Code Blue

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Code Blue

• Becca Maddox
• NURS 2205
• Spring 2002

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Code Blue

• Patient is either in respiratory or cardiac
  trouble
• Respiratory arrest quits or near quits
  breathing
• Cardiac arrest heart is in a rhythm that causes
  the cessation of effective circulation

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Respiratory Arrest

• Quits breathing
• Start mouth to mouth if airway is open
• Treat the cause - inc O2 delivery, med OD, inc
  secretions, diuretics, breathing tx
• If long term treatment is needed, may need to
  intubate and possibly ventilate until treatments
  are effective
• Monitor or move to a critical care unit

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Cardiac Arrest

• Identify no pulse
• Identify rhythm treat rhythm
• Then treat cause

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What to Do

• Call the code
• Make sure patient is on a hard surface
• Start BLS
• Help arrives with the Code Cart
• Place on monitor
• Quick look with paddles and identify rhythm or
  initiate AED protocol
• Code Team arrives
• Follow ACLS protocols
• Record events

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Roles of Code Members

• respiratory therapy - establish airway and
  breathing (O2, ambu, intubate)
• nurse - places on monitor, shocks, CPR
• nurse - starts IVs, pushes meds
• nurse - documents
• MD - directs code
• crowd control

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Things You Must Know About Your Patient

• Past Medical History
• Current Diagnosis
• Electrolytes - especially K
• Any significant lab values
• Meds given that day
• Any procedures that day
• What to do if you just got to work and have not
  made rounds?

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What is on a Code 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

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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
• Monitor that talk to you (AED)

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Mechanical vs Chemical Codes

• Mechanical - only CPR. Pt may be very specific
  about what they what done ie. intubation vs ambu
  bag
• Chemical - only drugs with no CPR, no chest
  compressions

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CODE RHYTHMS

• Asystole
• VT
• VFIB
• PEA Treat cause
• Heart blocks that have ceased to have adequate CO

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If Not a Shockable Rhythm

• Continue CPR
• Establish ventilation - ambu or intubate
• IVs- large bore and near to the heart
• Drugs

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Defibrillation vs Cardioversion

• Defibrillation Joules delivered at anytime of
  the cardiac cycle
• Depolarizes all the myocardial cells at once in
  the hope to reorganize and allow the SA node to
  take over the role of pacemaker

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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, IVs drugs
• Subsequent shocks will be 360j

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Cardioversion

• Delivers joules to terminate a dysrhythmia
• Must have a QRS complex - which means the patient
  has a pulse
• 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

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Cardioversion

• Sedate the patient (IV conscious sedation)
• Turn on synchronized knob on monitor
• Protect airway and breathing
• Rhythms that can be cardioverted AFib,
  Aflutter, VT with a pulse, SVT

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Problems

• Skinny vs heavy patients
• Cant touch metal
• Conductive gel or pads
• Must place gel or pads around the heart
• Can burn patient
• If awake, patient does feel pain
• Can produce a worse rhythm

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Emergency Drugs

• 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
  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)

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• 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

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• Vasopressin
• 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)

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• Lidocaine - antiarrhythmic effect, decreases
  ventricular excitability without depressing the
  force of contraction, depresses phase 4 of the
  cell cycle
• Used for VT 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

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• Dopamine - inotropic, cardiac stimulant,
  vasopressor
• Second drug for symptomatic bradycardia (after
  atropine)
• Use for hypotension (systolic BP lt 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)

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• 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

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• 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 gt 50
• Total dose of 17 mg/kg is given
• Maintenance infusion of 1-4mg/min
• Used if Lidocaine doesnt work

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• 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 cummulative 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)

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• 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

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• 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

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PEDIATRIC CODES

• Heart wrenching
• Same procedure followed as adults
• Drug doses are by kg
• Think respiratory not cardiac

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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

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Asystole

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

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PEA

• Epinephrine 1mg Q3-5 mins
• Treat cause

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Heart Blocks or Symptomatic Bradycardia

• Atropine 1 mg (up to 3 mg)
• Isuprel
• Pacemaker

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Back to the Code

• Remember the patients down time - if you save
  the heart what about the patients brain
• Remember what you are saying around patient and
  family members
• Once code is over how do you feel
• Comforting the family

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Codes

• How to document code procedures
• Rhythm strips
• Mortality rate
• Post mortem care
• Organ procurement