1/5/20141 responding to a code keith rischer rn, ma, cen
TRANSCRIPT
04/10/23 1
Responding to a Code
Keith Rischer RN, MA, CEN
04/10/23 2
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.
04/10/23 3
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
04/10/23 22
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