1. 2011 CPR & Code Blue Procedures Adult and Child
RN, LPN and Respiratory Therapists

2. Objectives
After completing this self-learning packet the reader will be able to:
1. List nursing responsibilities when initiating and/or assisting during a Code Blue.
2. Identify the procedure for ensuring code cart readiness as well as code cart security following a Code Blue.
3. Apply the American Heart Association's performance guidelines to case scenarios requiring:
-Adult one and two rescuer CPR
-Adult and Child Foreign Body Airway Obstruction (FBAO) Management
-Child one and two rescuer CPR

3. A B C or C A B New Guidelines Again?
In November 2010 the International Resuscitation Organization released new CPR guidelines.
The new guidelines are based upon review of research related to Patient Outcomes and performance of CPR.
The CPR procedures in this packet reflect the most recently published guidelines.
There are different guidelines for Health Care Professionals (HCP) vs. the lay rescuer-
This program identifies the CPR procedures for those responding to cardiac arrest situations as healthcare professional rescuers
(RN , LPN, Respiratory Therapists)

4. Guidelines 2010
The process to evaluate new research and establish the next set of revised guidelines began in International leaders in resuscitation began to systematically review resuscitation studies and literature for evidence of procedures and processes that improve outcomes in Cardiac Arrest.
Keypoints in 2010 Guidelines development:
Evidence –based
Collaborative
International
Process of improvement

5. So what did the research show?
To impact success in resuscitation outcomes* more emphasis needs to
be placed on starting and
maintaining well done CPR compressions.
Early Defibrillation in witnessed cardiac arrests is a key to improving survival.
* Patient survival to hospital discharge with
intact neurologic functioning.

6. So what did the research show?
Compressions are the key!
Compressions need to be hard-at least 2 inches in depth
Fast-at least 100 per minute
Started as soon as the cardiac arrest is recognized
Maintained with minimal interruption

7. So what does the research show?
Ventilation-More is NOT better!
Multiple studies of actual cardiac arrest situations, demonstrate that we over ventilate in volume and rate!
During CPR, blood flow to the lungs is decreased. Therefore, lower respiratory rate/volume still maintains an adequate perfusion/ventilation ratio.
Hyperventilation is Harmful! Hyperventilation (giving more air than is needed) causes increased intrathoracic pressure resulting in decreased venous return and decreased cardiac output.
Forceful or excessively large breaths given by rescuers can exacerbate gastric distention. Not only can gastric distention cause vomiting and aspiration, it can restrict lung movement as it elevates the diaphragm.

8. So what else did the research say?
“Hands Only CPR” is performing compression only CPR. intended for untrained or minimally trained bystanders who come upon the victim of a sudden, witnessed cardiac arrest.
“Hands only CPR” is easier for non trained bystanders to remember.
“Hands Only CPR” is NOT intended for
Medical personnel in the course of their duties
Infant or child victims
Cardiac arrest due to respiratory arrest ( ex: drowning)
Victims of unwitnessed cardiac arrest

9. Initial Steps of Adult CPR
No longer will we be doing the A, B, Cs.
To emphasize initiation of early compressions, the steps are now C-A-B:
C - compressions
A - airway
B - breathing

10. Steps for Adult CPR for the Healthcare Provider (HCP)
Assess unresponsiveness and overview for absence of normal breathing.
Call for help and a defibrillator.
Check pulse.
If no pulse, begin CPR compressions.
After 30 compressions, open airway and give 2 breaths.
Continue CPR at a ratio of 30 compressions to 2 breaths.
As soon as a defibrillator is available, assess for need to defibrillate.

11. Steps for Adult CPR for the Healthcare Provider (HCP)
1. Assess unresponsiveness and overview/observe for normal breathing.
Tap victim, shout out “are you ok?” while simultaneously looking for any signs of normal breathing.
Validate DNR status.

12. Steps for Adult CPR for the Healthcare Provider (HCP)
Assess unresponsiveness and overview/observe for normal breathing-DO NOT take the time to open the airway. DO NOT Look, Listen and Feel for breathing.
Abnormal breathing is frequently mistaken as presence of respirations.
Cardiac arrest victims may present or initially have a short period of seizure like activity or agonal gasps-this should not be identified as normal breathing.

13. Steps for Adult CPR for the Healthcare Provider (HCP)
2. Call for help and the defibrillator- do not leave the patient.
Note the time for recording on the code blue documentation form.
If there is no telephone in the immediate area and no one could hear your call for help, you should leave the patient briefly to call the Code Blue.
In any of the Kaleida Hospitals, direct helpers to call 7911 and inform the operator of your location and Code Blue.
The Code Cart with defibrillator is essential.

14. Steps for Adult CPR for the Healthcare Provider (HCP)
3.Check Pulse
Use easily accessible central pulse point-example carotid.
Assess for no longer than 10 seconds for a definite pulse-if unsure, proceed as if pulse not present.

15. Steps for Adult CPR for the Healthcare Provider (HCP)
4.Begin Chest Compressions to maintain forward blood flow
Lower half of sternum
Push Hard & Fast
At least 2 inches in depth
At least a rate of 100 per minute
Allow full re-expansion (or recoil) of chest wall between compressions
Avoid the zyphiod process and ribs
Place bed board under patient to facilitate chest compressions.

16. Steps for Adult CPR for the Healthcare Provider (HCP)
Compressions - why complete re-expansion of the chest?
Maintaining pressure on the chest and heart during compressions can cause:
Increased intrathoracic pressure
Decreased venous return
Decreased coronary and cerebral perfusion
Decreased blood flow

17. Steps for Adult CPR for the Healthcare Provider (HCP)
5. Following the first 30 chest compressions, begin rescue breathing. Deliver 2 breaths.
Use head tilt-chin lift position to maintain open airway position - do NOT pause to check for breathing!
If the chest does not rise with ventilation attempt, reposition the head, make a better seal and try again.
HCP in employment situation should always have available and use a barrier device to deliver mouth to mouth ventilations.
Deliver only enough air to cause a visible chest rise - more is NOT better.
Deliver each breath over only 1 second.

18. Steps for Adult CPR for the Healthcare Provider (HCP)
Continue CPR in cycles of 30 compressions to 2 ventilations (for 1 or 2 rescuers).
Pause no more often than every 5 cycles or 2 minutes for a 5 second pulse check.

19. Ventilations
Ventilation when there is an advanced airway (example Endotracheal tube) in place:
Do not interrupt compressions-Interpose one breath every 6-8 seconds for 8-10 breaths per minute.
For an apneic adult victim with a pulse, give only one breath every 5-6 seconds or breaths/minute.

20. Using a bag-mask device
Not recommended for 1 rescuer CPR.
Ideally used with 2 rescuers
performing the ventilation.
Until the victim is intubated, requires maintenance of the head tilt chin lift position.
Can be performed without supplemental oxygen.
Use supplemental oxygen as soon as available to administer a flow rate of at least liters per minute.

21. Steps for Child CPR for the Healthcare Provider (HCP)
For the purposes of CPR resuscitation - the guidelines identify a child as
1 year of age to puberty

22. Steps for Child CPR for the Healthcare Provider (HCP)
Assess unresponsiveness and overview for absence of normal breathing.
Call for help and a defibrillator.
Check pulse.
If no adequate pulse, begin CPR compressions.
After 30 compressions, open airway and give 2 breaths.
Continue CPR at a ratio of 30 compressions to 2 breaths.
(15 compressions to 2 breaths for 2 HCP)
As soon as a defibrillator is available, assess for need to defibrillate.

23. Steps for Child CPR for the Healthcare Provider (HCP)
1. Assess unresponsiveness
Tap victim, shout out, “Are you ok?” while simultaneously looking for any signs of normal breathing.
2. Call for help - in any of the Kaleida Hospitals, call 7911 to initiate a Code Blue.

24. Steps for Child CPR for the Healthcare Provider (HCP)
3. Check Pulse
Use easily accessible central pulse point-example carotid
Assess for no longer than 10 seconds for a definite pulse.
In a child-a pulse must be 60 beats per minute or more to be considered adequate-
With a less than 60 and signs of poor perfusion such as pallor, mottling or cyanosis - chest compressions should be initiated

25. Steps for Child CPR for the Healthcare Provider (HCP)
4. Begin Chest Compressions to maintain forward blood flow
Lower half of sternum
Push Hard & Fast
At one third the dimension of the chest or least 2 inches in depth
At least a rate of 100 per minute
Allow full re-expansion (or recoil) of chest wall between compressions
Do not compress the zyphiod process or ribs
Use one or two hands

26. Steps for Child CPR for the Healthcare Provider (HCP)
5. Following the first 30 chest compressions, begin rescue breathing.
Use head tilt-chin lift position to maintain open airway position.
Breathing-DO NOT take the time to open the airway.
DO NOT Look, Listen and Feel for breathing.
HCP in employment situation should always have available and use a barrier device to deliver mouth to mouth ventilations.
Deliver only enough air to cause a visible chest rise-more is NOT better.
Deliver each breath over only 1 second.

27. Steps for Child CPR for the Healthcare Provider (HCP)
Continue CPR in cycles of 30 compressions to 2 ventilations (15 compressions to 2 ventilations for 2 HCP rescuers).
If a code response has not been initiated because you are alone, call a code blue after the first 2 minute cycle of CPR.
Pause no more often than every 5 cycles or 2 minutes for a 5 second pulse check.

28. Ventilation - Child Ventilation when there is an advanced airway
(example Endotracheal tube) in place
Do not interrupt compressions-Interpose one breath every 6-8 seconds for 8-10 breaths per minute
For an apneic child victim with an adequate pulse, give only one breath every 3-5 seconds or breaths/minute

29. Foreign Body Airway Obstruction (FBAO)
Management is the same for adults and children
Definition=Sudden onset of respiratory distress with coughing, gagging, stridor and or wheezing
Mild=can cough forcefully or make some sounds
Severe=victim unable to make sounds

30. FBAO - Conscious Adult or Child
Perform Abdominal thrusts until object is expelled or victim unresponsive-
Use inward, upward thrusts just above the umbilicus.
For the adult victim, chest thrusts may be used for obese patients and females in the later stages of pregnancy.
If 2 rescuers are present - call for help immediately (7911).

31. FBAO- Unconscious Adult or Child
For a choking adult or child victim who becomes unresponsive:
Call for help (if not done already)
Start CPR chest compressions (do not pause for pulse or breathing check).
After 30 compressions, open the airway and look for a foreign object. If a foreign object is seen - remove it. NO blind finger sweeps!
Attempt 2 breaths.
Continue with cycles of compressions and breaths.

32. Code Blue Procedures My patient is coding and I am blue
I’m not quite sure what I need to do……

33. Code Blue Procedures Maintaining CPR is the first Priority!
Secondly, the cardiac rhythm needs to be assessed to determine if defibrillation is needed.

34. Initiate Cardiac Monitoring
In a Critical care or telemetry patient; assure leads are connected and verify rhythm.
In an unmonitored patient, attach defibrillator/cardiac monitor.
Make sure electrodes or multifunction pads are placed in the appropriate location on the chest and attached to the corresponding lead wire.
The Defibrillator should be set to “monitor” and “lead II”

35. Defibrillation
Defibrillation is most effective when done as soon as possible.
Assure safety of self and other staff during defibrillation by proper use of conductive gel (if paddles are used) and clearing personnel away from the victim during defibrillation attempts.
Assure that oxygen tubing is not directed to chest. Document time and energy level used on Code Blue Worksheet.

36. Communication
Staff at bedside need to clearly communicate assessments and interventions to the team leader
and recorder.
Ex “1 milligram of epinephrine is given”
“ The IV line infiltrated”
Offer pertinent information to Code Team-Example patient is diabetic or had a seizure.

37. Support Activities during a Code Blue
Make sure the IV line is patent –using pump or regular drip tubing, attach one liter of normal saline to keep the line open
Be prepared to suction

38. Medication Administration during a Code Blue
Verbally repeat back medication and dose to prescriber before administering.
All bolus medications administered should be followed by a flush.
Medication Infusions are not used when a patient is pulseless.
Once infusions are initiated, an IV pump with drug library should be used.
Retain medication packaging and enter all medications administered into the Electronic Medication system during or after the code.

39. Documentation during a Code Blue

40. Documentation during a Code Blue
The Code Blue Worksheet is the official record of all assessments and interventions during a code-it is a legal document and a permanent part of the medical record.
The original of the form is placed into the chart-the pink copy goes to the Code Committee for review.
Any code team member( RN, Pharmacist, NP, PA) may be assigned as recorder.
A single time piece should be used to assure accuracy in recording the event.

41. Infection Control During A Code Blue
All code responders must implement /maintain standard precautions when providing care to a coding patient.
All code carts have a supply of personnel protective equipment (gowns, masks, eye shields) for the very first responders.
Note: In most Code Blue situations a central line is not necessary. Insertion under unsterile conditions should be avoided as increases in infection rates may occur.

42. Code Cart Equipment
The same equipment should be available at codes in all Kaleida Buildings (see the following pages).
Code Carts vary between Kaleida sites , so equipment may be stocked differently.
Example-some adult Kaleida sites have a separate accessory box for pediatric code equipment.
See KH policy CL029-Appendix A for a complete and specific listing.

43. Code Cart Equipment Syringes and needles Angio caths
Predrawn saline flushes
Blood draw equipment
Blood Gas kits
Intracardiac needle
Alcohol prep pads/Tape
Nasogastric tube with lubricant

44. Code Cart Equipment Adult resuscitation bag with mask and tubing
Oxygen mask/tubing/flowmeter
Suction catheters and saline
Suction machine(type varies by site/location)
Yankauer suction Magill forceps
Intubation equipment (laryngoscope and blades, ET tubes, stylet, oral airways, Anesthetic spray, colormetric exhaled CO2 device)
Cuffed Trach (Size 7) with sterile hemostat
Infant face mask (for interim use when ventilating patients with metal trach tube or laryngectomy stoma)

45. Code Cart Equipment Sterile Gloves Tape Sterile Gauze
IV solution and tubing & stopcocks
Cardiac monitoring electrodes
Recording paper for defibrillator
Defibrillation gel

46. Code Cart Equipment - Pediatric
Intraosseus needles
Small gauge angiocaths, butterfly needles,
CV kits
Pediatric size oxygen masks/cannula
Pediatric pulse oximetry probes
Pediatric sized suction catheters, airways
Pediatric sized resuscitation bags
Pediatric sized intubation equipment
Feeding tube, NG tube

47. Code Blue Equipment Readiness
Each Unit or Department is required to complete daily check of their Code Cart each day the department is open.
The daily check includes:

48. Post Code Equipment Security
When stocked and ready for use:
the outside of the code cart will be locked using a numbered green lock.
the medication box (locked inside the code cart) will be locked with a red lock.
Following the code , the cart AND medication box must be relocked.
obtain blue locks from the outside of the code cart medication box.
use one blue lock to secure the med box –place the locked medication box on top of the code cart.
use the other blue lock(s) to assure that the outside of the cart is locked.
Initial on the code blue worksheet that the relocking has been done.
Remember…
Red and Green = Ready and Clean
Blue Lock =Restock