1. The Cardiothoracic Advanced Life Support Course : Delivering Significant Improvements In Emergency Cardiothoracic Care J. Dunning, T. Strang, S Ariffin, J Jerstice, D Danitsch, and A. Levine James Cook University Hospital, Middlesbrough, UK Wythenshawe Hospital, Manchester, UK University Hospital of North Staffordshire, Stoke-on-Trent,UK

2. The need for training n Emergency chest re-openings are becoming less common n Working time directive and reduced trainee numbers mean that non-surgical trainees will increasingly become the first-responders to emergencies

3. n The European Resuscitation Council guidelines December 2005 : n “Consideration should be given to training non- surgical personnel in the skills of emergency chest- reopening” The need for training

4.  Papworth : 6 year review, 79 re-openings  Reopening within 10 mins 48% survival  Reopening over 10 mins 12% survival Mackay JH, Powell SJ, Osgathorp J, Rozario CJ. EJCTS 2002  Brompton and Harefield : 4 year review 72 re-openings  All patients should be re-opened within 5 mins of arrest or 1 loop of unresponsive VF/VT or 2 loops of non VF/VT. Pottle A, Bullock I, Thomas J, Scott L Resuscitation 2002 The need for training

5. n Multiple critical care training courses in other specialties. BLS, ACLS, ATLS, CCrISP n No formal training for arrests post-cardiac surgery n After many ‘Traumatic’ arrests, we created the Cardiothoracic Advanced Life Support course in December 2003.

6. CALS 2006 n Performed 9 full courses. n Performed 3 ‘In House’ courses n 2 further ‘In house courses’ booked. n 3 more courses this year. n Published papers in BMJ, Annals of Thoracic Surgery, Nursing Times

7. ALS in the CICU : Are the new guidelines dangerous ?

8. If ventilated turn FiO2 to 100%. If necessary hand ventilate at 100% O2 +/- Check Pulse Assess Rhythm DURING CPR Correct reversible causes If not already: Check electrodes, paddle position and contact Attempt/verify: airway & 02 intravenous access Give epinephrine every 3 min Consider: amiodarone, atropine/ pacing, Non VF/VT Defibrillate x3 Shocks CPR x 1 min Re-open chest if 3 shocks fail. (see protocol) Re-open chest if Non VF/VT rhythm established (see protocol) If Pacing wires in situ set to DDD at 90bpm, 10V. Give 3mg atropine Potential reversible causes: Hypoxia, Hypovolaemia Hypo/hyperkalaemia Hypothermia Tension pneumothorax Tamponade Toxotherapeutic disorders Thromboembolic & mechanical obstruction VF/VT Precordial Thump if appropriate Commence Basic Life Support CPR 30:2 CPR 3 mins 1 min if immediately after defibrillation CALS Cardiac Arrest Protocol

9. Cardiac Arrest Protocol 1 1 1 2 3 6 5 4

10.  Person 2: Cardiac Massage : Rate 100bpm, watch arterial trace  Person 1: Airway : Oxygen to 100%, Check ET tube, check air entry bilaterally. Bag-valve.  Person 3: Defibrillator : Check rhythm, Shock as appropriate if fail, prepare internal paddles. if fail, prepare internal paddles.  Person 4: Command role : Check ABC, make decision to re-open as appropriate  Person 5: Drugs : Take all drugs to head. Stop all infusions, Give Adrenaline atropine etc, when ordered and time arrest  Person 6: Resource Commander : In charge of all further people at arrest. Arrange equipment for reopening, specialist help contact, Patient and staff movements

11. Chest Re-opening Protocol Non VF/VT or failure to gain output with 3 shocks  1. Continue Cardiac Massage  2. 2/3 people gown/gloves (no hand washing)  3. Open Thoracotomy set  4. Single Drape, no betadine  5. Knife down to Wires  6. Wire cutters to remove wires  7. Suck out chest  8. Sternal retractor  9. No output commence 2 handed massage AFTER checking for grafts

12. Emergency Sternotomy

17. Scenarios for Critically ill Cardiac Surgical patients n Lectures, practicals and scenario practice on a series of life threatening situations n Protocols for each situation

18. Course Content: Cardiac Arrests

19. Hypotension 3 causes of Hypotension –Hypovolaemia –Ventricular failure n Ventricular dysfunction n Tamponade n Dysrhythmia –High output state - Vasodilated

20. Hypovolaemia n Examination Low BP, Low CVP,low UO,cool peripheries, arterial swing, check drains n Diagnosis Hypovolaemia (? Bleeding) n Action PlanColloid bolus / blood n InvestigateABG, CXR, FBC, U&E, ECG, consider senior help n After colloid bolus reassess, ? Need for reopening

21. Tamponade n Examination Low BP, high CVP, cold peripheries,low UO, check drains, worse with fluids n Diagnosis Low output / LVF /Tamponade n Action PlanAdrenaline 4mg/50mls at 5mls/hr n InvestigateABG, CXR, FBC, U&E, ECG, Echo,consider PA catheter, consider senior help n After inotropes reassess ? IABP Re-open

22. CALS Day 1 09;00Introduction 09:15 – 10:30 TEST SCENARIOS 1 10:30 – 11:00 Normal and Abnormal patient progression 11:00 – 11:30Coffee 11:30 – 12:00 Low Blood Pressure (Cardiovascular problems) 12:00 – 12:30 Poor Gases (respiratory problems ) 12:30 – 13:30Lunch 13:30 – 14:00 Low urine output (renal issues) 14:00 – 16:00 3 x 40mins PRACTICAL : Data Interpretation Chest X-Rays, ECG’s, Blood Gases. 16:00 – 16.30Coffee 16:30 – 17:30 TEST CARDIAC ARREST MOULAGE 17:30 – 17:45 Close and summary 19:30 Cagneys tandoori

23. CALS Day 2 09:00 - 09:15 Introduction and summary of Day 1 protocols 09:15 – 09:40 Arrhythmias and pacemakers 09:40 – 10.00 Tracheostomy Emergencies 10:00 – 11:30 Practical Skills Stations Pacing, Airway Emergencies, IABP insertion 11:30 – 12:00 Coffee 12:00 – 13:00 The Cardiac Surgery Advanced Life Support Protocol 13:00 – 14:00 Lunch 14:00 – 15:00 Demonstration of Cardiac Arrest Protocol 15:00-15:30 Putting it all together 15:30 – 16:00 Coffee 16:00 – 18:00 Practical Skills Stations Scenario Practice, IABP set-up, Internal Massage 19:30 The Queen’s Head at Tirrill

24. Performance of CALS course Scenarios  24 candidates underwent pre- and post-course scenario test  8 pre-determined scenarios created  Videotapes retrospectively tested by independent surgeon blinded to pre- or post course

25. Scenarios ScenarioInitial ScenarioDefinitive Treatment Bleeding65 year old 2 ½ hrs post CABG, p110, BP 85/60, CVP -1, Sa02 90%. 800mls in drains. Colloid then blood boluses, Return to theatre Ischaemia60 year old 5 hours post CABG, p110 BP 80/45, CVP 20, Sao2 80% Adrenaline, PA catheter, IABP, return to theatre Tamponade75 year old 45mins post CABG. p120 BP 70/50, CVP 20, Sa02 85% Adrenaline +/- IABP, PA catheter, Echo, Return to theatre Respiratory Failure78year old lady 1 day post AVR. Extubated, p120 BP 135/70, CVP 9, Sao2 86% High Flow oxygen, CPAP then return to ICU and intubation High Output failure70 year old 8 hrs post AVR, p120 BP 90/40, CVP 8, Sao2 94% Noradrenaline, PA catheter, Return to ICU Ventricular Tachycardia 65 year old 3 hours post CABG, p240 BP 65/45, CVP 16, Sao2 90% DC cardioversion, post Cardioversion ECG Supraventricular Tachycardia 68 year old 6 hours post CABG, extubated. p180, BP 100/60, CVP 14, SaO2 90% DC cardioversion Acute Mitral Regurgitation 67 year old 2 hours post difficult Mitral repair, p130 BP 75/45, CVP 25, Sao2 85% Adrenaline, PA catheter, Echo and return to theatre

26. Performance of CALS course Cardiac arrests  Candidates split into groups of 6 : reflecting usual makeup of CICU skill-mix  Arrest scenario tested pre- and post course  Videotapes retrospectively tested by independent surgeon blinded to pre- or post course

27. Results : Critically ill patients

29.  Dangerous actions : Pre-test 15 Post-test 2 EXAMPLES : Treating Atrial fibrillation with a BP of 60/40 with amiodarone, electing to wait for FFP and platelets in a patient bleeding 600mls in half an hour with no coagulopathy, Giving colloid to a patient with left ventricular failure and a CVP of 25, Giving digoxin to treat a ventricular tachycardia (190bpm with a BP of 70/40). POST TEST re-opening a patient that was tamponading without requesting an echo to confirm the diagnosis, Starting adrenaline on a hypotensive patient who had a low blood pressure due to an SVT.

30. Results : Cardiac arrest Pre-course Mean (SD) Post course Mean (SD) Paired t- test P value Time to initiating CPR 71seconds (23) 13 secs ( 3.8) 0.114 Time to rhythm Check 74 secs ( 11) 42 secs (5) 0.044 Time to first drug administration 120 secs (14) 86secs ( 17) 0.093 Time to first decision to open chest 221secs ( 34) 83secs (4) 0.026 Time to incision 404secs ( 40) 176secs ( 8.9) 0.009 Time to internal cardiac Massage 451secs (39) 228secs (17) 0.011

32. Survey of CICU staff skills and experience n AIMS : –To identify the skills and experience of CICU staff in post surgical cardiac arrests –To investigate the current quality of cardiac arrest management. –To examine any areas where further training is needed

33. Survey of CICU staff skills and experience n METHODS: –Survey created –2 shifts approached at 3 UK cardiothoracic centres : Middlesbrough, Stoke, Wythenshawe –All Nursing staff on shift surveyed

34. Survey of CICU staff skills and experience n RESULTS –61 nursing staff questioned –48 staff nurses, 12 sister, 1 matron. –Mean CICU experience 5.5 years –52 had attended a BLS course –16 had attended an ACLS course

35. n Cardiac arrests attended : –None : 12 –1-3: 17 –4-10: 17 –<10: 15 Mean : 9 Experience in Post-Surgical Cardiac Arrests on the CICU

36. Performance of last cardiac arrest team you attended Managed well and nothing more could have been done 3557% Managed fairly well but some things were missed that may have benefited the pt 1626% Not performed well, but outcome would not have been affected by this 23% Not performed well, outcome could have been different if done differently 23% Experience in Post-Surgical Cardiac Arrests on the CICU

37. External Defibrillation Never seen this skill 23% Seen but could not perform 1016% Not performed but could do it 2134% Have performed and could do it 1830% Performed and could teach it 1016% Experience in Post-Surgical Cardiac Arrests on the CICU

38. Connect Internal Defibrillators Never seen this skill 1321.3 Seen but could not perform 1219.7 Not performed but could do it 1626.2 Have performed and could do it 1321.3 Performed and could teach it 69.8 Experience in Post-Surgical Cardiac Arrests on the CICU

39. Administer Adrenaline at correct time Never seen this skill 46.6 Seen but could not perform 1423.0 Not performed but could do it 1829.5 Have performed and could do it 1423.0 Performed and could teach it 1118.0 Experience in Post-Surgical Cardiac Arrests on the CICU

40. Maintain surgical sterility during arrest Never seen this skill 813.1 Seen but could not perform 1626.2 Not performed but could do it 2134.4 Have performed and could do it 1118.0 Performed and could teach it 58.2 Experience in Post-Surgical Cardiac Arrests on the CICU

41. Correctly put on Gown & gloves Never seen this skill 34.9 Seen but could not perform 1118.0 Not performed but could do it 2845.9 Have performed and could do it 1321.3 Performed and could teach it 69.8 Experience in Post-Surgical Cardiac Arrests on the CICU

42. Passing Instruments to a Surgeon Never seen this skill 914.8 Seen but could not perform 3455.7 Not performed but could do it 1321.3 Have performed and could do it 46.6 Performed and could teach it 11.6 Experience in Post-Surgical Cardiac Arrests on the CICU

43. Reopen Chest Never seen this skill 1727.9 Seen but could not perform 3963.9 Not performed but could do it 58.2 Have performed and could do it 00 Performed and could teach it 00 Experience in Post-Surgical Cardiac Arrests on the CICU

44. Removal of Sternal wires Never seen this skill 1016.4 Seen but could not perform 3455.7 Not performed but could do it 1118.0 Have performed and could do it 58.2 Performed and could teach it 11.6 Experience in Post-Surgical Cardiac Arrests on the CICU

45. Perform Internal massage Never seen this skill 2134.4 Seen but could not perform 3049.2 Not performed but could do it 711.5 Have performed and could do it 34.9 Performed and could teach it 00 Experience in Post-Surgical Cardiac Arrests on the CICU

46. Set up IABP machine Never seen this skill 2134.4 Seen but could not perform 2337.7 Not performed but could do it 1016.4 Have performed and could do it 58.2 Performed and could teach it 23.3 Experience in Post-Surgical Cardiac Arrests on the CICU

47. Summary n The following skills are poor and require further staff training : –Correctly putting on gown and gloves –Maintaining surgical sterility during arrest –How to pass the correct instruments to a surgeon –How to open chest and remove wires –How to set up and perform internal defibrillation –Setting up of an IABP machine

48. The Future n A Joint EACTS / ERC Statement on Resuscitation in Cardiothoracic Intensive Care units –to be published in Resuscitation. n 3 Courses per year n Providing support for units practicing cardiac arrests in their own units.

49. Questions?