CODE BLUE PROCEDURES Luis Enriquez RN, BS. Los Angeles County USC Medical Center Department of Emergency Medicine

CODE BLUE TEAM Trained patient care providers who perform resuscitation on any person who sustains Cardiopulmonary arrest Respiratory arrest Airway problem Train providers: Doctor Nurse Support Personnel

CODE BLUE ACTIVATION All employees must be educated to activate Code Blue response in the event of Cardiac arrest Respiratory arrest Activate Code Blue Response by Calling Hospital Emergency Operator Provide Information: Patient location, Adult/Pediatric Hospital Emergency Operator will activate response when notified of Code Blue event Code blue pager system Announce overhead the location of the code event

CODE BLUE MEMBERS Physician: Emergency Department Pediatric attending or senior resident Physician: Internal Medicine Physician: general Surgery Intensive Care Unit/Emergency Nurse Respiratory Therapist EKG (Electrocardiogram) Technician Nursing Supervisor Los Angeles County + USC Medical Center Code Blue Protocol

ROLE OF THE TEAM MEMBERS EMERGENCY PHYSICIAN Team Leader: direct overall patient care Manage the Code Medication Defibrillation Other procedures: Intubation, compressions Evaluate Code Blue procedures Effectiveness of Chest Compression Effectiveness of assisted respirations Rhythm/pulse check Document in the medical record

ROLE OF THE TEAM MEMBERS EMERGENCY NURSE Maintains airway/oxygenation/ventilation Applies monitor leads/defibrillator pads Starts Intravenous access Administer medications Administers Electrical Shock (ACLS trained) Assist with intubation procedures Completes CPR record

ROLE OF THE TEAM MEMBERS PRIMARY NURSE Activate code blue team Bring Emergency Resuscitation Cart Place backboard under patient Initiate 2 man Cardio Pulmonary Resuscitation Administer ventilations with 100% O2 with Bag/valve/mask Attach Electro cardiogram leads Attach “hands off” defibrillator pads Ensure patient Intra Venous access Prepare suction Obtain supplies from CPR Cart/Ward Stock Record events on CPR record

CODE BLUE NURSING SKILLS Identify respiratory/cardiac arrest Activate Code Blue Oxygen administration: Nasal cannula, mask Bag-Valve-Mask resuscitation with 100% O2 Cardiac Monitor/defibrillator pads Application Intra Venous access Medication Administration Defibrillation (ACLS trained) CPR documentation

ROLE OF THE TEAM MEMBERS SUPPORT PERSONNEL Respiratory Therapist Maintains airway and oxygenation/ventilation Assist with intubation procedures EKG Technician: Performs 12-lead EKG Pharmacist: Prepares medications

BASIC LIFE SUPPORT SURVEY 1- Establish Unresponsiveness 2- Activate Emergency Response System 3- Circulation 4- Defibrillation

Simplified adult BLS algorithm. Berg R A et al. Circulation 2010;122:S685-S705 Copyright © American Heart Association

ESTABLISH UNRESPONSIVENESS Tap and Shout “are you all right” Check for absent/abnormal breathing by scanning the chest for movement

ACTIVATE THE EMERGENCY RESPONSE SYSTEM Call for help or send someone for help Yell for help Code Blue protocol Get the Automatic External Defibrillator

CIRCULATION Check corotid pulse for 5-10 seconds If no pulse Begin Cardio Pulmonary Resuscitation Compress center of chest (lower ½ of sternum) Ratio: 30:2 compressions to breaths Depth: at least 2 inches Rate: at least 100 compressions per minute Allow complete chest recoil Minimize interruptions Switch providers every 2 minutes Avoid excessive ventilation If pulse present start rescue breathing 1breath every 5-6 seconds (10-12 breaths per min.) Check pulse every 2 minutes

DEFIBRILLATION If no pulse check for shockable rhythm as soon as AED arrives Provide shocks as indicated Follow each shock immediately with CPR compressions

Advance Cardiac Life Support Survey Airway Breathing Circulation Differential Diagnosis

AIRWAY Maintain patent airway in unconscious Pt’s Head tilt chin lift Simple airway adjuncts: Use advance airway if needed: Confirm proper placement Physical exam Quantitative waveform Capnography Secure Device to prevent dislodgement Monitor airway placement with continuous quantitative waveform Capnography

BREATHING Supplemental O2 when indicated Titrate O2 to oxygen sat ≥ 94% non arrest Pt’s 100% O2 for Pt’s in cardiac arrest Monitor adequacy of ventilation and oxygenation Clinical criteria: chest rise and cyanosis Quantitative waveform capnography Oxygen saturation Avoid excessive ventilation

CIRCULATION Monitor CPR quality Attach monitor/Defibrillator Monitor for arrhythmias or arrest rhythms Provide defibrillation/Cardioversion Obtain IV/IO access Give appropriate drugs Give fluids if needed

DIFFERENTIAL DIAGNOSIS search for and treat reversible causes H’s AND Hypoxia Hypovolemia Hydrogen ion (acidosis) Hypo/hyper kalemia Hypothermia T’s Tension pneumothorax Tamponade cardiac Toxins Thrombosis Pulmonary Thrombosis Coronary

ACLS Cardiac Arrest Algorithm. Copyright © American Heart Association

ACLS Cardiac Arrest Circular Algorithm. Neumar R W et al. Circulation 2010;122:S729-S767 Copyright © American Heart Association

Bradycardia Algorithm. Neumar R W et al. Circulation 2010;122:S729-S767 Copyright © American Heart Association

Tachycardia Algorithm. Neumar R W et al. Circulation 2010;122:S729-S767 Copyright © American Heart Association

NSR with Ectopy > VT>VF>NSR A 48 year old iron worker is brought to the Emergency Department by co-workers following an onset of sudden sever “pressure-type” chest pain radiating to his neck, jaw and left arm. He is pale slightly diaphoretic, and very anxious. Wide-complex tachycardia >VF>NSR A 63-Year-old woman alcoholic with a history of CHF is brought to the hospital by her daughters becouse of worsening symptoms of dyspnea, cough and wheezing. She looks moderately ill but denies chest pain.