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AS2.1-2 | Cardiopulmonary Resuscitation — PBL Case
CLINICAL SETTING
It is 2:30 PM on a Tuesday. Mr. Ramesh Kumar, a 58-year-old man with known hypertension and ischaemic heart disease, was admitted yesterday for investigation of exertional chest pain. He is on aspirin, metoprolol, and atorvastatin. He was comfortable this morning and his ECG showed non-specific ST changes. At 2:28 PM, the ward nurse hears a crash from Bay 3. She finds Mr. Kumar slumped sideways in his chair, unresponsive. She calls for help and notes no normal breathing — she observes two slow, noisy, irregular gasps. The crash trolley is 12 metres away. A first-year resident is the only doctor on the ward. The defibrillator is wall-mounted and takes 90 seconds to retrieve.
Trigger 1: First response: recognition and early BLS
The nurse activates the hospital arrest call. The first-year resident arrives and confirms: no response to pain, no normal breathing. He starts compressions. The nurse returns with the defibrillator. The resident notes the two gasps he saw were irregular and noisy — nothing like normal breathing. When the defibrillator pads are attached 90 seconds later, the monitor shows: ventricular fibrillation. CPR is ongoing. A second nurse counts compressions aloud and notes the rate is approximately 85/min and the resident is not allowing full chest recoil. The anaesthesiology registrar arrives within 3 minutes.
DISCUSSION POINTS
- What is the correct adult BLS compression rate, depth, and ratio — and what errors are being made in this scenario?
- The nurse observed two slow, noisy, irregular gasps before calling a cardiac arrest. Should she have waited to confirm the breathing pattern? What is the clinical significance of agonal breathing?
Click to reveal Trigger 2: ALS: rhythm identification, defibrillation, and drug management (discuss previous trigger first!)
Trigger 2: ALS: rhythm identification, defibrillation, and drug management
The anaesthesiology registrar takes over as team leader. She assigns roles: one nurse for compressions (rotating every 2 minutes), one resident on airway (BVM), and a third nurse for IV access and drugs. First shock delivered (200 J biphasic). CPR resumed immediately. After 2 minutes, rhythm check: VF persists. Second shock given. CPR resumed. IV access secured after the second shock. The team leader calls for adrenaline. After the third shock, amiodarone is prepared. The medical registrar asks: 'Should we give sodium bicarbonate for the metabolic acidosis?' A portable ABG shows pH 7.18, PaCO2 60 mmHg, HCO3 21 mmol/L. The arrest is now 14 minutes old.
DISCUSSION POINTS
- What are the correct doses and timing of adrenaline and amiodarone in shock-refractory VF? When exactly should each be given relative to the shock sequence?
- The ABG shows combined respiratory and metabolic acidosis. Is sodium bicarbonate indicated? What is the correct approach to acidosis during CPR?
Click to reveal Trigger 3: Rhythm changes, post-ROSC care, and team debriefing (discuss previous trigger first!)
Trigger 3: Rhythm changes, post-ROSC care, and team debriefing
After the fourth shock and the 150 mg amiodarone bolus, the rhythm converts to sinus tachycardia at 110/min. EtCO2 rises abruptly from 12 mmHg to 38 mmHg. A carotid pulse is present. ROSC achieved at 22 minutes. Mr. Kumar is unresponsive (GCS 4). His blood pressure is 78/50 mmHg. SpO2 is 87% on BVM. The 12-lead ECG shows ST elevation in leads II, III, aVF. The team transfers him to the ICU. Two hours later, the ward team gathers for a post-arrest debrief. One junior nurse asks: 'We got him back — does temperature matter if he makes it to the ICU?' Another intern asks: 'Why did EtCO2 suddenly jump? Does that mean the tube is in the wrong place?'
DISCUSSION POINTS
- What are the immediate post-ROSC management targets for ventilation, oxygenation, haemodynamics, and temperature in a comatose survivor with an inferior STEMI?
- What does the abrupt rise in EtCO2 from 12 to 38 mmHg signify, and how should it be interpreted in this context? What are the implications for ongoing management?
Group Task Assignments
Group 1: Collaborative Task
- As a group, construct a timeline of the arrest from recognition to ROSC, annotating: when each BLS error occurred, when adrenaline and amiodarone were given relative to the shock sequence, and when the first post-ROSC target should have been checked.
Group 2: Collaborative Task
- Draft a structured 10-item bedside 'arrest checklist' that the team leader could use in real-time during the next cardiac arrest on this ward — covering BLS quality check, rhythm identification, drug sequence, reversible cause search (4H4T), and ROSC recognition.
Learning Issues
Research these questions and bring your findings to the discussion.
- [AS2.1] What are the precise adult BLS technical parameters (rate, depth, ratio, compression fraction, recoil) and how do they differ for the paediatric and neonatal settings? How should agonal breathing be recognised and distinguished from normal breathing?
- [AS2.2] What is the complete ALS algorithm for shockable rhythms — covering defibrillation energy, adrenaline dose and timing, amiodarone dosing, and the management of non-shockable rhythms including reversible causes? What are the evidence-based post-ROSC targets and why is each recommended?