CASTeach 1-Simulation 1: VF - Resuscitation Council (UK)

Guidelines
CASTeach 1-Simulation 1: VF
Clinical Setting & History (may be adapted to candidate background)
S: Nurse on acute admissions unit, calling about the patient in side room 6.
B: 60-year-old patient admitted with chest pain and shortness of breath. Previous history of MI.
A: Chest pain has returned and seems to be increasing in severity, she is becoming more short of
breath and her level of consciousness is decreasing.
R: Started high-flow oxygen. Assessment is requested urgently as she may need further treatment.
Clinical Course
•
•
•
•
•
agonal gasping / no signs of circulation
initial rhythm is VF
rd
after 3 shock rhythm should change to sinus tachycardia
-1
P 100 min , BP 100/60 mm Hg
patient breathing and rousable.
Interventions
Discussion points:
VF
Checks patient - confirms cardiac arrest - starts CPR (30:2)
Calls resuscitation team / requests defibrillator
Defibrillator arrives
Applies defibrillator adhesive pads
VF
Checks monitor / confirms rhythm
st
1 shock
Airway/ventilation/oxygen
IV/IO access
2 min CPR
VF
Checks monitor/confirms rhythm
nd
2 shock
2 min CPR
VF
Checks monitor/confirms rhythm
rd
3 shock
2 min CPR
Adrenaline 1 mg IV
Amiodarone 300 mg IV
STach Checks monitor/confirms rhythm
Checks patient (signs of life / pulse)
ABCDE assessment
Post-arrest investigations
•
High quality CPR
•
Minimise pre-shock
pause between stopping
compressions and
giving shock
•
Post-shock CPR without
checking monitor
•
Uninterrupted chest
compressions after
advanced airway
insertion
•
Post-resuscitation care
including the ABCDE
approach
•
Discussion of immediate
re-vascularisation postROSC if ECG showed
new ST elevation
Handover and transfer
ICU/Catheter lab and CCU
May 2014
ALS Provider Course
CASTeach SIMULATIONS 1 to 3
Resuscitation Council (UK)
Tel: (020) 7388 4678 | Fax: (020) 7383 0773
[email protected] | www.resus.org.uk
Page 1 of 6
Guidelines
CASTeach 1 - Simulation 2: Pulseless VT
Clinical Setting & History (may be adapted to candidate background)
S:
B:
A:
R:
Standby call from ambulance service. 58-year-old man is en route with CPR in progress.
Unable to gain any history. Known to take medication for ‘high blood pressure’ and use inhalers.
In cardiac arrest. Intubated and cannulated, CPR in progress.
Resuscitation team requested to be standing by.
Clinical Course
•
•
•
•
no breathing/circulation
initial rhythm is pulseless VT
rd
after 3 shock the rhythm should change to sinus rhythm
patient remains unconscious with no respiratory effort after ROSC
Interventions
Prepares team and allocates tasks
VT
VF
VF
SR
Checks patient - confirms cardiac arrest - restarts CPR
Apply defibrillator adhesive pads
Checks monitor/confirms rhythm
st
1 shock
2 min CPR
Airway/ventilation/oxygen
IV/IO access
Checks monitor/confirms rhythm
nd
2 shock
2 min CPR
Checks monitor/confirms rhythm
rd
3 shock
2 min CPR
Adrenaline 1 mg IV
Amiodarone 300 mg IV
Recognises and treats relevant reversible causes of persistent VF*
Checks monitor/confirms rhythm
Checks patient (signs of life/pulse)
Ventilatory support
+
2+
*Post-arrest investigations (especially K and Mg )
AVPU - U (unresponsive)
Discussion points:
•
value of preparation and
allocation of roles
•
initial confirmation of
cardiac arrest with
simultaneous breathing
and circulation check
•
management of
persistent VF
•
post-arrest
investigations and
patient management
•
importance of accurate
handover and safe
transfer
•
discuss role of
temperature
control/therapeutic
hypothermia
Handover and transfer
Hands over to intensive care team.
Recognises need for temperature control/therapeutic hypothermia.
May 2014
ALS Provider Course
CASTeach SIMULATIONS 1 to 3
Resuscitation Council (UK)
Tel: (020) 7388 4678 | Fax: (020) 7383 0773
[email protected] | www.resus.org.uk
Page 2 of 6
Guidelines
CASTeach 2 - Simulation 1: Asystole
Clinical Setting & History (may be adapted to candidate background)
S: Resuscitation team called to medical ward. Handover from nursing staff on arrival.
B: 67-year-old man with a known history of coronary artery bypass grafting and diabetes. Recently
transferred from CCU after a recent MI. Fall in urine output and O2 saturations over the past 4 h.
A: He is in cardiac arrest and we have started CPR.
R: Please take over his care.
Clinical Course
•
•
•
•
•
Initial rhythm is VF
st
After 1 shock, rhythm changes to asystole
No reversible causes present (4 Hs and 4 Ts)
After 2 min returns to VF
nd
ROSC after 2 shock; no respiratory effort
Interventions
VF
Asy
VF
SR
Checks patient - confirms cardiac arrest - starts CPR (30:2)
Applies defibrillator adhesive pads
Checks monitor/confirms rhythm
st
1 shock
2 min CPR (30:2)
Airway/ventilation/oxygen
IV/IO access
Checks monitor/confirms rhythm
2 min CPR
Adrenaline 1 mg IV
Recognises and treats relevant reversible causes
(4 Hs and 4 Ts)
Checks monitor/confirms rhythm
Checks patient (signs of life/pulse)
nd
2 shock
2 min CPR
Checks monitor/confirms rhythm
Checks patient (signs of life/pulse)
Post-resuscitation care
Discussion points:
•
Need for continuous,
high-quality CPR with
uninterrupted chest
compressions after
advanced airway
insertion. Beware of
fatigue
•
If an organised rhythm
is seen during CPR,
only stop if signs of life
•
Fine VF or asystole?
CPR rather than
repeated shocks
•
All reversible causes –
emphasise need to
exclude relevant
reversible causes
•
Indications for referral
to ICU
Handover and transfer
ICU
Role of additional specialists (cardiology)
May 2014
ALS Provider Course
CASTeach SIMULATIONS 1 to 3
Resuscitation Council (UK)
Tel: (020) 7388 4678 | Fax: (020) 7383 0773
[email protected] | www.resus.org.uk
Page 3 of 6
Guidelines
CASTeach 2 - Simulation 2: Asystole
Clinical Setting & History (may be adapted to candidate background)
S: Patient found unresponsive in bed during 06:00 drug round.
B: 84-year-old woman admitted to the orthopaedic ward one week previously with fractured neck of femur.
Extensive past medical history.
A: Looks pale, feels very cold.
R: Nursing staff have commenced CPR. Healthcare assistant is bringing the cardiac arrest trolley.
Resuscitation team called but not yet present.
Clinical Course
•
•
•
•
No breathing / circulation
Initial rhythm is asystole
Remains in asystole for remainder of simulation
Resuscitation discontinued
Interventions
Asy
Asy
Checks patient - confirms cardiac arrest - starts CPR (30:2)
Applies defibrillator adhesive pads
Checks monitor/confirms rhythm
2 min CPR (30:2)
Airway/ventilation/oxygen
IV/IO access
Adrenaline 1 mg IV
Recognises and treats relevant reversible causes
Checks monitor/confirms rhythm
2 min CPR
Assesses rhythm
Continues further 2 min CPR cycles
Adrenaline 1 mg IV alternate cycles
Discusses stopping CPR with team
Discontinues resuscitation
Handover and transfer
Discussion points:
•
Priorities in the early
management of cardiac
arrest with limited
staff/resources;
•
Rotation of person
doing chest
compressions to avoid
fatigue
•
All reversible causes –
emphasise need to
exclude relevant
reversible causes
•
Process and indications
for discontinuation of
resuscitation
•
Role of debriefing after
successful and
unsuccessful
resuscitation attempts
•
Confirmation of death
Informs relatives/carers/those close to patient
Mortuary
May 2014
ALS Provider Course
CASTeach SIMULATIONS 1 to 3
Resuscitation Council (UK)
Tel: (020) 7388 4678 | Fax: (020) 7383 0773
[email protected] | www.resus.org.uk
Page 4 of 6
Guidelines
CASTeach 3 - Simulation 1: PEA
Clinical Setting & History (may be adapted to candidate background)
S: Sister on respiratory ward calling regarding Mr James. He appears to be deteriorating rapidly.
B: 35-year-old man, with no significant medical history. Admitted 3 days previously with
community acquired pneumonia. Managed with oral antibiotics and IV fluids. Now appears moribund.
A: The staff nurse looking after him is very concerned. He has a high EWS.
R: Have sat him up and increased his inspired oxygen. Request urgent assessment.
Clinical Course
•
•
A: compromised (gurgling/snoring) – clears with head tilt and oropharyngeal airway insertion
-1
-1
B: RR 40 min , SpO2 unrecordable, chest – coarse crackles, C: P 140 min , BP unrecordable, CRT > 5
sec, D: responsive only to pain E: nil
Cardiac arrest (PEA)
VF after adrenaline, oxygen and fluids
Sinus tachycardia after safe defibrillation
Assessment of relevant Hs and Ts.
•
•
•
•
Interventions
Discussion points:
STach Assesses ABCDE
Head tilt/chin lift or jaw thrust
Oropharyngeal airway
High-flow oxygen
Attaches ECG leads
IV access and IV fluids
Calls for help: resuscitation team
Patient stops breathing/arrests
PEA
Checks patient - confirms cardiac arrest - start CPR (30:2)
Checks monitor/confirms rhythm
Calls resuscitation team (if omitted earlier)
2 min CPR (30:2)
Airway/ventilation/oxygen
Adrenaline 1 mg IV
Recognises and treats relevant reversible causes
VF
Checks monitor/confirms rhythm
1st shock
2 min CPR
STach Checks monitor/confirms rhythm
Checks patient (signs of life/pulse)
Post-resuscitation care
•
Recognition and
intervention of patient at
risk of cardiac arrest
•
Reinforce ABCDE
approach
•
Lack of SpO2 reading
indication for high flow
oxygen
•
Role of focused cardiac
echo in cardiac arrest
•
Need for continuous
high-quality CPR
throughout
•
Post-resuscitation care
– in particular invasive
monitoring and
inotropes
•
Involvement of ICU
team to stabilise
patient prior to ICU
transfer
•
Role of audit
Handover and transfer
ICU
May 2014
ALS Provider Course
CASTeach SIMULATIONS 1 to 3
Resuscitation Council (UK)
Tel: (020) 7388 4678 | Fax: (020) 7383 0773
[email protected] | www.resus.org.uk
Page 5 of 6
Guidelines
CASTeach 3 - Simulation 2: PEA
Clinical Setting & History (may be adapted to candidate background)
S: Emergency alarm heard on general surgical ward. Doctors recently asked to review one of Mr Davies’
(colo-rectal surgeon) patients who has ‘gone-off’, but have been unable to see her yet.
B: 4 days post ‘curative’ right hemi-colectomy for colonic carcinoma.
A: Nursing staff inform you she has been complaining of chest pain and shortness of breath over the last
three hours. Subsequently became apnoeic and lost consciousness.
R: CPR is in progress on 70-year-old woman. 2222 call placed. You arrive at the same time as the
resuscitation team.
Clinical Course
•
•
•
•
•
•
No breathing/circulation
Initial rhythm is pulseless VT
st
After 1 shock rhythm changes to a broad complex bradycardia
Pulse absent – PEA
Consider reversible causes (4 Hs and 4 Ts) – pulmonary embolus
nd
Returns to sinus tachycardiarhythm after 2 two min cycle, low-volume pulse present with occasional
respiratory gasps
Discussion points:
Interventions
VT
PEA
PEA
ST
Checks patient - confirms cardiac arrest - starts CPR (30:2)
Applies defibrillator adhesive pads
Checks monitor/confirms rhythm
st
1 shock
2 min CPR (30:2)
Airway/ventilation/oxygen
IV/IO access
Checks monitor/confirms rhythm
Checks patient (signs of life/pulse)
2 min CPR
Adrenaline 1 mg IV
Recognises and treats relevant reversible causes
IV fluids
Checks monitor/confirms rhythm
Checks patient (signs of life/pulse)
2 min CPR
Checks monitor/confirms rhythm
Checks patient (signs of life/pulse)
Stabilisation
Post-arrest investigations
•
Adrenaline every 3–5
min (alternate loops)
once commenced
•
Reversible causes – in
particular
thromboembolism,
toxins (opioids),
hypovolaemia, hypoxia
•
Role of focused cardiac
echo in cardiac arrest
•
Post-resuscitation
stabilisation, additional
investigations and
treatment
•
Need for advanced
airway management
and ventilation if unable
to maintain
spontaneous breathing
•
Seek expert help for
treatment of pulmonary
embolism
Handover and transfer
ICU / HDU depending on progress
May 2014
ALS Provider Course
CASTeach SIMULATIONS 1 to 3
Resuscitation Council (UK)
Tel: (020) 7388 4678 | Fax: (020) 7383 0773
[email protected] | www.resus.org.uk
Page 6 of 6