The Cardiothoracic Advanced Life Support Course :

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• 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

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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

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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

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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

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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.

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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

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ALS in the CICU Are the new guidelines
dangerous ?
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CALS Cardiac Arrest Protocol
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Cardiac Arrest Protocol

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1
1

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2
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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

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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

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Emergency Sternotomy
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Scenarios for Critically ill Cardiac Surgical
patients

• Lectures, practicals and scenario practice on a
  series of life threatening situations
• Protocols for each situation

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Course Content Cardiac Arrests
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Hypotension

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

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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, UE, ECG, consider
  senior help
• After colloid bolus reassess , ? Need for
  reopening

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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, UE, ECG,
  Echo,consider PA catheter, consider
  senior help
• After inotropes reassess ? IABP Re-open

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CALS Day 1
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CALS Day 2
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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

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Scenarios
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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

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Results Critically ill patients
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Results Critically ill patients
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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.

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Results Cardiac arrest
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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

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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

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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

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Experience in Post-Surgical Cardiac Arrests on
the CICU

• Cardiac arrests attended
• None 12
• 1-3 17
• 4-10 17
• lt10 15
• Mean 9

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Experience in Post-Surgical Cardiac Arrests on
the CICU
Good


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Experience in Post-Surgical Cardiac Arrests on
the CICU
Moderate


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Experience in Post-Surgical Cardiac Arrests on
the CICU
Poor


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Experience in Post-Surgical Cardiac Arrests on
the CICU
Moderate


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Experience in Post-Surgical Cardiac Arrests on
the CICU
Poor


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Experience in Post-Surgical Cardiac Arrests on
the CICU
Moderate


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Experience in Post-Surgical Cardiac Arrests on
the CICU
Poor


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Experience in Post-Surgical Cardiac Arrests on
the CICU
Poor


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Experience in Post-Surgical Cardiac Arrests on
the CICU
Poor


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Experience in Post-Surgical Cardiac Arrests on
the CICU
Poor


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Experience in Post-Surgical Cardiac Arrests on
the CICU
Poor


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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

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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.

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Questions?