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All neurohospitalists should maintain accreditation in Advanced Cardiovascular Life Support. Relevant courses are available from local hospitals and from the American Heart Association (AHA). We also recommend revising EKG skills before starting on the ward. What follows is a brief revision of some important points.


No pulse

CASE 19-1

You are rounding on the neurology ward, when one of the nurse trainees calls out for help. You arrive in the room directed by the nurse standing in the corridor. You see Mr. AM admitted under the care of the neurology team for suspected seizure. The patient is in a nonmonitored bed.

What is the first step in the management of a patient suspected of cardiorespiratory arrest?

Check for response; an unconscious patient regardless of cause warrants an emergency alert.

  1. Stabilize neck: If there is trauma, make sure the neck is secured and immobilized.

  2. Check for airway: At the bedside, as first responder, you may secure the airway by three methods:

    • Hyperextend the neck if there is no contraindication

    • Place your fingers behind the mandibular angle and push forward.

    • Place an airway—one of the more convenient artificial airways is the “nasal trumpet.” It is inserted in the nares with the end lubricated with KY gel and the curvature facing down. It is advanced perpendicular to the coronal plane, and once in place, it is secured with tape.

  3. Check breathing: Look for chest rising or auscultate. The shiny mirrored surface of the queen square hammer can also be placed under the nose to look for exhalation in the form of condensation.

  4. Check pulse: The best places to look for a pulse are the carotid arteries bilaterally. Extend the fingers and place your hand in the coronal plane with the palmar surface facing backwards. Place the edges of the finger on the anterior edge of the sternocleidomastoid and press back and gently medially.

  5. Call code: Do make sure code is called as soon as you suspect that the patient is unresponsive.

What is your priority before the arrival of the crash cart?

  1. Institute basic life support: If a bag-and-mask device is available, stand at the head of the bed. It is often easier if the wheel locks are released and the bed is pushed forward. The newer beds often do not have a headboard, which may impede access. The older ones are designed so that the headboard may be removed by pulling upward. The bag-and-mask is connected to the wall oxygen. The mask is then secured with the three lateral digits, while the little finger is placed behind the angle of the jaw. The other hand is used to compress the bag. A good seal and chest movement confirms correct technique. The nurse may start chest compression. If the ...

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