Neighborhood Hospital Emergency Department Record Date: Thursday Arrival Time: 0912 Method of Arrival: EMS Condition upon arrival: Poor Triage Assessment Time: 1832 Information Obtained From: patient Name: Ocampo, Danilo Vital Signs: T: 36.7C RR: 26 HR: 111 BP: 91/42 MAP 57 O2 Sat: 99% 2L Pain: 10/10 Gender: M Race: Marital Status: Married Occupation:
5’ 7’’ Wt: LMP: N/A Pregnant: N/A Allergies: Medications: Metoprolol, lisinopril, aldactone, furosemide, potassium when taking furosemide, aspirin, isosorbide dinitrate, and nitroglycerin Reason for Seeking Care: Chest pressure, cough productive of Past Medical Hx: Significant Family Hx:
frothy, pink sputum. Fatigue and shortness of breath x few weeks, Hypertension, myocardial
Examination Findings: Social Hx: Immunizations:
Anxious and diaphoretic with increased work of breathing; HRRR, frothy
pink sputum with cough. Bilateral lower lobe crackles noted anterior- and ETOH: none
Triage Interventions: Oxygen .50 NRB, Morphine 4mg IVP, Nitrogycerine 1 tab SLx1, aspirin 325mg POx1, Furosemide 40mg IVPx1, stat 12-lead ECG. #16G IV catheter placed (L) AC, #18G IV catheter placed (R) FA, foley catheter placed. Labs- CH12, CBC, ABG, UA, Digoxin level, cardiac enzymes sent.
Triage Level: A Disposition: Triage Nurse Signature: Ron Litrell, RN Nursing Assessment: Time: 0925 ER Bed: Cardiac Room Mental Status/Neuro Head/Neck:
anxious, follows commands appropriately.
Respiratory: Cardiovascular Eyes/Ears:
S1, S2; no murmurs or extra heart sounds.
Abdomen: GU/Genitalia Musculoskeletal:
Abd flat, + bowel sounds all 4 quadrants;
moves all extremities with equal strength.;
soft, non tender, no distension or guarding.
RN signature: Sjori Kauffman, RN Physician Assessment/Notes Time: 0930 HPI Patient reports shortness of breath and angina off and on for few weeks. Increased lower extremity edema reported for few weeks, also noted on arrival. Has not been taking medications as prescribed for one week since wife’s illness. Pt. reports increasing fatigue and new onset chest pain, stated 10/10 on pain scale, with cough productive of pink, frothy sputum. Pt. has hx significant for hypertension, MI, angina, and class 2 heart failure. Examination Findings Neuro: Anxious but oriented. ENT: Normocephalic, PERRLA- 3mm. CV: HRRR; no murmurs; pulses +1 thready; cap refill 3 seconds. Resp: Shallow, rapid respirations with bilateral crackles noted. GU: Negative. Mus/Skel: Symmetrical and equal. Impression: Acute MI, worsening heart failure. Physician Orders: Physician Notes 0950- ECG shows significant ST elevation noted in V1 to V4. Lab results
returned as follows: CBC- WNL, CH12- K+- 3.6, Na- 136, CO2- 22,
Chloride- 100, BUN- 12, Creatinine- 0.8. ABG: pH- 7.28, CO2- 55, PaO2-
78, Bicarb- 24. UA- WNL, Digoxin level-0.1ng/ml. Cardiac enzumes: CK-
336 U/L, CK-MB- 10.8IU/L, Troponin- 1.0ng/ml.
1010- Cardiology consult arrives. Dr. Cox states pt. is mostly likely in heart
failure due to non-adherence to medication regimen. Dobutamine gtt.
1035- Patient having increased shortness of breath. Intubated with 7.0 ETT,
secured at 22cm. Vent settings- SIMV rate 16, FiO2 100%, PEEP 8, Pressure
1045- Patient into v-fib. Resuscitation efforts started. Please see code sheet.
25mcg IVP, Vecuronium 10mg IVP, and Etomidate 20mg IVP-for intubation. Stat chest xray for tube placement, stat ABG.
Consultation: Cardiolgy Arrival Time: 1010 Diagnosis: Acute MI progressing to cardiogenic shock Disposition: Deceased Physician Signature: James Gordon, MD RN signature: Sjori Kauffman, RN RT signature: Jenna Melendrez, RRT Emergency Department Nursing Flow Sheet Assessment/Response Initials
Morphine 4mg IV for chest pain. ECG done. Pt. c/o
Pt. states pain slightly improved post Morphine. SOB
unchanged Pt. remains anxious. Ativan 1mg IVP given for anxiety. Nitroglycering 1 tab SL given for chest pain.
Pt. states slight improvement, appears more
comfortable at this time, now slightly confused- reorients easily. Chest pain continues, “crushing” per pt. when asked.
Pt. states pain “horrible” when asked. Pt becoming
combative with increasing confusion. Morphine 2mg IVP given per Dr. Gordon. Pt. having frequent, multifocal PVCs.
Dobutamine gtt started at 5mcg/kg/min. per Dr. Cox,
cardiology. Pt having obvious respiratory distress, states “yes” when asked if he wants a breathing tube placed.
Pt. intubated by Dr. Gordon on 1st attempt. Ativan 2mg
IVP, Fentanyl 25mcg IVP, Vecuronium 10mg IVP, and etomidate 20mg IVP prior to intubation.
Pt. on vent per Jenna, RRT. See respiratory flowsheet.
Pt. remains unresponsive, dobutamine gtt increased to
8 mcg/kg/min. to increase MAP to 65. Chest xray
Pt. into V-fib, 0 pulses. Dr. Gordon at bedside. See
Fluid Intake Fluid Output Type Amount Running Time initated
Discharge Instructions: N/A Disposition: Time Discharged from ED: N/A RN Signature: Sjori Kauffman, RN Signature: Cardiopulmonary Resuscitation Record Date: Thrusday Location: ED- Cardiac room Service: Emergency Medicine Witnessed arrest: XUnwitnessed arrest:___ Respiratory arrest:___ Cardiac arrest: X Code Chronology Time Code Event Recognized: 1045 Time CPR started: 1045 Code Team Called? No Time Code Team Called: N/A Time Code Team Arrived: N/A AED Time: 1048 Code Status: Full Number of Shocks: 4 Presenting Hx R/T Code: chest pain, shortness of breath, cough productive of pink, frothy sputum. Hx. of heart failure, hypertension, MI. On cardiac monitor prior to arrest? Yes Intubated prior? Yes Admitting Dx: acute MI, heart failure Glasgow Coma Scale: Pupil Guage: 3 4 5 6 7 8 (mm)___ Pupils: Equal reac Fixed/No reac Unequal__________ Respiratory Assssment/Interventions:
Intubated during code? No Intubated by: Dr. Gordon Time of Intubation: 1035 Tube placement: 22cm at teeth
Spontaneous ventilation: No Size of ETT: 7.0 Oral X Nasal___ Bilateral breath sounds: Yes
Airway ETT X LMA___ Number of intubation attempts: 1- prior to code Ambu bag w/ 100% O2? Yes Comments:___________________________________________________________________________ Prior IV Status: Initiated IV Status: External Pacemaker Used: No Time Rhythm Joules Med/Dose/ Response Pulse BP Sp CPR BVM Fluid Comments Time Site FiO2 pH PaCO2 Pa02 HC03 %Sat Other Lab Post Arrest Status
Expired: Yes Time: 1057 Pronounced by: Dr. Gordon
Family Notified? Yes Name: Kristina- niece By: Dr. Gordon
Autopsy Requested? Yes Requested By: Kristina- niece
Donor Services Notified? Yes Time: 1115 By: Dr. Gordon
Print Name Signature Recorder:
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Neighborhood Hospital 
Emergency Department Nursing Flow Sheet 
Cardiopulmonary Resuscitation Record