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Aultman College of Nursing and Health Sciences
Nursing 203
METI Experience: Code Blue – Faculty
Goals:
 Discuss appropriate health history questions.
 Set priorities for specific presenting symptoms.
 Interpret the EKG findings throughout the scenario.
 Implement appropriate interventions for the abnormal assessment data.
 Perform a variety of roles during a code blue situation.
 Manage the client’s significant others during a critical situation.
 Evaluate own performance during the scenario.
Plan:
30 minutes
30 minutes
30 minutes
Contents of Code Cart
Review Code Cart
1. Medications and use – EPI, Atropine, Amio,
and Defibrillator
Lido, Sodium Bicarb, Narcan, Vasopressin,
Adenosine, Magnesium, Calcium Chloride
2. Code Blue Documentation Sheet
3. Intubation Tray (briefly)
4. Defibrillator (safe use), hands free, how to
shock
5. AED
6. Pacer
7. Ambu Bag
8. CPR board
Review various
Cardiac Rhythms
cardiac rhythms on
1. NSR, SB, ST, SVT, Afib, Aflutter, VTach
simulator
(with and without pulse), V fib, PEA,
Asystole
2. Students to identify each and explain
possible treatment options
4-5 students with
Simulation lab has roles of staff nurse, charge nurse,
METI
MICU/SICU nurse, respiratory, recorder
Have extra students observe
Clinical instructor can play role of ACLS
coordinator/resident doctor
Both groups
Questions located under debriefing. Allow students
to discuss feelings they had during code openly.
How will they run the next code more efficiently?
10-15
minutes
debrief
students on
code blue
30 minutes
Switch the above
another code groups
10/14 LB, 1/07kg
1
Remaining
time
Medications:
Name
Epinephrine
Vasopressin
Allow students to practice skills, retry problem
areas, and review sections they have questions about.
Dose
1mg IVP bolus q3-5m
Magnesium Sulfate
40u IVP bolus, once
(in place of 1st/2nd dose of
epinephrine)
1mg IVP may repeat q3-5m
1st dose – 6mg IVP
2nd dose – 12 mg IVP
3rd dose – 12 mg IVP
Each dose followed by a 20
ml NS flush
1mEq/kg IVP bolus
(give after 10 minutes of
cardiac arrest for metabolic
acidosis)
0.02-0.2mg q2-3min until
response obtained
(may need to repeat in 1-2h
due to half-life)
1st dose - 300 mg IVP
2nd dose – 150 mg IVP
Need a maintenance drip if
converts rhythm
1-1.5mg/kg IVP q3-5
minutes
Need a maintenance drip if
converts rhythm
1-2g/100ml D5W over 2m
Calcium Chloride
2-4 mg/kg IVP
Atropine
Adenosine
Sodium Bicarbonate
Narcan
Amiodorone
Lidocaine
Cardiac Rhythm Treatments:
Rhythm
Normal Sinus Rhythm (NSR)
Sinus Bradycardia (SB)
10/14 LB, 1/07kg
Use
Asystole, Vfib, pulseless
Vtach, PEA
(Different dose & Route for
anaphylaxis)
VF, asystole, PEA,
pulseless Vtach
Symptomatic bradycardia
SVT
Metabolic acidosis
associated with cardiac
arrest
Opioid overdose
Vfib or pulseless Vtach
Vfib or pulseless Vtach
VFib or Vtach (torsades de
pointes)
Treat hypocalcemia or
hyperkalemia
Treatment
No treatment – continue to monitor patient
Determine cause – may be normal (runners,
bearing down)
*If symptomatic – Atropine 1mg IVP
Pacer
2
Determine cause and remove – Anxiety,
pain, exercise
*Betablockers
Have patient bear down
Adenosine 6mg/12mg/12mg
Cardioversion
Betablocker, calcium channel blocker,
digoxin
Cardioversion
Need long term anticoagulant to prevent
blood clots
Amiodorone or Lidocaine
Cardioversion
Defibrillation, CPR, Amiodarone or
Lidocaine, Epinephrine
Defibrillation, CPR, Amiodarone or
Lidocaine, Epinephrine
CPR, epinephrine
Determine rhythm does not have pulse
CPR, epinephrine
Sinus Tachycardia (ST)
SupraVentricular Tachycardia (SVT)
Atrial Fibrillation (Afib) Atrial Flutter
Ventricular Tachycardia (VT) with a pulse
Ventricular Tachycardia (VT) pulseless
Ventricular Fibrillation (VF)
Asystole
PEA
Scenario Data:
Dr. Gerber admitted Fred Boron, a 79-year-old yesterday to Memorial 4 East with the
diagnosis of pneumonia. Fred has a history of COPD, MI, HTN and a CABG x2. Fred’s
cardiologists is Dr. Friedler and his pulmonologist is Dr. Mills.
Home medications include:
o Lopressor 25mg twice a day
o Lipitor 20mg at bedtime
o Baby ASA 81mg once a day
o Prednisone 20mg twice a day
o Albuterol 2 puffs four times a day and as needed
o Ventolin nebulizer every four hours
Midnight Nurse report:
4738 has stable vital signs, is breathing okay, has an IV running of NS. He has an
antibiotic ordered, but it has not come up from pharmacy (I didn’t have time to check on
it.). He has been a PIA… on the light all night.
Additional information if the students ask, if not they are on their own:
On admission:
 T – 100.8 F
 BP 150/92
 P – 110 (Sinus tach)
 R – 24
Most recent vital signs:
10/14 LB, 1/07kg
3
 T – 101 F
 BP – 146/88
 P – 120 (ST)
 R – 24-26
Code Status: Not addressed – no advanced directive on chart
Oxygen: 2L/NC – pulse ox 89 – 90%
Assessment:
 alert & oriented, restless
 Skin pink, diaphoretic
 Breath sounds clear but diminished
 Productive cough – coughs sputum into tissue
 Foley catheter drained 200ml dark amber
 IV of NS at 50ml/hr – infiltrated and didn’t restart it (didn’t have time)
 Tequin 400mg every 8 hours – needs initiated
 Last breathing treatment 0400
 Activity is up but gets SOB when walking
 Has BMP and ABG’s ordered this AM but not back yet
 Yesterdays labs in the chart
Sequence of Events:
#1 Baseline
Assessment
Patient Status
Desired Actions
o Ask
pertinent
health
history
questions
o Head to toe
assessment
o Start IV
o Initiate
antibiotic
after
checking for
allergies
o Assess pulse
ox
o Assess
oxygen for
correct
dosage
o Look for
AM labs
(not back
yet)
Truck Driver with
Code blue Pulseless
VT Overlay
10/14 LB, 1/07kg
4
Transition
Vital signs:
T – 101F
P – 124
R – 28
O2 sat. – 85%
Monitor – sinus tach
(Monitor leads pulled
off can the students
reapply correctly)
Lung sounds –
wheezes
SOB noted while at
rest and talking
C/O being tired
Cough persists with
productive sputum of
greenish yellow
Oxygen @ 2L/NC
(If the students
would like to
increase the oxygen
did they consider the
patient has a history
o Notify the
physician as
needed
o Assess
monitor for
vital signs
and EKG
rhythm
o Assess
respers
o O2 Sat
o Focused
assessment
o AM labs
back –
compare the
with
previous
labs
o call the
physician to
relay
assessment
data and labs
#2 Rhythm change
10/14 LB, 1/07kg
5
of COPD)
- Note how long it
takes for the student
to see the rhythm
change
- Vital signs
BP – 149/108
P – 123
R – 27
T – 101.2F
- Pulse ox – 86%
- Skin slightly
cyanotic
- should note the
potassium level is 3.3
- Notify the
physician for orders
MD. orders:
1. Routine
emergency
treat orders
2. Give an
additional
breathing
treatment
now
3. Tylenol
650mg po
now and
every 6 hours
for temp >
101F
4. Lidocaine
75mg IV
push stat
5. Add 20mEq
KCL to
current IV
fluid (need to
know if have
enough fluid
left in bag to
add this
amount of
KCL – what
are the KCL
rules)
6. BMP in A.M.
Telephone
order read
back
should be
used
Allow
students
to
complete
2 ,4 ,5
before
starting
into the
code
section
o Note the
- Student should note
patient is not pulseless VT
responding
- Call code blue
o Assess
(know number or
monitor
push the blue button)
screen (VT) - Retrieve the code
o Start CPR
cart
o Call the
- Start CPR and
code
attach the AED while
o Initiate
waiting for the code
ACLS
team to arrive. (Who
protocol
comes – RN from 4
o Handle
east, RN MICU,
family
Respiratory therapy,
members if
Medical resident as
present
assigned, Unit or
Division Director,
RN/LPN caring for
the patient,
Anesthesia as
needed)
- Follow ACLS
protocol
1. Give oxygen &
Attach AED
2. determine if a
shockable ryhthm
#3 Pulseless VTach
10/14 LB, 1/07kg
6
3. If (VT or VF)
4. Give one shock
biphasic 120 – 200j
Immediately
Resume CPR – 5
cycles (don’t stop
CPR only for shock)
5. check rhythm – if
shockable them give
one more shock
6. Resume CPR (5
cycles)
Epinephine 1mg IV
every 3-5 minutes
throughout Code OR
Vasopressin 40units
IV to replace the first
2 doses of epi
7. check rhythm
8.if shockable Shock
Resume CPR .
Consider
Antiarrhythmics –
amiodarone 300mg
IV x1, then an
additional 150mg x1
OR lidocaine 1 –
1.5mg/kg x1 then
0.5mg - .75mg
3doses max or
(3mg/kg)
Consider Magnesium
loading dose 1-2g IV
for torsades de
pointes
After 5 cycles of
CPR return to
number 5
#4 Course V – Fib
10/14 LB, 1/07kg
o Assess
monitor and
note change
o Continue
ACLS
protocol
7
- monitor changes to
V-Fib
- Same protocol as
above
o Assess
Physician orders:
monitor &
1. Lidocaine @
note changes
2mg/min
o Initiate MD
2. If patient
orders
allergic to
o Call for bed
Lidocaine
in CCU
give
o Prepare for
Bretylium
Transport
3. Transfer to
CCU
- Read back orders
- Set up lidocaine
- move to the CCU
#5 ST with 25%
PVC’s
Debriefing:
1. If unable to insert IV lines what are your options?
a. central line insert
b. medication via endotracheal tube
2. When would atropine be given?
a. for symptomatic bradycardia ONLY
3. When would bicarbonate be given?
a. If metabolic acidosis
4. How would you transport patient to ICU? What do you need?
5. What were your thoughts or feelings during the CODE? (anxious, nervous,
comfortable with interventions etc.)?
6. Did the group work as a team to support one another and enable best outcome for
patient?
Was communication clear and professional?
7.
What symptoms did the patient present that alerted you to a possible code situation? Is
there any actions the nurse could have taken to prevent the code?
10/14 LB, 1/07kg
8