Post Arrest Consult Team
PACT
“Resuscitation is just the beginning…”
Steven Brooks MD MHSc FRCPC, Principal Investigator
Laurie Morrison MD MSc FRCPC, Co-Principal Investigator
Funding
St. Michael’s Hospital
AFP Innovation Fund
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Rationale for PACT
• High mortality after OHCA resuscitation
• Post Cardiac Arrest Syndrome
• Hospital survival rates vary
• E.g. 25%-30% locally vs. 50-60% in US and
Europe
• Local data shows care is not standardized
• Studies from elsewhere show improved
survival with champions and a
standardized, multi-faceted approach
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Barriers
• Process concerns due to low volume of
OHCA
• Lack of a standardized approach
• Difficulty gaining experience
• The disjointed patient journey
• Access to specialized services
– (ICU, PCI, EP)
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Post Arrest Consult Team
(PACT)
• Building on other Centres of Excellence
models
– Trauma, stroke, STEMI etc
• Building on the CCRT model
– Dedicated consult service of RN/RT/MD to
assist MRPs and primary nurses with
complex/high risk patients
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Post Arrest Consult Team
(PACT)
• Guidelines inspired
• Evidence based
• Standardized clinical pathways
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PACT Process
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PACT Activation
• Single page PACT activation through locating
• Automated prehospital alert to PACT RN text
pager from upload of electronic ambulance call
report from Toronto EMS
• MDs will have cell phone/pager registered with
communications with call schedule
• RNs will have a PACT text pager which is
passed on to the PACT RN on call
• We will be tracking activation rates and missed
cases
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Goal directed gas exchange and
hemodynamics
• Hyperoxia is bad
– minimize FiO2 for oxygen saturation ≥ 94%
• Hypocarbia is bad
– ventilate to ETC02 of 35-40 mmHG or PaCO2
levels of 40-45 mmHG
• Hypotension is bad
– MAP goal specified in pre-printed order set
• Best evidence suggests these are urgent
issues
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Therapeutic hypothermia
Where PACT can have an IMPACT
• Cooling more eligible patients
• Appropriate core temperature monitoring
• Facilitating rapid decline in temperature through
the “danger zone” (quickly to 33.5)
– Proper placement/replacement of ice bags
– RAPID infusion of cold saline
– Shivering prevention/treatment
• Encouraging aggressive sedation, analgesia and paralytic
(PRN) as per hospital protocol
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Therapeutic hypothermia
Where PACT can have an IMPACT
• Use of the trouble-shooting checklist when
cooling rates are too slow
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Be aware of potential complications
during induction of hypothermia
• Shivering
– Will slow cooling
– Increase in metabolic rate and oxygen
demand
• Volume depletion
• Electrolyte abnormalities
– Hypokalemia, Hypomagnesemia,
hypophospatemia
• Glucose resistance
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PACT MD
Roles and Responsibilities
PACT MD
• 24-hour availability.
• In house M-F 9-5 with callback ASAP and
bedside assessment ASAP with a target of
within 15 minutes of consult.
• Home call for telephone consult afterhours with discretionary bedside
assessment
• For the ICU physicians call schedule
synchronized with ICU call
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PACT MD
• Interaction with the PACT RN modeled after the
CCRT
– PACT RN will discuss case details, clinical
assessment and plan with the PACT MD after initial
contact with the patient is made
– A collaborative plan with the PACT RN will be
determined
– Similar to a resident to staff exchange
• PACT MD will provide “suggest” orders as
needed and discuss them immediately with the
MRP or their delegate at the time of assessment
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PACT MD
• Initial involvement directed towards items in the
PACT clinical pathways that are urgent
– Gas exchange and hemodynamic goals
– Trouble-shooting therapeutic hypothermia to ensure
goal temperature reached
– Need for urgent coronary reperfusion?
– Making appropriate sub-specialty consultations
– Encouraging delayed neuroprognostication
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PACT MD
• Subsequent bedside follow-up daily during
acute phase of care
– Support maintenance of hypothermia
– Support safe, controlled rewarming at 24
hours
– Support neuroprognostication pathway
– EP involvement as per protocol
– Consider etiology in collaboration with primary
team
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PACT MD
• Clinical note expected for each consult
• Detail clinical assessment and management
plan, highlighting the important features related
to the PACT clinical pathways
• Hand-over PACT patient consult list to oncoming PACT MD for continuity of follow-ups
• Sign-off from patients when acute post arrest
issues are resolved (~72 hours?)
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PACT MDs
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•
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•
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Dr. Andrew Baker
Dr. Chris Hayes
Dr. Jan Friedrich
Dr. Sara Gray
Dr. Paul Dorian
Dr. Neil Fam
Dr. Laurie Morrison
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PACT RN
Roles and Responsibilities
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PACT RN
• 24 hour in-hospital presence for PACT
• Goal: Respond to page for consultation and attend
patient bedside as soon as possible to assist the
primary care team in the implementation of best
practices for the post-arrest patient
• PACT will only consult on out-of-hospital arrest patients;
requests for in-hospital post cardiac arrest patients will
be politely refused
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PACT RN
 An advocate for the patient and an ambassador for the
PACT
• Communication with primary MD, ED RN’s and PACT
MD and the RT’s
• WILL NOT take over primary nursing responsibilities
 Review PACT eligibility
• OHCA
• Comatose (not responding to verbal commands)
• ROSC
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The PACT RN as a Champion
• The PACT RN is expected to have the
greatest impact related to optimizing the
induction of therapeutic hypothermia
accurate temp measurement
surface cooling
sedation & analgesia
cold fluids-FAST
NMBA’s
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Therapeutic Hypothermia
• SMH Pre-printed Therapeutic Hypothermia
orders
ED
ICU
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Therapeutic Hypothermia
Pre-Printed Orders TH ED
Pre-Printed Orders TH ICU
•MD administer neuromuscular
blocking agents
•RN administer sedation & analgesia to
target Sedation Agitation Score (SAS) 1
prior to induction of neuromuscular
blockade
•RN to obtain a baseline Train of Four
(TOF) measurement (if available).
Administer neuromuscular blocking
agents (NMBA) as ordered below.
•MD in the ICU would give the first dose
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TH Potential Concerns
 PACT TH Trouble Shooting Checklist
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Cooling Equipment
• Pre-printed orders and quick
reference
• Ice packs (freezer)
• Cold fluids – saline
• zip lock bags
• Esophageal probe
– Guide for esophageal probe
placement
– Paper measuring tape
• Note ED does not have a
cooling blanket
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The PACT RN as a Champion
The PACT RN will also play a major role in
assessing the patient with respect to the
other clinical pathways
•
•
•
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Goal directed gas exchange/ Hemodynamics
12-lead ECG-urgent PCI
EPS
Neuroprognostication
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Hemodynamic Optimization and
Gas Exchange
 RT collaboration to help facilitate the gas exchange
targets

Minimize FiO2 to maintain O2 saturation of 94-96%

Ventilate ETCO2 to levels of 35 – 40 mmHg OR

Maintain PaCO2 levels of 40 – 45 mmHg

Maintain MAP goal specified in pre-printed order set
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Coronary Angiography
Assessment
• Check to see if 12-lead ECG
completed by the attending team
– If not done, work with ED RN to
complete
• Review the ECG with the MRP in the
ED and/or PACT MD to determine
possible STEMI
• If possible STEMI, discuss activation of
Code STEMI protocol
• Follow up with primary care team after
patient returns from Cath Lab
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Electrophysiologist Assessment
• Collaborate with PACT MD / MRP to call
for Electrophysiologist consult
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Patient Follow-Up
• If a patient has come in after hours please
provide Karen or Tessa with a patient
debrief, via email of in person.
• Karen Wannamaker and Tessa Diston as
PACT RNs will complete a follow up after
12 hours of ED admission to monitor
cooling.
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PACT RN Coverage
8:00 to 16:00 hrs Monday to Friday Karen
Wannamaker or Tessa Diston will be the
on call PACT RN.
16:00 hrs to 8:00 Monday to Friday and 24
hours weekend coverage, the CCRT nurse
will be the on call PACT RN.
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PACT RN Communication Tools
Pager and iPAD
 Two pagers with the same number have been
set up with locating for PACT
 iPAD has the electronic version of the Case
Report Form (eCRF)
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PACT RN Hand Over
After the PACT RN shift has ended
 Contact the next on call PACT RN
 Transfer pager (only applicable for CCRT
nurses)
 Provide a debrief of any PACT patient that
may have been admitted to Karen and Tessa
for 12 hour follow up
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Working Together… to COOL!
“You may have the greatest bunch of
stars in the world, but if they don’t play
together, the club won’t be worth a
dime.”
Babe Ruth
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A PACT Case
• 52 yr old male
• Acute onset chest pain followed by collapse
outside home
– Witnessed
– Bystander CPR initiated
• 911 call @ 20:32
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EMS Treatment
• Toronto Fire
– First on scene
– Confirmed VSA, continued CPR
– AED applied – 1st shock
ECG
Grid size is 0.20 s x 0.50 mV at Gain x1
Prompt: don't touch patient, analyzing
Analysis: started
20:37:43
20:37:44
20:37:45
20:37:46
20:37:47
20:37:48
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20:37:49
EMS Treatment
• Toronto EMS
– Bradycardic PEA, continued CPR
– Course V-fib – 2nd shock
– ROSC
– Intubation
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SMH Emergency Department
• Patient brought into a resuscitation bay
• Assessment by emergency RNs, ER residents
and MD
– BP 80/50, HR 110 Sinus Tachy, BVM ventilations
(apneic), O2 100% on FiO2 100%, Temp 36
• Tube position confirmed with colorimetric
ETCO2, RT paged, cxray ordered, blood drawn,
additional IVs established
• 12-lead ECG ordered
• Order for dopamine give for a BP 80/40
• ER puts in right femoral central line
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SMH Emergency Department
• Pre-printed post arrest therapeutic hypothermia
orders signed by emerg staff MD
• Several ice bags placed around patient
• Critical Care paged through locating
• PACT team activated
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A PACT Case
• After hours paging protocol – PACT RN
• PACT RN
– Calls back to emergency
– Attends ASAP
– Determines eligibility
– Undertakes a focused assessment of the
patient
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A PACT Case
• PACT-focused problem based approach
using the checklist and pathways
– Pt is comatose (not responding to voice or
painful stimuli)
– Intubated on vent. RT at bedside.
– On emergency cardioresp monitor
– BP 80/50, HR 110 Sinus Tachy, Vented O2
100% on FiO2 100%, Temp 36 (tympanic)
– Ice bags at neck and groin
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A PACT Case
• PACT RN actions?
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PACT RN Actions
• Discussed gas exchange goals with RT and obtained
orders from MRP or PACT MD
– Requested end-tidal CO2 monitor from RT
• Identified hypotension as an issue and advocated for
fluids/pressors/central line by primary team
– Pre-printed orders support this
• Ensured 12-lead ECG was done and assessed by MRP
– Draw attention to PCI pathway if indicated
• Helped bedside nurses place an esophageal temp probe
• Assisted bedside nurses with proper ice bag placement
and reminded about hourly replacement
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PACT RN Actions
• Started 2L cold saline bolus as per preprinted orders with pressure bags
• Encouraged sedation/analgesia and
paralytic PRN as per pre-printed orders
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PACT RN Actions
• At completion of initial assessment and
management, contacted the PACT MD through
locating to discuss the case
– Focus on:
•
•
•
•
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Hx and focused physical assessment
Review eligibility
Review interventions/investigations prior to PACT
Review any PACT interventions
Discussion with RN/MD around issues requiring attention by
PACT MD
• After MD contact, the PACT RN completed the
eCRF on iPAD
• Brief PACT RN note in chart
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PACT MD actions
• Reviewed case with the PACT RN over the
phone
• Provided verbal “PACT Suggest” orders for
ventilation parameters
• After review with PACT RN, contacts MRP
to discuss the suggest orders and discuss
the ECG/PCI pathway
• Assessment for PCI
• Assessment for EP involvement acutely
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PACT RN Actions
• One hour later – PACT RN follows up with
emerg
– BP 120/70 on 10 mcg/kg/min
– HR Sinus at 95
– Ventilated FiO2 40% O2 sats 95% ETCO2 40
– Temp (esophageal) 36 degrees
• Action?
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THANK YOU
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