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
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