Acute CrisisTraining with Simulation (ACTS)

Welcome to the ACTS Program

Overview

Toilets Refreshments Faculty Basic Assumptions

Housekeeping

Please read and sign our confidentiality agreement form…

Confidentiality

BLS and ALS Review

Rapid Review of Basic and Advanced

Life Support

Cardiac Arrest on the Ward

2010 MAJOR EMPHASISEVIDENCE BASED

• New Guidelines Due in 2015

• Good Quality CPR (2010)

• Early Defibrillation (2010)

NB - These two factors are the main determinant of return of spontaneous circulation

Evidence Based Guidelines (ILCOR)

Key changes to BLS algorithm

“Signs of life” removed Now DRSABCD If not responsive

SEND for help If not breathing

normally when airway opened start compressions before giving rescue breaths

Ratio = 30:2 in Adults D Attach external

defibrillator

“C A B” (ABC has become CAB)

Compressions• Minimise interruptions and use a

metronome• Swap on a regular basis• Defibrillator charged before stopping every 2

minutes for Rhythm check • Single shocks given (always 200 Joules)

Airway- Role of intubation de-emphasised: LMA used- Keep the Pillow – apply BVM – 2 rescuers

Major changes to ALS

Adrenaline - 1mg up front for all non-shockable rhythms• 1mg after the second shock in shockable rhythms • Repeat after every 4 minutes

Amiodarone - 300mg after the third shock in shockable rhythms

Atropine - No longer recommended for PEA or Asystole

Drugs

• C – “Continue compressions” • (“I won’t shock you”)

• O – “Oxygen away”• A – “All else clear”• C – “Charging”• H – “Hands off!”- “Shock Delivered” “Continue CPR”

Defibrillation

BLS Defibrillation Demo

Cognitive Aids and Checklists

The Simulation Lab

Orientation

Introduction - Simulation Lab

Debriefing = Learning

An Approach to the

‘Crashing’ Patient

General Tips

Anticipate and plan your behaviour Learn from each emergency you

attend Keep yourself relatively calm Do the basics well Assign roles Use cognitive aids

Overview

70 year old Heart Rate 32 Blood Pressure 79/30 (multiple readings)

Light-headed Confused Pale Looks Unwell

How would you approach this case?

4Hs and 4Ts Checklist

ABC-D.E.F.G. IV (and get a blood gas) O2 Monitor and ECG Call for help, CRM and use the ALS checklist

“Treat the Cause”

Mantra for Arrhythmia Management

25 minute Electives

Break into 3 groups of roughly even numbers

CRM – 5 minutes

Human factors What are Human Factors?

Acute Crisis Resource Management Skills Communication Teamwork Leadership

Overview

Structured communication tools

ISBAR

Assertiveness

What is effective communication?

Team Leaders

Team Members

Hypotension andSepsis Rapid Review

1. 59 year old male - large inferior STEMI

2. 65 year old female - bleeding gastric ulcer and BP 90/60

3. 74 year old female P 65 BP 105/60 RR24 Temp 35 mildly confused

4. 32 year old female DKA

- pH 6.9 BSL 45 HCO3 9

Which patient has the highest mortality?

1.Inferior AMI 5%2.GIH + low BP 11%3.Septic shock 25%4.Severe DKA <1%

Which patient has the highest mortality?

Infection

“SIRS” Criteria

Sepsis

Septic Shock

Fail to recognise

Under-appreciate mortality

Do not see as time critical

Take Home - Sepsis Pitfalls

Respiratory Failure

2 minute Review

Along with Sepsis, Respiratory Failure is a

leading cause of ICU admission

It is the number one reason for a Ward Based

ALS call at Westmead

High inspired oxygen concentrations do not depress ventilation in patients with acute respiratory failure

Rising CO₂ in these patients indicates fatigue, and a

need for ventilatory support

Get a Blood Gas

Start Treatment (O2, Nebs, Meds)

Call for Help Early

Follow the “management of acute hypoxia” guideline

Chest Pain and Myocardial Infarction

2 Minute Review

Make an ABC- D.E.F.G. assessment

Consider the Risks for Acute Coronary Syndrome

Cross Check using the Chest Pain pathway (NSW health)

Chest Pain

Morphine, Oxygen, Nitrates and Aspirin 12 lead ECG IV Access Judicious Pain Relief (nitrate/morphine) Send Bloods Ischaemic/infarcting myocardium causes

dynamic changes (time is muscle): Risk of arrhythmias Risk of pump failure

Classic Treatment is M.O.N.A.

Does the patient have a - STEMI = Call an ALS

Are there adverse signs that meet the grounds for escalation:

ALS or MET (PACE) Call

Call for help