Code Blue

To give a brief description of Code Blue

1. WORKSHOP ON CODE BLUE Continuing Nursing Education Program

2. INTRODUCTION TO CODE BLUE Angham Yahia Majrashi Nurse Educator

3. What is CODE BLUE? A message announced over a hospital’s public address system, indicating that a cardiac arrest or respiratory arrest requiring CPR is in progress; to be “coded” is to undergo CPR. The King Khalid Hospital code to be used by all staff to summon a trained team of medical personnel to undertake cardiopulmonary resuscitation.

4. Criteria for CODE BLUE? RRT CODE BLUE The patient is still responsive but there is a sudden deterioration in patient’s status Respiratory distress O2 saturation, Blood pressure, pulse is gradually dropping/below normal The patient is unresponsive 2. No respiration 3. No pulse What is the difference between Rapid Response Team (RRT) from Code Blue ?

5. What is cardiopulmonary arrest? It is the sudden loss of cardiac function, when the heart abruptly stops beating. Unless resuscitative efforts are begun immediately, cardiac arrest leads to death within a few minutes.

6. Video Clips Presentation #1

7. CODE BLUE TEAM Pamela Joy Bocala - Blanco CNEP Coordinator/Nurse Educator

8. What do you mean by CODE BLUE TEAM? Team  of providers sometimes called a “ code team” being required to rush to the specific location and begin immediate resuscitative efforts   in an emergency situation announced in a hospital or institution in which a patient is in cardiopulmonary arrest. TEAMWORK

9. The F irst Responder is not actually a member of a team but is the person who identifies and confirms cardiopulmonary arrest.

10. Who are the members of Code Blue Team? 1. Medical Specialist O n Call/ ER Specialist for ER Code Assume overall responsibility or the direction of activities. Communicate with event manager/recorder Issues all medical and resuscitative orders including resuscitation medications. Termination of Code Blue and final disposition of the patient. Communicate with patient’s family along with Nursing Supervisor at the end of the code. Complete documentation for medical records. Team Leader

11. Who are the members of Code Blue Team? 2. ICU Resident on Duty Manage the airway as directed by the team leader Perform bag-mask ventilation Prepare and assist with intubation Confirm ETT placement Secure ETT Complete documentation in the medical record Airway

12. Who are the members of Code Blue Team? 3. Anesthesia Resident Manage the airway if ICU resident is delayed Respond to instructions from Team Leader for changing roles Complete documentation in medical records Specialist

13. Who are the members of Code Blue Team? 4 . Resident on Duty in charge of the patient Perform an continue chest compression as instructed by team leader. Hand over to Compressor 2 when tired. Complete documentation in medical records Compressor 1

14. Who are the members of Code Blue Team? 5. Medical Resident on Duty Relieves Compressor 1 when tired Complete documentation in the medical record. Compressor 2

15. Who are the members of Code Blue Team? 6. Nursing Supervisor on Duty Help rapid transport of blood samples to laboratory Manage crowd control with security Communicate with the family Notify patient Affairs, Social Worker, Interpreter Attend to pastoral needs of the patient Coordinate patient transfer and placement with team leader. Communicator

16. Who are the members of Code Blue Team? 7 . ICU Nurse Established vascular access and ensure patency Administer IV medication as per verbal order of team leader Assist airway and intubation Insert NGT as indicated Vascular Access

17. Who are the members of Code Blue Team? 8. Ward Shift in Charge Nurse Ensure providers assume pre-assigned roles and that the team knows who is responsible for what role Assign RN1 as recorder Assign RN2 to bring equipment needed Once roles established, ensure management of the rest remaining work in the ward/unit. Ensure crowd control with the help of security with in the room/ward. Notify the switch board if code is over. Event Manager

18. Who are the members of Code Blue Team? 9. Bedside Nurse (RN 1) Provide history using SBAR communication Stay at bedside Ensure availability of workplace Continue as the recorder Maintain accurate written record of the timings of all intervention. Recorder

19. Who are the members of Code Blue Team? 10. Ward Nurse (RN 2) Get and ready the crash cart, other equipment such as suction. Clearly state “I am getting…” Distribute code cart supplies Operate monitor/defibrillator Prepare medication according to order from team leader Receive instruction from ICU RN or team leader. Runner

20. Who are the members of Code Blue Team? 11. Respiratory Therapist (RT) Helps ICU, anesthesia residents in airway management Airway Assistance

21. CODE BLUE RN2 RN 1 ICU NURSE COMP.2 COMP.1 ICU ROD/ SPECIALIST EVENT MANAGER OTHERS OTHERS OTHERS

22. Video Clips Presentation #2

23. EMERGENCY DRUGS USEd dURING Code blue Aswathy George Prince Sultan C ardiac Center Director of Nursing

24. Emergency Drugs Used During CODE BLUE CATEGORIZED BASED ON ADMNISTRATION ET ADMINISTRATION IVPB ADMINISTRATION IVP ADMINISTRATION

25. EPINEPHRINE Cardiac arrest: VF, pulseless, VT, asystole , PEA Symptomatic bradycardia after atropine, dopamine, and transcutaneous pacing Severe hypotension Anaphylaxis or severe allergic reactions in combination with large fluid volumes, corticosteroids, antihistamines Cardiac arrest IV dose: 1mg (10ml of 1:10,000 solution) every 3-5 minutes during resuscitation with each dose followed by 20ml IV flush

26. ATROPHINE First drug for symptomatic sinus bradycardia May be beneficial in presence of AV block at the nodal level or ventricular asystole ; will not be effective when infranodal block is suspected Asystole or pulseless electrical activity 1mg IVP Repeat every 3-5 minutes as needed to a maximum dose of 0.03-0.04mg/kg Bradycardia 0.5-1mg IV every 3-5 minutes as needed; not to exceed total dose of 0.04mg/kg Use shorter dosing interval (3 minutes) and higher doses (0.04mg/kg ) in severe clinical conditions Tracheal administration 2-3mg diluted in 10ml NS

27. LIDOCAINE Acute treatment for ventricular arrhythmias from myocardial infartion or cardiac manipulation ( eg . Cariac surgery. When amidiaron is not available pulseless VT

28. AMIDIARONE A wide variety of atrial and ventricular tachyarrhythmias For rate control of rapid atrial arrhythmias in patients with impaired LV function when digoxin ineffective Cardiac arrest 300mg IVP diluted in 20-30ml D5W Consider additional 150mg IVP in 3-5 minutes Maximum cumulative dose 2.2gm/24 hours IV

29. DOPAMINE Second drug for symptomatic bradycardia (after atropine) Hypotension (SBP ≤ 70-100 mmHg) with signs and symptoms of shock Cardiac arrest Use as a premixed bag of 400mg/250ml D5W or put 400mg in 250ml NS; titrate to patient response

30. VASOPRESINE Alternative pressor to epinephrine in the treatment of adult shock-refractory VF May be useful for hemodynamic support in septic shock 40 units IVP X1.

31. DEXTROSE Reverse severe hypoglycemia; symptomatically may manifest as nausea, hunger, headache, irritability, lethargy, ataxia, mental confusion Dose: o 10-50ml of Dextrose 50%.

32. ADENOSINE Drug of first choice for most forms of narrow-complex PSVT Effective in terminating arrhythmias due to reentry involving the AV node or sinus node Initial bolus of 6mg IVP over 1-3 seconds, followed immediately with 20ml NS flush, then elevate the extremity If needed, repeat with dose of 12mg after 1-2 minutes If needed, a third dose of 12mg may be given after 1-2 minutes.

33. PROCAINAMIDE PSVT uncontrolled by adenosine and vagal maneuvers as long as blood pressure stable o Stable wide-complex tachycardia of unknown origin 20mg/min IV infusion; maximum total dose 17mg/kg oUp to 50mg/min may be administered to total dose of 17mg/kg in urgent situations

34. SODIUM BICARBONATE If prolonged resuscitation with effective ventilation or upon return of spontaneous circulation after long arrest interval 1mEq/kg IV bolus Repeat half this dose every 10 minutes Use arterial blood gas analysis to guide bicarbonate therapy; an acute change in PaCO2 of 1 mmHg is associated with an increase of decrease in pH of 0.008 U

35. CRASH CART

36. Always check the crash cart for these emergency drugs (quantity, expiration date) before starting your shift. “By failing to prepare you are preparing to fail in your role of saving lives”

37. Documentation forms Used after Code blue Gloria Justalero Nurse Supervisor

38. Initiation and termination of code blue Ms. Edna Olarve ICU Head Nurse-KKH

39. Policies (MS-ICU-001 (4)) King Khalid Hospital- Najran is committed to resuscitate any individual suffering from Cardio Pulmonary Arrest within its premises. Code Blue is initiated in such a case to provide BLS and ACLS to the victim of cardiopulmanary arrest.

40. Policies (MS-ICU-001 (4)) King Khalid Hospital will provide a multidisciplinary Code Blue Team available on a 24 hour on call basis, comprising of members listed in order in this policy. Cardiac arrest in ICU will be managed by ICU team an code is not announced.

41. Policies (MS-ICU-001 (4)) Cardiac arrest in CCU will be managed by cardiology team during working hours (7:30am to 5:00pm) and after duty hours (5:oopm to the next day morning 7:30 am) will be managed by KKH Code Blue team along with cardiology on-call .

42. Procedures (MS-ICU-001 (4)) Core Standards The standards of the Saudi Heart Association for Basic Cardiac Life Support (BCLS) and Advanced Cardiac Life Support (ACLS) are adopted by King Khalid Hospital for Code Blue The CPR committee of KKH has the responsibility for overseeing an making recommendation on all aspects of Code Blue. Certification an Competency All hospital staff should possess valid BLS certificate to be able to take part in CPR Medical and Nursing staff should renew their BLS every 2 years to maintain the privilege

43. Procedures (MS-ICU-001 (4)) Initiation of Code Blue The first responder, if not CPR certified will: Call for HELP and dial “22” (switchboard) to initiate CODE BLUE providing the following information slowly and clearly and repeating the information if necessary: Responder identity The location of the patient

44. Procedures (MS-ICU-001 (4)) If first responder is BLS certified: She/He will start ABCs of CPR, attach defibrillator immediately upon arrival of this equipment and continue CPR until code team arrives an team leader takes over.

45. Procedures (MS-ICU-001 (4)) The switchboard will Announce “ATTENTION …CODE BLUE IN ( area )” three times clearly and bleep the Code Blue team. Continue to be attentive and direct responders to the location.

46. The team leader will identify self as leader and start conducting the procedures systematically after analyzing the rhythm. Each member of the team will start performing his/her role under guidance of the team leader till told to stop. Any change in role will be as per direction of the team leader and all must stay on the scene till allowed by him.

47. Termination of Code Blue It is decide by the team leader. If MRP of the patient available on site, his/her opinion can be sought in making this decision. The team leader will allow team members to stand down an return to regular duties, with exception of the Medical Specialist an Nursing supervisor who will asses an coordinate further intervention, as required.

48. Video Clips Presentation #3

49. megacode Dr. Deyaldeen ICU Resident-KKH

50. WHAT TO REMEMBER DURING THE CODE BLUE? RULE #1 CALM DOWN and DON’T PANIC

51. WHAT TO REMEMBER DURING THE CODE BLUE? RULE #2 Always starts with the BCLS

52. WHAT TO REMEMBER DURING THE CODE BLUE?

53. WHAT TO REMEMBER DURING THE CODE BLUE? RULE #3 Always be systematic in performing ACLS

54. Video Clips Presentation #4

55. In order to understand more regarding ACLS and what we have discussed previously here’s a return demonstration an code blue drill.

56. Thank you! We are hoping to see competent nurses during code blue.