A 70-year-old man presented to the emergency department in cardiac arrest. The cardiac monitor showed ventricular fibrillation. As a junior doctor, the respondent's task was to prepare the defibrillator. This involved: 1) switching on the machine and setting it to 200J; 2) opening the defibrillator pads and having an assistant apply gel; 3) placing the pads in the correct positions on the patient's chest; 4) shouting warnings before delivering shocks; and 5) reassessing the patient's rhythm after shocks and resuming chest compressions. An elderly man was found unresponsive in a parking lot. As a junior doctor on scene, the respondent's immediate actions were to:

1. Defibrillation *VF (cardiac arrest)
A 70-year-old man with known case of hypertension and diabetes mellitus for 20 years with
poor control by medication, come to the Emergency Department with chest pain. While
managing his chest pain, the patient is suddenly collapse and CPR is immediately perform.
The cardiac monitor is showing wide and irregular QRS complex.
You as a junior doctor in ED are required to assist the resuscitation team by preparing the
defibrillator machine. Explain the technique to prepare the defibrillator machine.
Identify the rhythm - Ventricullar fibrillation
I switch on the machine, press unsynchronised button, set for 200 J
I take out the pads by open book method and I ask assistant to apply the gel
I put the pad below the right clavicle and at the apex with good contact
Im shouting: “I’m charging now by pressing orange button, everyone clear except chest
compressor”
I recheck the rhythm and fully recharge
“I’M GIVING THE SHOCK, I CLEAR, YOU CLEAR, EVERYONE IS CLEAR”
I press the shock button simultaneously
I put back the pad + Reassess the rhythm
Chest compression is continued immediately

2. Basic Life Support (BLS)
An elderly man is found unresponsive at the parking lot. A crowd of people come to the
scene to see what is happening. You as a junior doctor walking to your car and also see the
scene. The other people do not know what to do with the elderly man.
What is your immediate action as a junior doctor?
“DR SCAB”
 Danger
 Response
 Shout
 Circulation
 Airway
 Breathing
Danger
I assess for the scene safety, clear the crowd.
The scene is safe now.
Response
I assess for the patient’s response. “Hello sir, are you okay? Can you hear me? (Tapping
the patient’s shoulder)
Patient is unresponsive.
Shout
Appoint someone call 999 and bring an AED!
Circulation
I feel for the carotid pulse, listen for the breathing and look for the chest rise (ears at the
patient’s mouth and look at the chest)
Patient has no pulse and no breathing
CPR
I perform high quality CPR immediately
I determine the location: I locate the sternum and put my hand between the nipple line
I use my dominant hand on top of the other hand and start chest compression
5 quality CPR= 30 compression by 2 ventilation, depth 2 inch/5 cm, 100-120
compression/min, allow chest completely recoil with minimal interruption.
ONE, TWO, THREE, FOUR, FIVE, SIX, SEVEN, EIGHT, NINE, TEN…THIRTY
I will do Head tilt chin lift
Then I give 2 rescue breath using mouthpiece if available and look for chest rise
I continue chest compression for 5 cycles while waiting for the AED
After complete 5 cycles of chest compression, I feel for carotid pulse, listen for breathing,
look for chest rise

3. If there is pulse and breathing
↓
Post ROSC algorithm
Left lateral position
If no pulse, no breathing
↓
Continue CPR for 5 cycle
Airway Assesment
A young man is found unresponsive at the jogging track. The surrounding people called the
ambulance immediately. You are one of the resuscitation team come at the scene. You
assess the patient and found that the pulse and breathing is present but unresponsive.
Explain the airway management in this young man.
I assess the airway patency by asking the patient name or condition. “ Sir are okay? What is
your name?
I do head tilt chin lift and open the airway.
I look for any foreign body, if any I remove by Magil forceps
I look for any blood or secretion, if any I do suctioning by Yanker suction
Now airway is cleared
I want to maintain the airway by inserting Goudell oropharyngeal airway
I chose the correct size by measuring the angle of the mouth to the tragus
I apply gel to the oropharyngeal airway
I introduce it by pressing the tongue downward and along the hard palate
When reaching soft palate I rotate OPA 180˚
I secure the airway by tape
I give supplemental oxygen
Circulation Assessment
1. Assess AVPU =Alert, Verbal = Are you Ok? Pain = If not, pain on trapezius (picit), if not =
unconcious
2. Hands = Pale/Palmar erthema, CRT, Warm/ Cold, Pulse, Connect to monitor *BP and
Heart Rate
3. Insert 2 large bore IV cannula (14-16 G Grey/orange), draw blood for investigation,
administer IV fluid
4. Assess for external bleeding - on the floor, on the bed, check for bleeding on the chest,
abdomen, pelvic, long bone *femur. If present, I will apply compression to stop bleeding
using gauze. (Tourniquet only to amputated limb/ unsalvagedable bleeding)
5. Assess for internal bleeding - cardiac tamponade *muffle heart, elevated heart sound,
hypotension, abdomen - tenderness, distension, long bone/pelvic tenderness
6. I will ask for fast scan to search for free fluid to confirm the bleeding *Morrison pouch,
Spleenorenal, Subxiphoid, Pelvic
7. Asess for stage of hypovolemic shock - if stage 3/4 start MTP (massive transfusion
protocol)

4. Disability
1. Assess GCS *Eye, Verbal, Motor
2. Pupil reflex
3. Lateralizing sign - Tone, Power - Pasive, Active *Grading
4. Capillary blood for GRBS
5. Intervention - GCS<8 = intubate, if sluggish pupil reflex - increase ICP (CT brain, mannitol)
If trauma patient/ Head injury = CT scan Brain, Mannitol for Decrease ICP
Grade muscle Power
0 - No power
1 - flickering
2 - horizontal movement
3 - against gravity
4 - against gravity + some resistance
5 - full power