Coláiste na hOllscoile Corcaigh

University College Cork

MED3/GM2 CLERKSHIP
IN
ANAESTHESIA & INTENSIVE CARE MEDICINE
AT
UNIVERSITY COLLEGE CORK MEDICAL SCHOOL

2010/11

1
 DEPARTMENT OF ANAESTHESIA & INTENSIVE CARE
MEDICINE

Med3/GM2 Medical Students

Module CP3002

Background

The anaesthetic/ICU component of module CP3002 will comprise two elements.

TERM 1

During Term 1 (Sept. to Dec.) it is proposed that students will attend the Operating

Theatres of either Cork University Hospital, South Infirmary/Victoria University

Hospital, Bon Secours Hospital or Mercy University Hospital on Tuesday,

Wednesday and Thursday mornings over a two week period. This is designed to

complement the intensive course on clinical skills offered during September.

Since this module is timed to occur at the introduction to the clinical curriculum, it is

appropriate and timely to expose students to the basics of clinical and practical skills,

BLS (Basic Life Support) and Resuscitation. Teaching of the theoretical concepts can

be followed by the demonstration and practice of skills in the Clinical Skills

Laboratory. Here students can develop and practise skills in a non-clinical

environment. The theoretical knowledge will then be reinforced and the clinical

skills demonstrated and applied in a clinical setting during the three weeks in the

hospital component of the module.

2
Because the work of anaesthetists straddles a number of clinical areas in a hospital

setting eg perioperative care, intensive care, acute and chronic pain management it is

hoped that students will be exposed to some or all of these areas during the two week

component of the clerkship.

------------------------

TERM 2

In Term 2, students will attend the Department of Anaesthesia/Intensive Care of a

designated Acute Teaching hospital for one full week attachment. This will

comprise one of a four week surgical clinical attachment.

During that week students will be exposed to:

a) Further small group teaching in a theatre setting.

b) Principles/practice of preoperative Anaesthetic Evaluation of patients.

c) Patient care in post operative recovery room.

d) Have two tutorials (airway management, resuscitation).

-------------------------

Educational Objectives

3
1 To enable the student to understand the roles of the anaesthetist within

a hospital setting.

2 To enable the student to learn how to assess a patient for anaesthesia

and surgery.

3 To enable students to gain a basic understanding of induction, maintenance

and emergence from anaesthesia, including intraoperative monitoring and

post operative care.

4 To allow students to observe and understand the principles of fluid and

electrolyte management intra and post operatively.

5 To enable students to observe and understand the principles of pain

assessment and management.

6 To learn the principles and practice of Cardiopulmonary Resuscitation.

7 To learn the theory and gain practical experience in airway management,

bag and mask ventilation, LMA insertion, ETT intubation and IV access.

4
Clerkship Content

The content of this clerkship can be divided into three areas:

1 Theory

2 Demonstration and practice of clinical and practical skills.

3 Assessment/Evaluation

Theory

Theoretical concepts will be taught both at tutorial sessions (at least two during the

three week hospital attendance) and on a one to one level in the Operating

Theatres.

Clinical /Practical Skills

Clinical skills such as history taking, preoperative patient assessment, patient

examination, interpretation of ECG’s and Chest Xrays will be demonstrated and

discussed.

Practical Skills

CPR, airway management, bag/mask ventilation, intravenous access, LMA/ETT

insertion will be demonstrated and practised.

Management of specific situations

e.g. Choking
Drowning
Smoke inhalation
Burns
Electrocution
Drug overdose
Severe haemorrhage
Multiple Injuries
Head/Spinal Injuries.

5
Assessment/Evaluation

In keeping with other clinical rotations anaesthesia assessment will be a part of

written/skill based assessment at end of year examinations (EMQ/OSCE).

Students are required to submit an essay following completion of clerkship

(which accounts for 30% of anaesthesia clerkship marks). See Gaffney Prize,

page 22.

Students will be asked to give an anonymous evaluation of the Anaesthesia clerkship

at the end of Term 2 attachment.

Recommended Reading:

How To Survive In Anaesthesia. Neville Robinson and George Hall, 2nd Edition.

6
Core Topics

Below are listed a number of core topics under various headings. These are simply

guidelines for both students and teachers. It allows teachers to cover what we regard

as important areas in this clerkship and it allows students to ensure that different

topics are covered on different days in Theatre/ICU. It also gives students headings

under which questions may be asked of their teachers.

Knowledge and understanding:

Roles of anaesthetist

Patient assessment

Induction, maintenance, emergence

Post operative care

Monitoring

Fluid management

Electrolytes

ICU – ABGs, shock, CCF, respiratory failure, ventilation

Anaphylaxis

Clinical Skills:

Pre-operative assessment

History taking

Examination – CVS, respiratory, head and neck

CXR

ECG

7
Technical Skills:

CPR

I.V. insertion

B-V-M ventilation

(LMA, ET tube insertion)

Attitudes

Standards of care

Vigilance

Appropriate behaviour to staff and patients

Problem Solving:

Simple anaesthetic plan

Management of clinical scenarios e.g. hypoxia, hypotension etc.

----------------------

8
 FOR CUH STUDENTS ONLY

Theatre Assignments

Students Numbered 1 – 12

Week 1 of Term 1

Th.1/1a Th. 2 Th.3 Th.4 Th. 5 Th.6 Th.7 Th.8 Th. 9

Tuesday 1/12 2/11 3 5/6 7 8 9 10 4

Wednesday 10 5 8/9 1/2 4 6/7 3 12 11

Thursday 4/7 12/6 10 9/4 3/11 5 8 2 1

Week 2 of Term 1

Tuesday 5/6 8/9 7 3/10 1 2 4 11 12

Wednesday 3 10 5/6 7/8 2 11 12/4 1 9

Thursday 8/9 1/4 11 10 5/12 9 6/7 3 2

FOR CUH STUDENTS ONLY

Theatre Assignments

Term 2

9
 Th.1/1a Th. 2 Th.3 Th.4 Th. 5 Th.6 Th.7 Th.8 Th. 9

Cardiac Ortho Neuro Ophth Gen/Vasc Gen. Gen. Gen/Vasc Trauma

Monday 4/7 3 2 11/1 8 12 6 9/10 5

Tuesday 11/5 7 4 12/8 9 3 2 1/10 6

Wed. 2 4 11/5 1/9 6/3 12 8 10 7

Thurs. 12/3 5 6 9 7/11 2/4 1 10 8

Friday 1 10/2 12/8 4 5/9 6 7 11 3

MED 111 ANAESTHESIA AND INTENSIVE CARE CLERKSHIP LOG

DATE: ________________

STUDENT NAME: ________________

Practical Procedures Performed Number

10
Manual ventilation (facemask/airway)

LMA Insertion

ETT Insertion

IV Insertion

Other e.g. Arterial Line

MED 111 ANAESTHESIA AND INTENSIVE CARE CLERKSHIP

COURSE EVALUATION FORM

Please rate the content of each of the core topics listed below as inadequate, adequate
or good by ticking the appropriate box.
Core Topic Inadequate Adequate Good
Resuscitation
Airway Management
Perioperative Patient Monitoring
Applied Pharmacology
Applied Physiology
Procedural Skills

Please rate the importance and relevance to practice of each of the core topics
listed below as very important, fairly important or not important by ticking the
appropriate box.
Core Topic Very Fairly Important Not Important

11
 Important
Resuscitation
Airway Management
Perioperative Patient Monitoring
Applied Pharmacology
Applied Physiology
Intensive Care Medicine
Procedural Skills
Any other comments

ERC Guidelines for Resuscitation 2005

Summary

Main changes in adult basic life support

 The decision to start CPR is made if a victim is unresponsive and not
breathing normally.
 Rescuers should be taught to place their hands on the centre of the
chest, rather than to spend more time using the ‘rib margin’ method.
 Each rescue breath is given over 1 sec rather than 2 sec.
 The ratio of compressions to ventilations is 30:2 for all adult victims of
cardiac arrest. This same ratio should also be used for children when
attended by a lay rescuer.
 For an adult victim, the 2 initial rescue breaths are omitted, with 30
compressions being given immediately after cardiac arrest is
established.

Main changes in automated external defibrillation

 Public access defibrillation (PAD) programmes are recommended for
locations where the expected use of an AED for witnessed cardiac
arrest exceeds once in two years.
 A single defibrillatory shock (at least 150J biphasic or 360J
monophasic) is delivered, immediately followed by two minutes of
uninterrupted CPR, without a check for termination of VF or a check for
signs of life or a pulse.

Main changes in adult advanced life support

CPR before defibrillation
 In out-of-hospital cardiac arrest attended, but unwitnessed, by
healthcare professionals equipped with manual defibrillators, give CPR
for 2 min (i.e. about 5 cycles at 30:2) before defibrillation.
 Do not delay defibrillation if an out-of-hospital arrest is witnessed by a
healthcare professional.
 Do not delay defibrillation for in-hospital cardiac arrest.

Defibrillation strategy

12
  Treat ventricular fibrillation/pulseless ventricular tachycardia (VF/VT)
with a single shock,followed by immediate resumption of CPR (30
compressions to 2 ventilations). Do not reassess the rhythm or feel for
a pulse. After 2 min of CPR, check the rhythm and give another shock
(if indicated).
 The recommended initial energy for biphasic defibrillators is 150-200 J.
Give second and subsequent shocks at 150-360 J.
 The recommended energy when using a monophasic defibrillator is
360 J for both the initial and subsequent shocks.

Fine VF
 If there is doubt about whether the rhythm is asystole or fine VF, do
NOT attempt defibrillation; instead, continue chest compressions and
ventilation.

Adrenaline (epinephrine)
 VF/VT
Give adrenaline 1 mg IV if VF/VT persists after a second shock.
Repeat the adrenaline every 3-5 min thereafter if VF/VT persists.
 Pulseless electrical activity / asystole
Give adrenaline 1 mg IV as soon as intravenous access is obtained,
and repeat every 3-5 min thereafter until return of spontaneous
circulation (ROSC) is achieved.

Anti-arrhythmic drugs
 If VF/VT persists after three shocks, give amiodarone 300 mg by bolus
injection. A further dose of 150 mg may be given for recurrent or
refractory VF/VT, followed by an infusion of 900 mg over 24 h.
 If amiodarone is not available, lidocaine 1 mg kg-1 may be used as an
alternative, but do not give lidocaine if amiodarone has already been
given. Do not exceed a total dose of 3 mg kg-1 during the first hour.

Thrombolytic therapy for cardiac arrest

 Consider thrombolytic therapy when cardiac arrest is thought to be due
to proven or suspected pulmonary embolus. Thrombolysis may be
considered in adult cardiac arrest on a case by case basis following
initial failure of standard resuscitation in patients in whom an acute
thrombotic aetiology for the arrest is suspected. Ongoing CPR is not a
contraindication to thrombolysis.
 Consider performing CPR for up to 60-90 min when thrombolytic
agents have been given during CPR.

Post resuscitation care - therapeutic hypothermia

13
  Unconscious adult patients, with spontaneous circulation, after out-of-
hospital VF cardiac arrest should be cooled to 32-34°C for 12-24 h.
 Mild hypothermia may also benefit unconscious adult patients, with
spontaneous circulation, after out-of-hospital cardiac arrest from a non-
shockable rhythm or after cardiac arrest in hospital.

Main changes in paediatric life support

Paediatric basic life support

 Lay rescuers or lone rescuers witnessing or attending paediatric
cardiac arrest will use a ratio of 30 compressions to 2 ventilations.
They will start with 5 rescue breaths and continue with the 30:2 ratio as
taught in adult BLS.
 Two or more rescuers with a duty to respond will use the 15:2 ratio in a
child up to the onset of puberty. It is inappropriate and unnecessary to
establish the onset of puberty formally; if the rescuer believes the
victim to be a child then they should use the paediatric guidelines.
 In an infant (less than 1 year) the compression technique remains the
same: two-finger compression for single rescuers and two-thumb
encircling technique for two or more rescuers. Above one year of age,
there is no division between one- or two-hand technique. The one or
two hands technique may be used according to rescuer preference.

 AED may be used in children above one year of age. Attenuators of the
electrical output are recommended between 1 and 8 years of age.
 For foreign body airway obstruction relief, in an unconscious child or
infant, attempt five rescue breaths and in the absence of response,
proceed to chest compressions without further assessment of the
circulation.

Paediatric advanced life support

 The Layngeal Mask Airway is an acceptable initial airway device for
providers experienced in its use. In hospital, a cuffed tracheal tube may
be useful in certain circumstances, e.g. in cases of poor lung
compliance, high airway resistance or large glottic air leak.The cuff
inflation pressure should be monitored regularly and must remain
below 20 cm H2O .

14
  Hyperventilation is harmful during cardiac arrest. The ideal tidal volume
should achieve modest chest wall rise.
 When using a manual defibrillator, a dose of 4 J kg-1 (biphasic or
monophasic waveform) should be used for the first and subsequent
shocks.

Asystole, pulseless electrical activity (PEA)

 Adrenaline IV or IO should be given at the dose of 10 mcg kg-1 and
repeated every 3-5min. If no vascular access is available and a
tracheal tube is in-situ, adrenaline may be given at the dose of 100
mcg kg-1 via this route until IV/IO access is obtained

Defibrillation strategy
 Ventricular fibrillation/pulseless ventricular tachycardia (VF/VT) should
be treated with a single shock, followed by immediate resumption of
CPR (15 compressions to 2 ventilations). Do not reassess the rhythm
or feel for a pulse. After 2 min of CPR, check the rhythm and give
another shock (if indicated).
 Give adrenaline 10 mcg kg-1 IV if VF/VT persists after a second shock.
 Repeat adrenaline every 3-5 min thereafter if VF/VT persists.

Temperature control
 After cardiac arrest, treat fever aggressively.
 A child who regains a spontaneous circulation but remains comatose
after cardiac arrest may benefit from being cooled to a core
temperature of 32-34°C for 12-24 h. After a period of mild hypothermia,
the child should be rewarmed slowly at 0.25-0.5°C h-1.

Resuscitation of the newborn

 Protect the newborm from heat loss. Premature babies should be
covered with plastic wrapping on head and body (apart from the face),
without drying the baby beforehand. The baby so covered should then
be placed under radiant heat
 Ventilation: an initial inflation for 2-3 seconds must be given for the first
few breaths to help lung expansion
 Trachal route for adrenaline is not recommended. If the tracheal route
must be used, a dose of 100 mcg kg-1 must be used.
 Suctioning meconium from the baby’s nose and mouth before delivery
of the baby’s chest (intrapartum suctioning) is not useful and no longer
recommended.
 Standard resuscitation in delivery room should be made with 100%
oxygen. However lower concentrations are acceptable.

15
Figure 2.1 Adult basic life support algorithm.

16
Figure 2.20 Algorithm for use of an automated external defibrillator.

17
Figure 4.1 Algorithm for the treatment of in-hospital cardiac arrest.

18
Figure 4.2 Advanced life support cardiac arrest algorithm.

19
Figure 6.1 Paediatric basic life support algorithm.

20
THE GAFFNEY PRIZE

An undergraduate prize in Anaesthesia and Intensive Care Medicine has been

established in honour of Dr. Desmond Gaffney, former Chairman, Department of

Anaesthesia, Cork University Hospital. A prize of €1000.00 will be awarded

annually for the best essay (1500 – 2000 words) on a topic relevant to the practice

of anaesthesia and/or intensive care medicine from registered medical undergraduates

at UCC. Submission of essays is mandatory for all Med3/GM2 students. The

successful applicant will be invited to present on the subject of their

essay at the following South of Ireland Anaesthetists Association Annual Scientific

Meeting.

The subject matter of the essay will relate to the clinical practice of Anaesthesia or

Intensive Care Medicine. Basic physiological or pharmacological topics can be

discussed, but only in so far as they relate to clinical practice. Candidates are

encouraged to select topics which are current and/or controversial. Submissions,

which include the application of new information (either recently published or

collected by the submitting student) or original ideas to well-established problems, are

encouraged.

Marks will be awarded according to the following criteria: Content (50%),

Presentation (20%), Originality (15%), Clinical Significance (15%). Students should

note that “Originality” may mean the presentation of an argument in favour or against

a proposed idea OR the presentation of original data collected by the submitting

student. Marks will also be awarded for attempts to demonstrate an understanding

of a topic rather than a recycling or assembly of previously published material.

21
 White A4 paper should be used with margins of at least 2.5 cms (1 inch), double-

spacing should be used throughout. All pages should be numbered consecutively,

beginning with the title page.

The title page should not include the author’s name. A maximum of 20 references are

permitted. The essay should be accompanied by a cover letter stating the title of the

article and the name, address, telephone number, student number and medical class

year of the author.

---------------

N.B. Students to submit their essays within four weeks of completion of their

Anaesthetic clerkship.

Essays to be submitted to the designated Gaffney Essay assignment

box in the Assessment area of Blackboard. (CP3002 / GM2004)

22
NOTES:

23