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

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.
3/25/2017

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
3/25/2017

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

5. Cardiac Arrest=Teamwork
3/25/2017

6. 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

7. 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

8. Managing Airway
3/25/2017

9. 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

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

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

12. Recording
3/25/2017

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

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

15. Ventricular Tachycardia
3/25/2017

16. Ventricular Fibrillation/Asytole
VF-AMI,
Asystole-absence of electrical activity-rarely resuscitated
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17. Don’t Let Him Go…
3/25/2017

18. 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 mg/kg IV q 3-5 min
max 3 mg/kg
3/25/2017

19. 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

20. 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

21. 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
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

22. 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

23. 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 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

24. 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

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