ACLS part 2

Since I wrote ACLS part 1 that I took the other day, perhaps I should write about the one that I retook. :)

I went to IMU that day, quite early to find out what time it will be hold and to attend my selective in the hospital that started on the same day. :)

It was a fruitful day, to be able to see my close friends after so long and to be independant (attend forensic apartment by myself) and to attend ACLS with confidence. :)

So this is the question that I got.

Patient came in with breathlessness, chest pain, suddenly went unconscious.

First thing CHECK responsiveness.
patient is not responding
Call for help.
Check pulse. (yay, I remembered!)
Pulse present.
So I said get my stuff to assist ABC by using oxygen mask. set up IV lines, get BP reading, and cardiac monitoring. BP was low. forgot how much..
The cardiac monitor shows 2nd degree type 2 heart block. (morbitz type 2)

I got it correct. :)
and so I said (to be safe) check for perfusion status. But if it's already type 2, the right thing is to start TCP right away. So anyway, perfusion status is poor, with all the symptoms going on and low BP, so I prepare for TCP.
while awaiting TCP, I'll start drug:
atropine 0.5mg every 3 to 5 min

then here's what I made wrong, forgot to check the effect. SO must check rhymtm again and pulse and BP.
it doesn't help
add in epinephrine 2-10microgram/min
or dopamine 2-10microgram/kg per min

check rhytm, the rhtyhm changed to ... shocking.. XD Ventricular tachycardia. (VT)
check pulse
no pulse
start CPR right away, prepare defib.
CPR for 5 cycles. no change, shock patient. 200 (for biphasic) and 360J for monophasic
and then resume CPR, check pulse and rhtyhm

pulse resume
rhymthm changed back to second degree heart block type 2

TCP was ready...
so leave to the professionals for that..
End of story..

that's what I got. :)
hope I pass this. :)

EDITED: passeddd! yay!

headache

It feels like the temple of my head is squeezing everybit into my mind.

It is aching pain.. 

Results from getting all tensed up for the ACLS I"m taking on Monday. 

Well, why tense up..? cause it's the second time I'm taking and I don't want to fail it again. 

I think I give lots of 'what if' situations when I'm studying the algorithm, and ends up with ' what if she (examiner) came up this... oh no.. what should I do?' questions. 

I know where I screwed up in last exam. When my friends were taking the exam, I can answer the questions that the lecturer asked them in my heart. I know where I should be going. but when it reaches me... 

I panicked, kept my mind focused on the second part of 'getting the bp set, oxygen mask, iv lines' cause I scared that I might forget. THAT leads me to forget the straight away thing after checking responsiveness and call for help is check pulse.. 

A total wrong right from the start and I lose all the confidence.  

she says no pulse. 

start cpr immediately.
get defib, give oxygen bag mask, set up iv lines, and cardiac monitoring. This is where it should come.
the cardiac monitor shows this:

the second part I get wrong, is I didn't figure out it's a PEA activity. 

the screen shows sinus tachycardia. 

the examiner looked at me saying "are you sure?" when I said 'shock' patient.. then I took a lot at the screen again.. I know I'm not wrong. It shows "sinus tachy." THEN after like 5 seconds of looking, the chart pop into my mind. only VT and VF is shockable. I was like.. 'OH HELL!!' and it's a 'pulseless' and so it's a PEA. should not shock the patient! this is non-shockable rhtyhm. 

continue cpr for 5 cycles and then add in atropine 1mg iv every 3-5 min. 

check rhtyme and pulse.

then she continued saying no use. no use for two times and I repeated my answer with atropine two times.. 

so what should I do? 

yes, investigate the causes..

I listed out the 5T and 6Hs. but took some time again listing cause I was panicking already.. 

I was all 'crap crap' 

then she asked me what's the most possible cause in this patient. 

pt is young asthmatic. 

I said "hypoxia"

what else? 

eh... 

what others in young asthmatic? 

so. then after I paused for awhile i decided to give it a shot since it's the only answer in my mind, so I said "tension pneumothorax"

correct..

so what should I do? 

needle decompression. 

landmarks?

second intercostal space, midclavicular line. 

and you'll hear a hiss sound after poking

then what do you do?

check rhtyhm and assess vital signs. 

take x ray

patient returned normal

pulse present.

yay.. then..? 

what did you do just now?

I think think back.. needle decompression... 

insert chest tube! 

take x ray. 

asssess vital signs. 

patient returned normal

monitor. 

post resuscitation care.


so the most important thing for me is not to panic..  and have confidence. oh well.. I got the most difficult twisted case.

I studied hard for this time.
I must pass this time.
I can be a leader when I want.

best wishes for me.