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