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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

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slide1

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

the need for training
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
the need for training3
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”
the need for training4
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

the need for training5
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.
cals 2006
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
slide8

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

cardiac arrest protocol10
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
chest re opening protocol
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
scenarios for critically ill cardiac surgical patients
Scenarios for Critically ill Cardiac Surgical patients
  • Lectures, practicals and scenario practice on a series of life threatening situations
  • Protocols for each situation
hypotension
Hypotension

3 causes of Hypotension

  • Hypovolaemia
  • Ventricular failure
    • Ventricular dysfunction
    • Tamponade
    • Dysrhythmia
  • High output state - Vasodilated
hypovolaemia
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
tamponade
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
performance of cals course scenarios
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
performance of cals course cardiac arrests
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
results critically ill patients29
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.

survey of cicu staff skills and experience
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
survey of cicu staff skills and experience33
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
survey of cicu staff skills and experience34
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
experience in post surgical cardiac arrests on the cicu
Experience in Post-Surgical Cardiac Arrests on the CICU
  • Cardiac arrests attended :
    • None : 12
    • 1-3 : 17
    • 4-10 : 17
    • <10 : 15

Mean : 9

summary
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
the future
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.