NRSG 408 MI CLINICAL CASE STUDY

Last updated 12 January 2024

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Part II. Clinical Reasoning and Application

I. Scenario 1:

A 70-year-old woman was admitted the hospital 2 days ago and underwent a right total hip replacement. The patient has a history of hypertension, degenerative joint disease, pulmonary embolism, and coronary artery disease. She just finished a physical therapy session and has been resting in her hospital room. When you walk into the room to check your patient, you notice that she is unresponsive with no respiration or pulse. You immediately start CPR and call a code. When the emergency team arrives, the patient is attached to the ECG monitor, which displays the rhythm shown in ECG 1. Answer the following questions:

ECG 1

1. The interpretation of this rhythm is:

Ventricular fibrillation

Ventricular tachycardia

Accelerated idioventricular

Asystole

2. Your FIRST treatment of the patient is to:

Administer 300mg of amiodarone

Defibrillate at 120 Joules (diphasic)

Consider 1 mg of atropine

Synchronized cardioversion at 360 joules

3. Following the appropriate treatment in question 2, ECG 2. What is the following rhythm?

ECG 2

Ventricular tachycardia

Atrial tachycardia

Fine Ventricular fibrillation

Coarse Ventricular fibrillation

4. Your next appropriate treatment of choice for this patient is to

Provide five cycles (2 min) of CPR.

Defibrillate at 360 J (or equivalent biphasic energy).

Consider 1-2 g of magnesium sulfate.

Defibrillate at 200 J (or equivalent biphasic energy).

5. Following the appropriate treatment in question 4, ECG -3 shows on the monitor as:

ECG 3

A Torsade de pointes.

Asystole.

Ventricular fibrillation.

Ventricular tachycardia.

6. Your next appropriate treatment for this patient is to

Defibrillate at 200 Joules

Administer Amiodarone 300 mg bolus

Administer epinephrine 1 mg (10 mL of 1:1000).

Either A or C

7. The patient is still pulseless with no respirations at this time. The next most appropriate treatment includes:

Administer Amiodarone 300 mg bolus

Administer Atropine 300 mg bolus

Administer epinephrine 1 mg (10 mL of 1:1000).

Either A or C

8. After administering the above treatments including medications, CPR, and defibrillation the rhythm shows as:

Ventricular fibrillation converting to a sinus rhythm. (VTach into sinus)

Ventricular tachycardia converting to asystole

Torsade de pointes.

Atrial tachycardia converting to a sinus

9. What are 4 possible reversible causes this patient may have experienced?

a. Include a rationale or additional labs, assessments and information you would like to have to determine a likely reversible cause.

Hypoxia: Ptn has a hx of htn, CAD, and just had a hip replacement. The increased physical activity from her physical therapy may have increased the oxygen demand of her heart. Need an ABG for accurate results of oxygen saturation. Count respirations.

Hypovolemia: She had a recent total hip replacement and may have experienced blood loss. Her physical therapy could have opened the surgical site and she may have bled in her room. Need a CBC to look at hematocrit and visual inspection of the surgical site. Blood pressure and MAP to see if organs are being perfused.

• Thrombosis, Pulmonary: She has a history of pulmonary embolism and

has been in bed from the surgery. Her physical therapy could have

moved the clot into her lung, causing respiratory arrest. Need a CT or US to look for clot, d-dimer blood test, listen to lung sounds

Thrombosis, Coronary: Ptn has a history of CAD and has been immobile following her surgery. The CAD would cause stenosis of her coronary arteries and would make it easier for a embolus to block blood flow. Need EKG to see ischemia, injury, or infarction, ECHO to look at ejection fraction, CT or US, d-dimer, heart sounds

II. Scenario 2:

You come on shift and walk in your room to assess your 48-year-old female patient. Upon walking in the room she appears to be asleep. You quietly cycle the blood pressure monitor and try to locate her pulse oximeter that appears to be disconnected. Your blood pressure will not give you a reading. You try to wake your patient up and find that she is unconscious without a palpable pulse.

ECG 1

Identify the following rhythm:

Junctional rhythm

Sinus rhythm

Accelerated junctional rhythm

Pulseless electrical activity

Your initial treatment is to start CPR and:

Defibrillate at 120 Joules (monophasic)

Consider and treat possible causes

Administer 300mg of Amiodarone

Administer 6mg Adenosine

Following appropriate treatment in question 2, the patient still does not have a pulse or respirations and the ECG monitor shows: ECG 2

Junctional Tachycardia with PEA

Atrial tachycardia with PEA

Accelerated junctional rhythm with PEA

Sinus tachycardia with PEA

Your next treatment of choice is to administer:

Epinephrine 1 mg

Hold the digoxin

Vasopressin 40 Units

Amiodarone 300 mg

Following the appropriate treatment in question 4, the patient is still not breathing but does have a pulse. The monitor shows:

ECG 3

Accelerated junctional rhythm

Atrial tachycardia

Sinus bradycardia

Junctional tachycardia

Your next appropriate treatment for this patient is to:

Begin chest compressions

Administer 0.5mg of atropine

Stop ventilating the patient

Administer 6 mg of adenosine

Following the correct treatment in question 6, the patient now has an advanced airway in place and has a blood pressure of 110/70 mm Hg. The rhythm interpretation is:

ECG 4

Sinus tachycardia

Sinus bradycardia

Junctional Rhythm

Normal sinus Rhythm

Scenario III

You float to the Emergency room and receive report for the paramedics. An 80-year old female was found lying in an alleyway. She had an unwitnessed arrest, and currently has no pulse or respiration. ECG 1

The interpretation of this rhythm is:

PEA

Asystole

Agonal Rhythm

Third degree AV block

After taking over CPR the next best treatment would be:

Defibrillating with 120 Joules (monophasic)

Administering 6mg of Adenosine

Consider the reversible causes

Consider beta blockers

Your next appropriate treatment includes:

Amiodarone 300mg