The to pulseless electrical activity or Ventricular asystole



The timely and appropriate
identification of and response to patient deterioration is essential for
optimal patient outcomes and avoidance of preventable harm
Forrester,2015.Whatever the causes nursing staff needs to take control of the
situations and ensure patients are adequately monitored and deterioration in
their condition is quickly acted uponnursing times 2011regular monitoring and
appropriate intervention by scoring with the help of national early warning
score will help to prevent patient’s deterioration as much as possible. It also
necessary to use structured communication method like SBAR to get immediate
response and medical intervention.


The adrenaline
(1:10000100mcg/ml) intravenous injection is recommended for use in
cardiopulmonary resuscitation, specifically for the treatment of cardiac arrest
due to pulseless electrical activity or Ventricular asystole or as an adjunct
to electrical defibrillation in the treatment of ventricular fibrillation or
pulseless ventricular tachycardia. It may be repeated every 3-5minutes as intravenous
or intraosseous if necessary – without interrupting the CPR administration
through central line results in a faster response than the peripheral line,
however, placement of central line should not interfere with chest compression.
The drug administering through peripherally must be followed by a flush of at
least 20ml of sodium chloride 9%injection to avoid any extravasation or tissue
damage and to help with an entry into the central circulation. In case of acute
hypotension, adrenaline is also given as a continuous infusion. BNF,2016-2017 

Defibrillation is an emergency
procedure performed to terminate ventricular arrhythmias, especially
ventricular fibrillation is potentially lethal, but survivable rhythm; commonly
found in victims of sudden cardiac arrest Rozner Marc A 2015. Ventricular
fibrillation is caused by Myocardial infarction, Ischaemia, undiagnosed
coronary artery disease. In Mr X’s case he had repeated Myocardial infarction revealed
by the troponin level of   400 and ST
Elevation in anterior leadsV1-V4 which leaded to Ventricular fibrillation.
Defibrillation   success depends on the
sufficient current being delivered to the myocardium. However, the delivered
current is difficult to determine because it is influenced by transthoracic impedance
and electrode position. Furthermore, much of the current is diverted along
non-cardiac pathways in the thorax and as a result as little as 4% reaches the

Defibrillation is the passage
of an electrical current of sufficient magnitude across the myocardium to
depolarise a critical mass of cardiac muscle simultaneously ,enabling the
natural pacemaker tissue to resume control .To achieve this ,all
defibrillations have three features in common ;a power source  capable of providing direct current, a
capacitor that can be charged to a predetermined energy level and two
electrodes which are placed on the patient’s chest, either  side of the heart, across which the capacitor
is discharged. 

Marks, Link MD 2015 says the
chain survival as articulated by American heart associationAHA calls for
immediate recognition of cardiac arrest and activation of Emergency medical service,
early CPR, rapid defibrillation, effective advanced life support and integrated
post cardiac arrest care, inadequacy of any of these facts will reduce the
chance of survival. According to adult advanced life support algorithm during
the CPR need to correct the reversible causes like hypovolaemia, hypoxia,
hyperkalaemia or hypokalaemia, hypothermia, Tension pneumothorax, Thrombosis coronary
and pulmonary, Tamponade, and cardiac toxinsHoughton,2014

Cardiopulmonary resuscitation
is a lifesaving technique useful in many emergencies, such as heart attack or
similar events in which someone’s breathing, or heartbeat has stopped Mayo
clinic,2017. According to the British heart association: to carry out CPR a
person must provide chest compression on casualty’s chest and give them series
of rescue breath in a ratio 30;2resus council UK,2016 to help save their life
when they are in cardiac arrest. The American heart association recommends
everyone know how to give CPR – including trained or untrained people, even
bystanders so that CPR can begin immediately in the situations where it has to
be conducted. Cardiac arrest is caused by an electrical problem in the heart,
this electrical problem causes the heart to stop pumping the blood around the
body and to the brain. It causes the person to fall unconscious and stop

As my colleagues came along I
asked them to put the crash call out and to bring the crash trolley. Whilst
connecting the patient to the defibrillator all the resuscitation team
arrived.  The defib monitor showed
Ventricular fibrillation, so one of the resuscitation team provided shock with
200 J -and advice to continue with CPR with the rate of 30 Compression and 2
rescue breaths by using bag valve mask, resus team decided to give emergency
drugs like adrenaline 10000;1 intravenous as per adult advanced life support
algorithm 2016 since patient was not having any cardiac output and no signs of
life. Whilst one of the resus team managed to intubate the patient – to help
with artificial breath. After the 1st cycle they analysed the rhythm, which
showed pulseless electrical activity so continued with CPR another 3 minutes
and repeated adrenaline 1000;1 intravenously since there was no cardiac output.
Again, rhythm analysed showed ventricular fibrillation. Shock was repeated with
300J and CPR was continued for another 2 minutes. This time the rhythm showed
sinus tachycardia decided to give intra venous amiodarone infusion and to
transfer the patient to Intensive Care Unit…

As per my referrals  on call Doctor  came to the ward to review  the patient and  I repeated the observation since the news
score is -5  I found Mr X is not
responding I  have done my  quick ABCDE assessment by open mouth his
mouth and checked for airway; it  was
clear and patent, breathing  was very
deep and shallow, I have checked the circulation by repeating observation  and also with capillary re- fill  check which shows 4minutes was unable to
record the blood pressure and palpate the pulse, and also checked the blood
sugar and gladsome coma scale-3/15  as
part of checking disability .I quickly checked the whole body to confirm any
Exposure heat loss or leaking wound or drain- but I couldn’t find anything like
that, I have shouted out for help pulled the emergency alarm and started
Cardiopulmonary resuscitationResuscitation Council UK,2016 by providing high
flow oxygen with chest compression.

As the patient was having
chest discomfort, I asked my colleague to do the ECG Electro cardio gram
whilst I bleeped the on-call doctors to come and review the patient. I
continued with him by inserting Intravenous access and collected all routine
bloods, including high sensitivity troponin. Mr X’s ECG showed St elevation in
v1, v2, v3, and v4. I repeated the bleep to on-call doctor and also called
outreach team and referred the patient to them by using news National early
warning scoreand SBAR situation, background, assessment, and recommendations.
According to resuscitation council UK 2011 a structured communication tool
such as SBAR should be used to call for help.

As part of this module, a case
study will help us to understand the depth of the learning outcomes, so I have
started to develop a case study from my area of practice. During my shift, a
patient went into cardiac arrest, but we managed to transfer him to ITU.  I picked up the case study and as per NMC 2016
code of conduct I am going to call the patient Mr X.  Mr X was an 80 years old man admitted AF H/O MI
and had VF Ventricular fibrillation Arrest. Ventricular fibrillation is a
life-threatening arrhythmia characterised by high-frequency, irregular waves of
varying amplitude that can be seen on any type of ECG device,
2017.  He was a self-caring man but was
complaining about shortness of breath and chest discomfort. As I started my
shift, I carried out his regular observation, which showed news 5 due to his
high Heart rate106per minute, low blood pressure 85/70mm of hg and the oxygen saturation
94 percentage on air.  I started him on
Oxygen 2litre via nasal canula, and I also wanted to give glycerine trinitrate
sublingual 2 puffs to relieve the chest discomfort -But its contraindicated due
to low blood pressure. All nitrates are contraindicated in hypotensive conditions
(Joint Formulary Committee., 2016).

 NEWS will help the nursing professionals to
recognise patient’s deterioration as early as possible and which will help us
to flag out patient’s   deterioration   and thus medical attention and treatment can
be given without having any delay. By using SBAR whilst referring patients -the
person who responds to those referrals   
will have appropriate understanding about patient’s problems and
complaints and the response will be quicker and appropriate and will be in a
timely manner. According to De Mister et al 2013, by using SBAR nurses could
be empowered to formulate recommendations to a physician. This is only possible
after formal assessment of the patient and knowing the situation and the
background of the patient. if the nurses are better prepared before calling a
physician and by structuring the communication, physician should be better
informed and able to prioritise in their work, give the best order and take the
right actions.

According to Downey et al
(2017), National early warning score is a standard method to assess and detect
the patient’s deterioration as early as possible. This score is calculated with
the use of seven parameters: pulse rate, respiratory rate, temperature,
peripheral oxygen saturation level, and the supplemental oxygen they are using
during the time of   checking of vital
signs, systolic blood pressure, and the neurological status assessed using AVPU
A-alert, V- responds to voice, P-responds to pain, U- unresponsive score
Kovacs et al., 2016. The news will be scored as single or multiple parameter
systems or the combination of single and multiple parameter systems (Le Lagarde
and Dwyer, 2017). The national early warning score has been shown to be a better
discriminator of outcomes than other EWS systems. In acute medical admissions,
the ability of NEWS to discriminate cardiac arrest, death and unanticipated ICU
admission in patients admitted to surgical specialities compare to admissions
in medical. Kovacs et al., 2016).

When patients come to the
hospital they put their trust in the professional who care for them
(, 2017). At least 10-15yrs ago people were facing a lot of
trouble as mortality and morbidity were high – due to a lack of facilities and
knowledge. As a result of all this, national early warning scorenews system
was implemented by a royal college physicianHawkes-2012. In this essay, I am
going to explain the importance of proper patient assessment by checking ABCDE airway,
breathing, circulation, disability and exposure, early detection by using NEWS
and appropriate action taken in timely manner by referring patients to doctors by
using SBAR situation, background, assessment, and recommendations. It is also
necessary that the patient gets their treatment on time by providing
appropriate medical intervention. 
Forrester 2015 says that the timely and appropriate identification of
and response to a patient’s deteriorating condition by health professionals is
essential for optimal patient outcomes and the avoidance of preventable harm.

As part of my continuous
practice development in my career I have had the opportunity to do this module
recognising deteriorating patient. It is essential to understand about
deteriorating patients as I work in acutely ill patient areas. Recognising the
deteriorating patient is a problem in acute clinical settings, general wards
and even in the community. A patient’s condition can deteriorate quickly and
potentially result in unnecessary death. Although this is more common in acute
clinical settings; it can happen in any setting, so all nurses should be aware
of signs of deterioration (Felton, 2012). In general, the clinical signs of
deterioration are the same, regardless of the underlying causes, because they
reflect a falling respiratory, cardiovascular or neurological system resuscitation