Simulation Scenario – The Ideal Paediatric Resuscitation

my name is dr. Ellen Taylor I am the co-director of simulation training here at Princess Margaret Hospital for children we have created this video with a grant from the WHI nickel training network and we're grateful to them for their assistance pediatric resuscitations are daunting for many staff and they don't happen very often therefore many staff will not have had the opportunity to take part in a pediatric resuscitation during their career they may not even have seen one we wanted to create a video to highlight what the first few minutes of award based resuscitation might look like and to highlight some of the non-technical skills that are involved after watching this video we hope that you will have a good understanding of what non-technical skills you will need in a pediatric resuscitation whether that stimulated or real this video may form part of a workshop or further discussion or standalone as part of your own self-directed learning we hope it will be helpful you I need some help charlie I need some help in here please calling for help early is a vital part of any crisis this should be done by shouting and pressing the nearest emergency buzzer generally speaking you should do this when you start to feel uncomfortable in a situation and when there are too many tasks to perform on your own remember it is better that help arrives early and that the crisis isn't as serious as first thought then waiting into a situation is out of your control and wasting valuable time this is Charlie he's three months old he's coming with severe dehydration can you please step can you start compressions early role allocation in the crisis helps improve the speed of response team performance and gives structure to an already difficult and stressful situation role allocation can be self assigned or assigned by the leader remember it's important to try and get people into the most appropriate roles for their skill set having the wrong person in the wrong role may result in error or failure to deliver the best care pmh ward to a room five the most important part of any resuscitation is the immediate commencement of good quality basic life support this should be maintained the whole way through the resuscitation with minimal interruptions good quality BLS will preserve blood supply to the body's vital organs and is absolutely critical to a good outcome remember most people can only maintain good quality chest compressions for a two-minute period so staff should be rotated into and out of this role regularly this is Charlie who's three months old turning with dehydration found unresponsive my name is Lisa I'm the nursing clinical educator in the emergency department our sub R is an effective tool for use in handover even under stressful or time-critical circumstances it can be used to help structure important information that needs to be handed over usually in a critical situation or resuscitation there are central pieces of information that the team will need to direct their management the importance of a succinct but Sarah handover cannot be underestimated remember most members of a resuscitation team will know nothing about the patient when they are oh we've got a good seal with 200 techniques and we've got good chest expansion okay Devin gonna briefly ask you to pause see if y'all see you can check your pulse for us can do that now there's no okay continue CPR please Deb okay mommy's got the pads on alright now we've got the defibrillator on now so again we're gonna do a brief pause in a second okay well we charge the defibrillator up to four joules per kilo joules okay so away with the oxygen first continue CPR away with your CPR fully charged now stop there please dip okay we've got asystole so dump the charge and back on the chest after okay we've gone Eirene asystole we're on the non shoppable side of the algorithm so we're gonna do adrenaline every four minutes yep towles checks every to recess car strong leadership is a very important part of creating a cohesive team explicit announcing of leadership helps prevent confusion as to who is leading the leader should ideally stand at the end of the bed and not take part in any practical tasks as these could be distracting too them the scribe should stand alongside the leader to document timings give prompts and record orders and actions that have taken place leaders aim to give direction to the team in terms of specific role allocations tasks to be carried out as well as giving the team focus and direction as to where the situation is heading leaders should not be dictatorial but inclusive and welcome suggestions from members of the team the leader does not necessarily need to be the most experienced person in the room and co leadership can be formed in appropriate circumstances okay Marga we're going to need 10 most effective communication is critical to ensure that the team works well together to achieve the best possible outcome communication errors are among the most common errors and resuscitations closed loop communication is an effective method of communication and has been shown to reduce error rates by removing ambiguity from instructions allowing questions if the instruction was not heard clearly and allowing others in close proximity to be aware of the proposed course of action once a team leader has either requested information or asked for a procedure to be performed by a named person that person should then acknowledge this request verbally and then confirm it when it is done this allows for clarification of requests if needed and avoids errors of omission closed loop communication allows the sender to know that their requests have been heard and understood the use of names avoids the problem of such requests being made into an empty space when a team leader asks out loud for a procedure to be done unless they specify who they want to perform the procedure then there will be a risk it will not be done at all if possible the team leader should use eye contact when making requests allowing for nonverbal as well as verbal clarification if the team names are not known it's perfectly acceptable to address staff members by their role allocations that airway nurse or circulation doctor this is another reason why role allocation is so important I think that the resuscitation dose of adrenaline is one of the few drug dosages that doctors and nurses working in a pediatric setting should know it off by heart it's worth understanding that 10 Mike's per kilo is equal to 0.1 mils of 1 in 10,000 adrenaline okay that's 1004 mixed dosage to you at 10:08 can you continue with CPR okay we've got the rhythm as well when you are team leader can be very difficult to act effectively if you are trying to remember the relevant algorithm in your head that's why we recommend getting the algorithm out and placing it on the table in front of you and the scribe this means you can free up space to think about all the other details the algorithms can be found on the recess trolleys and specific algorithms can also be found on the APL s website if you will regularly be acting in a team leader position I recommend that you keep a copy of these on your phone or somewhere that you can find them easily when you are in an emergency situation yes please could you take over CPR few Deb's please okay Deb can you come and take I've come here and start subscribing for us and look at the cognitive aid of the non shockable side of the algorithm so what time did we stand we started at 1004 we ordered the first Joseph's in at 1004 we've given you two the next days at 1000 right we'll do a pulse check at 1006 we're still in the first cycle of CPR the role of the scribe is to maintain an accurate and legally binding account of a critical event as part of this describe will be tasked with capturing the time of onset of an event date the event of a survey shion's at two-minute intervals all interventions procedures medications and fluids given capturing or treating staff and family members present and communication with all treating teams and ensuring the family are supported an important feature of this role is colocation with the leader of the resuscitation to ensure information is accurately captured in what can be a noisy space I'm Mary and anesthetist would you like me to speak over the airway with drugs and medication medications and fluids it's coming up for two minutes okay keep checking pulse please hmmm okay continue CPR and there's still asystole on the monitor the team is with him now and they're doing everything they can can I please ask who the leader is yeah I'm the junior medical officer I'll be leading until the rest of the code blue team arrives okay the emphasis in much resuscitation training is on leadership however I think good followership is essential as well in many critical events somebody in the room could have changed outcomes had they spoken up good followers are accountable for their actions the leaders role is to create the environment so that this can happen but good followers can facilitate this too and that could involve asking explicitly who is leading this resuscitation it could involve speaking up with concerns by using a graded assertiveness technique it means being engaged and responsible together with the whole team that's a good point okay let's do an overview I think we've got this disabled man here we've got a five heal a three-month-old child in a systolic cardiac arrest we've got street of severe diarrhea and vomiting over the last three to five days we are in the non shockable side of the algorithm we've given one taste of adrenaline we're now going to start consuming 4-h and 14 this is my patient and I think that's consistent with his presentation he came in very dehydrated yesterday here you have just heard the team leader use explicit communication repeating the assessment and stating the working diagnosis and treatment aims out loud this is a useful technique which allows questions to be asked by the team it avoids team members working on counterproductive tangents and therefore avoids errors it allows the entire team to create a shared mental model of the patient's situation this means that all team members can understand both the clinical and logistical implications of the case it ensures that team members are familiar with one another's roles and responsibilities they can anticipate the needs of other team members this collaborative approach helps break down boundaries between individuals with varying levels of expertise and it helps reduce the perception of a power differential between professionals think we're gonna need a fluid bolus of 20 miles per kilo magnet hundred mils of normal saline and we'll need a venous blood gas taken off so we can check the electrolytes does anyone have anything else they want to add at this stage oh hi I'm Simon the ICU consultant this is Claire with the code team would you give us a hand over what's happened yeah I'm toll on the junior medical officer been leading this code and this is Charlie who's a three month or of 5 kilo child who's in a systolic cardiac arrest we're on the second cycle of CPR he's got a background of a few days history of severe diarrhea and vomiting currently we're going in one dose of adrenaline and we're in the process of giving off first 20 ml per kilo normal saline fluid bolus the plan was to continue down the non shockable side of the algorithm continue further balises of adrenaline and further bonuses of fluids to take a venous blood gas to check for electrolyte imbalance and to clean you to continue to check the rest of the 48 in the 40s okay so three-month-old asystolic arrests likely due to hyperbole new electrolyte abnormalities given the history and you're following the non shockable algorithm taking it for ages and 40s that sounds great if it's okay I'll take over leadership of the code now that's fine Thank You Simon okay to summarize the non-technical skills that are essential during a pediatric resuscitation our call for help early allocate roles perform continuous basic life support use I sabar to handover have a clear leader communicate effectively know the dose of adrenaline use a cognitive aid where possible be a good follower we do hope that this video will be useful to you and we're grateful to waa clinical training Network for their assistance you

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