Septic Shock and Cardiac Arrest

I:       You are the ICU registrar, called by the ICU Nurse to assess a new admission. The HDU registrar reviewed the patient a few hours prior, and the patient has arrived without warning. 

S:      He/she would like a plan for the 59F who has just been transferred from the ED 

B:      Patient been in ED for past 4 hours and transferred with an ED nurse. Suspected diagnosis of LRTI.  

A:     Assess and formulate ICU plan 

R:     Assist the HDU resident  

• Initially A clear, B RR 30/min, clear chest, O2 sats 88% on 4L via nasal cannulae, C HR 48bpm SR, NIBP cycling at the start of the scenario – eventually comes up as 76/54 D responds to painful stimuli by groaning, eyes closed 
• Patient collapses into PEA 
• Continue in PEA until fluid boluses given, and reversible causes considered 
• Agonal breathing at rate of 8/min on ROSC, sats remain low – candidate needs to secure airway and commence mechanical ventilation 
• Reassessment of the patient and institutes post resuscitation care 
• At this point ICU consultant phones unit to enquire about the new admission. ICU registrar to give summary and formulate a plan with consultant on phone 

• Initial Settings: RR 30/min 

• O₂ sats 88% on 4L via nasal cannulae 
• Chest fields clear 
• HR 48bpm SR 
• NIBP cycling at the start of the scenario – eventually comes up as 76/54 
• No capnography 

Allow candidate time to assess patient and instigate immediate resuscitative measures/investigations 

• PEA arrest 

• Post arrest: No spontaneous respirations 

• O₂ sats 86% on high flow oxygen 
• HR 126bpm SR 
• NIBP 166/97 – next BP drops to 90/56 

• On intubation: RR at whatever ventilator is set at 
  • O₂ sats improve to 94% slowly over 1 minute 
  • BP 105/63 if patient has given appropriate pressor/inotrope 
  • HR 118bpm SR 
  • ETCO₂ 5.6kPa (only if candidate requests capnography) 

ED Student Nurse: 

• You are on your ED placement 
• You are quite proud and pleased that ED let you transfer the patient alone 
• Patient is 59 years of age and has a chest infection. She has had some antibiotics – you don’t know which 
• The ED Consultant said she has given her some “met-arm-olol” for her blood pressure. She also mentioned that she was concerned she might arrest 
• The patient has one cannula and some fluid running through it 
• You know nothing else 
• If the candidate gets upset or disgruntled you get upset and leave the room 
• Otherwise leave when the patient has a cardiac arrest unless specifically told to stay by the candidate 

HDU Resident: 

• You are admitting a patient from the ED which is routine and have been assured the patient is stable 
• When asked by the candidate how the patient is you say they’re fine 
• You are unaware that the patient is arresting and are quite surprised and shocked 
• You are incredibly keen to be involved including intubating the patient, which you will be able to do if properly guided 
• You feel upset that you didn’t realize this was happening and will seek feedback from the candidate as to what went wrong – you will get upset if the feedback is harsh 
• If the candidate is performing exceptionally well you will start to seek reassurance and distract them while they attempt to resuscitate the patient 
• Be insistent that doing the “head end” during the intubation would be a brilliant learning opportunity for you 

HDU Nurse: 

• You are a competent staff nurse who has worked at the unit for a number of years 
• You were also reassured the patient was stable. You don’t know anything more than the student nurse hands over 
• You take direction very well and will perform tasks that are asked of you 

HiLLO: 5, 11