MANAGING A CODE BLUE

1. MANAGING A CODE BLUE ANTOINETTE SPEVETZ, MD GREG STAMAN, RN SEPTEMBER 3, 2010

2. ACLS ALGORYTHM:

3. ACLS • Emphasis on high-quality CPR and minimal interruptions. Rescue breaths given over 1 s at a rate of 8 to 10 per minute. Chest compressions at a rate of 100/min with depression of chest at least 1/3 of its height. • Use of LMA and esophageal-tracheal combitube as well as of endotracheal intubation is limited to providers with adequate training and opportunities to practice or perform these procedures.

4. ACLS • Confirmation of endotracheal tube placement requires both clinical assessment and the use of a device (e.g., exhaled CO2 detector, esophageal detector device). Use of a device is part of (primary) confirmation and is not considered secondary confirmation

5. ACLS • The algorithm for treatment of pulseless arrest was reorganized to include VF/pulseless VT, asystole and PEA • The priority skills and interventions during cardiac arrest are BLS skills, including effective chest compressions with minimal interuptions • Insertion of an advanced airway may not be a priority

6. Check responsiveness Activate emergency response system / Call for defibrillator Perform primary ABCD survey CPR until monitor / defibrillator arrives. Give Oxygen. VF/VT Defibrillate x 1 Immediate CPR (30:2)1 Obtain IV/IO Access After 2 minutes of CPR, Pulse and Rhythm Check VF/VT Defibrillate x 1 Immediate CPR Consider Epinephrine 1 mg q3 min. or Vasopressin 40 U (once) After 2 minutes of CPR, Pulse and Rhythm Check VF/VT Defibrillate x 1 Immediate CPR Consider antiarrhythmic agent Amiodarone 300mg or Lidocaine 1.5 mg/kg If Torsades de pointes, consider MgS04 2 Gm

7. Check responsiveness Activate emergency response system / Call for defibrillator Perform primary ABCD survey CPR until monitor / defibrillator arrives. Give Oxygen. Non shockable rythm Immediate CPR (30:2)1 Obtain IV/IO Access Consider Epinephrine 1 mg q3 min. or Vasopressin 40 U (once) Consider Atropine 0.5 – 3 mg for asystole or bradycardia PEA After 2 minutes of CPR, Pulse and Rhythm Check Non shockable rythm Immediate CPR Search for Treatable Causes Consider Epinephrine 1 mg q3 minutes Repeat pulse and rhythm check every 2 minutes Exhaust all treatable causes for narrow QRS complex PEA Consider early termination of resuscitation attempt for agonal rhythm and asystole

8. ACLS • If an advanced airway is inserted, rescuers should no longer deliver cycles of CPR. Chest compressions should be delivered continuously (100 per minute) and rescue breaths delivered at a rate of 8 to 10 breaths per minute (1 breath every 6 to 8 seconds) • Providers must organize care to minimize interruptions in chest compressions for rhythm check, shock delivery, advanced airway insertion or vascular access

9. ACLS • Intravenous or intraosseous (IO) drug administration is preferred to endotracheal administration • Treatment of VF/pulseless VT • To attempt defibrillation, 1 shock is delivered (see “Defibrillation” for defibrillation doses using monophasic or biphasic waveforms) followed immediately by CPR (beginning with chest compressions

10. ACLS • Providers do not attempt to palpate a pulse or check rhythm after shock delivery. If an organized rhythm, is apparent during rhythm check after 5 cycles (about 2 minutes) of CPR, the provider checks a pulse • Drugs should be delivered during CPR, as soon as possible after rhythm checks • If a third rescuer is available, that rescuer should prepare drug doses before they are needed

11. ACLS • If a rhythm check shows persistent VF/VT, the appropriate vasopressor or antiarrhthmic should be administered as soon as possible after the rhythm check. IT can be administered during the CPR that precedes (until the defibrillator is charged) or follows shock delivery • The timing of drug delivery is less important than is the need to minimize interruptions in chest compressions • For symptomatic bradycardia the dose of atropine has been decreased to 0.5 mg repeatable up to a total of 3 mg

12. Situational Awareness

13. Closed Loop Communication By repeating back verbal orders during a code, we are closing the loop with the person conveying the message. Closing the loop allows the senders of the message to hear what they said reflected back to them, and to confirm that their message was received correctly.

14. Code Team: • ICU or CCU fellow • Anesthesia/nurse anesthetist • Surgery • ED Resident/Attending/Nurse based upon location of code • Respiratory Care • ICU and CCU Nurse • Pharmacy (as available) • Nursing supervisor • MAR • -Each of the above will carry a pager and be responsible for responding to the code. If out of the building, they are • responsible to hand over the pager to an equally qualified person. • -Medical admitting hospitalist (MAH) will attend code as available to observe and debrief. code called overhead page/pager sounds above group responds MAR wears “sticker” and is in charge fellow’s primary role is to back up the resident CCU fellow 8a-4p M-F ICU fellow 4p-8a, weekends & holidays “home team” is designated to contact the family to inform them of the situation intubate/line placement by anesthesia or qualified personnel extra personnel excused patient dies patient survives note written by MAR attending/family informed MAR writes note and attending/family informed bed available no bed “home team” is responsible for the patient ICU/CCU nurse stays with the patient. If the patient is stable, housestaff to give pager number and physically check patient every 30 minutes as needed patient transported by ICU/CCU Team *”home team” is medical or surgical team or service responsible for patient fellow has the ultimate determination as to who is responsible for the patient’s care

15. A Few Pointers……… Saving the world....one patient at a time!

16. Case 1: • 80-year-old woman with multiple illnesses, including chronic obstructive pulmonary disease (COPD), was found pulseless and cyanotic in her hospital bed

17. Case 1 Review: • The nurse had seen numerous codes, but never participated in one until that night • She did not relay the fact that it was hard to ventilate the patient toward the end of the code • Calling the code: very ambiguous as per ACLS manual: • The victim responds, regains an adequate pulse, and begins to breath • A trained professional provider assumes responsibility • The rescuers are too exhausted to continue • A medical professional decides it’s time to stop, or • Obvious signs of death are apparent.

18. Case 2: • 55 yo F, housekeeper, brought to ED for lightheadedness and pallor • The patient reports not feeling well for several hours • history of diabetes, and she reports taking her insulin 2 hours ago, but has not yet eaten • denies CP but has SOB/N but no vomiting • PE: pale diaphoretic 97 40 90/60 22 97% • Rest of PE WNL except for 1+ LE pitting edema • Initial management?

20. Case 2 (Cont.): • ABC, Check EKG, BS or give D50, put on monitoring • The patient is placed on the transcutaneous pacer and set at 60. 100% paces with BP 100/50. The patient felt better, but was uncomfortable secondary to the pacer. While waiting for CCU team to evaluate the patient, the patient becomes unresponsive, apneic and although 100% paced, pulseless. • What will you do next?

21. Case 2 (Cont.): • Bag her- do CPR- intubate when possible- put a transvenous pacer • Pt got an emergent transvenous pacer. Pacer captures initially, but within 5-10 minutes patient again becomes pulseless. CPR is begun again, but your patient remains pulseless and dies. • Would you have done anything differently?

22. CUH Advanced LifePak Training Automatic External Defibrillator Operation

23. CUH Advanced LifePak Training AED Door Lead Button

24. CUH Advanced LifePak Training Lead Select Defibrillator (Gray Box) Cardioversion Print Button Pacer (Green Box) Speed Dial Service Light

25. CUH Advanced LifePak Training Event Capture Log Meds/events/etc. Waveform Size (Increase/decrease gain) Options Button Code Summary (Provides full report) Pause (Suspends pacing when pushed/held) Home Button Alarm Controls