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By: manosh (141 month(s) ago)

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Code Blue : 

Code Blue

Code Blue: 

Code Blue Patient is either in respiratory or cardiac difficulties Respiratory arrest – stops or inadequate breathing Cardiac arrest – heart is in a rhythm that causes the cessation of effective circulation

Respiratory Arrest: 

Respiratory Arrest Patient stops breathing Open airway, start mouth to mouth/mask Treat the underlying cause – include high O2 delivery: medicine OD, chemical, gas, secretions, choking, other airway obstruction If long term treatment is needed, may need to intubate (LMA) and ventilate until treatments are effective When stable move to hospital

Cardiac Arrest: 

Cardiac Arrest Identify no pulse Identify rhythm – treat rhythm Then treat cause immediately

What to Do: 

What to Do Call the code ask for local trained help Make sure patient is on a hard surface Start BLS Request help from MD, RN or whoever available on site Place on monitor Quick look with paddles/electrodes and identify rhythm or initiate AED protocol immediately Request cardiac drugs needed from assistant Follow ACLS protocols Record events in writing when time permits

Roles of Attending Staff: 

Roles of Attending Staff Establish airway and breathing ( high O2, ambu-bag, BVM – later, intubate - LMA) nurse - places on monitor, shocks, CPR nurse - starts IV’s, pushes meds nurse - documents MD, if available – directs the code crowd control – request from security

Things You Must Know About Your Patient: 

Things You Must Know About Your Patient Past Significant Medical History Current Diagnosis/Opinion Recent history from colleagues (what happened just prior to collapse) Any significant lab values if available Medication given or taken that day Anything unusual with health recently

What is on the Resuscitation Cart?: 

What is on the Resuscitation Cart? Usually a rolling tool box with doors Monitor and defibrillator Airway/Breathing supplies First line drugs Second line drugs IV and suction equipment Paperwork

Placing on Monitor: 

Placing on Monitor You have to know what the rhythm is to be able to treat - shocking and drugs saves lives Three lead monitor Five lead monitor Quick look paddles (manual defibrillator –LifePak 10 and 12) Monitor that talks to you (AED) Philips Heartstream FR2 and XLT


CODE RHYTHMS Asystole VT - Ventricular Tachycardia (Pulseless) VF - Ventricular Fibrillation PEA – Pulseless Electrical Activity – Treat underlying cause Heart blocks that have ceased to have adequate Cardiac Output

If Not a Shockable Rhythm: 

If Not a Shockable Rhythm Continue CPR Establish ventilation - ambu or intubate LMA IV’s- large bore and near to the heart Drugs

Defibrillation vs. Cardioversion: 

Defibrillation vs. Cardioversion Defibrillation – Joules delivered at any time of the cardiac cycle Depolarizes all the myocardial cells at once in the hope to reorganize and allow the SA node to resume the role of pacemaker

How to Defibrillate: 

How to Defibrillate Conductive gel or pads Charge paddles Shock 200j – check rhythm Shock 300j – check rhythm Shock 360j – check rhythm Start CPR, establish ventilation, IV’s drugs Subsequent shocks will be 360j AED will perform shocks with appropriate current automatically ( apply and use immediately in pulseless, unresponsive victim)


Cardioversion Delivers joules to terminate a dysrhythmia Must have a QRS complex - which means the patient has a pulse and is conscious Joules delivered at the end of the QRS complex which causes ventricular Usually deliver less joules Never deliver the energy at the T wave – could cause VT or VFib Also called synchronized cardioversion


Cardioversion Sedate the patient (IV conscious sedation) Turn on synchronized knob on monitor Protect airway and breathing Rhythms that can be cardioverted – Atrial Fibrillation, Atrial flutter, Ventricular Tachycardia with a pulse, Supra Ventricular Tachycardia. NB: Cardioversion would not normally be conducted at an RAC, unless on the advise of the EMS specialist.

Problems with Cardioversion: 

Problems with Cardioversion Lean vs. heavy patients Be aware of metal objects Conductive gel or pads Must place gel or pads around the heart Can cause burns to the patient Conscious patient does feel pain Can produce a more sinister rhythm

Emergency DrugsNot all drugs listed, available at RN RAC’s: 

Emergency Drugs Not all drugs listed, available at RN RAC’s Standard protocols set up by the American Heart Association – ACLS (Advanced Cardiac Life Support) Oxygen Epinephrine – Alpha and Beta stimulant; given IV or ETT; for VF, pulseless VT, asystole andamp; pulseless electrical activity; in symptomatic bradycardia after atropine, dopamine and transcutaneous pacing; severe hypotension, anaphylaxis 1 mg every 3-5 minutes during resuscitation, follow each dose with 20 ml IV flush Higher dose (up to 0.2 mg/kg) may be used 1 mg dose fails Continuous infusion 30 mg in 250 ml MS or D5W, run at 100 ml/hr and titrate to response Via ETT give 2 – 2.5 mg diluted in 10 ml NS For profound bradycardia and hypotension give 2-10 mcg/min (1mg in 500 ml NS to infuse at 1-5 ml/min)


Atropine – first drug for symptomatic sinus bradycardia; can be given via ETT; second drug after epinephrine or vasopressin for asystole or bradycardic PEA For asystole and PEA give 1 mg IV push, repeat every 3-5 minutes to a max dose of 0.03 to 0.04 mg/kg For bradycardia give 0.5 to 1 mg IV every 3-5 minutes as needed, not to exceed total dose of 0.04 mg/kg Down ETT give 2 to 3 mg diluted in 10 ml normal saline


Vasopressin (not available at RAC’s) One time dose of 40 U IV push May be used as an alternate pressor to epinephrine in the treatment of adult shock-refractory VF May be useful for hemodynamic support in vasodilatory shock (septic shock)


Lidocaine - antiarrhythmic effect, decreases ventricular excitability without depressing the force of contraction, depresses phase 4 of the cell cycle Used for VT andamp; VFib – IV push followed by a drip Initial dose 1 - 1.5mg/kg May repeat 0.5 – 0.75 mg/kg every 5-10 minutes to max total dose of 3mg/kg drip administered 1-4mg/min (30-50 mcg/kg/min) May be given via ETT at 2 to 4 mg/kg


Dopamine - inotropic, cardiac stimulant, vasopressor Second drug for symptomatic bradycardia (after atropine) Use for hypotension (systolic BP andlt; 70 to 100 mm Hg) with signs and symptoms of shock Alpha and Beta effects at low doses Only alpha effects at higher doses (Dose limit 20mcg/kg/min)


ISOPROTERENOL – Pure Beta stimulant (IV push or drip) Use cautiously as a temporizing measure if external pacer is not available for treatment of symptomatic bradycardia Temporary control of bradycardia in heart transplant patients (denervated heart unresponsive to atropine) Do not give with epinephrine; can cause VT/VF Mix 1 mg in 250 ml NS, RL or D5W. Infuse at 2 to 10 mcg/min. Titrate to adequate heart rate If used for torsades de pointes that is unresponsive to magnesium, titrate to increase heart rate until VT is suppressed


Pronestyl (Procainamide) - antiarrhythmic, slows heart rate, slows conduction Useful for a wide variety of arrhythmias May be used to treat PSVT uncontrolled by adenosine and vagal maneuvers if blood pressure stable Stable wide-complex tachycardia of unknown origin Atrial fibrillation with rapid rate in Wolff-Parkinson-White syndrome Proarrhythmic, especially in setting of AMI, hypokalemia or hypomagnesemia Must give 20 mg/min slow IV push until one of the following occurs: Arrhythmia suppression Hypotension QRS widens by andgt; 50% Total dose of 17 mg/kg is given Maintenance infusion of 1-4mg/min Used if Lidocaine doesn’t work


Amiodarone - Used for a wide variety of atrial and ventricular tachyarrhythmias and for rate control of rapid atrial arrhythmias in patients with impaired LV function when digoxin has proven ineffective Treatment of shock-refractory VF/pulseless VT Treatment of polymorphic VT and wide-complex tachycardia of uncertain origin Control of hemodynamically stable VT when cardioversion is unsuccessful Use as adjunct to electrical cardioversion of SVT, PSVT May be used for rate control in treatment of atrial fibrillation or flutter when other therapies are ineffective May cause vasodilation and hypotension. May prolong QT interval In cardiac arrest, given 300 mg IV push (dilute in 20 – 30 ml NS). Consider an additional 150 mg in 3 to 5 minutes. Maximum cumulative dose of 2.2 g IV/24 hrs For wide complex tachycardias may be given rapid infusion (150 mg IV over 10 minutes and repeat 150 mg every 10 minutes as needed), slow infusion (360 mg IV over 6 hours – 1 mg/min) or maintenance infusion (540 mg IV over 18 hours – 0.5 mg/min)


Verapamil Alternative drug (after adenosine) to terminate PSVT with narrow QRS complex, adequate blood pressure and preserved LV function May control ventricular response in patients with atrial fibrillation, flutter, or multifocal atrial tachycardia Expect blood pressure drop caused by peripheral vasodilation. IV calcium is an antagonist that restore blood pressure in toxic cases Use with extreme caution in patients receiving oral beta blockers IV infusion 2.5 to 5 mg IV bolus over 2 minutes. Second dose 5 to 10 m if needed in 15 to 30 minutes. Max dose 20 mg. Alternative infusion of 5 mg bolus every 15 min to total dose of 30 mg. In older patients, administer over 3 minutes


Sodium bicarbonate Preexisting hyperkalemia Preexisting bicarbonate-responsive acidosis (DKA) Tricyclic, cocaine or diphenhydramine overdoses To alkalinize urine in aspirin or other overdose Prolonged resuscitation with effective ventilation Upon return of spontaneous circulation after long arrest interval 1 mEq/kg IV bolus. Repeat half this dose every 10 minutes thereafter If rapidly available, use ABG analysis to guide bicarbonate therapy


PEDIATRIC CODES Emotional Same procedure followed as adults Drug doses are by kg Think respiratory not cardiac

Continue the Code for VT/VF: 

Continue the Code for VT/VF Epinephrine 1 mg IV Shock 360 Lidocaine 1-1.5 mg/kg Shock 360 Epinephrine 1 mg Shock 360 Lidocaine or Pronestyl or Amiodarone


Asystole Epinephrine 1mg Q3-5 mins Atropine 1mg Q3-5 mins Continue CPR


PEA Epinephrine 1mg Q3-5 mins Treat the underlying cause, if identifiable

Heart Blocks or Symptomatic Bradycardia: 

Heart Blocks or Symptomatic Bradycardia Atropine 1 mg (up to 3 mg) Isuprel Pacemaker

Back to the Code: 

Back to the Code Remember the patients’ arrest time - if you save the heart what about the patient’s brain Remember what you are saying around the patient and observers Once code is over how do you feel Comforting the friends Hospital transfer ASAP when stable


Codes How to document code procedures Rhythm strips Mortality rate Onward transportation when stable Post mortem care

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