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Responding to a Code

Responding to a Code. Keith Rischer RN, MA, CEN. Today’s Objectives…. Identify clinical situations in which a code would be called. Differentiate a code for respiratory arrest versus cardiac arrest. State emergency measures when initiating a code before the code team arrives.

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Responding to a Code

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  1. Responding to a Code Keith Rischer RN, MA, CEN

  2. Today’s Objectives… • Identify clinical situations in which a code would be called. • Differentiate a code for respiratory arrest versus cardiac arrest. • State emergency measures when initiating a code before the code team arrives. • Identify dysrhythmias and interventions experienced in a code situation. • Discuss the specific roles of each of the emergency team members. • Discuss the role of the patient’s assigned nurse in a code situation. • Practice responding to a code including recording on a code record. • State actions for using a portable defibrillator.

  3. Today’s Schedule… • Past experiences with codes • Discussion of legal and ethical issues • Code team membership • Responsibility of each member • Equipment and safety issues • Brief review CPR protocols/defibrillation • Implementation of code scenarios/debriefing • Post code issues

  4. Legal & Ethical Issues • DNR order • No DNR order • Advanced directives • Organ donation • Code review • Ethic Committee

  5. Cardiac Arrest=Teamwork

  6. Code Team Responsibilities • Primary nurse caring for patient • Second nurse (possibly from code team/defibrillator certified) • Rapid response nurse • Medication nurse • Scribe (nurse/manager/supervisor) • Respiratory/Anesthesia • Team leader • Ancillary departments (EKG, I.V. Team) • Patient representative and/or clergy • Runner • Security

  7. Basic Life Support: Primary Survey • Airway • Open airway, look, listen, and feel for breathing. • Breathing • If not breathing, slowly give 2 rescue breaths. • Circulation • Check pulse. If pulseless, begin chest compressions at 100/min • 30:2 ratio. • Consider precordial thump with witnessed arrest and no defibrillator nearby • Attach monitor, determine rhythm. If VF or pulseless VT: shock 1 time • Defibrillate • YouTube - • YouTube – • YouTube -

  8. Managing Airway

  9. Primary Survey continued priorities • Airway • Establish and secure an airway device (ETT, LMA, COPA, Combitube, etc.). • Breathing • Ventilate with 100% O2. Confirm airway placement (exam, ETCO2, and SpO2). Remember, no metabolism/circulation = no blue blood to lungs = no ETCO2. • Circulation • Evaluate rhythm, pulse. If pulseless continue CPR, obtain IV access, give rhythm-appropriate medications (see specific algorithms). PIV preferred initially vs. central line. • Differential Diagnosis • Identify and treat reversible causes.

  10. ACLS Medications • Adenosine • Atropine sulfate • Amiodarone • Cardizem (diltiazem) • Dopamine HCL • Dobutamine hydrochloride • Epinephrine HCL (Adrenalin)

  11. ACLS Medications • Levophed (Norepinephrine) • Lidocaine HCL • Magnesium • Nitroglycerine (NTG) • Oxygen • Sodium Bicarbonaate • Vasopressin

  12. Recording

  13. Defibrillation • Patho • Bi-phasic • Nursing Responsibilities

  14. ACLS Rhythms: Most Common • VT-VF • Asystole • Tachycardia • AFib w/RVR (symptomatic) • SVT • Bradycardia (symptomatic)

  15. Ventricular Tachycardia

  16. Ventricular Fibrillation/Asytole

  17. Don’t Let Him Go…

  18. VT-VF Arrest • Shock 360J* • Epinephrine 1 mg IV q3-5 min. • Vasopressin 40 U IV • one time dose (wait 5-10 minutes before starting epi). • Shock 360J* • Amiodarone 300mg IV push. • May repeat once at 150mg in 3-5 min • Shock 360J* • Lidocaine 1.0-1.5 mg/kg IV q 3-5 min • max 3 mg/kg • Shock 360J*

  19. Asytole • Consider bicarb, pacing early • Transcutaneous Pacing (TCP) • Not shown to improve survival • If tried, try EARLY • Epinephrine 1 mg IV q3-5 min • Atropine 1 mg IV q3-5 min • Max 0.04 mg/kg • Consider possible causes • Hypoxia • Hyperkalemia • Hypothermia • Drug overdose (e.g., tricyclics) • Myocardial Infarction

  20. Atrial Fibrillation • Rate control: • Cardizem (Diltiazem) 20-25mg IV bolus • Cardizem gtt 5-15 mg/hr • beta-blocker • Cardiovert: • If onset < 48 hours cardioversion OR Cardizem • If onset > 48 hours: avoid drugs that may cardiovert (e.g. amiodarone) • Delayed Cardioversion: • anticoagulate adequately x 1 week, then cardioversion

  21. Bradycardia • If AV block: • 2nd degree (type 2) or 3rd degree: standby TCP, prepare for transvenous pacing • slow wide complex escape rhythm: Do NOT give lidocaine. • Atropine • 0.5-1.0 mg IV push q 3-5 min • max 0.04 mg/kg • Pacing • Use transcutaneous pacing (TCP) immediately if sx severe • Dopamine • 5-20 µg/kg/min • Epinephrine • 2-10 µg/min

  22. Post Code Concerns • Autopsy • Family presence • Survival • Saving life is priority regardless • Seen in less experienced nurses, MD’s • Holistic • Save life • Addressing needs of the family • Seen in more experienced providers and those who were sensitive to their own spirituality

  23. Code Case Study • 92 y.o. female with no significant past medical history on file who presents to the emergency department this evening for evaluation post cardiac arrest. • The patient was found at her home in Fairbault, MN by her family. She was having gurgling respirations and the family performed some "compressions" and contacted 911 at 2117. • When EMS arrived at 2149 they moved the patient to the ambulance and attempted intubation 3 times. At this time air lift arrived and it was found that the patient had no pulse. • CPR was started and it was thought that she was in a fib at that time. Family MD state to stop resuscitation and patient had return of spontaneous circulation. • At that time she was loaded into the aircraft and airlifted away from the scene at 2219. She was placed on ventilation and had fixed/dilated pupils, no spontaneous movement, poor color, and low BP. • En route she was given bicarbonate amp IV, epinephrine amp IV x2, atropine amp IV x2,. At 2200 the patient changed to PEA. The patient is currently taking Atendol, Lasix, Coumadin, and Aricept.

  24. Code Case Study • PHYSICAL EXAM: • VITAL SIGNS: BP 109/67 | Pulse 112 | Resp 12 | SpO2 99% • GENERAL APPEARANCE: Critically Ill, UnresponsiveComments: Obtunded. Intubated. Mildly cyanotic. • LUNGS: Comments: Breath sounds clear but upper airway noises heard. CARDIAC: Regular Rhythm FINDINGS: Murmurs: Systolic Murmur 1/6. Heart Sounds: DistantSKIN: Comments: Unremarkable. Abdomen soft but distended. NEUROLOGIC: Unconscious. Unresponsive. MUSCULOSKELETAL: No Deformity • EKG:Heart Rate: 109 BPM-Atrial fibrillation with rapid ventricular response

  25. Labs

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