To open up Critical Care week, resuscitation and trauma expert Dr. George Mastoras provides us with some tips to improve your (and your team’s) resuscitation and crisis resource management skills.

1. Make teamwork everyone’s business

  • ‘Team orientation’ is associated with higher team performance, especially among Flash teams, like those involved in ED resuscitation. (Hunziker 2009 & 2010)
  • Allows an opportunity for Mental Rehearsal,which may decrease stress levels. (Lorello 2016, Harvey 2010, Hicks 2018)
  • ‘Prime the pump’ for effective teamwork:
    • Start every resuscitation with a team huddle (ideally, before the patient arrives, or within minutes of arrival).
    • Familiarize the team with what to expect, what the first 5-10 minutes of resuscitation will look like.
    • Take the opportunity for equipment checks: do you have airway equipment, lines for access (IO, central lines, art lines), ultrasound gelled up and ready?
  • Engage in continuous planning
    • Delegate tasks and triage their priority: do you want IV access first or monitors on? How quickly do you want to transition to manual CPR? Who will check for pulses?
    • Encourage the team to perform cross-monitoring.
    • Brief the team early on any potential “unorthodox” plans you have running in your head: thoracotomy, double-sequential defibrillation, or even just plans to run an especially long code because the patient has predictors for a favourable outcome.
  • Establish a Shared Mental Model that enhances the team’s Situational Awareness, and circle back to it often, providing updates for team members that may have been occupied with tasks, and to make sure you didn’t miss anything.

2. Resuscitate before you intubate

  • YOU HAVE TIME. Much more than you think you do.
  • Hypoxemia
    • Pre-oxygenate with an ambubag + PEEP valve, snugly held over the face. (Baillard 2006, Strayer 2015)
    • Everyone gets apneic O2 nasally – even if the evidence is equivocal, there’s no harm so why not?
    • Turn on the sat beeps on your monitor so you have an auditory cue for hypoxemia.
    • Sit the patient up. Position them well – ears at the sternal notch. (Khandelwal 2016)
  • Hemodynamics
    • Respect the shock index. HR ÷ BP. Anything > 1 is predictive of a peri-intubation crash. (Miller 2016, Heffner 2012)
    • Volume, a background drip of NE, and push-dose pressors (Weingart 2015) (epi is my favourite, phenyl is OK too) are your best friends. Have all 3 happening. Every time.
  • Take a time-out:
    • The best way to make sure things are optimized is to take a time-out. This doesn’t have to be a formal checklist, but before proceeding with intubation we should develop an hard cognitive stop to assess optimization, recap, and discuss the airway plan as a team.

3. Dare to be bold

  • Sometimes we need to take definitive action. This is what we signed up for. Often, we spend too much time pontificating and deliberating when a patient needs an emergent therapy.
  • But we can all fall victim to Errors of Omission(Farkas 2014)
    • Our obsession with “doing no harm” creates passivity, and we swing to the other end of the spectrum: failing to act when necessary. Our culture in medicine is one that creates an tendency to favour these errors of omission: maybe we can get away with just those two peripheral IVs, maybe we can get away without intubating, maybe we can get away with another bolus instead of starting vasopressors.
    • Probably also influenced by the cognitive impacts of stress, cognitive appraisal, and procedural comfort. (Harvey 2010)
    • BUT: failure to take action when action is needed is still failure. 
  • The point is:
    • If your nurse wonders whether the patient might need a central line, they need a central line.
    • If you can’t get reliable BPs, or your finger palpation of the pulse can’t decide whether it feels something or not, the patient needs an arterial line.
    • If your RT expresses some apprehension about whether BPAP will be enough, you need to intubate.
    • If the patient is moaning with transcutaneous pacing but unstable without it, they need a TVP.
    • If you’re contemplating a third bolus, or a fourth bolus, the patient probably needs vasopressors.
    • If you’re considering calling a Code Bleed, the patient needs a Code Bleed.
  • Be aware that we all have a cognitive predisposition towards errors of omission, thinking that they are somehow less harmful than errors of commission, and guard against biasing ourselves too far in that direction

4. Invest more time at the bedside

  • Avoid the post-intubation high five
    • When the resuscitation starts to settle out, when the adrenaline switches off, we have a tendency to relax our vigilance. We might start reviewing another case or step out of the room for one reason or another.
    • In fact, this is often the moment of greatest vulnerability, and we need to be aware of it and guard against it. (Grossman 2008)
    • The best way to do that, is first to recognize that moment. Then, circle back to the beginning. I use the opportunity to do a recap, which includes the following, every time (ABCDEF):
      • Airway check: ETT size and positioning, securing device, CXR called, Post-intubation sedation and analgesia
      • Breathing/vent check: Ventilator strategy discussed with RT
      • Circulatory status: Review of vitals and infusions, including access & adequacy
      • Drugs (given & pending): Cognitive stop point – TXA? Antibiotics? Antidotes? Ino/pressors?
      • Expected next steps: announce Plan for the next 15 minutes… further treatments, investigations, destination?
      • Feedback from team: any other thoughts, questions, ideas?
    • Be cautious handing over care to the admitting service – whether 2nd year Cardio Fellow or ICU senior, these are trainees who are less experienced and possibly out of their depth.
      • This is the blessing and curse of tertiary care medicine, we have access to so much specialty care, but we have to ensure that our trainees have the adequate knowledge to care for these complex and sick patients.
      • One strategy when consultants arrive: judo throw (adapted from Reid 2013)
        • Use their energy/enthusiasm to establish a shared-care model…
        • They come in guns blazing, and you’re not ready for them to take over just yet: “Thanks so much for coming, we’re just stabilizing this lady who is a ROSC after VFib, can I get you to do a quick echo for me? Have a look at this ECG? etc…”
        • Makes them feel welcome, wanted, and useful
        • You remain in control of the resuscitation.
      • When it is finally time to leave – formally hand over care 
        • Confirm with the consultant (1) we have an agreed-upon plan that they will be carrying forward, and (2) they are comfortable with taking over the reins
        • Then formally announce to the room that Dr So-and-So will be taking over

5. Debrief

  • Every resuscitation ought to be debriefed.
    • After the storm has passed, there’s a surprising amount of emotional baggage that often needs to be addressed among your team. “Do you think she’s going to make it?” “How the hell could that have happened to someone so young?” “Did we do enough?”.
    • There’s always plenty of learning points to take away: what went well, why you approached the problem in a certain way, any educational feedback to the team, any breakdowns in teamwork/communication/etc.
  • There are numerous debriefing strategies out there (e.g.: PEARLS, DISCERN, INFO)… it’s better to run one imperfectly than to not debrief.
    • The basic steps are:
      • Allow for emotional offloading
      • Recap the case and invite analysis. Here, spend much more time listening/inviting dialogue than talking yourself
      • Summarize and remind the team how phenomenal they are, and that they gave the patient everything humanly possible.
      • For more, see this excellent blog post at St. Emlyns: http://stemlynsblog.org/good-to-talk-debrief-in-the-emergency-department/

 

References

Baillard C, Fosse JP, Sebbane M, Chanques G, Vincent F, Courouble P, Cohen Y, Eledjam JJ, Adnet F, Jaber S. Noninvasive ventilation improves preoxygenation before intubation of hypoxic patients. Am J Respir Crit Care Med. 174(2): 2006. doi: 10.1164/rccm.200509-1507OC

Eppich W, Cheng A. Promoting Excellence and Reflective Learning in Simulation (PEARLS): development and rationale for a blended approach to health care simulation debriefing. Simul Healthc. 2015 Apr;10(2):106-15. doi: 10.1097/SIH.0000000000000072.

Farkas J. Errors of commission vs. errors of omission. EMCrit blog 2014: https://emcrit.org/pulmcrit/errors-of-commission-vs-errors-of-omission/

Grossman D, Christensen LW. On Combat. 2008. Human Factor Research Group Inc; 3rd ed. edition (Oct. 1 2008).

Harvey A, Nathens AB, Bandiera G, LeBlanc VR. Threat and challenge: cognitive appraisal and stress responses in simulated trauma resuscitations. Medical Education 44(6):2010. doi: 10.1111/j.1365-2923.2010.03634.x

 

Heffner AC, Swords DS, Nussbaum ML, Kline JA, Jones AE. Predictors of the complication of postintubation hypotension during emergency airway management. J Crit Care. 27:6 (2012). doi: 10.1016/j.jcrc.2012.04.022.

 

Hicks C, Petrosoniak A. The Human Factor: Optimizing Trauma Team Performance in Dynamic Clinical Environments. Emerg Med Clinics 36(1):2018. doc: 10.1016/j.emc.2017.08.003

Hunziker S, Tschan F, Semmer NK, Zobrist R, Spychiger R, Breuer M, Hunziker PR, Marsch SC. Hands-on time during cardiopulmonary resuscitation is affected by the process of teambuilding: a prospective randomised simulator-based trial. BMC Emergency Medicine, 9(3): 2009. doi: 10.1186/1471-227X-9-3

Hunziker S, Buhlmann C, Tschan F, Balestra G, Legeret C, Schumacher C, Semmer NK, Hunziker P, Marsch S. Brief leadership instructions improve cardiopulmonary resuscitation in a high-fidelity simulation: A randomized controlled trial. Critical Care Medicine, 38(4):2010. doi: 10.1097/CCM.0b013e3181cf7383

Khandelwal N, Khorsand S, Mitchell SH, Joffe AM. Head-Elevated Patient Positioning Decreases Complications of Emergent Tracheal Intubation in the Ward and Intensive Care Unit. Anesth Analg. 122(4): 2016. doi: 10.1213/ANE.0000000000001184

Lorello GR, Hicks CM, Ahmed SA, Unger Z, Chandra D, Hayter MA. Mental practice: a simple tool to enhance team-based trauma resuscitation. CJEM 18(2):2016. doi: 10.1017/cem.2015.4.

May N. It’s Good to Talk – Debrief in the Emergency Department. St. Emlyn’s blog, 2013: http://stemlynsblog.org/good-to-talk-debrief-in-the-emergency-department/

Miller M, Kruit N, Heldreich C, Ware S, Habig K, Reid C, Burns B. Hemodynamic Response After Rapid Sequence Induction With Ketamine in Out-of-Hospital Patients at Risk of Shock as Defined by the Shock Index. Ann Emerg Med. 2016 Aug;68(2):181-188.e2. doi: 10.1016/j.annemergmed.2016.03.041. Epub 2016 Apr 27.

Mullan PC, Wuestner E, Kerr TD, Christopher DP, Patel B. Implementation of an In Situ Qualitative Debriefing Tool for Resuscitations. Resuscitation 2013:84(7). doi: 10.1016/j.resuscitation.2012.12.005

Reid C. Making Things Happen. 2013. http://resus.me/smacc-2013/smacc2013-making-things-happen/

Rose S, Cheng A. Charge nurse facilitated clinical debriefing in the emergency department. CJEM. 2018 May 7:1-5. doi: 10.1017/cem.2018.369.

Strayer RJ, Caputo ND. Noninvasive ventilation during procedural sedation in the ED: a case series. Am J Emerg Med. 33(1): 2015. doi: 10.1016/j.ajem.2014.10.023. Epub 2014 Oct 18.

Weingart S. Push-dose pressors for immediate blood pressure control. Clinical and Experimental Emergency Medicine. 2015;2(2):131-132. doi:10.15441/ceem.15.010.

Westli HK, Johnsen BH, Eid J, Rasten I, Brattebø G. Teamwork skills, shared mental models, and

performance in simulated trauma teams: an independent group design. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 18(47):2010. doi: 10.1186/1757-7241-18-47

 

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