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INTRO TO CODE BLUE

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INTRO TO CODE BLUE

PURPOSE

Experience management of code blues Suggest initial management plans of acute care cases Practice leadership, communication, collaboration, and interdisciplinary teamwork skills Practice effective CPR and early defibrillation

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INTRO TO CODE BLUE

OBJECTIVES

By the e en end d of

• f Intro
• To
• Code
• de Blue

e (ITC TCB), medi edical al st studen dents s will be be abl able e to:

• :
• Demonstrate an approach to the assessment of an acute care patient (i.e. ABCs)
• Suggest initial management plans for select acute care patient presentations

(ACS, anaphylaxis, tension pneumothorax, and UGIB)

• Demonstrate an approach to the management of cardiac arrest cases
• Discuss the importance of early CPR and defibrillation in cardiac arrest cases
• Demonstrate effective CPR and BVM techniques
• Demonstrate accurate dosing and frequency of epinephrine administration in

cardiac arrest cases

• Select the appropriate defibrillation dose for cardiac arrest cases
• Recognize the following rhythms: VF, VT, PEA, asystole
• Demonstrate the management of VF and pulseless VT
• Demonstrate the management of asystole and PEA
• List causes of cardiac arrest, using H’s and T’s as a mnemonic
• Describe and demonstrate the ACLS elements of effective team dynamics
• Discuss the roles of the interdisciplinary health care team in cardiac arrest cases

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INTRO TO CODE BLUE

CASES

① ACS | VF ② Anaphylaxis | Asystole ③ Tension Pneumothorax | Pulseless VT ④ Upper GI Bleed | PEA

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INTRO TO CODE BLUE

SIM AND DEBRIEF LOGISTICS

22.5 minutes per SIM session 15 minute SIM 5 minute debrief 2.5 minute transition / preparation

• Each learner will be a team leader once
• Roles: team leader (e.g. doctor), airway (e.g. RT),

compressor (e.g. nurse), meds/defib (e.g. nurse)

• The facilitator will act as another role, the recorder

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Assessment | Primary Survey ABCs Action | Primary Survey Help, O2, IV, Monitor Assessment | Secondary Survey SAMPLE, Vitals, Head-to-toe Action | Secondary Survey Targeted tx Management | Code Blue Quality CPR, Early Defib, Hs and Ts, Teamwork

INTRO TO CODE BLUE

OSCE FORMAT

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INTRO TO CODE BLUE

PRIMARY SURVEY

Primary = immediately life-threatening Assessment Airway: patency, secretions Breathing: RR, O2 Sat, work of breathing, lung sounds Circulation: HR, BP, LOC, bleeding, temp Action Call for help O2 IV Monitor Fluids

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INTRO TO CODE BLUE

SECONDARY SURVEY

Assessment SAMPLE Signs/symptoms Allergies Medications PMHx Last oral intake Events prior Vitals Head-to-toe Action Investigations, differential diagnoses, treatments

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INTRO TO CODE BLUE

CODE BLUE MANAGEMENT

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INTRO TO CODE BLUE

ARREST RHYTHMS

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VF Pulseless VT

2 shockable (defib) rhythms

Asystole

Everything else with NO pulse is PEA (Pulseless Electrical Activity)

PEA

INTRO TO CODE BLUE

CODE BLUE ALGORITHMS

Pulseless VT, VF SHOCK SHOCK EPI

2min CPR Rhythm Check 2min CPR Rhythm Check

Nothing Nothing EPI

2min CPR Rhythm Check 2min CPR Rhythm Check

Asystole, PEA

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INTRO TO CODE BLUE

CODE BLUE EXAMPLE

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Monitor ¡ Pulse ¡ Assessment ¡ Ac0on ¡ VF ¡ None ¡ VF ¡arrest ¡ Start ¡compressions ¡ 200J ¡shock/defib ¡ 2 ¡minutes ¡of ¡CPR ¡ VT ¡ None ¡ Pulseless ¡VT ¡arrest ¡ Start ¡compressions ¡ 200J ¡shock/defib ¡ 1mg ¡epi ¡1:10,000 ¡IV ¡ 2 ¡minutes ¡of ¡CPR ¡ Bradycardia ¡ None ¡ PEA ¡ Start ¡compressions ¡ No ¡shock/defib ¡ 2 ¡minutes ¡of ¡CPR ¡ Asystole ¡ None ¡ Asystole ¡ Start ¡compressions ¡ No ¡shock/defib ¡ 1mg ¡epi ¡1:10,000 ¡IV ¡ 2 ¡minutes ¡of ¡CPR ¡ No response, no pulse start 2 minutes of CPR

INTRO TO CODE BLUE

CPR / CCR

“CCR” = Cardio-Cerebral Resuscitation Compressions CCP survival Less time b/w compression & shock survival

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INTRO TO CODE BLUE

Early CPR, Early Defib

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INTRO TO CODE BLUE

Hs and Ts

Hypovolemia Tension PTX Hypoxia Tamponade Hydrogen ion Toxins Hyper/hypoK Thrombosis (pulmonary) Hypothermia Thrombosis (coronary)

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INTRO TO CODE BLUE

ACS

① Anti- Anti-an angi ginal al O2, nitroglycerin, morphine ② Anti-pl plat atel elet et 1st: ASA (162mg PO chewable) 2nd: P2Y12 inhibitor (clopidogrel, ticagrelor, or prasurgrel – not if hx stroke/TIA) 3rd: glycoprotein IIb/IIIa inhibitor (consider at PCI) ③ Anti-coagu

• agulat

ation

• n

If fibrinolytics: UFH, LMWH, or fondaparinux If PCI: UFH, bivalirudin, or UFH+bivalirudin ④ Revasc ascular arizat ation

• n

Fibrinolytics (TNK), PCI, or CABG ⑤ Risk sk fac actor

• r redu

eduction

• n

Beta-blocker, ACEi/ARB, and Statin Aldo antagonist (e.g. eplerenone): on BB/ACEi, either sx HF or DM, and EF<40% Quit smoking

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INTRO TO CODE BLUE

ACS DOSES FOR SELECT MEDS

Drug g Load

• ad

Mai ainten enan ance e Durat ation

• n

ASA 162mg PO 81mg/day Lifelong Clopidogrel 600mg pre-PCI 300mg lytics <24h 75mg > age 75 75mg/day 1 year Ticagrelor 180mg 90mg BID 1 year Heparin IV bolus weight based IV infusion (Goal 1.5-2x PTT) 48h or until revascularization LMWH IV bolus weight based SC injections Up to 8 days or until revascularization ACEi

• Lifelong

Beta-blocker

• Lifelong

Statin

• Lifelong

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INTRO TO CODE BLUE

ANAPHYLAXIS

57% unrecognized or not labeled in ED as anaphylaxis Multisystem syndrome Distributive shock (widespread vasodilation) and hypovolemic shock (fluid extravasation, reduced venous return) Symptoms: Derm (80-90%): flushing, itching, urticaria, angioedema Resp (70%): nasal sx, throat sx, cough, wheeze, SOB GI (45%): N/V/D, abd pain, dysphagia CVS (45%): faint, tachycardia, hypotension, collapse CNS (15%): dizziness, headache, LOC Other: metallic taste in mouth

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INTRO TO CODE BLUE

ANAPHYLAXIS DX

Exposure to allergen and either: Low BP (e.g. sBP<90 in adults or sBP decreased by 30%) 2 or more systems involved (i.e. multisystem syndrome): Derm Resp CVS GI

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INTRO TO CODE BLUE

ANAPHYLAXIS TX

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1st line: epinephrine 1:1000 IM anterolateral thigh 0.3mg adults 0.15mg pediatrics Adjuncts CVS: fluids Resp: oxygen, salbutamol Derm: H1 and H2 blocker Prevention of biphasic or protracted reaction Steroids (controversial) Long-term Epinephrine injector Wear/carry allergy identification

INTRO TO CODE BLUE

EPINEPHRINE IS FIRST LINE

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Alpha-1 Vasoconstriction Increased peripheral vascular resistance Decreased mucosal edema and membrane leakage Beta-1 Increased inotropy (contractility) Increased choronotropy (heart rate) Beta-2 Bronchodilation Decreased mast cell and basophil mediator release

INTRO TO CODE BLUE

TENSION PNEUMOTHORAX

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Needle decompression 14G needle 2nd ICS mid-clavicular line Chest tube 5th ICS just anterior to midaxillary line

INTRO TO CODE BLUE

Acute Upper GI Bleed

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Pre-Scope IV fluids and blood Assume PUD (most common, threatening, treatable) Empiric PPI bolus (e.g. IV pantoprazole 8mg) Assume variceal bleed (threatening, treatable) Empiric octreotide (e.g. 50mcg IV then 50mcg/h) Consults: GI, surgery, interventional radiology Intubate early: lower aspiration risk Balloon tamponade if still bleeding Post-Scope Add abx for varices (ceftriaxone or fluoroquinolone) Add PPI infusion for PUD (e.g. IV pantoprazole 8mg/h)

INTRO TO CODE BLUE

ACLS EFFECTIVE TEAM DYNAMICS

• Closed-loop communication
• Clear messages
• Clear roles and responsibilities
• Knowing one’s limitations
• Knowledge sharing
• Constructive intervention
• Re-evaluation and summarizing
• Mutual respect

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