Acute Crisis Training with Simulation (ACTS)

Welcome to the ACTS Program

Overview

Housekeeping Toilets Refreshments Faculty Basic Assumptions

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BLS and ALS Review

Rapid Review of Basic and Advanced Life Support International guidelines International Liason Committee on Resuscitation Australian Resuscitation Council ARC AHA Predominantly expert panel Based on available evidence Coordinate research Utstein style uniform definitions and reporting templates ARC is what we use at Westmead on basiss that it is international best practice (and what the Coroner expects)

Cardiac Arrest on the Ward Increasing number of ALS calls (>5/day) Reduced number of Cardiac Arrests on Ward as a result of early detection (<50/year) Less Working Hours for Interns and Residents Less exposure as a Junior Doctor to After Hours work and non-supervised decision making Resultant Gap in Training

2010 MAJOR EMPHASIS EVIDENCE BASED With every minute Chances are reduced by 7-10% Within 4-6 minutes Brain damage and permanent death start to occur After 10 minutes Few attempts at resuscitation succeed

Evidence Based Guidelines (ILCOR) New Guidelines Due in 2015 Good Quality CPR (2010) Early Defibrillation (2010) NB - These two factors are the main determinant of return of spontaneous circulation Clearly, the evidence points to the importance of good quality Chest compressions & early defibrillation This concept of good quality CPR was introduced in 2005 as well but the sequence of initiating CPR was still ABC and the focus was airway , however the sequence has been swapped, and now there is even more emphasis on good quality compressions . Why good quality CPR? Because it maintains coronary perfusion pressure and may help establish a shockable rhythm. Statistically, for every min that passes b/w collapse & defib, survival rates from a VF arrest decrease 7-10%. Whereas, if early CPR is commenced the decrease in survival rate is gradual & averages 3-4% Why early Defib? Because it saves lives. Most cardiac arrests in adults are due to VF/VT origin & defibrillation is the only medically proven procedure which saves lives. The earlier you shock them the more likely it is going to be successful. In examples of ICD, defibrillation is almost always successful in reverting VT/VF into normal sinus rhythm because it is given within 15-20 secs. The longer they are in VF the more likely the shock is going to be unsuccessful & they might go into asystole. Again, statistically, if defib occurred < 3 min after collapse there is a 66% chance of survival to D/C as compared to 20% if done longer than 10-12 mins from collapse.

Key changes to BLS algorithm “Signs of life” removed Now DRSABCD If not responsive SEND for help If not breathing normally when airway opened start compressions before giving rescue breaths Ratio = 30:2 in Adults D Attach external defibrillator The steps in adult basic life support are summarized by the letters DRSABCD:   D- Danger- On discovery of the collapsed person alert others nearby. Ensure the safety of yourself and bystanders. Ensure that the victim is not at risk of further injury due to the environment. R- Response Establish that the patient has lost consciousness by verbal means eg “are you OK” and non-injurious stimulation (squeezing the shoulders). If the patient is unresponsive, assess the airway. S- Send for Help CALL FOR HELP/ACTIVATE THE ALS SERVICE/EMS SYSTEM FOR YOUR AREA (Call 000, 112) NOTE THE TIME A- Airway- Open the patient’s airway with head tilt and jaw thrust manoeuver. B- Breathing Ascertain if the patient is breathing (look, listen and feel). If normal breathing is detected place the patient in the recovery (lateral) position unless cervical spine injury is suspected. If the patient is not “breathing normally” and is “unconscious and unresponsive”- commence chest compressions. Gasping is a sign of cardiac arrest and occurs in up to 40% of cardiac arrests. Spend no more than 10 seconds making this decision. If in doubt commence chest compression. If alone use your mobile phone to call for help or leave the patient and summon help from nearby if there is no other option. C- Circulation Unless very experienced at checking pulses do not check for a pulse. Begin external cardiac compression (ECC).To perform ECC place the heel of one hand over the lower half of the sternum or what you perceive to be the centre of the chest. Place the other hand on top. Depress the sternum by at least 1/3 the antero-posterior diameter of the chest (5-6cm), at a rate of at least 100 per minute. Do not exceed 120 compressions per minute. The compression to relaxation ratio should be 1:1. Allow for complete recoil of the chest before the next compression. Ensure the patient is on a firm surface if possible. After 30 compressions pause and provide 2 ventilations then resume compressions. Allow 1 second for each inspiration. Look for rise in the victim’s chest with each inspiration. Continue with this 30:2 ratio until either: ٠ the patient begins to breathe normally or show other signs of life (eye opening, movement, groaning) ٠ the EMS system team or a suitably qualified person instructs you to stop ٠ you are too exhausted to continue If more than 1 rescuer is available swap the role of external cardiac compression after every 2 minutes (or 5 cycles) because ECC is exhausting. D-Defibrillation For out of hospital cardiac arrests, when an on-site AED is applied, the incidence of shockable rhythm associated arrest is up to 65%. Survival to hospital discharge for patients with an out-of-hospital VF arrest treated by EMS is about 22%. Defibrillate the patient as soon as a defibrillator becomes available and the patient has a shockable rhythm. Use an Automated External Defibrillator (AED) if one is available. Attaching the AED takes priority over CPR. AEDs can be used by minimally-trained rescuers to provide rapid biphasic defibrillation. These devices involve a few simple steps. 1) Turn the AED on 2) Follow the voice prompts which are (in general): “attach electrodes to patient’s bare chest” (electrode position will be pictured) 3) “analysing rhythm, do not touch the patient” 4) “shock advised- push flashing button” 5) The AED will then advise to continue CPR for 2 minutes 6) After 2 min the AED will advise to stop CPR and will reanalyze the rhythm and so on 7) If shock is not advised the AED will say “if no signs of life, recommence CPR” AED’s can be used unmodified in children older than 8 years or greater than 25 kg. In children 1-8 years use paediatric pads with an attenuator to reduce the delivered energy (to 50-75 J), if available, otherwise use the device unmodified. In children less than 1 year use the device if no other option is available. Excessively hairy patients may need the hair shaved from the site of pad placement.  Do not place the AED pad over an implanted device.  Do not use the AED on a wet patient. Dry the patient. AEDs greatly increase survival for out-of-hospital cardiac arrest associated with shockable rhythms. In a study by Valenzuela published in JAMA in 2000, casino security guards using an AED for pa1ents in cardiac arrest (and no CPR) achieved a survival to hospital discharge of: a) 74% for patients shocked within 3 minutes b) 49% for patients shocked after 3 minutes. This is the highest survival from cardiac arrest for any model. It is estimated that between 40 and 70% of out-of-hospital cardiac arrests are associated with a shockable rhythm initially. Evidence for the effectiveness for CPR? Some critics have argued that CPR provides little more than placebo treatment for cardiac Arrest management. CPR gives well-meaning rescuers “something to do” until the defibrillator and/or EMS arrives. However there is evidence that for out-of-hospital cardiac arrest with VF, CPR doubles or triples the rate of survival. It is estimated that survival from VF arrest decreases by 3-4% per minute with CPR and by 10%-12% per minute without CPR. CPR buys time. Precordial Thump A precordial thump is a blow to the mid-sternum with the ulnar surface of the fist. The ARC has deemphasized the precordial thump. It is not thought to be effective for VF. A single thump is suggested for a ECG monitored, witnessed cardiac arrest due to pulseless ventricular tachycardia if a defibrillator is not immediately available and within 15 seconds of the arrest occurring. This manoeuver is contraindicated if the patient has had a recent sternotomy for coronary artery grafts or valve replacement, or the patient has had recent chest trauma.

Major changes to ALS “C A B” (ABC has become CAB) Compressions Airway Minimise interruptions and use a metronome Swap on a regular basis Defibrillator charged before stopping every 2 minutes for Rhythm check Single shocks given (always 200 Joules) Airway Role of intubation de-emphasised: LMA used Keep the Pillow – apply BVM – 2 rescuers So the major emphasis is still on chest compressions, by minimal interruptions meaning you are still compressing whilst the defib is being charged You are resuming compressions as you deliver the shock and not pausing and checking the rhythm & pulse You are delivering single shock instead of the old 3 stacked shock protocol Studies showed there is no benefit of 3 over 1 and you save time as well However there are certain exceptions in which you may deliver 3 stacked shocks such as in a cardiac catheterisation or in an arrest post early cardiac surgery The role of early tracheal intubation has been de-emphasised as you do not want to spend more time on this rather supraglottic airways such as Laryngeal Mask Airways can hold the fort as good as etts Endotracheal administation of drugs not recommended

The ALS protocol remains otherwise unchanged

Drugs Adrenaline Amiodarone Atropine - 1mg up front for all non-shockable rhythms 1mg after the second shock in shockable rhythms Repeat after every 4 minutes Amiodarone - 300mg after the third shock in shockable rhythms Atropine - No longer recommended for PEA or Asystole Adrenaline Adrenaline is used during cardiac arrest to provided peripheral vasoconstriction due to its α receptor effects, directing available cardiac output to the brain and heart. Adrenaline’s β 1 effects (positive inotropy and chronotropy) are not significant in restoring spontaneous circulation from VF, asystole or EMD. Adrenaline’s β 2 effects however, may be of benefit by dilating cerebral vasculature and improving cerebral perfusion. Adrenaline use does increase the rate of ROSC but does not increase the rate of survival to hospital discharge. Side Effects Are many and include; tachycardia due to β 1 effects. Frequently an intense tachycardia occurs leading to recurrent VF and myocardial ischaemia. b) severe hypertension if spontaneous circulation is re-established. c) tissue necrosis if extravasation occurs Dose Adult 1 mg every 4 minutes of resuscitation for cardiac arrest. If given by peripheral IV cannula, flush each dose with 20 ml of N/S. If required, commence an adrenaline infusion. Add 6 mg to 100 ml of N/S (60 µg/ml), start at 2.5 ml/h (infusion range 1-20 µg min = 1- 20 ml/h). An adrenaline infusion can also be used for severe symptomatic bradycardia if atropine and transcutaneous pacing fail. Amiodarone A uniform and optimal dosing schedule for amiodarone has not yet been established. 1) For VF and pulseless VT Give 300 mg by IV bolus. Mix the drug in 20 ml of 5% glucose. Amiodarone is not compatible with normal saline. If the initial dose is ineffective give a second dose of 150 mg mixed with 20 ml of 5% glucose. Alternatively an initial dose of 5 mg/kg IV bolus and a second dose of 2.5 mg/kg IV bolus is also acceptable. 2) For tachydysrhythmias, as described above, mix 5 mg/kg of amiodarone with 100 ml of 5% glucose and administer IV over 20 min to 2 hours preferably via a central line. Follow this with 10-15 mg/kg in 500 ml 5% glucose over 24 h. Amiodarone infusions administered over a longer period than 2 hours must be contained in glass or polyolefine bottles, and a non-PVC giving set, because the amiodarone adsorbs to PVC. NB: Glucose 5% in glass bottles are available in all high dependency wards. Contraindications pregnancy (excluding cardiac arrest) thyroid dysfunction. iodine hypersensitivity. porphyria Precautions/Side Effects Hypotension Bradycardia Heart block

Defibrillation C – “Continue compressions” (“I won’t shock you”) O – “Oxygen away” A – “All else clear” C – “Charging” H – “Hands off!” - “Shock Delivered” “Continue CPR”

BLS Defibrillation Demo

Cognitive Aids and Checklists Hs and Ts Checklist

The Simulation Lab Orientation

Introduction - Simulation Lab

Debriefing = Learning

An Approach to the ‘Crashing’ Patient

General Tips Anticipate and plan your behaviour Learn from each emergency you attend Keep yourself relatively calm Do the basics well Assign roles Use cognitive aids Consider You – others and the environment

Overview Approach Checklist

Approach Checklist ABCDEFG History & Examination H.H.H.H. T.T.T.T. ALS Cards Checklist

How would you approach this case? 70 year old Heart Rate 32 Blood Pressure 79/30 (multiple readings) Light-headed Confused Pale Looks Unwell

4Hs and 4Ts Checklist

Mantra for Arrhythmia Management ABC-D.E.F.G. IV (and get a blood gas) O2 Monitor and ECG Call for help, CRM and use the ALS checklist “Treat the Cause”

25 minute Electives Break into 3 groups of roughly even numbers

CRM – 5 minutes

Overview Human factors Acute Crisis Resource Management Skills What are Human Factors? Acute Crisis Resource Management Skills Communication Teamwork Leadership

Structured communication tools ISBAR Assertiveness What is effective communication?

Team Leaders

Team Members

Hypotension and Sepsis Rapid Review

Which patient has the highest mortality? 59 year old male - large inferior STEMI 65 year old female - bleeding gastric ulcer and BP 90/60 74 year old female P 65 BP 105/60 RR24 Temp 35 mildly confused 32 year old female DKA - pH 6.9 BSL 45 HCO3 9

Which patient has the highest mortality? Inferior AMI 5% GIH + low BP 11% Septic shock 25% Severe DKA <1%

Septic Shock Sepsis “SIRS” Criteria Infection

Take Home - Sepsis Pitfalls Fail to recognise Under-appreciate mortality Do not see as time critical

Respiratory Failure 2 minute Review

Along with Sepsis, Respiratory Failure is a leading cause of ICU admission It is the number one reason for a Ward Based ALS call at Westmead

High inspired oxygen concentrations do not depress ventilation in patients with acute respiratory failure Rising CO₂ in these patients indicates fatigue, and a need for ventilatory support

Get a Blood Gas Start Treatment (O2, Nebs, Meds) Call for Help Early Follow the “management of acute hypoxia” guideline

Chest Pain and Myocardial Infarction 2 Minute Review

Chest Pain Make an ABC- D.E.F.G. assessment Consider the Risks for Acute Coronary Syndrome Cross Check using the Chest Pain pathway (NSW health)

Classic Treatment is M.O.N.A. Morphine, Oxygen, Nitrates and Aspirin 12 lead ECG IV Access Judicious Pain Relief (nitrate/morphine) Send Bloods Ischaemic/infarcting myocardium causes dynamic changes (time is muscle): Risk of arrhythmias Risk of pump failure May not always apply – discuss with the students e.g. Morphine in RV infarct e.g. GTN in same e.g. O2 when Sats are good (Apoptosis increases in Hyperoxia)

Call for help Does the patient have a - STEMI = Call an ALS Are there adverse signs that meet the grounds for escalation: ALS or MET (PACE) Call