1 / 49

The Cardiothoracic Advanced Life Support Course : Delivering Significant Improvements In Emergency Cardiothoracic Care

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

Anita
Download Presentation

The Cardiothoracic Advanced Life Support Course : Delivering Significant Improvements In Emergency Cardiothoracic Care

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  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 • Emergency chest re-openings are becoming less common • Working time directive and reduced trainee numbers mean that non-surgical trainees will increasingly become the first-responders to emergencies

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

  4. The need for training • 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

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

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

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

  8. Precordial Thump if appropriate Commence Basic Life Support CPR 30:2 If ventilated turn FiO2 to 100%. If necessary hand ventilate at 100% O2 Assess Rhythm VF/VT +/- Check Pulse Non VF/VT 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 , If Pacing wires in situ set to DDD at 90bpm, 10V. Give 3mg atropine Defibrillate x3 Shocks Re-open chest if Non VF/VT rhythm established (see protocol) Re-open chest if 3 shocks fail. (see protocol) Potential reversible causes: Hypoxia, Hypovolaemia Hypo/hyperkalaemia Hypothermia Tension pneumothorax Tamponade Toxotherapeutic disorders Thromboembolic & mechanical obstruction CPR 3 mins 1 min if immediately after defibrillation CPR x 1 min CALS Cardiac Arrest Protocol

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

  10. Cardiac Arrest Protocol • 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. • 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

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

  14. Course Content: Cardiac Arrests

  15. Hypotension 3 causes of Hypotension • Hypovolaemia • Ventricular failure • Ventricular dysfunction • Tamponade • Dysrhythmia • High output state - Vasodilated

  16. Hypovolaemia • Examination Low BP, Low CVP,low UO,cool peripheries, arterial swing, check drains • Diagnosis Hypovolaemia (? Bleeding) • Action Plan Colloid bolus / blood • Investigate ABG, CXR, FBC, U&E, ECG, consider senior help • After colloid bolus reassess , ? Need for reopening

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

  18. CALS Day 1

  19. CALS Day 2

  20. Performance of CALS courseScenarios • 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

  21. Scenarios

  22. 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

  23. Results : Critically ill patients

  24. Results : Critically ill patients

  25. Results : Critically ill patients • 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.

  26. Results : Cardiac arrest

  27. Survey of CICU staff skills and experience • 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

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

  29. Survey of CICU staff skills and experience • 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

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

  31. Experience in Post-Surgical Cardiac Arrests on the CICU Good

  32. Experience in Post-Surgical Cardiac Arrests on the CICU Moderate

  33. Experience in Post-Surgical Cardiac Arrests on the CICU Poor

  34. Experience in Post-Surgical Cardiac Arrests on the CICU Moderate

  35. Experience in Post-Surgical Cardiac Arrests on the CICU Poor

  36. Experience in Post-Surgical Cardiac Arrests on the CICU Moderate

  37. Experience in Post-Surgical Cardiac Arrests on the CICU Poor

  38. Experience in Post-Surgical Cardiac Arrests on the CICU Poor

  39. Experience in Post-Surgical Cardiac Arrests on the CICU Poor

  40. Experience in Post-Surgical Cardiac Arrests on the CICU Poor

  41. Experience in Post-Surgical Cardiac Arrests on the CICU Poor

  42. Summary • 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

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

  44. Questions?

More Related