Post on 19-Aug-2020
transcript
1 | P a g e Version 2.0
NWC EMSS, 800 W Central, 901 Kirchoff Bldg, Arlington Heights, IL 60005, 847.618.4480
Arrest Documentation Quick Reference When documenting cardiac arrest care, the following items should be documented at applicable times and
listed intervals.
Each attempt at an intervention must be listed individually as successful or unsuccessful. (Except Chest Compressions)
✓ Intervention to Document Location/Power
Tool Interval
Initial Vitals (Including 0 pulse, resp, b/p) Vitals Tool DO NOT USE CPR VITALS TOOL
Vitals (Including 0 pulse, resp, b/p, and ETCO2) CPR Vitals Tool every 2 minutes after initial
ECG Rhythm CPR Vitals Tool Initial & every 2 minutes
Chest Compressions (Manual, w/ Feedback
Device, or w/ Mechanical Device) Procedures Tool Start/Re-Start & Stop (Rosc or Termination)
DO NOT document changes in Compressor
Oxygen (BVM) Medications Tool Time O2 was connected
Oral Airway Procedures Tool Time inserted or attempted
Nasal Airways Procedures Tool
Vascular Access Attempts (IV or IO) IV/IO Tool Time of attempt
Normal Saline (Total mL infused) Medications Tool End of call or arrival at destination
Epinephrine Medications Tool Initial & every 3-5 mins
Amiodarone (VT/VF only) Medications Tool Initial & 5 min if VF/VT persists
Defibrillation (VF/VT Only) Monitor Tool Time(s) shock delivered
Advanced Airway Attempts (ETT or Supraglottic)
Airway-suc (or) Airway-Unsuc
Time of attempt. Use appropriate tool for successful or
unsuccessful.
Blood Glucose Check Vitals Tool Time glucose is checked
Any other medications Medications Tool Document time administered
Assessments Assessment Tool
Time Performed: - Lung Sounds - Pupil - Pertinent findings / Trauma
Use of AutoVent Procedures Tool Time AutoVent was connected to Pt
ROSC Documentation Considerations
CPR Stop - ROSC Procedures Tool Time of ROSC
Full set of vitals Vitals Tool DO NOT USE CPR VITALS TOOL
12-Lead ECG Monitor Tool
Nor-Epi (if applicable) Medications Tool Time drip started
2nd site Vascular Access Attempts (IV or IO) IV/IO Tool Time of vascular access attempt
Pacing (if applicable) Monitor Tool Time pacer started
2 | P a g e Version 2.0
NWC EMSS, 800 W Central, 901 Kirchoff Bldg, Arlington Heights, IL 60005, 847.618.4480
Cardiac Arrest Report Guide
Documenting Vitals and Patient’s ECG Rhythm (every 2 minutes)
Vitals and Patient’s ECG Rhythm during a full arrest are documented every two minutes during CPR.
INITIAL VITALS, use the normal Vitals & ECG Power Tools to document (even if the patient is in cardiac arrest.)
While Pt is in arrest, use the “CPR Vitals” power tool
Upon ROSC, use the normal vitals & ECG power tools.
Use the “CPR Vitals” Power Tool to simplify documentation.
INITIAL VITALS
CPR VITALS
q. 2 minutes
3 | P a g e Version 2.0
NWC EMSS, 800 W Central, 901 Kirchoff Bldg, Arlington Heights, IL 60005, 847.618.4480
Document the following within the power tool:
Heart rate and respiratory rate defaulted to 0 (zero).
o If the heart rate is not zero because you are providing CPR to an infant with a pulse less than 60, document the
actual pt’s pulse.
Document the measured EtCO2
4 | P a g e Version 2.0
NWC EMSS, 800 W Central, 901 Kirchoff Bldg, Arlington Heights, IL 60005, 847.618.4480
Document the patient’s ECG rhythm.
o If the patient is in PEA select the underlying patient rhythm along with the “PEA” button.
o The field of ECG Rhythm can have more than one field selected
o E.g.: Patient is in “Idioventricular Rhythm” with no pulse, select both Idioventricular and PEA buttons.
ROSC and non-arrest vitals should be documented via normal power tools.
ECG Rhytms when the Pt has a pulse must be documented per standard documentation practices.
5 | P a g e Version 2.0
NWC EMSS, 800 W Central, 901 Kirchoff Bldg, Arlington Heights, IL 60005, 847.618.4480
Documenting Defibrillation
Document every time that the patient was defibrillated during the cardiac arrest event.
Select the “Monitor” Power Tool from the right column.
Select the crew member that performed the defibrillation and time of the event.
Select “Defibrillation” as your “Event Type”.
Fill in the “Energy” of the defibraillation. (joules setting of the device)
Fill in “1” for “Toatl Number of Shocks Delivered.” (Each defibrillation or intervention must be documented individually)
Select the “Type of Shock” delievered by your monitor.
6 | P a g e Version 2.0
NWC EMSS, 800 W Central, 901 Kirchoff Bldg, Arlington Heights, IL 60005, 847.618.4480
Documenting Chest Compressions
CPR (chest compressions) is to be documented as a procedure only at the following benchmarks:
o Anytime chest compressions are started (or restarted for re-arresting patients)
o When the method of delivering compressions changes (e.g.: switching from manual to mechanical device*)
o When chest compressions are discontinued. (ROSC or field termination of resuscitation.)
DO NOT document every time compressors change (q. 2 minutes).
*Mechanical CPR device means an automated device to deliver chest compressions.
7 | P a g e Version 2.0
NWC EMSS, 800 W Central, 901 Kirchoff Bldg, Arlington Heights, IL 60005, 847.618.4480
Options for discontinuing CPR may be quickly found by typing in “cpr dis” into the search window.
If CPR is performed with the ResQPOD in place, use the appropriate procedure.
If CPR is performed with a Feedback Device in place, use the appropriate procedure.
8 | P a g e Version 2.0
NWC EMSS, 800 W Central, 901 Kirchoff Bldg, Arlington Heights, IL 60005, 847.618.4480
Documenting Advanced Airways (King, Orotracheal, Nasal, Surgical)
Select appropriate Advanced Airway Power Tool from the right column, based upon the outcome of the procedure
Remember to complete the “Crew Member” field in the upper right.
Choose the correct “Airway” procedure from the list of procedures.
o The list is pre-selected to only have those procedures that are allowed by the system
Choose the appropriate blade size if a lyrgnascope was used for intubation.
9 | P a g e Version 2.0
NWC EMSS, 800 W Central, 901 Kirchoff Bldg, Arlington Heights, IL 60005, 847.618.4480
Complete all remaining fields in the power tool, including those fields under the “Airway Confirmation” section.
10 | P a g e Version 2.0
NWC EMSS, 800 W Central, 901 Kirchoff Bldg, Arlington Heights, IL 60005, 847.618.4480
Documenting Medications Select “Meds” Power Tool from the right column.
Properly document all of the medications adminsitered during the cardiac arrest incident.
Common items that are forgotten and not documented are as follows:
o Oxygen
o Normal Saline (Total ammount given)