done now?
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Case 9
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Scenario
A 19-year-old man presents with a complaint of a “rapid heartbeat” and chest discomfort.
You have four ALS personnel available to assist you.
Emergency equipment is available.
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General Impression
You see a nervous-appearing young man sitting upright on a stretcher.
His breathing is unlabored.
His skin is pink.
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Primary Survey
Airway: “My heart is racing and feels like it is going to pound out of my chest.”
Breathing: 18 breaths/min, unlabored Circulation
Strong radial and carotid pulses that are too fast to count accurately
Heart rate of approximately 200 beats/min Warm, pink, and moist skin
Defibrillation: biphasic machine available
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Case 9
What would you like to do next?
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Case 9
The patient’s vital signs are as follows: Blood pressure: 134/90 mm Hg Heart rate: 214 beats/min Ventilatory rate: 18 breaths/min
Breath sounds are clear and equal.
The patient’s SpO2 on room air is 99%.
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Case 9
The patient has been placed on the cardiac monitor.
What is the rhythm shown on the monitor?
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SAMPLE History Signs/symptoms Rapid heartbeat and chest discomfort
OPQRST Symptoms began when the patient was at rest; he describes his chest discomfort as “pressure” and rates his discomfort at 1/10; his symptoms have been present for about 25 minutes
Allergies None
Medications None
Past medical history None
Last oral intake Caffeine-free soda 1 hour ago
Events prior Patient was sitting in the college library when his symptoms began
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Physical Examination Findings
Head, ears, eyes, nose, and throat
No abnormalities noted
Neck Trachea midline, no jugular venous distention
Chest Breath sounds clear bilaterally
Abdomen No abnormalities noted
Pelvis No abnormalities noted
Extremities No abnormalities noted
Posterior body No abnormalities noted
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Case 9
An IV has been started in the right antecubital vein.
A 12-lead ECG has been ordered.
Is this patient stable or unstable?
How would you like to proceed?
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Case 9
The patient has complied with your instructions, but no change is observed on the cardiac monitor.
What would you like to do next?
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Case 9
Adenosine has been given as ordered.
What would you like to do next?
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Case 9
A cardiology consult has been requested. The cardiologist is en route and is expected to arrive in about 20 minutes.
The patient’s chest discomfort has resolved.
His blood pressure is now 122/70 mm Hg, his heart rate is about 40 beats/min, and his ventilatory rate is 16 breaths/min. His skin is warm, pink, and dry.
The patient states that he feels “much better.”
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Case 9
What is the rhythm on the monitor?
What should be done now?
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Case 10
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Scenario
A 73-year-old woman presents with a sudden onset of slurred speech. The patient’s son is present. The time is 0906.
You have four ALS personnel available to assist you.
Emergency equipment is available.
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General Impression
You find the patient awake and supine on a stretcher.
You see equal rise and fall of her chest.
Her skin is pink and looks dry.
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Primary Survey
Airway: Patient attempts to speak, but her speech is garbled and unintelligible
Breathing: 18 breaths/min, quiet and unlabored
Circulation Strong and regular radial and carotid pulses Heart rate of approximately 70 beats/min Warm, pink, and dry skin
Defibrillation: biphasic machine available
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Case 10
What would you like to do next?
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Case 10
The patient’s vital signs are as follows: Blood pressure: 217/93 mm Hg in the left arm and
208/90 mm Hg in the right arm Heart rate: strong and regular at 74 beats/min Ventilatory rate: 18 breaths/min
Breath sounds are clear and equal.
The patient’s SpO2 is 98% on room air.
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Case 10
The patient has been placed on the cardiac monitor.
What is the rhythm?
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SAMPLE History
Signs/symptoms Patient awoke at 0730 with slurred speech; it is apparent that the patient can understand you, although you cannot understand her
Allergies None
Medications Niaspan (Niacin), lisinopril with hydrochlorothiazide (Zestoretic), gabapentin (Neurontin)
Past medical History
Seizures, hypertension, pacemaker, high cholesterol
Last oral intake Dinner about 1900 last evening
Events prior The patient’s son states that his mother has complained of heartburn and not feeling well for about 24 hours; she awoke this morning with slurred speech and said that she was “feeling sick,” with nausea, dizziness, and sweating
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Physical Examination FindingsHead, ears, eyes, nose, and throat
Pupils equal and reactive but sluggish; right-sided facial droop present
Neck Trachea midline, no jugular venous distention
Chest Breath sounds clear bilaterally; pacemaker noted in left pectoral region
Abdomen No abnormalities noted
Pelvis No abnormalities noted
Extremities Pulses, movement, and sensation equal bilaterally
Posterior body No abnormalities noted
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Case 10
What would you like to do next?
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Case 10
An IV has been started.
A 12-lead ECG has been ordered.
The patient’s serum glucose level is 143 mg/dL.
Why is it important to determine the serum glucose level of a patient with a suspected stroke?
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Case 10
After obtaining the SAMPLE history, what are three questions that you should ask about a patient who presents with signs and symptoms of an acute stroke?
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Case 10
The patient’s son states that his mother complained of heartburn and not feeling well for about 24 hours.
She awoke at 0730 this morning with slurred speech (which is new for this patient) and said that she was “feeling sick,” with nausea, dizziness, and sweating.
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Case 10
The patient does not have a headache, chest pain, or shortness of breath.
Although the patient has a history of seizures, her last seizure was 4 months ago.
There is no history of recent trauma.
What would you like to do now?
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Case 10
What areas are assessed with the use of the Cincinnati Prehospital Stroke Scale?
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Case 10
Facial droop is present on the right.
The patient is unable to repeat a phrase clearly.
The upper extremities move equally.
The patient has not been feeling well for 24 hours.
She awoke at 0730 today with slurred speech.
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Case 10
What would you like to do now?
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Case 10
What is the time target for a possible stroke patient evaluation by a physician?
What are the time targets for obtaining and reading a computed tomography scan?
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National Institute of Neurological Disorders and Stroke (NINDS) Recommended Stroke Evaluation
Targets for Potential Fibrinolytic Candidates
Activity Target
Door to physician evaluation 10 minutes
Door to access to neurologic expertise (in person or by phone)
15 minutes
Door to computed tomography completion 25 minutes
Door to computed tomography read 45 minutes
Door to drug/intervention 60 minutes
Door to neurosurgical availability (on site or by transport)
2 hours
Door to admission to monitored bed 3 hours
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Questions?