Responding to a Code Keith Rischer RN, MA, CEN 3/25/2017

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. 3/25/2017

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 3/25/2017

Legal & Ethical Issues DNR order No DNR order Advanced directives Organ donation Code review Ethic Committee 3/25/2017

Cardiac Arrest=Teamwork 3/25/2017

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 3/25/2017

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 – Assess responsiveness (speak loudly, gently shake patient if no trauma - "Annie, Annie, are you OK?"). Call for help/crash cart if unresponsive. ABCD's (sorry, can't get a much better mnemonic than that ... maybe "A Big Cruel Dude [just beat me up and I coded?"] ) 3/25/2017

Managing Airway 3/25/2017

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. 3/25/2017

ACLS Medications Adenosine Atropine sulfate Amiodarone Cardizem (diltiazem) Dopamine HCL Dobutamine hydrochloride Epinephrine HCL (Adrenalin) 3/25/2017

ACLS Medications Levophed (Norepinephrine) Lidocaine HCL Magnesium Nitroglycerine (NTG) Oxygen Sodium Bicarbonaate Vasopressin 3/25/2017

Recording 3/25/2017

Defibrillation Patho Bi-phasic Nursing Responsibilities 3/25/2017

ACLS Rhythms: Most Common VT-VF Asystole Tachycardia AFib w/RVR (symptomatic) SVT Bradycardia (symptomatic) 3/25/2017

Ventricular Tachycardia 3/25/2017

Ventricular Fibrillation/Asytole VF-AMI, Asystole-absence of electrical activity-rarely resuscitated 3/25/2017 16

Don’t Let Him Go… 3/25/2017

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). Amiodarone 300mg IV push. May repeat once at 150mg in 3-5 min Lidocaine 1.0-1.5 mg/kg IV q 3-5 min max 3 mg/kg 3/25/2017

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 Bicarb (NaHCO3). Consider for indications below: Class 1: hyperkalemia Class 2a: bicarbonate-responsive acidosis, tricyclic OD, to alkinalize urine for aspirin OD Class 2b: prolonged arrest Not for hypercarbia-related (respiratory) acidosis, nor for routine use in cardiac arrest Consider termination. If patient had >10min with adequate resucitative effort and no treatable causes present, consider cessation - it is, after all, the final rhythm. 3/25/2017

Atrial Fibrillation Rate control: Cardiovert: 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 3/25/2017

Bradycardia If AV block: Atropine Pacing Dopamine Epinephrine 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 3/25/2017

Post Code Concerns Autopsy Family presence Survival Holistic Saving life is priority regardless Seen in less experienced nurses, MD’s Holistic Save life Addressing needs of the family Seen in more experienced providers and those who were sensitive to their own spirituality 96% nurses believe that spiritual care is component of holistic care but 66% feel inadequate to perform spiritual care interventions Spirituality defined as values, beliefs, behaviors of the individual related to purpose and meaning in life, connectedness to others, self and capacity for transcendance Study showed positive correlation for those with high measure of spirituality and support for family presence 3/25/2017

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. 3/25/2017

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: 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 3/25/2017

Labs Family decided not to be aggressive once in ED-withdrew vent support and died 9 minutes later 3/25/2017