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1/5/20141 Responding to a Code Keith Rischer RN, MA, CEN.

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Presentation on theme: "1/5/20141 Responding to a Code Keith Rischer RN, MA, CEN."— Presentation transcript:

1 1/5/20141 Responding to a Code Keith Rischer RN, MA, CEN

2 1/5/20142 Todays 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 patients 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 1/5/20143 Todays 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 1/5/20144 Legal & Ethical Issues DNR order No DNR order Advanced directives Organ donation Code review Ethic Committee

5 1/5/20145 Cardiac Arrest=Teamwork

6 1/5/20146 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 1/5/20147 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 1/5/20148 Managing Airway

9 1/5/20149 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 1/5/ ACLS Medications Adenosine Atropine sulfate Amiodarone Cardizem (diltiazem) Dopamine HCL Dobutamine hydrochloride Epinephrine HCL (Adrenalin)

11 1/5/ ACLS Medications Levophed (Norepinephrine) Lidocaine HCL Magnesium Nitroglycerine (NTG) Oxygen Sodium Bicarbonaate Vasopressin

12 1/5/ Recording

13 1/5/ Defibrillation Patho Bi-phasic Nursing Responsibilities

14 1/5/ ACLS Rhythms: Most Common VT-VF Asystole Tachycardia AFib w/RVR (symptomatic) SVT Bradycardia (symptomatic)

15 1/5/ Ventricular Tachycardia

16 1/5/ Ventricular Fibrillation/Asytole

17 1/5/ Dont Let Him Go…

18 1/5/ 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 mg/kg IV q 3-5 min max 3 mg/kg Shock 360J**

19 1/5/ 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 1/5/ 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 cardioversion If onset > 48 hours: avoid drugs that may cardiovert (e.g. amiodarone) Delayed Cardioversion: anticoagulate adequately x 1 week, then cardioversion

21 1/5/ 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 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 1/5/ Post Code Concerns Autopsy Family presence Survival Saving life is priority regardless Seen in less experienced nurses, MDs Holistic Save life Addressing needs of the family Seen in more experienced providers and those who were sensitive to their own spirituality

23 1/5/ 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 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 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 1/5/ Code Case Study PHYSICAL EXAM: VITAL SIGNS: BP 109/67 | Pulse 112 | Resp 12 | SpO2 99% GENERAL APPEARANCE: Critically Ill, Unresponsive Comments: 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: Distant SKIN: Comments: Unremarkable. Abdomen soft but distended. NEUROLOGIC: Unconscious. Unresponsive. MUSCULOSKELETAL: No Deformity EKG:Heart Rate: 109 BPM-Atrial fibrillation with rapid ventricular response

25 1/5/ Labs

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