The Cardiothoracic Advanced Life Support Course Delivering

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 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

The need for training n The European Resuscitation Council guidelines December 2005 : n “Consideration should be given to training nonsurgical personnel in the skills of emergency chestreopening”

The need for training Ø Papworth : 6 year review, 79 re-openings Ø Reopening within 10 mins 48% survival Ø Reopening over 10 mins 12% survival Mackay JH, Powell SJ, Osgathorp J, Rozario CJ. EJCTS 2002 Ø Brompton and Harefield : 4 year review 72 re-openings Ø 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 n Multiple critical care training courses in other specialties. BLS, ACLS, ATLS, CCr. ISP 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.

CALS 2006 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 n

ALS in the CICU : Are the new guidelines dangerous ?

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

Cardiac Arrest Protocol 5 1 1 1 2 3 4 6

Cardiac Arrest Protocol Ø Person 2: Cardiac Massage : Rate 100 bpm, watch arterial trace Ø Person 1: Airway : Oxygen to 100%, Check ET tube, check air entry bilaterally. Bag-valve. Ø Person 3: Defibrillator : Check rhythm, Shock as appropriate if fail, prepare internal paddles. Ø Person 4: Command role : Check ABC, make decision to re-open as appropriate Ø Person 5: Drugs : Take all drugs to head. Stop all infusions, Give Adrenaline atropine etc, when ordered and time arrest Ø 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 Non VF/VT or failure to gain output with 3 shocks Ø Ø Ø Ø Ø 1. 2. 3. 4. 5. 6. 7. 8. 9. Continue Cardiac Massage 2/3 people gown/gloves (no hand washing) Open Thoracotomy set Single Drape, no betadine Knife down to Wires Wire cutters to remove wires Suck out chest Sternal retractor No output commence 2 handed massage AFTER checking for grafts

Emergency Sternotomy

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

Course Content: Cardiac Arrests

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

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

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

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

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

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

Scenarios Scenario Initial Scenario Definitive Treatment Bleeding 65 year old 2 ½ hrs post CABG, p 110, BP 85/60, CVP -1, Sa 02 90%. 800 mls in drains. Colloid then blood boluses, Return to theatre Ischaemia 60 year old 5 hours post CABG, p 110 BP 80/45, CVP 20, Sao 2 80% Adrenaline, PA catheter, IABP, return to theatre Tamponade 75 year old 45 mins post CABG. p 120 BP 70/50, CVP 20, Sa 02 85% Adrenaline +/- IABP, PA catheter, Echo, Return to theatre Respiratory Failure 78 year old lady 1 day post AVR. Extubated, p 120 BP 135/70, CVP 9 , Sao 2 86% High Flow oxygen, CPAP then return to ICU and intubation High Output failure 70 year old 8 hrs post AVR, p 120 BP 90/40, CVP 8, Sao 2 94% Noradrenaline, PA catheter, Return to ICU Ventricular Tachycardia 65 year old 3 hours post CABG, p 240 BP 65/45, CVP 16, Sao 2 90% DC cardioversion, post Cardioversion ECG Supraventricular Tachycardia 68 year old 6 hours post CABG, extubated. p 180, BP 100/60, CVP 14, Sa. O 2 90% DC cardioversion Acute Mitral Regurgitation 67 year old 2 hours post difficult Mitral repair, p 130 BP 75/45, CVP 25, Sao 2 85% Adrenaline, PA catheter, Echo and return to theatre

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

Results : Critically ill patients

Results : Critically ill patients

Results : Critically ill patients Ø 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 600 mls 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 (190 bpm 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.

Results : Cardiac arrest Pre-course Mean (SD) Post course Mean (SD) Paired ttest P value Time to initiating CPR 71 seconds (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) 86 secs ( 17) 0. 093 Time to first decision to open chest 221 secs ( 34) 83 secs (4) 0. 026 Time to incision 404 secs ( 40) 176 secs ( 8. 9) 0. 009 Time to internal cardiac Massage 451 secs (39) 228 secs (17) 0. 011

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

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

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

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

Experience in Post-Surgical Cardiac Arrests on the CICU Performance of last cardiac arrest team you attended Managed well and nothing more could have been done 35 57% Managed fairly well but some things were missed that may have benefited the pt 16 26% Not performed well, but outcome would not have been affected by this 2 3% Not performed well, outcome could have been different if done differently 2 3%

Experience in Post-Surgical Cardiac Arrests on the CICU External Defibrillation Never seen this skill 2 3% Seen but could not perform 10 16% Not performed but could do it 21 34% Have performed and could do it 18 30% Performed and could teach it 10 16%

Experience in Post-Surgical Cardiac Arrests on the CICU Connect Internal Defibrillators Never seen this skill 13 21. 3 Seen but could not perform 12 19. 7 Not performed but could do it 16 26. 2 Have performed and could do it 13 21. 3 Performed and could teach it 6 9. 8

Experience in Post-Surgical Cardiac Arrests on the CICU Administer Adrenaline at correct time Never seen this skill 4 6. 6 Seen but could not perform 14 23. 0 Not performed but could do it 18 29. 5 Have performed and could do it 14 23. 0 Performed and could teach it 11 18. 0

Experience in Post-Surgical Cardiac Arrests on the CICU Maintain surgical sterility during arrest Never seen this skill 8 13. 1 Seen but could not perform 16 26. 2 Not performed but could do it 21 34. 4 Have performed and could do it 11 18. 0 Performed and could teach it 5 8. 2

Experience in Post-Surgical Cardiac Arrests on the CICU Correctly put on Gown & gloves Never seen this skill 3 4. 9 Seen but could not perform 11 18. 0 Not performed but could do it 28 45. 9 Have performed and could do it 13 21. 3 Performed and could teach it 6 9. 8

Experience in Post-Surgical Cardiac Arrests on the CICU Passing Instruments to a Surgeon Never seen this skill 9 14. 8 Seen but could not perform 34 55. 7 Not performed but could do it 13 21. 3 Have performed and could do it 4 6. 6 Performed and could teach it 1 1. 6

Experience in Post-Surgical Cardiac Arrests on the CICU Reopen Chest Never seen this skill 17 27. 9 Seen but could not perform 39 63. 9 Not performed but could do it 5 8. 2 Have performed and could do it 0 0 Performed and could teach it 0 0

Experience in Post-Surgical Cardiac Arrests on the CICU Removal of Sternal wires Never seen this skill 10 16. 4 Seen but could not perform 34 55. 7 Not performed but could do it 11 18. 0 Have performed and could do it 5 8. 2 Performed and could teach it 1 1. 6

Experience in Post-Surgical Cardiac Arrests on the CICU Perform Internal massage Never seen this skill 21 34. 4 Seen but could not perform 30 49. 2 Not performed but could do it 7 11. 5 Have performed and could do it 3 4. 9 Performed and could teach it 0 0

Experience in Post-Surgical Cardiac Arrests on the CICU Set up IABP machine Never seen this skill 21 34. 4 Seen but could not perform 23 37. 7 Not performed but could do it 10 16. 4 Have performed and could do it 5 8. 2 Performed and could teach it 2 3. 3

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

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.

Questions?