In this station, you’re tasked with showing the proctor you know how to correctly diagnose a rhythm strip and then state your treatment of the patient experiencing that arrhythmia. Attacking these scenarios is easy. Just follow these steps in order:

1. Review the scenario presented out loud and then examine the strip. 
   • Look closely for pulse status (absent or present) and any clues regarding whether you feel the patient is Stable or Unstable.
2.  State to the proctor, “This is __________. I believe they are (Stable or Unstable) based on the information provided.
3. General treatment of a patient experiencing this is _____________. 
   • This is simply a regurgitation of the proper ACLS algorithm. 
     • If the patient is not experiencing a rhythm within an ACLS algorithm, remember this memory aid: BSI and V-O-M-I-T
       • BSI: Body Substance Isolation Precautions, is my scene safe? (Yes? Keep going. No? Wait for PD to clear the scene)
       • Vital Signs
       • Oxygen
       • Monitor (4-Lead and 12-Lead) & Medications (If ACS, think M-O-N-A: Morphine or Fentanyl, Oxygen, Nitro, and Aspirin). “I will watch the patient and the monitor en route, observing for signs of any improvements or deterioration.”
       • IV. 18G is usually very appropriate.
       • Transport (Usually code 3): Don’t forget treatment en route. Vitals every 3-5 minutes, notify receiving hospital, etc
     • Go down the algorithm, letting the proctor know that you’d be observing for changes, treating accordingly, and switching out CPR compressors every two minutes, doing rhythm checks, etc. See V-O-M-I-T information below to help round out your treatment.

EXAMPLE 1: 

You’re called to the scene of an unconscious 48-year-old male found down at a local park. He appears to be homeless, and some of his friends wave you down to his location on your arrival. You find him lying face down, and he does not respond when performing a “shake and shout.”  This is the rhythm you find him in, and you note no carotid pulse:

Your Response:

• BSI, is my scene safe? This patient is unstable, is in PEA, and requires rapid treatment. 
• I will ensure my crew provides high-quality CPR to start, rotating compressors every two minutes. 
• I will have an ALS partner perform an ETT on him while my third partner obtains an IV. Once we have an IV, we will give 1mg of Epinephrine 1:10,000 every 3-5 minutes, assuming the patient stays in the Asystole/PEA algorithm.
• We will ensure BVM ventilations are delivered with high-flow oxygen and that our monitor is in paddles mode with a 4-lead and 12-lead ECG connected in case we get ROSC. 
• Once we have our system in place, are delivering high-quality compressions, rotating compressors, and doing rhythm checks every two minutes, I will begin to ask the patient’s friends if they know anything about what could have caused this. 
• My plan moving forward would be to work the code where he is to ensure we’re giving the best CPR we can until we’ve met protocol to cease all efforts in the field. 
• If we get a ROSC, we will transport to the nearest trauma center code 3. En route, we would perform VS every 3-5 minutes, obtain a 12-lead ECG, and observe the patient and the monitor for any signs of deterioration or improvement. 

Notes:

• Be able to recite the H’s and T’s. 
• Be able to describe what you’re looking for on the 12-lead.

EXAMPLE 2:

You’re called to the scene of a 72-year-old female who states she “feels funny.” The patient’s daughter is on scene and states that her Mom began feeling very weak and complained of intermittent chest discomfort. The patient states she “feels fine, just had a moment of weakness, is all.” You check her VS and ECG and find the following:

BP: 118/68, HR as shown, RR of 20/minute and non-labored, SpO2 of 94% on room air. 

Your Response:

• BSI, is my scene safe? This patient is stable for now but has the potential to become unstable if this rhythm turns into something else. 
• This rhythm is Sinus Pause. 
• I would ask one of my crew members to obtain a 12-lead ECG. I would explain to the patient her heart rate is showing an irregularity, and I would ask her if she’d been diagnosed with anything like that before.
• Assuming this is new-onset, I would tell her we’d recommend treatment and transport to the hospital. Code 1 for now unless she became unstable. To me, unstable would mean a change in her VS, a change in mentation, or an increase in her chest pain and discomfort. 
• I would place her on a nasal cannula at 4L/min with end-tidal capabilities. 
• I would obtain a peripheral IV. 
• I would also inquire about her chest pain. If she was still feeling discomfort, I would treat her with the following: Morphine IV, 324mg of baby ASA, and 0.4mg of SL nitro spray. 
• I would watch the patient and the monitor and observe for any signs of deterioration or improvement. 
• I would check VS every 3-5 minutes. 
• I would call the hospital and let them know we’re inbound and what our ETA is. 

Notes:

• Be able to describe the atypical presentation the elderly, women, and diabetics can have in regard to chest pain.