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WARNING Learners, please complete the Learner Survey (ucalgary.ca/codeblue/surveys) before viewing this PowerPoint 1 INTRO TO CODE BLUE 2 INTRO TO CODE BLUE PURPOSE Experience management of code blues Suggest initial


  1. WARNING Learners, please complete the Learner Survey (ucalgary.ca/codeblue/surveys) before viewing this PowerPoint 1 ¡

  2. INTRO TO CODE BLUE 2 ¡

  3. 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 3 ¡

  4. INTRO TO CODE BLUE OBJECTIVES By the e en end d of of Intro o To o Code ode Blue e (ITC TCB), medi edical al st studen dents s will be be abl able e to: o: � 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 4 ¡

  5. INTRO TO CODE BLUE CASES ① ACS | VF ② Anaphylaxis | Asystole ③ Tension Pneumothorax | Pulseless VT ④ Upper GI Bleed | PEA 5 ¡

  6. 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 � 6 ¡

  7. INTRO TO CODE BLUE OSCE FORMAT � 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 7 ¡

  8. 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 8 ¡

  9. 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 9 ¡

  10. INTRO TO CODE BLUE CODE BLUE MANAGEMENT 10 ¡

  11. INTRO TO CODE BLUE ARREST RHYTHMS VF 2 shockable (defib) rhythms Pulseless VT Asystole Everything else with NO pulse is PEA PEA (Pulseless Electrical Activity) 11 ¡

  12. INTRO TO CODE BLUE CODE BLUE ALGORITHMS Pulseless VT, VF SHOCK EPI SHOCK 2min CPR 2min CPR Rhythm Check Rhythm Check Asystole, PEA Nothing EPI Nothing 2min CPR 2min CPR Rhythm Check Rhythm Check 12 ¡

  13. INTRO TO CODE BLUE CODE BLUE EXAMPLE No response, no pulse � start 2 minutes of CPR 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 ¡ 13 ¡

  14. INTRO TO CODE BLUE CPR / CCR � “CCR” = Cardio-Cerebral Resuscitation � Compressions � � CCP � � survival � Less time b/w compression & shock � � survival 14 ¡

  15. INTRO TO CODE BLUE Early CPR, Early Defib 15 ¡

  16. INTRO TO CODE BLUE Hs and Ts Hypovolemia Tension PTX Hypoxia Tamponade Hydrogen ion Toxins Hyper/hypoK Thrombosis (pulmonary) Hypothermia Thrombosis (coronary) 16 ¡

  17. INTRO TO CODE BLUE ACS ① Anti- Anti-an angi ginal al � O2, nitroglycerin, morphine ② Anti-pl plat atel elet et � 1 st : ASA (162mg PO chewable) � 2 nd : P2Y 12 inhibitor (clopidogrel, ticagrelor, or prasurgrel – not if hx stroke/TIA) � 3 rd : glycoprotein IIb/IIIa inhibitor (consider at PCI) ③ Anti-coagu oagulat ation on � If fibrinolytics: UFH, LMWH, or fondaparinux � If PCI: UFH, bivalirudin, or UFH+bivalirudin ④ Revasc ascular arizat ation on � Fibrinolytics (TNK), PCI, or CABG ⑤ Risk sk fac actor or redu eduction on � Beta-blocker, ACEi/ARB, and Statin � Aldo antagonist (e.g. eplerenone): on BB/ACEi, either sx HF or DM, and EF<40% � Quit smoking 17 ¡

  18. INTRO TO CODE BLUE ACS DOSES FOR SELECT MEDS Drug g Load oad Mai ainten enan ance e Durat ation on ASA 162mg PO 81mg/day Lifelong Clopidogrel 600mg pre-PCI 75mg/day 1 year 300mg lytics <24h 75mg > age 75 Ticagrelor 180mg 90mg BID 1 year Heparin IV bolus weight IV infusion 48h or until based (Goal 1.5-2x PTT) revascularization LMWH IV bolus weight SC injections Up to 8 days or until based revascularization ACEi - - Lifelong Beta-blocker - - Lifelong Statin - - Lifelong 18 ¡

  19. 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 19 ¡

  20. 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 20 ¡

  21. INTRO TO CODE BLUE ANAPHYLAXIS TX � 1 st 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 21 ¡

  22. INTRO TO CODE BLUE EPINEPHRINE IS FIRST LINE � 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 22 ¡

  23. INTRO TO CODE BLUE TENSION PNEUMOTHORAX � Needle decompression � 14G needle 2 nd ICS mid-clavicular line � Chest tube � 5 th ICS just anterior to midaxillary line 23 ¡

  24. INTRO TO CODE BLUE Acute Upper GI Bleed � 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) 24 ¡

  25. 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 25 ¡

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