Hot session took a whole new meaning in a super cramped simulation training room packed with enthusiastic participants performing life support drills. Participants came close to performing CPR on real people as some of the facilitators nearly collapsed.
Dr. Lucy Reed ED director, Dr. Riaz Khan DEMT, Stuart Davidson
Clinical nurse educator and Dr. Andrea Harding (ED advanced trainee) led Advanced life support training for ED registrars and Emergency nurses joined for an hour. The first two hours was a refresher course on ALS and the next two hours was for APLS.
Adult life support
The first ALS hour consisted of 3 skills-practice stations (Drugs/Equipment, CPR/ Defib and BLS/AED). In the next hour, participants had an hour of scenario-based ALS simulation. Two ALS scenarios were simulated.
Emergency nurses joined for the ALS simulation sessions which was excellent.
The first scenario covered VF arrest in the context of a STEMI. ROSC was achieved after 3 cycles of CPR and the patient was expected to go to Cath lab. Emphasis was on the adherence to the ALS algorithm and technique.
The second scenario covered the case of a hypokalemic VT arrest in a young patient with Anorexia nervosa. The focus was on the 4 Hs and Ts being considered early, in tandem with performing good quality CPR.
The salient learning points from the scenarios were:
- DRSABCD approach to BLS. Be bold to call for help early.
- Identify team and allocate roles early
- Closed loop communication
- Leadership should be distinct (stand back and lead from end of bed)
- It is mandatory to know the ALS algorithm
- COACHED mnemonic for defibrillation minimizes interruptions to CPR
C: Compressions Continue
O: Oxygen away (if free flowing BVM)
A: All others clear
C: Charging defibrillator (200J)
H: Hands off (compressor)
E: Evaluating rhythm
D: Defibrillate or Disarm
- Early defibrillation is time critical in a shockable rhythm.
- Please remember ‘Fine VT’ is non-shockable (managed like PEA/ Asystole)
- Please familiarize yourselves with our defibrillators.
- Please be aware of post resuscitation care. The ARC guidelines give clear evidence based recommendations. ALS flowcharts list the most important ones e.g. Targeted temperature management, cardiology intervention etc. It is important that all resus staff be familiar with the ARC guidelines. Further resuscitation training will be made available to all staff throughout the year.
- ECMO resus is available at Launceston General hospital. This is led by ICU. Consider and activate the process early if indicated.
Acute Paediatric Life support
In the first hour staff attended the following APLS skill stations:
- Differences in resuscitation of neonates, infant and children from adults. ABCD approach. A practice session on intraosseous drill (Ezi IO) use was included.
- Defibrillation/CPR. It is mandatory to know the APLS algorithm for Neonatal and Childrens resuscitation.
- Drugs & Paediatric calculations. A pediatric resus tool such as the ones provided by RCH or Monash Childrens hospital (referenced to RCH). will help all the staff in a resus scenario handle the same doses and calculations. The resus cubicle has a pre-formatted white board for the most essential calculations to be written down. Please use these routinely.
Following the skills stations, participants attended APLS simulation. The scenario was that of a floppy infant arriving in hypovolemic arrest. Prompt fluid resus and adherence to APLS guidelines led to ROSC.
The key learning points from this session were:
- Team-leading needs to be very clear and calm – everyone is feeling stressed so outwardly we must convey calm. Panic is contagious.
- Communication is the key – closed loop, clear and regular summary of where the scenario is up to
- Identify/ announce what is being treated – “OK team, we are now in PEA – continue CPR for 2 minutes, 10mcg/kg of adrenaline and consider/treat any reversible causes,” and so on
- Pre-planning is vital. Mistakes could happen when doses are being calculated in the heat of the moment.
- Use a weight based guide. e.g. Monash – then we are all on the same page
- Make requests more practical– 100 mcg of adrenaline is confusing, whereas 1 ml of 1:10 000 is practical and easy to manage
- Remember the parents will almost certainly be present. They need to provided with support from an experienced health care professional – social work is the obvious, but if not identify an appropriate person – NOT the team leader. There is good evidence that parents in the resus room of their child cope with the aftermath and grief better than if not present
The sessions ended with a recap and general discussion about ensuring these skills are kept up to date and well practiced. Visualizing a scenario and going through the algorithms in your head is good practice. You must know this content – it is core knowledge to our specialty and we should be experts at resuscitation.