Download 402-420-Responding-to-Code1

Responding to a Code
Keith Rischer RN, MA, CEN
5/25/2017
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Today’s Objectives…
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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…
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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
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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
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Airway
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Breathing
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Open airway, look, listen, and feel for breathing.
If not breathing, slowly give 2 rescue breaths.
Circulation
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Check pulse. If pulseless, begin chest compressions at 100/min
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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
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Managing Airway
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Primary Survey continued priorities
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Airway
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Breathing
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Ventilate with 100% O2. Confirm airway placement (exam,
ETCO2, and SpO2). Remember, no metabolism/circulation = no
blue blood to lungs = no ETCO2.
Circulation
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Establish and secure an airway device (ETT, LMA, COPA,
Combitube, etc.).
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
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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
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Patho
Bi-phasic
Nursing Responsibilities
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ACLS Rhythms: Most Common
VT-VF
 Asystole
 Tachycardia
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AFib w/RVR (symptomatic)
SVT
Bradycardia (symptomatic)
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Ventricular Tachycardia
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Ventricular Fibrillation/Asytole
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Don’t Let Him Go…
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VT-VF Arrest
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Shock 360J*
Epinephrine 1 mg IV q3-5 min.
Vasopressin 40 U IV
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Shock 360J*
Amiodarone 300mg IV push.
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May repeat once at 150mg in
3-5 min
Shock 360J*
Lidocaine 1.0-1.5 mg/kg IV q
3-5 min
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one time dose (wait 5-10
minutes before starting epi).
max 3 mg/kg
Shock 360J*
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Asytole
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Consider bicarb, pacing early
Transcutaneous Pacing (TCP)
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Epinephrine 1 mg IV q3-5 min
Atropine 1 mg IV q3-5 min
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Not shown to improve survival
If tried, try EARLY
Max 0.04 mg/kg
Consider possible causes
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Hypoxia
Hyperkalemia
Hypothermia
Drug overdose (e.g., tricyclics)
Myocardial Infarction
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Atrial Fibrillation
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Rate control:
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Cardizem (Diltiazem) 20-25mg
IV bolus
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beta-blocker
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Cardizem gtt 5-15 mg/hr
Cardiovert:
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If onset < 48 hours
cardioversion OR Cardizem
If onset > 48 hours: avoid
drugs that may cardiovert (e.g.
amiodarone)
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Delayed Cardioversion:
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anticoagulate adequately x 1
week, then cardioversion
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Bradycardia
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If AV block:
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Atropine
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Use transcutaneous pacing (TCP)
immediately if sx severe
Dopamine
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0.5-1.0 mg IV push q 3-5 min
max 0.04 mg/kg
Pacing
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2nd degree (type 2) or 3rd degree:
standby TCP, prepare for
transvenous pacing
slow wide complex escape
rhythm: Do NOT give lidocaine.
5-20 µg/kg/min
Epinephrine
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2-10 µg/min
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Post Code Concerns
Autopsy
 Family presence
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Survival
 Saving
life is priority regardless
 Seen in less experienced nurses, MD’s
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Holistic
 Save
life
 Addressing needs of the family
 Seen in more experienced providers and those
who were sensitive to their own spirituality
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Code Case Study
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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
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PHYSICAL EXAM:
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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: Distant
SKIN: 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
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