MegaCode and Team management okay let's go ahead and start her on 2

- ACLS AHA liters of o2 miss Fernandez we've got

you hooked up to a monitor so we can
team dynamics are critical during a take a look at your heart rhythm okay
resuscitation attempt the interaction and we've started you on oxygen so you
among team members has a profound can breathe a little easier if pulse ox
impact reading is 95% with 2 liters of o2
on the effectiveness of each individual dr. right okay it looks like we have
as well as the patient's overall sinus bradycardia Dana let's go ahead
survival the better you work as a team and get an IV started right now miss
the better the potential outcome for Fernandez mrs. Fernandez can you hear
your patient that's why it's so me
important that you understand not just mrs. Fernandez she's unresponsive you
what to do in a resuscitation attempt feel a pulse okay let's call a code the
but how to communicate and perform as an patient's gone into v-fib start chest
effective team regardless of your role compressions three compressions Mandell
as team member or team leader welcome to you'll be on defibrillator Shelley
the American Heart Association's you'll be recording recording Sam you'll
megacode and team resuscitation video in manage the airway Dana have you been
this video we're going to demonstrate able to establish an IV access yet I've
and model an effective resuscitation tried several times but it's failed okay
team in a case scenario our simulation let's move on to IO access please let me
will have six team members you may have try oh access six twenty seven twenty
fewer members depending on the situation eight twenty nine thirty one two three
so be prepared to adjust your roles four five six seven eight nine ten
accordingly our case study begins in a charging at 200 joules shock Witte clear
local emergency department where a 65 the patient shocking on three one two
year old woman has been brought in three shocking shock delivered
complaining of epigastric and back I have IO access now great we'll
discomfort hello I'm dr. Jackson what's continue CPR for two minutes and
bothering you today doctor I don't feel evaluate the need for additional
good I feel really bad I'm dizzy and I'm defibrillation Shelley I'll rely on you
sick of my stomach my son was really to monitor the quality of the chest
worried about me what me in ok are you compressions Dana you'll need to draw
having chest pain right now the drugs up before each rhythm check so
no but I'm party started in my stomach if the arrest persists we can move
and now it's in my back okay we're gonna quickly to drug therapy let's begin with
see if we can find out what's going on one milligram of epinephrine all right
okay one milligram epinephrine three two
joette do we have a set of vitals from minutes
this Fernandez yeah blood pressure is 70 okay let's analyze switch roles
over 40 heart rate is 45 beats per okay the patient remains in v-fib the
minute respiratory rate is 16 breasts protocol for this biphasic device is
for a minute and pulse ox is 92 percent escalated dosing let's shock again at
300 joules shocking at 300 joules Cold NSS is used
charging clear the patient shocking on Check vital signs during ROSC
three ECG is STEMI PCI will be done
one two three shocking shock delivered Team debriefing
continue CPR continue compressions one Offer affirmation
two Dana please give one milligram of Supra glottic airway
epinephrine Alternative to ET tube as advanced airway
one milligram epinephrine and the Iowa Confusion at the start
squished great Good communication skills like a closed
we've given two shocks and given one loop communication
milligram of epinephrine the next No horsing around during a code
medication to consider is amiodarone Assigning roles again
they know please prepare 300 milligrams IO is intraosseous
of amiodarone trying 300 milligrams of Location of IO is at the left tibia
amiodarone Sam are you getting good Biphasic devise 200
chest rise yes Epinephrine 1 mg
and I'm being careful not to deliver Shock delivered then
ventilations too quickly or porcelain Anti arrhythmic given
okay great let's continue there two Vasopressin is only given inlace of the first
Minutes or second epinephrine
From Peter Quilala to Everyone 10:19 AM
Q- Roles have been specified 5H and 6Ts
Perform BLS The role of the Chinese girl is the
Patient is V fib pharmacist’s role
Shocked defibrillated ET inserted
Dana is the medication Nurse Hooked to BV and ventilation resumed
2 shocks delivered Post Cardiac Care Algorithm after ROSC
Epinephrine given 1 mg
Amiodarone 300mg prepared
Epinephrine given 1 mg okay let's analyze switch roles okay the
Amiodarone 300mg prepared patient is in persistent VF let's shock
2 minutes switch roles, analyze rhythm still again at 360 joules charging at 360
at Vfib joules shock ready clear the patient
Amiodarione given shocking on three one two three shocking
Reversible cause of cardiac arrest consider shock delivered
6H and 5Ts continue CPR continuing CPR f1 shoot we
Sinus Bradycardia without pulse continue can't give amiodarone now thanks Shelley
compressions Dana please give 300 milligrams of
In the 2021 guidelines Vasopressin is NO amiodarone hey senator milligrams of
LONGER advised amiodarone given and the IO is flushed
Rapi weak pulse ROSC or return of we've given three shocks after the
spontaneous circulation second shock we administered one
Therapeutic hypothermia protects the brain milligram of epinephrine and we've just
after ROSC given 300 milligrams of amiodarone our
next drug will be vasopressin Dana patient's blood pressure is 82 over 40
please prepare 40 units of vasopressin with a heart rate of 130 and a rhythm of
trying 40 units of vasopressin signs tachycardia okay the patient is
let's review any reversible causes by hypotensive let's start with a liter of
considering the hsm TS saline since we've started with
what about hypervolemia that's a good hypothermia let's use cold saline for
thought we have IO access established the bolus yeah we'll switch out for cold
but no obvious signs of internal or saline tubes in
external bleeding anybody else have any oK we've got good breath sounds let's
other suggestions have we considered establish waveform capnography the o2
hypoxia is the airway still patent still saturation is 96% here's a 12-lead okay
getting good test ride she came in with she has a STEMI Mandel please call the
epigastric discomfort and symptomatic cath lab and tell them that we have a
bradycardia have we considered coronary STEMI patient PCI and hypothermia can be
thrombosis that's a great point safely combined after cardiac arrest the
everything seems to suggest a STEMI two return of spontaneous circulation or
minutes okay let's analyze switch roles roske is no longer the end of the
okay the monitor shows sinus bradycardia cardiac arrest protocol more scientific
do we have a pulse I don't feel a pulse studies show that survival rates improve
continue chest compressions dictate you significantly with the comprehensive
a taste compressions one two three system of post cardiac arrest care it is
Shelly how long has it been since our important to know your local systems
last dose of epinephrine three minutes plan for the management of post cardiac
okay arrest patients hypothermia is the only
Dana let's go ahead and give 40 units of intervention that has been shown to
vasopressin 40 units of vasopressin improve neurologic recovery the
given and the IO is flushed Mandel your resuscitation team should consider
compressions are slowing down can you inducing hypothermia for any patient who
pick up the pace of it two minutes remains comatose after Ross several
let's analyze switch roles studies show improved outcomes for
okay the monitor shows sinus tachycardia patients whose bodies were cooled to 32
Sam do we have a pulse to 34 degrees Celsius for 12 to 24 hours
I can feel a rapid weak pulse okay great a new recommendation in the 2010
let's initiate immediate post cardiac guidelines is the introduction of a
arrest care Dana let's get a blood structured team debriefing studies show
pressure a complete set of vital signs teams who debrief together perform
pulse ox and labs Mandel let's start a better on subsequent codes here's how
12-lead ECG please can we check to see team debriefing differs from simple
if this patient is breathing and feedback feedback is geared toward
responsive ma'am can you squeeze my correcting actions effective debriefing
fingers she's still unresponsive still focuses on correcting the thought
not breathing process that leads to the action while
okay let's insert an advanced airway and debriefing takes longer than simple
prepare for therapeutic hypothermia your feedback it results in deeper
understanding the hallmark of structured especially if ventilations became too
debriefing is a learner centered self difficult one benefit of using a
analysis and active participation in bag-mask ventilation is that
discussion the goal is to gather ventilations are at regular intervals
information on how the code progressed and it kept me from ventilating too much
to analyze the information to create an however because she wasn't intubated we
accurate record and to summarize the didn't have in tidal co2 readings to
goals for future improvement monitor CPR quality or detector Oscar
thanks team nice job I made a few notes yeah that's a good observation it is a
during my evaluation so let's talk about trade-off when to consider inserting an
what went well and why you made the advanced airway Dana how did you feel
decisions that you made well from my about your treatment especially moving
perspective I thought the code went very to IO access early in the code IO access
well Shelly did a good job monitoring and adults is new to me but I found that
the quality of chest compressions Shelly it was easy to push drugs through so
did we have any prolonged pauses or what are the take-home messages I
interruptions in the chest compressions thought it was great that we assigned
no Joette Mandel both switched positions code team roles early in the day because
quickly and resume compressions when the code was called I knew exactly
even as the defibrillator was charging what I supposed to do yeah because
Mandel did you get tired or have any before we did that we'd walk into a room
trouble with the pace of compressions at and there'd be some confusion good
the end of the code I was starting to anything else okay again nice job
slow down but Shelly was able to correct successful teams not only have medical
the rate of compression so I was able to expertise and mastery of resuscitation
pick up the pace it is easy to lose skills they also practice good
track of how fast you should be communication skills and adhere to the
compressing so having someone pacing key elements of effective team dynamics
you these elements help teams work together
through the code is helpful yeah maybe in the most efficient way possible let's
we should use a metronome to help keep review those now closed loop
pace or make it standard practice to do communication this is important for both
compression checks at points during the the team leader and team members when
code that's a good idea let's try that the team leader gives an order the team
next time Sam what do you think of member should confirm that he or she
managing the arrest without an advanced heard and understood the order the team
airway we were getting good chest rising leader should make sure the team
entire time so we didn't need to member understood the order before
interrupt chest compressions to insert assigning additional tasks clear messages
an endotracheal tube you know we could Using concise clear language helps prevent
have inserted a supraglottic airway that misunderstandings speaking in a tone of
could have been done without voice that is loud enough to understand
interrupting the chest compressions you but also calm and confident helps keep
know that could have been an option all team members focused on the task at
hand clear roles and responsibilities as a team during the code reviewing how
when everyone knows their job and a code went not only helps individual
responsibilities during a code the team team members perform better and
functions smoothly the team leader subsequent codes but may also bring
should clearly define and delegate tasks system deficiencies to light now we'll
according to each team members area of play the mega code resuscitation case
competence know your limitations every study again this time as you watch look
member on the team should know his or for the key elements of effective team
her limitations and the team leader dynamics closed loop communication:
should be aware of them ask for clear messages, clear roles and
assistance and advice early not when the responsibilities, knowing one's
situation deteriorates knowledge sharing limitations, knowledge sharing,
this is a critical component of constructive intervention, summarizing
effective team performance team leaders and re-evaluation, and mutual respect
should ask for good ideas for a the
differential diagnosis and frequently patient's gone into v-fib start chest
ask for observations from team members compressions any compressions
about possible oversights constructive Mandell you'll be on defibrillator
intervention sometimes a team member or shellie you'll be recording recording
the team leader may correct actions that Sam you'll manage the airway Dana have
are incorrect or inappropriate it's you been able to establish an IV access
important to be tactful especially if yet I've tried several times but it's
you have to correct a colleague who is failed okay let's move on to IO access
about to make a mistake whether it's a please let me tayo access 6 27 28 29 30
drug dosage or intervention summarizing two three four five six seven eight nine
and re-evaluation summarizing ten
information out loud is a good way to charging at 200 joules shock ready clear
maintain an ongoing record of treatment the patient shocking on three one two
and acts as a way to reevaluate the three shocking shock delivered
patient's status the interventions I have i/o access now great we'll
performed and where the team is within continue CPR for two minutes and
the algorithm of care this technique can evaluate the need for additional
also help team members respond to defibrillation Shelly I'll rely on you
the patient's changing condition finally to monitor the quality of the chest
all team members should display mutual compressions Dana you'll need to draw
respect in a professional attitude to the drugs up before each rhythm check so
other team members regardless of their if the arrest persists we can move
personal expertise or training it's quickly to drug therapy let's begin with
important that the team leaders speak in one milligram of epinephrine all right
a friendly controlled voice avoiding one milligram epinephrine three two
shouting or unnecessary aggression not minutes
only is it important to know what to do okay let's analyze switch roles okay the
during a megacode event it's as patient remains in v-fib the protocol
important to know how to work together for this biphasic device is escalated
dosing let's shock again at 300 joules other suggestions have we considered
shocking at 300 joules charging clear hypoxia is the airway still patent still
the patient shocking on three one two good and good test ride
three she came in with epigastric discomfort
shocking shock delivered continue CPR and symptomatic bradycardia probably
configure compressions one Dana please considered a coronary thrombosis that's
give one milligram of epinephrine one a great point everything seems to
milligram epinephrine and the iowa's suggest a STEMI two minutes
pushed okay let's analyze switch roles okay the
great we've given two shocks and given monitor shows sinus bradycardia do we
one milligram of epinephrine the next have a pulse I don't feel a pulse
medication to consider is amiodarone continue chest compressions picked on
they know please prepare 300 milligrams you at chest compressions one two three
of amiodarone trying 300 milligrams of Shelly how long has it been since our
amiodarone Sam are you getting good last dose of epinephrine three minutes
chest rise yes okay Dana let's go ahead and give 40
and I'm being careful not to deliver units of vasopressin 40 units of
ventilations too quickly or forcefully vasopressin given and the IO is flushed
okay great let's continue there two Mandel your compressions are slowing
minutes down can you pick up the pace a bit two
okay let's analyze switch roles okay the minutes
patient is in persistent VF let's shock let's analyze switch roles
again at 360 joules charging at 360 okay the monitor shows sinus tachycardia
joules shock ready clear the patient Sam do we have a pulse
shocking on three one two three shocking I can feel a rapid weak pulse okay great
shock delivered let's initiate immediate post cardiac
continue CPR continuing CPR one two arrest care Dana let's get a blood
three we can give amiodarone now thanks pressure a complete set of vital signs
Shelley Dana please give 300 milligrams pulse ox and labs Mandel let's start a
of amiodarone Hey Center milligrams of 12-lead ECG please can we check to see
amiodarone given and the IO is flushed if this patient is breathing and
we've given three shocks after the unresponsive ma'am can you squeeze my
second shock we administered one fingers she's still unresponsive
milligram of epinephrine and we've just still not breathing okay let's insert an
given 300 milligrams of amiodarone our advanced airway and prepare for
next drug will be vasopressin Dana therapeutic hypothermia the patient's
please prepare 40 units of vasopressin blood pressure has 82 over 40 with a
on 40 units of vasopressin heart rate of 130 in a rhythm of science
let's review any reversible causes by tech a cardio okay the patient is
considering the hsm TS hypotensive let's start with a liter of
what about hypervolemia that's a good saline
thought we have IO access established since we've started with hypothermia
but no obvious signs of internal or let's use cold saline for the bolus yeah
external bleeding anybody else have any we'll switch out for cold saline
tubes in
oK we've got good breath sounds let's
establish waveform capnography the o2
saturation is 96% here's a 12-lead okay
she has a STEMI Mandel please call the
cath lab and tell them that we have a
STEMI patient PCI and hypothermia can be
safely combined after cardiac arrest in
this section of the course we've shown
you the key steps involved in the adult
cardiac arrest algorithm as well as the
post cardiac care algorithm to promote a
positive patient outcome in the event of
the return of spontaneous circulation
you've also evaluated the megacode
scenario with the key elements of
effective team dynamics and structured
team debriefing combining your knowledge
of essential arrest skills with
effective team dynamics can give your
team a better chance of success with
every resuscitation attempt