1. WCHOB 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: 1. Adult one and two rescuer CPR 2. Adult and Child Foreign Body Airway Obstruction (FBAO) Management 3. Child one and two rescuer CPR

3. A B CC A B 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 2007. 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: 1. Evidence –based 2. Collaborative 3. International 4. 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 performed 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 did the research show?  Ventilation-More is NOT better! M ultiple 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, using lower respiratory rates/volumes will maintain an adequate perfusion/ventilation ratio.

8. So, what did the research show?  Ventilation-More is NOT better!  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.

9. So, what else did the research say?  “Hands Only CPR”  “Hands Only CPR” is performing compression only CPR. This is intended for untrained or minimally trained bystanders who come upon the victim of a sudden, witnessed cardiac arrest.  “Hands only CPR”  “Hands only CPR” is easier for non trained bystanders to remember. “Hands Only CPR” “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

10. 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 1. C - compressions 2. A - airway 3. B - breathing

11. Steps for Adult CPR for the Healthcare Provider (HCP) 1. Assess for unresponsiveness and absence of normal breathing. 2. Call for help and a defibrillator. 3. Check pulse. 4. If no pulse, begin CPR compressions. 5. After 30 compressions, open airway and give 2 breaths. 6. Continue CPR at a ratio of 30 compressions to 2 breaths. 7. As soon as a defibrillator is available, assess for need to defibrillate.

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

13. Steps for Adult CPR for the Healthcare Provider (HCP)  Assess unresponsiveness and observe for normal breathing - 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!

14. Steps for Adult CPR for the Healthcare Provider (HCP) 2. 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 would hear your call for help, you should leave the patient briefly to call the Code Blue. 7911 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.

15. Steps for Adult CPR for the Healthcare Provider (HCP) 3. 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.

16. Steps for Adult CPR for the Healthcare Provider (HCP) 4 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 xiphoid process and ribs. Place bed board under patient to facilitate chest compressions.

17. 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

18. Steps for Adult CPR for the Healthcare Provider (HCP) 5. 5. Following the first 30 chest compressions, 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.

19. 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.

20. Ventilations  Ventilation when there is an advanced airway (i.e. Endotracheal tube) in place: Do not stop/interrupt compressions - give 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 10 - 12 breaths/minute.

21. 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 10 - 12 liters per minute.

22. 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

23. Steps for Child CPR for the Healthcare Provider (HCP)  Assess unresponsiveness and 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.

24. 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.

25. 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. 60 In a child-a pulse must be 60 beats per minute or more to be considered adequate. With a pulse less than 60 and signs of poor perfusion such as pallor, mottling or cyanosis - chest compressions should be initiated.

26. 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 1/3 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 xiphoid process or ribs. Use one or two hands.

27. Steps for Child CPR for the Healthcare Provider (HCP) 5. Following the first 30 chest compressions, give 2 breaths. Use head tilt-chin lift position to maintain open airway position. Breathing- 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.

28. Steps for Child CPR for the Healthcare Provider (HCP) (15 compressions to 2 ventilations for 2 HCP rescuers). 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. 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.

29. Ventilation - Child  Ventilation when there is an advanced airway (i.e. Endotracheal tube) in place.  Do not interrupt compressions - give 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 12 - 20 breaths/minute.

30. 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.

31. 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).

32. FBAO- Unconscious Adult or Child For a choking adult or child victim who becomes unresponsive: Call for help (if not done already) 1. Start CPR chest compressions (do not pause for pulse or breathing check). 2. After 30 compressions, open the airway and look for a foreign object. If a foreign object is seen-remove it. NO blind finger sweeps! 3. Attempt 2 breaths. 4. Continue with cycles of compressions and breaths.

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

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

35. Initiate Cardiac Monitoring  In Critical Care assure leads are connected and verify rhythm.  In an unmonitored patient, attach defibrillator. 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”

36. 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.

37. 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- i.e. patient is diabetic or had a seizure.

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

39. 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 drips are not used when a patient is pulseless.

40. Medication Administration during a Code Blue  Once infusions are initiated, an IV pump with drug library must be used.  Retain medication packaging and enter all medications administered into the electronic medication system during or after the code.

41. Documentation during a Code Blue

42.  The Code 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, NP, PA) may be assigned as recorder.  A single time piece should be used to assure accuracy in recording the event.

43. Infection Control during a Code Blue  All code responders must implement /maintain standard precautions when providing care to a coding patient.  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.

44. Code Cart Equipment 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.

45. WCHOB Adult/Pediatric Crash Cart Equipment

46. Drawer #1

47. WCHOB Adult/Pediatric Crash Cart Equipment  Drawer #2

48. WCHOB Adult/Pediatric Crash Cart Equipment  Drawer #3

49. WCHOB Adult/Pediatric Crash Cart Equipment  Drawer #4

50. WCHOB Adult/Pediatric Crash Cart Equipment  Drawer #5

51. WCHOB Adult/Pediatric Crash Cart Equipment  Drawer #6

52. 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:

53. 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