Cardiac arrest simulation teaching (CASTeach) session Instructor guidance Key learning outcomes Overall aim: Scenarios should be facilitated by the Instructor in such a way that they are performed correctly. Instructors will guide candidates through questions and prompts to achieve the management of the scenario according to current guidelines. Following this session, candidates should be able to: develop competence and confidence in managing the deteriorating patient develop competence and confidence in managing the first few minutes of a cardiac arrest before the arrival of a resuscitation team or other expert help appropriately hand over care to the resuscitation team develop competencies required to function as a member of a resuscitation team facilitate the application of current guidelines and skills taught in the workshops/skill stations into the practical management of the deteriorating and arrested patient Simulation Management These simulations are designed for healthcare professionals who may be called to act in the role of a first responder to a patient at risk of, or in cardiac arrest. Candidates should be encouraged to participate in a way that is consistent with their everyday practice whilst allowing them to develop the range of skills required by resuscitation team members. The simulations should be used to develop the essential competencies required by those who have to respond first to a cardiac arrest. The principle skills required of a first responder are: to recognise the deteriorating patient, to call for help, and to provide early CPR, early defibrillation, and an efficient hand over to the resuscitation team. A shockable rhythm has been included in each scenario to ensure that all candidates have the opportunity to further practise defibrillation. This may make some of the simulation scenarios unrealistic but this compromise will help maximise the opportunities for candidates to practise their skills. The simulations are generic to accommodate the different clinical backgrounds of candidates on the course. The instructor should tailor the scenarios so that they are appropriate to the candidate s background. For example, Scenario 1 could be presented as You are called to the home of a 55-year old patient who is complaining of chest pain for a community responder; or You are asked to see a 55-year old patient admitted with chest pain for a medical nurse/doctor; or You are asked to see a 55-year old patient who is three hours post-op for a surgical nurse/doctor. The scenarios should be run sequentially (i.e. CASTeach 1, then CASTeach 2) for all groups. Scenarios are designed to last up to 10 minutes, followed by five minutes for discussion and feedback. The discussion points are designed to facilitate consistent teaching between stations and should be covered by the instructor. These may be covered during the scenario itself. A candidate nominated as the first responder should lead each scenario. A second helper may be provided if such a person is likely to be available in the participant s usual place of work. Page 1 of 9
The first responder role may evolve to the team leader of the scenario when additional human resources (other candidates arrival) permit. This role is supported by the instructor. All candidates should undertake the role of first responder on at least one occasion. The precise timing of the arrival of the resuscitation team is left to the discretion of the instructor. They can be introduced early if the first responder is struggling or later if they are progressing well. The resuscitation team referred to in the scenarios may be a hospital cardiac arrest team, medical emergency team (MET), ambulance service paramedic response or other advanced team with responsibilities for managing cardiac arrests. The first responder/team leader should hand over the care of the patient to the resuscitation team upon its arrival. They should then participate as a member of the resuscitation team as resuscitation continues. The instructor may play the role of the resuscitation team leader and guide the team members if appropriate to the candidate group. It is recognised that not all course participants will be authorised or trained for procedures such as IV access or drug prescription and administration. Where these tasks are required as interventions in scenarios, participants who are not trained/authorised to undertake these procedures should state which treatment should be given by an appropriately trained/authorised person. The CASTeach scenarios are used as an opportunity to consolidate skills taught in the workshops, such as defibrillation, airway management, external chest compressions and ECG interpretation. Instructors should encourage good practice and monitor/give feedback on performance in these areas as required. The instructor must encourage high quality chest compressions and ventilations with minimum interruptions for other interventions (e.g. defibrillation). Aim for interruptions in chest compressions of less than 5 s for rhythm checks and attempting defibrillation. The scenarios should be tailored to be used with an AED or manual defibrillator. If there is spare time after completing the six core scenarios, the instructor may present the group with additional scenarios prepared in advance by the Course Director. Background information for the candidates should be delivered in an ISBAR format (Identify, Situation, Background, Assessment, Recommendation); alternatively RSVP (Reasons, Story, Vital signs, Plan) can be used depending on local practice. For example: Instructor presentation to candidate: I: Hello, this is nurse Jones calling from the acute admissions unit. S: I m contacting you about Mrs Smith who has chest pain B: She s 60-years-old and was admitted yesterday with shortness of breath. She s had a previous MI two years ago, and is being treated for an ACS A: I m a bit worried about her to be honest she has chest pain and becoming more short of breath. She looks terrible. My colleague is doings observations and the observation response chart indicates a need for urgent review R: I ve started oxygen and told the ward sister about her. Could you please come and review her urgently as I think she s deteriorating and may need further treatment Page 2 of 9
Simulation summary Simulation 1 Simulation 4 PEA Simulation 2 Simulation 5 /Asystole Simulation 3 Simulation 6 PEA Abbreviations Asy SR PEA P RR STach ISBAR RSVP A B C D E ORC EWS Asystole Sinus rhythm Pulseless electrical activity Pulse Respiratory rate Sinus tachycardia Ventricular fibrillation Identify, Situation, Background, Assessment, Recommendation Reasons, Story, Vital signs, Plan Airway Breathing Circulation Disability Exposure Observation response chart Early warning score Team Leader (First Responder) Scribe Airway Drugs/Fluids/IV Compressions Defibrillator Operator/ Airway Assistant Example of a role rotation of candidates to ensure all undertake each position in the team Page 3 of 9
ALS1 Simulation 1: early defibrillation I: Nurse on acute admissions unit. S: Calling about the patient just admitted. B: 55-year-old patient admitted with chest pain and shortness of breath. Previous MI. A: Chest pain and short of breath, saturation less than 94% on room air. R: Started high-flow oxygen as oxygen. Urgent review is requested. Collapses with agonal gasping on arrival Initial rhythm is ROSC after 2 nd shock Patient regains consciousness Cardiac arrest management Confirm cardiac arrest (breathing/circulation) Call for help/resuscitation team/defibrillator Start CPR (30:2) Get resuscitation equipment Defibrillator arrives Apply self-adhesive pads Recognition of cardiac arrest agonal breathing seizure High quality CPR Continue after shock unless patient shows signs of life 1st shock CPR (30:2) for 2 min Airway/ventilation/oxygenation/IV access Minimise interruptions to chest compression, and ensure they are for less than 5 s 2 nd shock Give adrenaline 1 mg IV/IO Coordination of defibrillation and CPR Post-resuscitation care to include consideration of PCI ISBAR or RSVP handover SR ABCDE approach after ROSC Handover Page 4 of 9
ALS1 Simulation 2: PEA- I: Relative of patient. S: Asked to see middle-aged man who has just collapsed. B: He has just arrived with chest pain, has been given aspirin and anti-platelet medication. A: He is unresponsive and gasping. R: Candidate is nearby and asked to help. No breathing/circulation Initial rhythm is PEA (SR) Resuscitation team arrives after During second cycle rhythm changes to sinus rhythm No respiratory effort Confirm cardiac arrest (breathing/circulation) Call for help/resuscitation team/defibrillator Start CPR (30:2) Apply self-adhesive pads during CPR PEA Check patient (breathing/circulation) Call resuscitation team/help (if not already) CPR 30:2 for 2 min Airway/Ventilation/Oxygenation Adrenaline 1mg IV/IO CPR 2 min SR ABCDE approach after ROSC Hand over to resuscitation team How to call the resuscitation team Relatives may initiate emergency response Initial confirmation of cardiac arrest Asynchronous compression ventilation once airway secured (100 compression min -1, 10 ventilations min -1 ) Allocating and planning tasks to minimise any interruptions in chest compression, and ensure interruptions are for less than 5 s Handover using ISBAR or RSVP Scenario can be used for anaphylaxis and thrombosis Page 5 of 9
ALS1 Simulation 3: I: Locum/Agency Dr/Nurse asks for help. S: 50-year-old with shortness of breath. B: 1 day history of dizziness and shortness of breath. A: Collapsed and unresponsive. R: Called to see immediately. No breathing/circulation Initial rhythm is ROSC after 3 rd shock Resuscitation team arrives after ROSC Confirm cardiac arrest Call for help/resuscitation team Start CPR (30:2) Get resuscitation equipment Apply self-adhesive pads High quality CPR, minimise interruptions, and ensure interruptions are for less than 5 s Safe defibrillation VT CPR (30:2) for 2 min Airway/Ventilation/Oxygen/obtain IV access 2 nd shock Give adrenaline 1 mg IV/IO 3 rd shock Give amiodarone 300 mg IV/IO Patient tolerating effective compressions and VT rhythm on checking no requirement for pulse check Drugs timing and doses Switch person delivering compressions every 2 min to avoid fatigue and maintain high quality chest compression Temperature control after ROSC SR ABCDE approach after ROSC Hand over to resuscitation team (ISBAR) Page 6 of 9
ALS1 Simulation 4: PEA I: Orthopaedic ward/clinic staff (or rehab gym/radiographer etc) request help. S: 55-year-old man with bleeding after knee replacement. B: Now patient feeling unwell and light headed and looks pale. A: A: clear; B: RR 40 min -1, chest movement/breath sounds normal; C: P 130 min -1, BP 90/50 mmhg; D: Pain; E: looks pale, cool to touch, evidence of blood loss in drains and/or dressings. R: Asked to attend urgently. Initial ABCDE approach Stops breathing, agonal gasps, no palpable pulses Initial rhythm is PEA rate approximately 140 min -1 Develops VT after fluids and adrenaline given ROSC after No respiratory effort after ROSC STach ABCDE assessment Oxygen/IV or IO access/ecg monitor Seek expert / surgical help to stop bleeding Fluids/blood Cardiac arrest management PEA Check patient (breathing/circulation) Call for help/resuscitation team CPR (30:2) for 2 min Adrenaline 1mg IV/IO Airway/Ventilation/Oxygen Consider reversible causes (4 Hs and 4 Ts) Continue fluid/blood replacement (Continue for 1 further PEA loop if required) VT CPR 2 min STach Assist with post resuscitation care Handover (ISBAR) Discussion Points: The ABCDE approach Reversible causes of cardiac arrest (4Hs and 4Ts recognition, exclusion and treatment) Importance of stopping bleeding Introduce cardiac arrest audit/ documentation Page 7 of 9
ALS1 Simulation 5: - Asystole I: Called by a non-healthcare team member (ancillary services/receptionist). S: An elderly woman has been found unresponsive. B: No history available. A: Unresponsive. R: Asked to help as nearby. Unconscious, cyanosed, no breathing or signs of circulation Initial rhythm is After first shock rhythm changes to asystole Resuscitation team arrives after 3-5 min Remains in asystole after 20 min CPR Resuscitation stopped when further CPR unlikely to be effective. Check patient (breathing/circulation) Start CPR (30:2)/call for help/defibrillator When defibrillator arrives Asy Asy Attach self-adhesive pads/confirm rhythm CPR 30:2 for 2 min Airway/Ventilation/Oxygen/obtain IV/IO access Adrenaline 1mg IV/IO and then every alternate loop Further cycles until relevant Hs/Ts excluded/considered Consider stopping CPR (may continue for up to approximately 20 min or when all possible reversible causes assessed/excluded/identified/treated when able) Rotation of individuals doing compressions Discuss all reversible causes emphasise need to exclude relevant reversible causes Criteria for initiating and discontinuing resuscitation attempts How to diagnose death Informing relatives Ongoing care for patient Documentation requirements Consideration for team Debriefing and possibly other support services Page 8 of 9
ALS1 Simulation 6: PEA I: A nurse has asked for urgent review. S: 75-year-old man with community acquired pneumonia for at least the last 2 days. B: Increasing confusion, cough and shortness of breath. A: A: clear; B: RR 28 min -1, audible wheeze, SpO 2 unrecordable; C: P 120 min -1 (sinus tachycardia BP 80-90 systolic; capillary refill 3 s; D: verbal response; E: Temp 38.7 C, nil else of note. R: Observation response chart indicates to call for immediate review. During E of ABCDE approach, patient collapses Initial rhythm PEA (sinus tachycardia rate 120 min -1 ); continue for one further cycle if reversible causes not identified and treated followed by ROSC after first shock No respiratory effort Initial approach The ABCDE approach Oxygen/IV access/monitor ECG Call for help IV fluids, antibiotics Cardiac arrest management PEA SR Check patient (breathing/circulation) Call resuscitation team/help (if not already) CPR 30:2 for 2 min Airway/Ventilation/Oxygenation Adrenaline 1mg IV/IO (then repeat alternate loops) Recognise and treat relevant reversible causes (hypoxia, hypovolaemia) Continue for further cycle if required Post-resuscitation care Handover to ICU team (ISBAR) Recognition of deteriorating patient Oxygen and pulse oximetry Recognise and treat reversible causes (hypoxia and hypovolaemia most likely) Hand over to ICU team Post resuscitation care (include discussion on safe transfer/transport) Additional Sepsis Six Page 9 of 9