Team approach in resuscitation

Lecturer: Rosa HO
Date: 16 September 2024
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)61182-9/fulltext?version=printerFriendly
Learning outcomes

• Identify the important elements of an effective resuscitation team.

• Understand a team approach in resuscitation within the hospital
setting.
• Describe the use of different airway adjuncts for airway management.
• Outline the treatment algorithm for VT, VF and asystole.
• Learn the algorithm of basic life support (BLS) and advance cardiac life
support (ACLS).
Resuscitation team
• A well organised team, with a defined roles can certainly improve
patient outcomes for survival.
• The exact composition of the resuscitation team will vary between
organisations, but generally the team should possess the following
skills:
o advanced airway management and intubation skills
o intravenous access skills including central venous access
o defibrillation and external pacing abilities
o medication administration skills
o post-resuscitation skills.

(Dwyer & Dennett, 2019)

Roles in resuscitation team
• The team leader gives direction and guidance, assigns tasks and makes
clinical decisions without directly performing specific procedures.
• The leader nominates the roles of arrest team members.
• Roles of team members include airway management, chest compression,
medication administration (including IV access), documentation of events
and care of family members.
• The team members:
✓Clear about the role assignments (First responder, Right /Left side nurse
& Runner)
✓Prepare to fulfill the resuscitation role and responsibilities with well
practiced resuscitation skills
✓Knowledgeable about the algorithms
Communication within the resuscitation team

Leadership Teamwork
oUse of Closed-Loop oConfirm receipt of orders
Communication oConfirm completion of tasks
oUse of short, clear statements oVoice critical findings “Call Out”
(“Less is more”)
oCommunicate specific findings
oThink out loud
oGive orders to a person
oInvite feedback and input from
the team

TeamSTEPPS www.ahrq.gov
https://bmjopen.bmj.com/content/3/10/e003525
Closed-Loop Communication

Confirm the message was heard and understood

By receiving a clear The team leader listens

Team leader gives a response and eye contact, for confirmation of task
message/ order to a team team leader confirms the performance from the
member team member heard and team member before
understood the message assigning another task
2. Clear
Clearmessages
Messages

Team Leader
-Convey the message in a calm Team member
and direct manner (identify receiver -Repeat the medication order
first) -Question an order if there is any
- Be concise doubt
(e.g., Drug name + dosage +
route needed, instead of jargon)
Avoid yelling!
Only one
person should
talk at any
time
(AHA, 2016)
 What are the roles in a resuscitation team?
Airway

Medication Defibrillation

Scribe Compression

Ward Team
person Leader
Where does the
Can you think of any more roles? T/L stand?
Who can be the
T/L
Resuscitation/Code Blue team
• Team Leader: stands at foot of the bed to view and interpret the situation use
ACLS flowchart & COACHED
• Airway: maintains airway by applying airway manoeuvre such as jaw thrust and
applying bag mask ventilation as per BLS and ACLS
• Defibrillation Nurse: attaches defib pads and turns on defibrillator to monitor
patient and follows instructions from T/L when to defibrillate or dump charge
• Medication Nurse: follows instructions from T/L on when to administer
medication and flush after each administration of medication. Also, needs to
predict what medication is required i.e., adrenaline and a 20 mL normal saline
flush
• Scribe / Documentation Nurse: has the very important job of documenting of
everything that has happened, given & attended chronologically. Usually stands
next to the T/L and keeps time of CPR cycles and when medication has been
administered.
• Compression Nurse: taking turns in applying cardiac compressions 2 minutes
then rotate with someone else.
Team approach in resuscitation

This video demonstrate team approach in resuscitation using ACLS

algorithm from American Heart Association.
ACLS Megacode: https://www.youtube.com/watch?v=90q19HTvm28
 Team Leader

• Organize and monitor individual performance

• Check the reversible causes (5H’s & 5T’s) of cardiac arrest.
• Recognize return of spontaneous circulation (ROSC)
o Return of pulse and blood pressure
o Abrupt sustained increase in PETCO2 40mmHg
https://www.capnography.com/physiology/petco2-cardiac-output
o Spontaneous arterial pressure waves
 Team member: First responder
• Assess client’s response.
• Shout for help/direct someone to call for help/press CPR alarm button on
bedside.
• Assess breathing and carotid pulse for at least 5 seconds but no more than
10 secs.
• Deliver high-quality CPR (30:2 for 5 cycles/ 2 minutes with basic airway in
place)
o Correct placement of hands/finger in lower half of breastbone
o Compression rate of at least 100-120/min
o Adequate depth of at least 2 inches (5cm)
o Complete chest recoil after each compression
o Minimize interruption in compression (Resume CPR immediately after shock)
o Avoid excessive ventilation
o Wear PPE
 LUCAS® 2|3 Chest Compression System

Video:
https://player.vimeo.com/external/246245347.sd.mp4?s=e3d5c863e0c175ddaed1cef
bf7eb424209f34167&profile_id=165
 Team member: Right/Left side nurse
• Put on PPE
• Insert CPR board to optimize resuscitation
• Attach ECG leads and identify any arrhythmias or cardiac arrest
rhythms
o(e.g., Ventricular fibrillation, Pulseless Ventricular tachycardia and
Asystole)
• Attach defibrillation pads and perform defibrillation if shockable
rhythm was noted
• Obtain IV/IO (intraosseous) access
• Prepare and administer medication
oEpinephrine and Amiodarone
Intraosseous access
• Intraosseous access is a widely accepted approach to gain venous
access during cardiopulmonary resuscitation (CPR) of a critically ill
child.

https://youtu.be/KHXSfh2ZRDM
Team member: Airway nurse
• Put on PPE
• Maintain patent airway
• Prepare airway adjuncts
• Provide oxygenation and ventilation through BVM
• Prepare equipment and assist for intubation
• Verify endotracheal tube placement
• Secure the endotracheal tube
• Maintain oxygenation and ventilation either through BVM or
ventilator
• Continue monitor vital signs e.g., SpO2 and end-tidal PCO2 (PETCO2)
Without Advanced airway:

Allow the chest to fall completely then

squeeze for the second time

After giving the ventilation (2nd breath)

The compressor will immediatelybegin another
30 compressions
With advanced airway:
(Supraglottic airway or endotracheal intubation)

With advanced airway

[Laryngeal mask airway (LMA), combitube or
endotracheal tube]

Provide continuous chest

compression and
asynchronous ventilation

Ventilate the adult at a rate of 1 breath per 6 - 8 secs

+
Perform continuous chest compressions at a rate of
100 – 120 beats/min
 Team member: Runner

• Change to compressor role every 5 cycles or 2 minutes.

o To prevent compressor fatigue
o To prevent deterioration in quality and rate of chest compression
o Role change within 5 seconds
• Assist in other procedure
• Record and report the resuscitation process
• Transfer client to ICU for further management.
Cardiopulmonary Resuscitation Record
Guidelines in Resuscitation Record Documentation
• Accurate documentation during resuscitation is important for medical
record, accurate communication, medico-legal purposes, and auditing.
• The resuscitation record form is designed to improve documentation of
events during resuscitation.
• The form includes most of the important information needed, with check
boxes and prompts to facilitate recording.
• Space is also provided for narrative of events or if extra information needs
to be documented.
• The form consists of 2 pages: the first page is completed by the nurses
involved in the resuscitation, and the second page is completed by the
resuscitation team leader.
• The resuscitation form is the hospital patient record for resuscitation and
should be kept in the patient’s hospital progress notes. The other copy
should be faxed to the Resuscitation Committee for purpose of auditing.
(Adapted from PWH Resuscitation Manual Version 6.0 July 2016)
Nursing report (written)

8/6/2023 Nursing Mr. Wong was found unresponsive with no pulse and no respiration at
16:55 16:10. Resuscitation call was activated, and CPR commenced immediately. Mrs.
Wong (pt’s husband) was informed at 16:20. Crash team arrived at 16:15. Mr.
Wong developed Ventricular Fibrillation at 16:13, defibrillation, Adrenaline &
Amiodarone were given as charted. Mr. Wong had return of spontaneous
circulation at 16:20, HR 55bpm, BP 98/54mmHg, RR 6 breaths/min, PETCO2
40mmHg and SpO2 88%. Size 7.5 endotracheal tube was inserted and marked at
21cm at lips. ETT placement was confirmed by CXR. Mr. Wong was put on
ventilator with SIMV mode. Mrs. Wong arrived ward at 16:50. Mr. Wong’s
condition was updated and further treatment plan in ICU were explained by
medical officer in-charge. Mandy RN Mandy CHAN------------------------------------------
Nursing Report (Verbal)
Guidelines on communication using SBAR:
Provide information according to situation, background, assessment and recommendation
❑Situation (S)
The current situation or problem (can use one sentence description of need)
❑Background (B)
A brief patient’s background (obtain information by reviewing patient’s clinical notes)
❑Assessment (A)
Your assessment of the patient (can express your viewpoint in the issue)
❑Recommendation (R)
Your recommendation of what is needed from the medical officer
(State the actions that have been done to fix the problem)

[Adapted from Guideline on communication using Situation-Background-Assessment-

Recommendation (SBAR) Version 3.0 May 2018]
CPR & ACLS algorithm
https://cpr.heart.org/en/resuscitation-science/cpr-and-
ecc-guidelines/algorithms
https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-
guidelines/algorithms
 Indicates
good quality CPR

PETCO2 10 – 20
mmHg

https://cpr.heart.org/-/media/CPR-Files/CPR-Guidelines-Files/Algorithms/AlgorithmACLS_CA_Circular_200612.pdf
Adapted from PWH Resuscitation Manual Version 6.0 July 2016
https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/covid-19-resuscitation-algorithms
 HEPA filter

https://clinical.stjohnwa.com.au/clinical-skills/breathing/bag-valve-mask-ventilation
https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/covid-19-resuscitation-algorithms
https://cpr.heart.org/-/media/CPR-Files/CPR-
Guidelines-
Files/Algorithms/AlgorithmACLS_PCAC_200622.pdf
 Post-resuscitation phase
• The aim of post-resuscitation care is the
maintenance of cerebral and myocardial
perfusion and the return of a patient to a
state of best possible health.
• Coordinated care and specific interventions
initiated in the post-arrest phase can
influence outcomes.
• Control of body temperature (Targeted
Temperature Management 32-36 degrees
Celsius for 24 hours), identification and
treatment of precipitating causes e.g.,
acute coronary syndromes, and
optimisation of mechanical ventilation are a
few of the targeted objectives of care.

http://www.pacificmedicalsystems.com/application/product/44/?cid=2
Airway management
Airway Maneuvers
Optimal Head Position
• It may provide a patent airway in the majority of patients requiring
airway support e.g., Bag-valve-mask ventilation (BVM).
• The most commonly used techniques to achieve optimal head
position and maintain a patent airway include:
❑The sniffing position
❑The head-tilt/chin-lift
❑The jaw-thrust maneuvers

(Davies et al., 2014)

Sniffing position
• The sniffing position is achieved by elevating the head (15°) and
extending it on the neck (35°) of a patient in the supine position.
• It provides optimal exposure of the glottis by aligning the oral,
pharyngeal, and laryngeal axes to facilitate airway management.

(Davies et al., 2014)

Manoeuvres to open up airway

Head tilt/jaw lift Jaw thrust

(Davies et al., 2014)
Airway management
▪ Basic/Simple Airway Adjuncts
o Oropharyngeal Airway
o Nasopharyngeal Airway
▪ Bag-Mask Ventilation
▪ Advanced Airway Adjuncts
o Laryngeal mask airway (LMA)
o Esophageal-tracheal tube (Combitube)
o Endotracheal tube (ET Tube)
▪ Endotracheal Intubation
Oropharyngeal airway (OPA)

• The airway is inserted into the patient's mouth past the teeth, with
the end facing up into the hard palate, then rotated 180°, taking care
to bring the tongue forward and not push it back.
• Oropharyngeal airways are poorly tolerated in conscious patients and
may cause gagging and vomiting.
• Video: How To Insert an Oropharyngeal Airway - Critical Care
Medicine - Merck Manuals Professional Edition
Nasopharyngeal airway (NPA)

• A nasopharyngeal airway is inserted through the nares into the

nasopharynx to open the airway; suction catheters can be passed to
facilitate secretion clearance.
• It can be difficult to insert and requires generous lubrication to
minimise trauma.
• NPA should not be used for patients with a suspected head injury.
• NPA are better tolerated than an oropharyngeal airway.
• Video: https://www.youtube.com/watch?v=uALM3HqtTnI&t
Bag-Mask or Bag Valve Mask Ventilation
• Bag–mask ventilation with a self-
inflating bag (and reservoir), non-
return valve and mask delivers
assisted ventilation at a FiO2 of
1.0
• Also known as manual
resuscitators and self-inflating
resuscitation systems
• It may be connected to a face
mask, laryngeal mask airway
(LMA) or endotracheal tube (ETT)
• Complications: gastric
insufflation, increasing the risk of
vomiting and subsequent
aspiration.
 Methods for BVM

(Davies et al., 2014)

Video: How To Do Bag-Valve-Mask (BVM) Ventilation - Critical Care Medicine - Merck Manuals Professional Edition
Laryngeal mask airway (LMA)
oSupraglottic airway (SGA) placement, other example I-gel
I-GEL
oLMA is positioned blindly into the pharynx to form a low-
pressure seal against the laryngeal inlet
oIt is easier and quicker to insert than an endotracheal tube,
and is particularly useful for operators with limited airway
skills
USES:
• Mechanical ventilation
• As an alternative to bag–mask ventilation or failed
endotracheal
Complications: gastric aspiration, partial airway obstruction,
coughing or gastric insufflation
Video: Standard LMA insertion
https://www.youtube.com/watch?v=89QcBcANJE8&t LMA
Oesophageal-tracheal tube (Combitube)
• The Combitube is more widely used in North
America for emergency situations.
• It is a dual-lumen, dual-cuff oesophageal-
tracheal airway that enables ventilation if
inserted into either the oesophagus or trachea.
• Only one size needed for most adults
• Complications may occur in up to 40% of
patients and include aspiration pneumonitis,
pneumothorax, airway injuries and bleeding,
oesophageal laceration and perforation and
mediastinitis.

Video: How To Insert an Esophageal-Tracheal Double Lumen Tube (Combitube®)

or a King Laryngeal Tube - Critical Care Medicine - Merck Manuals Professional
Edition
 Proximal cuff at posterior hypopharynx

Most of the time, the distal balloon is in the esophagus. With both
cuffs inflated, the only place the ventilation can go is into the trachea.
Endotracheal tube

• A flexible plastic tube with cuff on end which sits inside the trachea (fully
secures airway – the gold standard of airway management)
• Attached to ventilation bag/machine
• Uses:
❑Ventilation during anesthetic for surgery
❑Patient can’t protect their airway (e.g., if GCS <8, high aspiration risk or given
muscle relaxation)
❑Potential airway obstruction (airway burns, epiglottitis, neck haematoma)
❑Inadequate ventilation/oxygenation (e.g., COPD, head injury, ARDS)
https://oxfordmedicaleducation.com/clinical-skills/procedures/endotracheal-tube/
Preparation for intubation
o oxygen supply
o suction supply, with a range of Yankauer and y-suction catheters/closed suction
device
o laryngoscope blades and compatible holder, with a functioning light, including
second laryngoscope in case of device failure
o appropriately-sized face mask
o manual ventilation with a bag valve mask (e.g., Ambu® resuscitator) attached to
oxygen supply
o ETT
o water-based lubrication of tube and cuff (while maintaining sterility)
o capnography (chemical CO2 detectors are often used in emergency situations)
o ventilator and circuit
o emergency/resuscitation trolley at bedside
o Full PPE (gloves, eye protection etc.)
o drugs (sedative and muscle relaxant; note sedatives should be administered
before a muscle relaxant so that the patient is unaware of paralysis)
 Equipment
▪ Laryngoscope with various size of
blades (1-3)
▪ Endotracheal Tube (4)
o Male 7.5 –8mm; Female 7 –7.5mm
▪ Malleable stylet or Bougie stylet for
difficult airway (5, 15)
▪ Orophapharyngeal airway (6, 7)
▪ 10 mL / 20mL syringe (12)
▪ CO2 detector
▪ Water-soluble lubricant
▪ Suction unit [includes Yanker sucker
(9)]
▪ Magill forceps (10)
▪ Adhesive tape
http://torontonotes.ca/category/coloured-atlas/anesthesia-perioperative/
Insertion technique
• Apply traction to the long axis of the laryngoscope handle (this lifts the
epiglottis so that the V-shaped glottis can be seen)
• Insert the tube in the groove of the laryngoscope so that the cuff passes the
vocal cords
• Remove laryngoscope and inflate the cuff of the tube with ~10-15ml air from a
20ml syringe
• Attach ventilation bag/machine and ventilate (~10 breaths/min) with high
concentration oxygen and observe chest expansion and auscultate to confirm
correct positioning
• Consider applying CO2 detector or end-tidal CO2 monitor to confirm
placement
• Secure the endotracheal tube with tape
• If it takes more than 30 seconds, remove all equipment and ventilate patient
with a bag and mask until ready to retry intubation.
• Video: https://www.youtube.com/watch?v=BNf5FtIU-5U
 End Tidal CO2 detector

• An indicator that measure CO2 eliminated by the lungs

• Attach to the endotracheal tube to monitor ETCO2 levels with breath-
to-breath response. A colour change between inspiration and
expiration helps to verify proper tube placement in seconds.
• It changes color in response to CO2 concentration from purple to
yellow.
https://www.medtronic.com/covidien/en-us/products/intubation/nellcor-adult-pediatric-colorimetric-co2-detector.html
Capnography
 Correct ET tube position

https://www.radiologymasterclass.co.uk/tutorials/chest/chest_tubes/chest_xray_et_tubes_anatomy#top_2nd_img
Securement of endotracheal tube
• In clinical practice, there is a wide variability of methods used to secure the ETT
including using adhesive tape, cloth tape ties, and commercial ETT holders.

The modified cow hitch. A: Make a loop and pass under/around the endotracheal tube. B: Pass the loose ends
through the loop. C: Pull ends tight. D: Pass one loose end around the tube. E: Tie a normal knot. F: Pull tight.
 Other methods of ETT securement
AnchorFast SlimFit Oral Endotracheal
Thomas Select Tube Holder Tube Fastener

Video: https://www.youtube.com/watch?v=0kNnATdxRJc https://www.hollister.com.au/en-au/anchorfast

References
American Heart Association. (2020). CPR & First Aid Emergency Cardiovascular Care:
Algorithms. https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-
guidelines/algorithms
Davies, J., Costa, B., & Asciutto, A. (2014). Approaches to Manual Ventilation. Respiratory
Care, 59(6), 810-824. https://doi.org/10.4187/respcare.03060
Dwyer, T., & Dennett, J. (2019). Resuscitation. In M. Aitken & W. Chaboyer (Eds.). ACCCN’s
critical care nursing (pp. 880-908). Elsevier Australia.
Hambrecht, K. (2020). Cardiopulmonary resuscitation: basic and advanced life support. In
E. Brown, T. Buckley, R. Aitken & S. Lewis (Eds.). Lewis’s medical-surgical nursing:
assessment and management of clinical problems (pp. 1936-1968). Elsevier Australia.
Rose, L., & Paulus, F. (2019). Ventilation and oxygenation management. In M. Aitken & W.
Chaboyer (Eds.). ACCCN’s critical care nursing (pp. 493-538). Elsevier Australia.
Wong, N. (2021). Team approach in resuscitation in hospital; Airway management;
VT/VF/Asystole management Lecture [Power Point Slide].
Miler, C. (n.d.). There’s No “I” in Code: Team Dynamics in Resuscitation.
https://www.physio-
control.com/uploadedFiles/Physio85/Contents/Trade_Shows/Resuscitation%20Team%20D
ynamics%20NTI%202016%20web.pdf
Thank you!