1. CODE BLUE MANAGEMENT ACLS CASES Part 4

3. Respiratory Arrest Management of respiratory arrest
Giving supplementary oxygen
Opening the airway
Providing basic ventilation
Using adjuncts
suctioning

4. Respiratory Arrest Critical concepts
Avoid delivering excessive ventilations
Increases intra thoracic pressure
Decreases venous return to the heart
↓Carbon dioxide
Causes gastric inflation
Vomiting
aspiration

5. Respiratory Arrest Administering supplementary O2
Acute cardiac symptoms
Respiratory distress
Titrate to maintain ≥94%

6. Respiratory Arrest Basic airway opening techniques Head tilt-chin lift
Jaw thrust

7. Respiratory Arrest
Airway management
OPA
NPA

8. Respiratory Arrest Providing basic ventilation Head tilt-chin lift
Jaw thrust
Mouth-to-mouth
Mouth-to-nose
Mouth-to-barrier
Bag-mask

9. Respiratory Arrest Suctioning Need suction force of -80 to -120 mmHg
Soft vs. rigid catheters
Catheter
Use for
Soft
Aspiration of thin secretions
Intra tracheal suctioning
Suctioning when NPA is in use
Rigid
Orophraynx
Thick, particulate matter

10. Respiratory Arrest Oropharyngeal suctioning Step Action 1
Measure the catheter from tip of nose to earlobe
Gently insert into oropharynx beyond tongue 2
Apply suction (occlude) while withdrawing with a rotating or twisting motion
If using a rigid device (Yankauer) place tip gently into oral cavity. Advance by pushing the tongue down to reach oropharynx

11. Respiratory Arrest Endotracheal tube suctioning STEP ACTION 1
Sterile technique 2
Insert catheter (Do not occlude) 3
Apply suction (occlude) while withdrawing with a rotating or twisting motion
DO NOT exceed 10 seconds
Precede and follow with 100% O2

13. Ventricular Fibrillation/Pulse less Ventricular Tachycardia
What you will need
Epinephrine
Advanced airway
Amiodarone
Defibrillator

14. Managing Ventricular Fibrillation/Pulse less Ventricular Tachycardia
VF/VT (left side)
Not recommend continued use of the AED when a manual defibrillator is available
If you do not know the effective dose range, deliver the maximal energy
Immediately after the shock, resume CPR

15. Safety during Defibrillation
Cont…..
Safety during Defibrillation
Be sure oxygen is not flowing across patient’s chest
When shocking, the operator should face the patient, NOT the machine

16. Cont…… Paddles vs Pads Reduces transthoracic impedance
Equally effective
Pads
reduce arcing
Allow for monitoring
Recommended by the AHA

17. Cont…… Rhythm Check After 2 minutes (5 cycles)
Should not exceed 10 seconds
Perform a pulse-check—preferably during rhythm analysis- only if an organized rhythm is present

18. ASYSTOLE Give priority to Intravenous/Intraoseous access
Search for underlying cause
Do not stop CPR to administer drugs
TCP not recommended
Routine shock not recommended

19. Asystole/PEA
Asystole/PEA
What you will need
Epinephrine
Defibrillator

20. PEA Think of reversible causes (5 H & 5T’s) 5 H’s Hypovolemia Hypoxia
Hydrogen ion (acidosis) excess
Hypo/hyperkalemia
Hypothermia

21. Cont….. 5 T’s Toxins Tamponade, cardiac Thrombosis, coronary
Thrombosis, pulmonary
Tension pneumothorax

22. Antiarrhytmics Amiodarone Lidocaine MgSO4 (Magnesium Sulphate)
First-line antiarrhythmic agent in cardiac arrest
Improves rate of ROSC ( return of spontaneous circulation)
Lidocaine
MgSO4 (Magnesium Sulphate)
1-2g (diluted in 10 mL D5W) bolus over 5 – 20 minutes
For Torsade

23. Cardiac Arrest Treatment Sequences
Rhythm checks & shocks organized around 5 cycles (2 mins)

24. Physiologic Monitoring During CPR
AHA recommends using quantitative waveform capnography in intubated patients to monitor CPR quality
End-Tidal CO2
Main determinant of PETCO2 during CPR is blood delivery to the lungs
PETCO2 <10 mm Hg during CPR suggest ROSC unlikely. Improve chest compressions and vasopressor therapy
If PETCO , indicator of ROSC

25. Cont….. Coronary Perfusion Pressure
Measured by intra-arterial catheter
<20 mm Hg, try to improve chest compressions and vasopressor therapy

26. Monitoring CPR Quality
Push hard (2 in) and fast ≥100/min
Minimize interruptions
Avoid excessive ventilation
Rotate compressor every 2 minutes
If no advanced airway, 30:2
Quantitative waveform capnography
If PETCO2 <10 mmHg, attempt to improve CPR quality
Intra-arterial pressure
If diastolic <20 mmHg, attempt to improve CPR quality

27. Routes of Access for Drugs
IV Route
Peripheral line preferred
Central line access not necessary
Drugs take 1-2 minutes to reach central circulation
Give by bolus
Follow with a 20mL bolus of IV fluid
Elevate extremity for about secs

28. Routes of Access for Drugs
Intraosseous route
Preferred over the endotracheal route
Endotracheal Route
The optimal dose via this route is unknown
Typical dose is 2-2 ½ times the IV route
Dilute dose in 5 to 20 mL of H2O or saline

29. Intraosseous route

30. Adult Immediate Post-Cardiac Arrest Care

31. Post-Cardiac Arrest Care
Optimize ventilation and oxygenation
Waveform capnography
Use lowest FIO2 to maintain ≥94% (wean 100%)
Begin ventilations at bpm, titrate to PaCO2 of mm Hg
Avoid using ties that pass circumferentially around neck  obstructs venous return from brain

32. Post-Cardiac Arrest Care
Foundational Facts: Recue breaths for CPR with an advanced airway
During CPR, compression to ventilation ratio is 30:2
Once advanced airway is in place, compressions no longer interrupted
Ventilating via advanced airway give 1 breath every 6 to 8 secs. (8-10 bpm)

33. Post-Cardiac Arrest Care
Most common and easily reversible causes of PEA
Hypovolemia
Hypoxia
Assess, assess, assess for their presence

34. Cardioversion Synchronized vs. unsynchronized Synchronized
Unstable SVT
Unstable atrial fibrillation
Unstable atrial flutter
Monomorphic tachycardia with pulses

35. Cardioversion Energy doses for cardioversion
Initial: 200 J (monophasic)
J (Biphasic)
Atrial Flutter & SVT (50 to 100 J)