Paediatric Resuscitation

Transcription

1 Paediatric Resuscitation RESUS4KIDS Fenton O Leary and Kate McGarvey

2 Conflict of Interest RESUS4KIDS is a Child Health Network project funded by The New South Wales Ministry of Health No financial interest by any of the team Courses are free to attend for participants No cost to facilities in New South Wales

3 Presentation outline Guidelines Epidemiology of out of hospital paediatric arrest Evidence around 4 specific issues Evidence linking human factors to resuscitation and therefore why we have included this in RESUS4KIDS Example of part of the RESUS4KIDS course Summary of the RESUS4KIDS program

4 Guidelines

5 209 cases, 193 had resus attempts 25% ROSC on arrival at hospital 7% survived to discharge Only one (0.9%) survived who was transported to hospital without ROSC Significantly increased survival for those in VF (35% vs 4%)

6 138 cases, 62% mortality Survivors: Weekend arrests No CPR at time of arrival at hospital Not asystole No atropine or Bicarbonate Fewer Adrenaline doses Shorter duration of CPR Drowning or asphyxial arrest NB Case selection

7 46 patients had > 3 doses Adrenaline Only 7 survived to discharge 1 comatose 3 severe disability 1 moderate disability 1 normal outcome

8 Pulse check versus check for signs of lifepeds-002a Treatment recommendations: Palpation of a pulse (or its absence) is not reliable as the sole determinant of cardiac arrest and need for chest compressions. If the victim is unresponsive, not breathing normally, and there are no signs of life, lay rescuers should begin CPR. In infants and children with no signs of life, healthcare providers should begin CPR unless they can definitely palpate a pulse within 10 s.

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10 Mistakenly perceived pulse when non existent 14-24% of time Failed to detect pulse when present 21-36% time Radial pulse Experience Often took > 10 seconds to decide

11 So what? If you are sure a pulse is there within 10 seconds then don t compress If at all unsure COMPRESS Practise feeling pulses in infants and children

12 Bag-mask ventilation versus intubationpeds-008 Treatment recommendations: BMV is recommended over tracheal intubation in infants and children who require ventilatory support in the out-of-hospital setting when transport time is short.

13 No advantage of intubation over BVM by Paramedic

14 No advantage of intubation over BVM by Paramedics

15 118 Higher rate of mortality and neurological impairment Increased risk of cardiac arrest and mortality Increased risk of failed intubations and complications in children No increased risk of failed intubations

16 So what? Its ok not to intubate paediatric patients in the field BMV is an effective intervention Careful appraisal of literature

17 Compression-only CPRPeds-012A Treatment recommendations: Rescuers should provide conventional CPR (rescue breathing and chest compressions) for in-hospital and out-of-hospital paediatric cardiac arrests. Lay rescuers who cannot provide rescue breathing should at least perform chest compressions for infants and children in cardiac arrest.

18 5170 patients (71% non cardiac) Non cardiac causes Better outcomes with conventional CPR (7.2% vs 1.6%) Cardiac causes No difference (9.9% vs 8.9%)

19 So what? Ventilations are good in non cardiac causes As you often don t know the cause Ventilations are always good!

20 Compression prior to defibrillation Whether a period of CPR should be performed before defibrillation in VF, especially after long response times, continues to be the subject of intense debate. The theoretical rationale for performing CPR before shock delivery is to improve coronary perfusion and thereby the chances of achieving sustained ROSC Inconsistent evidence to support or refute a delay in defibrillation to provide a period of CPR for patients in VF/pulseless ventricular tachycardia cardiac arrest.

21 10 relevant articles Retrospective papers Benefit Prospective RCTs No benefit No harm

22 So what? Does no harm May or may not benefit If already part of training program then ok not to change

23 Human factors and resuscitation

24 45 crews Standardised scenario Debrief afterwards

25 45 crews Standardised scenario Debrief afterwards Errors: Cognitive Procedural Affective Teamwork

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27 Major issues at arrests: Lack of organisation Lack of equipment Non functioning equipment

28 Major issues at arrests: Lack of organisation Lack of equipment Non functioning equipment Team dynamics Team leadership Team membership Stress Debriefing Conflict in teams

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32 303 students 39% response rate 5 Undergraduate Paramedic programs Readiness for Interprofessional Learning Scale (RIPLS) Interdisciplinary Education Perception Scale (IEPS)

33 Double degree students score higher on teamwork and collaboration Professional identity scores suggest as students progress through their courses they become less willing to engage in collaborative learning Differences between Monash and other Universities Students believe collaborative learning makes them more effective team members improves working relationships after qualification enhances communication skills Students do not want to waste time learning with other healthcare students Students feel that it is not necessary for healthcare students to learn together Students perception that effective clinical problem solving skills can only be learnt from students in their own discipline

34 1510 EMTs and Paramedics (62% response rate) Integrity Appearance/personal hygiene Patient advocacy Empathy Self-confidence Careful delivery of service Respect Communication skills Time management skills Teamwork/diplomacy skills Self-motivation

35 EMT-Paramedics are more critical of their colleagues than are EMT-Basics More experienced EMTs are harsher critics of their peers than are newer EMTs

36 RESUS4KIDS

37 RESUS4KIDS When Cardiac arrest occurs, the immediate and skilled action of the first responder is critical (Hunziker et al., 2011) RESUS4KIDS teaches this knowledge and skills Focuses on the first 10 minutes of a paediatric collapse Resuscitation for healthcare rescuers

38 Healthcare Rescuer The ARC differentiate between Basic Life Support rescuer and Advanced Life Support by paediatric healthcare rescuers. Advance life Support: resuscitation with the aid of equipment and drugs to restore and maintain airway, breathing and circulation to infants and children in a hospital or other environment where cardiopulmonary arrest may be encountered. Guideline 12.1 page 1 ARC 2010

39 RESUS4KIDS E-Learning Practical course

40 E-Learning Pre-Learning Interactive Pre and post tests Additional optional modules: - 4 H s & T s - IO access - Abnormal cardiac rhythms - Intubation (coming soon)

41 Short Practical Course Reinforces e-learning 90 minutes in length - 30 mins on teamwork and communication - 60 mins scenario based teaching - Interdisciplinary

42 RESUS4KIDS Teamwork and Communication The Surgeon Commercial TV show Education tool in relation to TEAM WORK, LEADERSHIP & COMMUNICATION! Language is Colourful

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44 Audience participation

45 Thoughts What did you think? What was their communication like? How did this contribute to the atmosphere of the resuscitation? Was there a clear team leader? What would you do differently if you were the help arriving at this scene?

46 RESUS4KIDS Scenario based teaching Highly engaging learning opportunity. Active Learning Participants are able to practise the skills demonstrated in the e-learning in a situation that mirrors reality as closely as possible Scenario Based Learning is based on the understanding that in order for a learner to acquire and retain skills & knowledge, the learner must be placed in a scenario where their decisions affect, or alter subsequent events leading to new events. This occurs just like in real life. California State Polytechnic University

47 Active Experimentation - This occurs within a new concrete experience - Takes the new understanding eg. airway manoeuvres and experiment with these in your clinical practice Kolb s Learning Cycle Concrete Experience - Participate in R4K short practical course New Understanding Formed - How to use the different equipment - Sequential approach to a child in arrest Reflective/ Observation - Reflect on their experience during R4K - What did the participant learn? Kolb s learning cycle shows the learning process that participants go through to transform the knowledge learnt from R4K and how to in turn implement it into clinical practice. Kaufman, D.M., & Mann, K.V. (2010). Teaching and Learning in medical education. How theory can inform practice. In T. Swanwick (Ed.) Understanding medical education : evidence, theory and practice. (pp16-36). Oxford, UK: Wiley- Blackell

48 Active Experimentation - This occurs within a new concrete experience - Takes the new understanding eg. airway manoeuvres and experiment with these in your clinical practice Kolb s Learning Cycle Concrete Experience - Participate in R4K short practical course New Understanding Formed - How to use the different equipment - Sequential approach to a child in arrest Reflective/ Observation - Reflect on their experience during R4K - What did the participant learn? Kolb s learning cycle shows the learning process that participants go through to transform the knowledge learnt from R4K and how to in turn implement it into clinical practice. Kaufman, D.M., & Mann, K.V. (2010). Teaching and Learning in medical education. How theory can inform practice. In T. Swanwick (Ed.) Understanding medical education : evidence, theory and practice. (pp16-36). Oxford, UK: Wiley- Blackell

49 Active Experimentation - This occurs within a new concrete experience - Takes the new understanding eg. airway manoeuvres and experiment with these in your clinical practice Kolb s Learning Cycle Concrete Experience - Participate in R4K short practical course New Understanding Formed - How to use the different equipment - Sequential approach to a child in arrest Reflective/ Observation - Reflect on their experience during R4K - What did the participant learn? Kolb s learning cycle shows the learning process that participants go through to transform the knowledge learnt from R4K and how to in turn implement it into clinical practice. Kaufman, D.M., & Mann, K.V. (2010). Teaching and Learning in medical education. How theory can inform practice. In T. Swanwick (Ed.) Understanding medical education : evidence, theory and practice. (pp16-36). Oxford, UK: Wiley- Blackell

50 Active Experimentation - This occurs within a new concrete experience - Takes the new understanding eg. airway manoeuvres and experiment with these in your clinical practice Kolb s Learning Cycle Concrete Experience - Participate in R4K short practical course New Understanding Formed - How to use the different equipment - Sequential approach to a child in arrest Reflective/ Observation - Reflect on their experience during R4K - What did the participant learn? Kolb s learning cycle shows the learning process that participants go through to transform the knowledge learnt from R4K and how to in turn implement it into clinical practice. Kaufman, D.M., & Mann, K.V. (2010). Teaching and Learning in medical education. How theory can inform practice. In T. Swanwick (Ed.) Understanding medical education : evidence, theory and practice. (pp16-36). Oxford, UK: Wiley- Blackell

51 RESOURCES

52 RESUS4KIDS & NSW RESUS4KIDS is currently not a mandated course October ,150 lessons accessed 9, 239 completed e- Learning 3,840 short practical course 557 trainers 33 Super Trainer

53 RESUS4KIDS & NSW Ambulance 196 E-Learning 129 Short practical course Approximately 40 R4K trainers Bill Donaldson Super trainer and contact person UTAS about to implement R4K

54 A paramedics experience Found R4K course was beneficial in reinforcing previous training and additional information Pulse points e.g. brachial or femoral rather than carotid Neutral position for airway management Guedel airway measurement Mask placement to achieve adequate seal Chest compression techniques and rates Drug dose calculations Reversible causes that were considered with patients improvement with airway management and 100% oxygen Not the paramedics involved

55 Interested? To complete the e-learning go to To complete the practical course contact Bill, your local hospital, paramedic educator or us To find out more visit