Trigger
You are an intern the emergency department of a regional hospital. An elderly gentleman named Steven is in the department for workup of some sudden-onset chest pain.
A nurse has just called out for help with Steven, who has become unresponsive.
Tasks
- Manage this situation.
Actor’s Script
You are a nurse working in a regional emergency department and you are looking after Steven, who has just become unresponsive.
You have called the candidate to assist you. Please guide them down the following sequence of events…
- When the candidate enters the room…
“Hello doctor. Steven has just become unresponsive and I’d like your help assessing him.”
- When the candidate attempts to speak to the patient…
“He isn’t saying anything. I’m worried he’s unresponsive.”
- When the candidate attempts to elicit a response…
“He’s completely unresponsive”
- When the candidate looks for signs of life…
“There’s no pulse and he is not breathing”
- The candidate should call for help promptly
Reach for the wall and say “I’ve pressed the emergency bell”
- Once the candidate has demonstrated chest compressions…
Say “I can take over now” and begin doing compressions
- When the candidate is demonstrating the “defibrillator dance”, no not stop or resume CPR without being asked to by the candidate. They are being assessed on their safety and communication skills.
Resources
First Rhythm Check
Second Rhythm Check
Marking Key
Introduction
- Washes hands
- Introduces name and role
Initial Management
- Checks for danger
- Assesses for response
- Sends for help
- Assesses for signs of life
- Look, listen and feel for breathing
- Demonstrates adequate chest compressions
- 30:2 compressions:breaths ratio
- 1/3 of the AP chest diameter
- 100-120 beats per minute with adequate recoil
- Demonstrates bag valve mask technique for two breaths
- Must observe a chest rise
Inform the candidate that resuscitation trolley has arrived and they can now move on to defibrillation
- Correctly attaches defibrillator pads
First Shock
- Safely demonstrates the “defibrillator dance” with correct verbalisations throughout
- Compressions continue
- Oxygen away
- All else clear
- Charging to 200J
- Hands away (confirms with nurse)
- Evaluating…
- Dump or deliver
- Recognises VF and delivers the shock
Ask the candidate to verbalise the four H’s and four T’s
Four H’s and T’s
- Correctly recalls all eight items
- Hypoxia
- Hypovolaemia
- Hypo/hyperkalaemia + metabolic derangement
- Hypo/hyperthermia
- Toxins
- Thrombosis
- Tension pneumothorax
- Tamponade
Second Shock
Tell the candidate that two minutes have passed and they can return their attention to the defibrillator
- Recognises VF and delivers the shock
- Administers 1mg adrenaline
Post-Resuscitation Care
Indicate that the patient has begun groaning and moving on the bed. Ask the candidate what this means.
- Correctly identifies return of spontaneous circulation
Ask the candidate what the appropriate post-resuscitation care is for this patient.
- Mentions A-E assessment
- Asks for a 12 lead ECG
- Says they would treat underlying cause