OK, you have completed your Advanced Life Support (ALS) and Basic Life Support (BLS) education.
Perhaps it was a few months back. Or perhaps you are due for a refresher.

And then your patient arrests. When you least are expecting it.
You immediately experience the arrest response mind donk.

Your brain is  total beige…. and all your knowledge of the ALS algorithm seems to be folded up into an origami flapping bird that is migrating south to your sphincter.

I am going to give you a rough thought-script to simplify the whole thing and get you over any mental donk by moving you to move your nursing team through the things that need to be done.

This is NOT a substitute to the ALS pathway you have been taught, it is just a quick script to cover the first few minutes. By that time there should be plenty of assistance unfolding.

And…I am purposefully skipping over all the intermediate skills and interventions that need to be applied. A knowledge of BLS and ALS pathways is assumed.

Really, you know what to do.
It may have just been a while since you have had to access that part of your brain.
The purpose of this is to give you some solid waypoints, some goals to aim to reach quickly and effectively.

• A = Assemble (yourself and your team).
• B = BLS (yes or no)?
• C = Connect & Charge a defibrillator.
• D = Decide to shock.
• E = Every 2 minutes.

Assemble (yourself and your team).

Assemble yourself!  Take a serious instant to wring the adrenaline out of your brain. ALS is easy.
Assemble your team. Yes, you are going to be checking for Danger and Responsiveness and whatnot, but your first waypoint is to have help at hand.
ALS is a team sport.

BLS (yes or no)?

When you undertake BLS and ALS courses, you are taught to assess airway, breathing, and circulation assessment and intervention respectively.
But the key decision point here is “Do I need to start BLS?”
Keep that in mind and move through your assessment swiftly to get to that point.
Then make the call.

If chest compressions are now in progress check that they are being delivered effectively. This is of great importance. If they are not, correct the technique or replace the person doing them.

Connect & Charge the defibrillator

Your next task is to have the patient connected to the defib.
BLS continues.
Once it arrives, ensure that there is minimum disruption (i.e. nil) to chest compressions whilst the pads are applied.
Once pads are applied, turn the defib on¹.

So again, you will:

• Continue BLS
• Call for a defibrillator.
• Connect the defibrillator.
• Charge the defibrillator.

It is a simple as BLS + Connect and Charge.

Decide to shock:

Now you are at your second decision point. Your first one was BLS yes or no.
The defib is connected and charged.
BLS stops².
The rhythm is assessed.
The decision to shock is made.
I am not going to go through all the rhythms here, but to help narrow the options: if the monitor looks like normal ECG complexes or is a flat line, you are NOT going to shock.

If you are unsure what the rhythm is, ASK the team for help. If you are still unsure, recommence CPR until someone arrives who can identify the rhythm.

The decision:

Do not shock.

• Sinus rhythm (PEA)
• Asystole.

Shock:

• Pulses VT.
• VF.

Once this decision has been executed, BLS recommences immediately.

Every 2 minutes:

BLS now continues for 2 minutes without interruption until the defib is charged and the decision to shock is again made. Or until the patient lets you know that they are no longer appreciating CPR.

During this time you need to:

• Obtain and secure IV access.
• Draw up Adrenaline 1mg.
  If you just shocked the patient it will be given after the NEXT shock. If you have not shocked your patient it will be given NOW.
• Maximise the airway and chest compression quality.
  Consider adding airway adjuncts (naso/oropharyngeal).
  Consider preparing to replace the person delivering CPR at the next rhythm check if they are fatigued.

There you have it. You are now well into the resuscitation. The donk has passed.
Hopefully the full team has arrived, is organised and following the cardiac-respiratory arrest algorithm by this stage.
HERE IT IS.

1. if the defibrillator is an AED, at this point you follow the audible instructions given by the unit [↩]
2. most ALS courses recommend that everyone EXCEPT the person delivering CPR are stood clear whist the defib is charging [↩]

Following my post on securing on how to secure an endotracheal tube (ETT) with tape, I a received a comment from Kaye Rolls a Clinical Nurse Consultant at the Intensive Care Coordination & Monitoring Unit.
You can follow Kay on Twitter (@kaye_rolls).

Turns out she is indeed an expert on the art (but perhaps not quite yet science) of ETT security. She is co-author of a set of guidelines published by NSW Health titled: Stabilisation of an Endotracheal Tube for the Adult Intensive Care Patient (pdf)

The 3 methods currently used to stabilise an ETT are:

• Tying the ETT to the patients head using white cotton (Trachy) tape.
• Taping the ETT to the patients face with medical adhesive tape.
• Using a commercial tube holder.

A recent survey of NSW ICUs and High Dependency Units (HDUs) with the capacity to provide short term ventilation was conducted to determine local ETT management practices.
Participants from 41 of the 44 eligible units responded (response rate 93%). The white cotton tape method was the most frequently reported method for stabilising the position of an ETT (78%, n=32) however nine units reported using this method in conjunction with a commercial product and a further seven units reported using this method in conjunction with medical adhesive tape.
Renewing or changing the ETT tapes is a procedure completed frequently by critical care nurses, however, only 41% (n=17) of NSW ICUs/HDUs had a written guideline for this procedure and only nine of these protocols were less than two years old.
Intensive Care WIKI

There is really not much research evidence to support the use of any one method over another, but the guidelines provide some clear principles for specific clinical situations.

As there is so little evidence, these guidelines are based on consensus opinion reached following a meeting of the Intensive Care Collaborative Consensus Development Conference in 2006–07

Here is a summary of the practice recommendations:

• Two clinicians must always be present to change the method of securing the endotracheal tube. One clinician changes the tapes while the other holds the ETT in position.
• Of the two clinicians changing the ETT securement at least one clinician must be an experienced member of the critical care team.
• The method of stabilisation should be consistent within units to promote staff proficiency in safe and effective ET stabilisation.
• The use of adhesive tape/devices should be avoided in patients with impaired facial skin integrity (for example burns, cellulitis).
• The use of adhesive tape/devices should be avoided in patients with extreme diaphoresis
• The use of adhesive tape/devices should be avoided in male patients with beards.
• Endotracheal tube securing methods that may cause venous occlusion should be avoided for patients at risk of raised intracranial pressure
• The ETT securing method should be renewed if the tapes are soiled.
• The ETT securing method should be renewed if the ETT is able to
  migrate/move more than 1 cm.
• When using cotton tape the ETT securing method should be renewed if a clinician is unable to insert two fingers between tape and skin.
• The ETT securing method should be renewed if the ETT position on CXR is incorrect (tip should be 2.5cm above the carina).
• The ETT securing method should be renewed if the method of tube stabilisation is not consistent with Unit practice.
• In the absence of other indications the tube stabilisation method should be renewed at least once every 24 hrs to enable skin and mucosal assessment and to prevent sustained pressure on a single point.
• Assessment of the face should include the condition of the skin of the face, ears and back of neck. In addition the assessment of the oral cavity should be inline with the assessment completed for adequate oral hygiene and includes the mouth, teeth, gums, tongue, mucous membranes, lips and barriers to mouth care.
• The ventilator tubing should be supported by a ventilator arm that keeps the patient’s head in the midline and prevents pressure on the lips.

 

Graded assertiveness is a learned skill. It is a process of communicating, advocating and directing with hardcore clarity that is useful in stressful or crisis scenarios.

There are many factors that can block good communication during critical events including differences in seniority or experience, job position, personal power, personal agendas, fear of ‘loss of face’ and plain old pig-stubbornness.

One form of graded assertiveness that has been developed, can be remembered with the word PACE.
PACE consists of 4 stages or tiers of communication. Each one is a measured escalation that systematically (if the problem is not resolved) transfers power from other, to shared, and finally to self.

Here is one (not particularly brilliant) example to give you some idea of PACE in action.

1. Probe: “did you know that this patient has a serious allergy to Latex?”
2. Alert: “I think there might be Latex in the gloves you are using. Lets just check on the box”.
3. Challenge: “It is against our policy for you to do this procedure wearing Latex gloves if the patient has an allergy. You should not continue”.
4. Emergency: “Step away from the patient. You will not continue with this. I am contacting the consultant immediately”.

By using the 4 stages as a guideline you have a structured momentum that empowers you to move forward despite perhaps feeling uncomfortable doing so.

In such ‘moments of crisis’ you become an advocate for your patient, your colleagues or yourself.

Another tool that will help during graded assertiveness is to develop a structured template ahead of time that you can mentally access when you need to communicate a plan for engaging with problems or issues.

1.  Attention:  “Excuse me John….”
2.  State your concern:  “I notice from your fluid balance chart that the man in bed 6 has not had any output from his IDC in the last 2 hours.
3. State the problem as you see it: “I think this man is deteriorating, and we need to have him reviewed.”
4. State a solution: “I will phone doctor Kumar to come and review him urgently”.
5. Obtain an agreement: ” Does that sound OK to you?”

When you have a spare 20 minutes, I assertively recommend you listen to this podcast from HarrisCPD on PACE.

————————————

Read more:

Life in the Fast Lane: Communication in a Crisis.

Critical Care: Patient safety and acute care medicine: lessons for the future, insights from the past.

It was a busy shift. One of my colleagues came over to me and asked me to check her dosage calculations for a drug she was about to give a 5 year old girl.
I was doing about a hundred things ( a-hundered-and-five if you count what I was actually doing outside my head) but I said “sure…” and went over to do the quick drug check.
After all, she was an experienced nurse…everything would be good, so this would only take a moment.

One minute later I was back on my own task list, when I realised that I had not really checked her calculations at all. I had stood there and nodded in agreement. I had said “I concur…” But my mind had never accompanied my body over to the desk.
I couldn’t tell you what the calculation was. I had not really looked at the medication expiry date and……crap….I don’t think I even really looked to confirm it was actually the right medication!

I zipped back over to her and re-did the check. Everything was fine. No thanks to me.
My inattention had potentially put the patient and my colleague at risk.
Thankfully all I had actually done was to let them both down.

I have already spoken a little to the topic of nursing mindfulness and using the act of washing your hands to anchor you to this state. STOP washing your hands

Paying attention to what you are doing is such a simple thing. Remembering to do it is deceptively difficult. In fact, most of the time we are not paying attention to just how much we are not paying attention.
And when it comes to the domain of calculating and preparing medications in-attentively …..here there be dragons.

How about another prompt or anchor to trigger some attentiveness during that most important of activities: medication management?
The trigger is the word drug.

1. Deep breath.
   Simple. Pay attention to yourself as you take one slow breath. This is like logging into the mindfulness/pay-attention network.
2. Re-focus.
   Bring your full attention to the task at hand. Opening a medication, or drawing up antibiotics, or checking a drug calculation with a colleague. Politely exterminate any interruptions.
3. Understand.
   This is important. You have cleared you mental desk, you are focused on the task….now you must engage your knowledge and skills that relate to it. Understand what you are doing, what you are about to give and why ( think about your medications rights).
   If you do not understand, do not proceed.
4. Go.
   Now…go and deliver the medication.

Develop a link between the act of interacting with any drug and using the mnemonic DRUG to cradle your medication activity within a container of mindfulness and attention.

It only takes a few seconds to remind yourself to pay attention and disentangle yourself (even if only for a few moments) from all the interruptions, distractions, and mental wanderings that crowd out your shift and pull you towards error.

Developing a DRUG habit will give you that little mental nudge to manage medications more safely, and more effectively.

I have already shown you a very good short introductory video on using the Oxylog 3000 ventilator.

And now here is something a little more advanced for those of us who are more experienced with managing ventilated patients.

Scott Weingart, an ED Intensivist from New York City and author of the eminent EMcrit has produced a set of 2 videos (also available as podcasts over on his site) on ‘Dominating the Vent’.

For those of you who think you have a fairly good grasp of the basic concepts of ventilation, I strongly recommend you take the time to watch these 2 videos. Like…..do it.

There is also a handout to accompany this lecture which you should download as a pdf and follow along with.

Here is a taster of some of the juicy tips that Scott covers in the first lecture:

• Tidal volume (Vt) should be used to protect the lungs, and NOT to try to alter CO2.
• Initial vent Tidal Volume is 6–8 mls/kg based on predicted body weight. “Injured lungs are baby lungs”
• Initial Vent Resp Rate should be16–18 (18 is better and Scott will tell you why).
• Patient oxygenation is best controlled in response to pt ABG’s via changes to FiO2 and PEEP and the use of a PEEP chart.
• MYTH: High levels of PEEP causes pneumothorax.
• MYTH: high levels of PEEP causes high ICP.
  Do not fear rolling up your patients PEEP
  PEEP of 18–24 are not totally uncommon in this setting.
• Best way of controlling high airway pressures is to measure Plateau pressures (NOT peak pressures).
  If pressure > 30cmH2O, lower the Vt.

Part 1 (Ventilation of the injured lung)

EMCrit Lecture – Dominating the Vent: Part I from Scott from EMCrit on Vimeo.

If you cannot see the player above, here is a link to the video.

Part 2 (Ventilation of the obstructed lung eg Asthma COAD)

Dominating the Vent Part II from Scott from EMCrit on Vimeo.

If you cannot see the player above, here is a link to the video.

And here are some tips from his second vid:

• Vt initially 8mls/kg based on pts predicted body wt.
• FiO2: 40–100%
• PEEP: 0 (or ‘ZEEP’)
• RR: most important setting in the obstructed lung.
  Need to set low (start at 10 BPM and titrate)
• I:E ratio of 1:4 or 1:5.
• If patients are not given time for alveoli to empty before next breath is delivered pressure will build.
• If asthmatic, don’t forget to administer bronchodilators to treat the underlying issue.
• If your patient is crashing the first thing you need to do is disconnect them from the ventilator ( & then bag via bag-vale-mask).

As an important corollary to this information, I would hasten to add that any changes to ventilation settings must be made (at the very least) in close and immediate consultation with the doctor in charge of that patients care.