ALS course documents

Initial assessment and resuscitation skill station

Key learning outcomes By the end of this session the candidate will: Assess the collapsed patient, using an ABCDE approach Perform high quality chest compressions Recognise the need for defibrillation

Jan 2011 v. 0.1

Perform safe defibrillation with minimum interruption to chest compressions

Instructor information Within this skill station there are four key skills: A. Initial assessment using an ABCDE approach B. Delivery of high quality chest compressions C. Task allocation and planning for defibrillation D. Recognition of VF and safe defibrillation Candidates should be advised that the skills taught are subject to continuous assessment. At least one ERC ALS instructor, and one other member of faculty, who is either a full instructor or an Instructor Candidate, must supervise the skill station. Candidates must demonstrate competence in all four sections. The practical skills of using an ABCDE approach, CPR, task allocation, planning and defibrillation should be taught around a simple simulation. Deliver a simulation relevant to the candidates clinical background. In order not to confuse candidates this is best achieved by simulating a patient who has a VF arrest. Two other candidates should assist and be competent in performing chest compressions and bag-mask ventilation. If a fourth candidate is present, they should be asked to feedback at the end of the simulation. Section A: Initial assessment using an ABCDE approach Clinical case You are called to assess a 55-year-old patient who has been admitted to a general ward and has developed central chest pain. Instructor information The defibrillator is not available during the initial assessment.

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Emphasise safety to all candidates and be prepared to intervene to stop the simulation if necessary. Assess: Responsiveness Airway (e.g. patency, debris) and give high-flow oxygen Breathing adequacy (e.g. respiratory rate, expansion, percussion, breath sounds, SpO2) Circulatory status (e.g. pulse, blood pressure, capillary refill, urine output) look for evidence of haemorrhage (drains, PR bleeding) Disability (conscious level, e.g. AVPU, pupils) Exposure

Section B: Correct performance of CPR Clinical case progression The patient becomes unresponsive Call for help Open airway Check breathing and circulation Call resuscitation team and send for defibrillator Commence CPR Deliver high quality chest compressions 1. Depth 2. Rate 3. Duty cycle 4. Recoil Section C: Task allocation and planning Two assistants arrive Allocate tasks to assistants: o o o o o Identify skill level of assistants Instruct one assistant to start bag-nask ventilation and second assistant to take over chest compressions in accordance with skill levels Confirm high quality CPR is being delivered Pads will be applied with ongoing CPR CPR will stop for a quick rhythm check and then resume Plan for defibrillation while CPR is ongoing, explaining:

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If VF confirmed, defibrillator will be charged whilst chest compressions are ongoing, all other assistants stand clear, remove oxygen When defibrillator charged, person delivering chest compressions will be given order stand clear As soon as clear, shock will be delivered Restart CPR immediately after shock delivered

Section D: Recognition of VF and safe defibrillation Clinical case progression CPR 30:2 is in progress. The defibrillator arrives o o o Correctly applies self-adhesive pads whilst CPR continues Briefly stops CPR, confirms VF on monitor (<10 sec), resumes CPR Gives instructions to person delivering compressions to continue, ask all others to stand clear, removes oxygen if necessary. Charges defibrillator whilst CPR ongoing o o o o o Ensures that rescuer giving chest compressions is the only person touching the patient Announce stand clear to person delivering chest compressions Deliver shock immediately after compressions stop Immediately resume CPR without rechecking rhythm Indicate that CPR should be continued for 2 min prior to checking rhythm

Instructor information points for discussion / further demonstration Calling the resuscitation team Combined assessment of the breathing and circulation Minimise interruption to chest compressions by task allocation and planning Safety of team, wearing gloves to minimise risk of shock transfer Transthoracic impedance (pad size, contact, hairy chest) Enviromental hazards / risks Biphasic / monophasic waveforms Automated external defibrillation `Dumping`the energy from changed paddles

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Allow candidates to ask questions and reflect on the session content before terminating the session with a succinct summary of all the major points covered.

Summary Rapid and effective patient assessment Provision of effective ventilation and compressions Task allocation and planning prior to defibrillation Minimising pre-shock pause Recognition of VF Shockable limb of the ALS algorithm Theory and practice of safe defibrillation

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