Stabilization of Cardiogenic Shock for Critical Care Transport, a Simulation.

Audience: This simulation is designed for critical care transport providers but can be easily adapted for the inpatient setting. It is applicable to an interdisciplinary team including nurses, respiratory therapists, medical students, emergency medicine residents, and emergency medicine attendings.

Introduction: Cardiogenic shock carries an incredibly high burden of morbidity and mortality. Acute myocardial infarction accounts for 81% of cardiogenic shock patients and is a common indication for transfer to a tertiary care facility.1 Hypotension due to cardiogenic shock is often refractory to volume resuscitation and often requires pharmacologic intervention. Additionally, the resultant end organ dysfunction frequently requires advanced ventilatory support.1-6 This simulation aims to educate critical care transport providers on the best practices for management of the cardiogenic shock patients requiring resuscitation and intubation prior to transport.

Educational objectives: By the end of this simulation session, learners will be able to: 1) recognize the need for intubation in an unstable patient in cardiogenic shock who requires transport, 2) appropriately titrate bi-Level non-invasive ventilatory support (BiPAP) to optimize oxygenation and ventilation in preparation for intubation, 3) choose appropriate vasoactive medications to support the hemodynamics of a patient in cardiogenic shock, 4) perform rapid sequence intubation using appropriate induction and paralytic agents and dosing for a patient in cardiogenic shock, 5) choose appropriate initial lung-protective ventilator settings, and 6) implement an adequate analgesia and sedation plan for transport of an intubated patient in cardiogenic shock.

Educational methods: This session was conducted using high-fidelity simulation, allowing learners to manage a patient in cardiogenic shock and respiratory distress requiring intubation. Each session was followed by a debriefing and discussion.

Research methods: Qualitative feedback provided by participants during the discussion session was utilized to adjust the simulation between each session. In addition, participants were surveyed using a five-point Likert scale (strongly disagree to strongly agree) on if the simulation met their professional and educational needs, its efficacy and appropriateness for Level, and whether it would change future practice.

Results: A total of 36 learners, including 20 physicians and 16 nurses, participated in the simulation over a total of nine sessions. Twenty out of the thirty-six participants completed the survey (both RNs and MDs) and 100% responded "strongly agree" to all four prompts (top response out of a five Likert scale). Feedback provided by participants was used after each session to adjust the simulation. Changes implemented included the addition of a nurse confederate, greater emphasis on management and titration of non-invasive ventilation for optimal preoxygenation, and initiation of post intubation sedation and analgesia.

Discussion: Cardiogenic shock is a common cause of mortality, often requires transport, and is particularly challenging to manage. This simulation was overall effective at educating learners on the resuscitation of cardiogenic shock, including appropriate use of vasopressors and ventilatory support.

Topics: Cardiogenic shock, hypoxic respiratory failure, vasopressor management, airway management, intubation, non-invasive positive pressure ventilation management, ventilatory management, emergency medicine, critical care transport medicine.