The Cardiothoracic Advanced Life Support Course :

1. 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

2. The need for training • Emergency chest re-openings are becoming less common • Working time directive and reduced trainee numbers mean that non-surgical trainees will increasingly become the first-responders to emergencies

3. The need for training • The European Resuscitation Council guidelines December 2005 : • “Consideration should be given to training non-surgical personnel in the skills of emergency chest-reopening”

4. The need for training • Papworth : 6 year review, 79 re-openings • Reopening within 10 mins 48% survival • Reopening over 10 mins 12% survival Mackay JH, Powell SJ, Osgathorp J, Rozario CJ. EJCTS 2002 • Brompton and Harefield : 4 year review 72 re-openings • 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

5. The need for training • Multiple critical care training courses in other specialties. BLS, ACLS, ATLS, CCrISP • No formal training for arrests post-cardiac surgery • After many ‘Traumatic’ arrests, we created the Cardiothoracic Advanced Life Support course in December 2003.

6. CALS 2006 • Performed 9 full courses. • Performed 3 ‘In House’ courses • 2 further ‘In house courses’ booked. • 3 more courses this year. • Published papers in BMJ, Annals of Thoracic Surgery, Nursing Times

7. ALS in the CICU : Are the new guidelines dangerous ?

8. Precordial Thump if appropriate Commence Basic Life Support CPR 30:2 If ventilated turn FiO2 to 100%. If necessary hand ventilate at 100% O2 Assess Rhythm VF/VT +/- Check Pulse Non VF/VT 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 , If Pacing wires in situ set to DDD at 90bpm, 10V. Give 3mg atropine Defibrillate x3 Shocks Re-open chest if Non VF/VT rhythm established (see protocol) Re-open chest if 3 shocks fail. (see protocol) Potential reversible causes: Hypoxia, Hypovolaemia Hypo/hyperkalaemia Hypothermia Tension pneumothorax Tamponade Toxotherapeutic disorders Thromboembolic & mechanical obstruction CPR 3 mins 1 min if immediately after defibrillation CPR x 1 min CALS Cardiac Arrest Protocol

9. Cardiac Arrest Protocol 5 1 1 1 2 3 4 6

10. Cardiac Arrest Protocol • Person 2: Cardiac Massage : Rate 100bpm, watch arterial trace • Person 1: Airway : Oxygen to 100%, Check ET tube, check air entry bilaterally. Bag-valve. • Person 3: Defibrillator : Check rhythm, Shock as appropriate if fail, prepare internal paddles. • Person 4: Command role :Check ABC, make decision to re-open as appropriate • Person 5: Drugs : Take all drugs to head. Stop all infusions, Give Adrenaline atropine etc, when ordered and time arrest • Person 6: Resource Commander :In charge of all further people at arrest. Arrange equipment for reopening, specialist help contact, Patient and staff movements

11. Chest Re-opening Protocol Non VF/VT or failure to gain output with 3 shocks • 1. Continue Cardiac Massage • 2. 2/3 people gown/gloves (no hand washing) • 3. Open Thoracotomy set • 4. Single Drape, no betadine • 5. Knife down to Wires • 6. Wire cutters to remove wires • 7. Suck out chest • 8. Sternal retractor • 9. No output commence 2 handed massage AFTER checking for grafts

12. Emergency Sternotomy

17. Scenarios for Critically ill Cardiac Surgical patients • Lectures, practicals and scenario practice on a series of life threatening situations • Protocols for each situation

18. Course Content: Cardiac Arrests

19. Hypotension 3 causes of Hypotension • Hypovolaemia • Ventricular failure • Ventricular dysfunction • Tamponade • Dysrhythmia • High output state - Vasodilated

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

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

22. CALS Day 1

23. CALS Day 2

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

25. Scenarios

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

27. Results : Critically ill patients

28. Results : Critically ill patients

29. Results : Critically ill patients • 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 600mls 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 (190bpm 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.

30. Results : Cardiac arrest

32. Survey of CICU staff skills and experience • 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

33. Survey of CICU staff skills and experience • METHODS: • Survey created • 2 shifts approached at 3 UK cardiothoracic centres : Middlesbrough, Stoke, Wythenshawe • All Nursing staff on shift surveyed

34. Survey of CICU staff skills and experience • 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

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

36. Experience in Post-Surgical Cardiac Arrests on the CICU Good

37. Experience in Post-Surgical Cardiac Arrests on the CICU Moderate

38. Experience in Post-Surgical Cardiac Arrests on the CICU Poor

39. Experience in Post-Surgical Cardiac Arrests on the CICU Moderate

40. Experience in Post-Surgical Cardiac Arrests on the CICU Poor

41. Experience in Post-Surgical Cardiac Arrests on the CICU Moderate

42. Experience in Post-Surgical Cardiac Arrests on the CICU Poor

43. Experience in Post-Surgical Cardiac Arrests on the CICU Poor

44. Experience in Post-Surgical Cardiac Arrests on the CICU Poor

45. Experience in Post-Surgical Cardiac Arrests on the CICU Poor

46. Experience in Post-Surgical Cardiac Arrests on the CICU Poor

47. Summary • 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

48. The Future • A Joint EACTS / ERC Statement on Resuscitation in Cardiothoracic Intensive Care units • to be published in Resuscitation. • 3 Courses per year • Providing support for units practicing cardiac arrests in their own units.

49. Questions?