Code blue management

Code blue Management

1. CODE BLUE MANAGEMENT Michelle Antimano,RN

2. CODE BLUE is generally used to indicate a patient requiring resuscitation or otherwise in need of immediate medical attention, most often as a result of a respiratory or cardiac arrest. What is Code Blue

3. Cardiopulmonary Resuscitation (CPR ) is an emergency procedure performed in an effort to manually preserve intact brain function/ provide adequate blood circulation until further measures are taken to restore spontaneous blood circulation and breathing in a person in cardiac arrest . Cardiac Arrest is the sudden loss of cardiac of cardiac function, breathing and consciousness.

4. CODE BLUE TEAM CARDIOLOGY REGISTRAR ANESTHETIST CARDIOLOGY/SURGICAL RESIDENT OVER ALL NURSING SUPERVISOR REGISTERED NURSES RESPIRATORY THERAPIST CPR Committee

5. Criteria for Code Blue RRT The patient is responsive but there is a sudden deterioration in patient’s status. Respiratory distress. O2 saturation, BP, pulse is gradually dropping/below normal. CODE BLUE Unresponsive Pulseless Apneic

6. CALM DOWN AND DON’T PANIC WHAT TO REMEMBER DURING CODE BLUE RULE #1

7. Always start with BCLS RULE #2 WHAT TO REMEMBER DURING CODE BLUE

8. RULE #3 Always BE SYSTEMATIC IN PERFORMING ACLS

9. SECOND RESPONDER : Activate Code blue and bring the crash cart to patient’s area. Attach the monitor/defibrillator to patient. Connect valve-mask bag device to high flow O2 FIRST RESPONDER : After establishing unresponsiveness, CALL FOR HELP! Initiate CPR.

10. CODE BLUE ACTIVATION > Dial 855-0999 ( Overhead paging system) > State the type of Emergency Code >Give the exact location (floor, room number) >Repeat 3 times. Example: Code Blue 4 th floor room number 401! (3x )

11. NURSES ROLES AND RESPONSIBILITIES DURING CODE BLUE Assembling materials needed. Proper bed positioning. Ensuring O2 source and suction equipment. Ensuring ET is secured Nurse #1 AIRWAY

12. NURSES ROLES AND RESPONSIBILITIES DURING CODE BLUE Nurse #2 MEDICATION/DEFIBRILLATION Must secure IV access promptly if not yet established. Prepare and give medications as directed by team leader. Select the joules as per team leader’s advice, charge the defibrillator , apply gel on the paddles before giving to the doctor. Make sure that the doctor has a clear view of the monitor

13. NURSES ROLES AND RESPONSIBILITIES DURING CODE BLUE DOCUMENTATION Nurse #3 Ensures all observation are taken and recorded. The code blue will be documented in a code blue record which will be signed by the recording nurse and code physician.

14. NURSES ROLES AND RESPONSIBILITIES DURING CODE BLUE Nurse #4 CIRCULATING Ensures all needed equipment and materials are available at the bedside. Responsible for sending specimens such as blood gases.

15. Post Resuscitation Activities Obtaining 12 lead ECG Obtaining CXR Laboratory work ups NGT & IFC insertion Coordinate with Critical unit for transfer Documentation

16. PRIMARY SURVEY

17. SECONDARY SURVEY

18. HIGH QUALITY CPR 2MINUTES/5 CYCLES EPINEPHRINE 1 mg every 3-5 minutes (IV/IO) ASYSTOLE PEA ARRHYTMIAS

19. PULSELESS VTACH POLYMORPHIC VTACH/ TORSADE DE POINTES VENTRICULAR FIBRILLATION

20. C -Chest pain A - Altered Mental Status S - SOB H - Hypotension 50 HR - CASH = MONITOR <50 HR + CASH = DATE Treatment: D- Dopamine A- Atropine T- transcutaneous pacing E- Epinephrine Atropine 0.5mg IV 3-5 minutes as needed. Maximum dosage is 3mg. Epinephrine 2-10mcg/min or Dopamine 2-10mcg/kg/min Transcutaneous pacing BRADYCARDIA

21. Stable (Narrow QRS Complex) >150 HR – CASH = MANEUVERS /DRUGS vagal maneuver, Adenosine >150 HR + CASH = SYNC CARDIOVERSION Narrow/ reg = 50-100joules narrow-/ irreg =120-200joules Stable ( Wide/ Regular/ Monomorphic ) Consider antiarrythmic infusion. Amiodarone Patients with unstable tachycardia should be treated immediately with synchronized cardioversion . Wide/ reg =100joules Treat underlying condition SINUS TACHYCARDIA Stable (Narrow QRS Complex) Stable (Wide/ Regular/Monomorphic)

22. It is a means of storing and transporting vital equipment and drugs which may be required during a code blue (cardiac emergency) to the location of emergency . CRASH CART

23. EMERGENCY DRUGS (1st DRAWER) TOP AND SIDE OF TROLLEY (HANG)

24. IVF & MISCELLANEOUS (3rd DRAWER) CIRCULATORY ACCESS (2nd DRAWER)

25. PPE & OTHER EQUIPMENT (5th DRAWER) AIRWAY & BREATHING DEVICES (4th DRAWER)

26. 1. Crash cart must be checked at the beginning of every shift by the assigned CPR nurse. 2. Standardization must be maintained. 3. Defibrillator performance check must be done along with crash cart checking and keep the test strip for documentation. 4. Crash cart items and medications must be checked monthly for expiry dates. 5. Each unit will have a crash cart placed in an easily accessible location. 6. In case of CPR, all items must be replaced after each use. “By failing to prepare, You are preparing to fail In your role to save lives”

27. INDICATIONS: Cardiac arrest: VF/ pulseless VT, asystole , PEA Symptomatic bradycardia : alternative to dopamine after atrophine . anaphylaxis DOSAGE: 1mg (10ml of 1:10,000 solution) IV/IO every 3-5 min during CPR Profound bradycardia or hypotension: 2-10mcg/min infusion (titrate according to patient’s response) ETT: 2 – 2.5mg Pedia dose: 0.01mg/kg IV/IO every 3-5 min max dose : 1mg CONTRAINDICATIONS/PRECAUTIONS: Increase cerebral and myocardial oxygen demand EPINEPHRINE

28. INDICATIONS : First drug for symptomatic bradycardia Organophosphate poisoning DOSAGE: 0.5 mg IV every 3-5 minutes as needed not to exceed total dose of 3 mg. CONTRAINDICATIONS/ PRECAUTIONS: Use with caution in presence of MI and hypoxia. May not be effective with Type II and 3 rd degree AV block Doses of < 0.5 mg may result in paradoxical slowing of heart rate. ATROPINE SULPHATE

29. INDICATIONS : 2 ND –line drug for symptomatic bradycardia Hypotension (SBP <70 mmHg) with signs and symptoms of shock Low cardiac output Poor perfusion to vital organs DOSAGE: 1-5 mcg/kg/min IV infusion-increase renal blood flow and urine output 5-15 mcg/kg/min- may increase renal output, cardiac output, HR and cardiac contractility 1 0-15 mcg/kg/min-increase BP and stimulate vasoconstriction (shock) CONTRAINDICATIONS/ PRECAUTIONS: Tachyarrhythmia Severe vasoconstriction Hypertension Extravasation DOPAMINE

30. INDICATIONS : Life threatening arrhythmias: VF/pulseless VT unresponsive to shock delivery, CPR and vasopressor Recurrent, hemodynamically unstable VT Some atrial and ventricular arrhythmias DOSAGE: VF/VT Cardiac arrest: 1 st dose: 300mg IV/IO push 2 nd dose: 150mg IV/IO push if needed Life threatening arrhythmias: 150 mg diluted with 150 ml D5W IV infusion over 10 minutes. 360 mg over 6 hours (1 mg/ min) 540 mg IV over 18 hours (0.5 mg/min) Maximum cumulative dose: 2.2g IV over 24 hours CONTRAINDICATIONS/ PRECAUTIONS: Hypotension Risk for substantial toxicity Terminal elimination is extremely long Bradycardia AMIODARONE

31. INDICATIONS : Drug of choice for stable-narrow complex SVT. DOSAGE: 6-12-12 Initial dose of 6 mg IV rapidly then another 12mg if needed and 3 rd dose of 12mg if still needed. Flush with 20ml saline Elevate the extremity. CONTRAINDICATIONS/ PRECAUTIONS: Contraindicated with: -2 nd or 3 rd degree AV block -Sick sinus node or symptomatic bradycardia -suspected bronchoconstrictive or bronchospastic lung disease -hypersensitivity to adenosine Transient side effects include flushing, chest pain or tightness, brief periods of asystole or bradycardia , ventricular ectopy ADENOSINE

32. INDICATIONS: Alternative to Amiodarone in cardiac arrest from VF/VT Stable monomorphic VT with preserved ventricular function DOSAGE: Initial 1-1.5mg/kg IV/IO For refractory VF may give additional 0.5-.75mg/kg IV push repeat in 5-10 minutes Maximum of 3 doses or 3mg/kg. Maintenance infusion: 1-4mg/ minute (30-50mcg/kg/min) Pedia dose: 1mg/kg IV/IO Maintenance infusion: 20-50 mcg/kg/min CONTRAINDICATIONS/ PRECAUTIONS: Contraindicated in prophylactic used in AMI Discontinue infusion immediately if signs and symptoms of toxicity develop LIDOCAINE

33. INDICATIONS: Torsades de pointes or suspected Hypomagnesemia in cardiac arrest Life threatening ventricular arrhythmias due to digitalis toxicity DOSAGE: Cardiac arrest due to hypomagnesemia or torsades de pointes : 1-2 g diluted in 10ml of D5W IV/IO Torsades de pointes with pulse or AMI with hypomagnesemia : 1-2 g mixed in 50-100ml D5W over 5-60 min IV. CONTRAINDICATIONS/PRECAUTIONS: Occasional fall in BP with rapid administration. Use with caution if renal failure is present MAGNESIUM SULPHATE