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

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Responding to a Code

Keith Rischer RN, MA, CEN

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Today’s 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 patient’s assigned nurse in a code

situation. Practice responding to a code including recording on a code

record. State actions for using a portable defibrillator.

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Today’s 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

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Legal & Ethical Issues

DNR order No DNR order Advanced directives Organ donation Code review Ethic Committee

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Cardiac Arrest=Teamwork

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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

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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 -

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Managing Airway

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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.

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ACLS Medications

Adenosine Atropine sulfate Amiodarone Cardizem (diltiazem) Dopamine HCL Dobutamine hydrochloride Epinephrine HCL (Adrenalin)

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ACLS Medications

Levophed (Norepinephrine) Lidocaine HCL Magnesium Nitroglycerine (NTG) Oxygen Sodium Bicarbonaate Vasopressin

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Recording

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Defibrillation

Patho Bi-phasic Nursing Responsibilities

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ACLS Rhythms: Most Common

VT-VF Asystole Tachycardia

• AFib w/RVR (symptomatic)• SVT

Bradycardia (symptomatic)

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Ventricular Tachycardia

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Ventricular Fibrillation/AsytoleVentricular Fibrillation/Asytole

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Don’t Let Him Go…

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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 1.0-1.5 mg/kg IV q

3-5 min • max 3 mg/kg

Shock 360J*

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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

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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

• If onset > 48 hours: avoid drugs that may cardiovert (e.g. amiodarone)

• Delayed Cardioversion: anticoagulate adequately x 1

week, then cardioversion

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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 • 0.5-1.0 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

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Post Code Concerns

Autopsy Family presence

• SurvivalSaving life is priority regardlessSeen in less experienced nurses, MD’s

• HolisticSave lifeAddressing needs of the familySeen in more experienced providers and those

who were sensitive to their own spirituality

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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 2117.

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 2219. 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.

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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: DistantSKIN: Comments: Unremarkable. Abdomen soft but distended. NEUROLOGIC: Unconscious. Unresponsive. MUSCULOSKELETAL: No Deformity

EKG:Heart Rate: 109 BPM-Atrial fibrillation with rapid ventricular response

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Labs