Cardiac arrest simulation teaching (CASTeach) session

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.

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 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'

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Simulation summary

Simulation 1

VF

Simulation 2

VF

Simulation 3

VF

Simulation 4 Simulation 5 Simulation 6

PEA VF/Asystole PEA

Abbreviations

Asy SR PEA

P RR STach VF 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

Scribe

Team Leader (First

Responder)

Airway

Drugs/Fluids/IV

Defibrillator Operator/

Airway Assistant

Compressions

Example of a role rotation of candidates to ensure all undertake each position in the team

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ALS1 Simulation 1: early defibrillation

Clinical Setting and History (may be adapted to candidate background) 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.

Clinical Course Collapses with agonal gasping on arrival Initial rhythm is VF ROSC after 2nd shock Patient regains consciousness

Interventions 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 VF 1st shock CPR (30:2) for 2 min Airway/ventilation/oxygenation/IV access Check monitor/confirm rhythm VF Check monitor/confirm rhythm 2nd shock CPR for 2 min Give adrenaline 1 mg IV/IO SR Check patient (signs of life/pulse) ABCDE approach after ROSC Handover

Discussion points:

Recognition of cardiac arrest

? agonal breathing

? seizure

High quality CPR

Continue CPR for 2 min after shock unless patient shows signs of life

Minimise interruptions to chest compression, and ensure they are for less than 5 s

Coordination of defibrillation and CPR

Post-resuscitation care to include consideration of PCI

ISBAR or RSVP handover

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ALS1 Simulation 2: PEA-VF

Clinical Setting and History (may be adapted to candidate background)

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.

Clinical Course No breathing/circulation Initial rhythm is PEA (SR) Resuscitation team arrives after 1st shock During second cycle rhythm changes to sinus rhythm No respiratory effort

Interventions 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

VF Check monitor/confirm rhythm 1st shock CPR 2 min

SR Check monitor/confirm rhythm Check patient (signs of life/pulse) ABCDE approach after ROSC Hand over to resuscitation team

Discussion points:

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

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ALS1 Simulation 3: VF

Clinical Setting and History (may be adapted to candidate background)

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.

Clinical Course

No breathing/circulation Initial rhythm is VF ROSC after 3rd shock Resuscitation team arrives after ROSC

Interventions Confirm cardiac arrest Call for help/resuscitation team Start CPR (30:2) Get resuscitation equipment Apply self-adhesive pads

VF Check monitor/confirm rhythm 1st shock CPR (30:2) for 2 min Airway/Ventilation/Oxygen/obtain IV access

VF Check monitor/confirm rhythm 2nd shock CPR for 2 min Give adrenaline 1 mg IV/IO

VT Check monitor/confirm rhythm 3rd shock CPR for 2 min Give amiodarone 300 mg IV/IO

SR Check monitor/confirm rhythm Check patient (signs of life/pulse) ABCDE approach after ROSC Hand over to resuscitation team (ISBAR)

Discussion points:

High quality CPR, minimise interruptions, and ensure interruptions are for less than 5 s

Safe defibrillation

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

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ALS1 Simulation 4: PEA

Clinical Setting and History (may be adapted to candidate background)

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.

Clinical Course

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 1st shock No respiratory effort after ROSC

Interventions 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 Check monitor/confirm rhythm 1st shock CPR 2 min STach Check monitor/confirm rhythm Check patient (signs of life/pulse) 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

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ALS1 Simulation 5: VF - Asystole

Clinical Setting and History (may be adapted to candidate background)

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.

Clinical Course

Unconscious, cyanosed, no breathing or signs of circulation Initial rhythm is VF 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.

Interventions Check patient (breathing/circulation) Start CPR (30:2)/call for help/defibrillator

When defibrillator arrives VF Attach self-adhesive pads/confirm rhythm

1st shock CPR 30:2 for 2 min Airway/Ventilation/Oxygen/obtain IV/IO access Asy Check monitor/confirm rhythm CPR for 2 min Adrenaline 1mg IV/IO and then every alternate loop

Discussion points:

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

Further cycles until relevant Hs/Ts excluded/considered

Asy Consider stopping CPR

(may continue for up to approximately 20 min or when all possible reversible causes

assessed/excluded/identified/treated when able)

Ongoing care for patient Documentation requirements Consideration for team Debriefing and possibly other support services

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