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INTRO TO CODE BLUE

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INTRO TO CODE BLUE

PURPOSE

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Experience management of code blues Suggest plans for acute care cases ¡ Practice leadership and teamwork skills ¡ Practice early CPR and defibrillation

INTRO TO CODE BLUE

CASES

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ACS | VF ¡ Anaphylaxis | Asystole ¡ Tension PTX | Pulseless VT ¡ Upper GI Bleed | PEA ¡

INTRO TO CODE BLUE

LOGISTICS

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SIM ¡

Debrief ¡

TEAM LEADER (MD) ¡ AIRWAY (RT) ¡ CPR (RN) ¡ MEDS/ DEFIB (RN) ¡ RECORDER (RN) ¡

INTRO TO CODE BLUE

OSCE FORMAT

PRIMARY Y SURVEY ¡

Assessment ¡ Action ¡

ABCs ¡ Help, O2, IV, Monitor ¡

SECONDARY Y SURVEY ¡

Assessment ¡ Action ¡

History, Vitals, Exam ¡ Targeted Treatment ¡

CODE CODE BLUE BLUE ¡

Assessment ¡ Action ¡

Rhythm, Pulse ¡ CPR/Defib, Epi, Hs&Ts, Team ¡

INTRO TO CODE BLUE

PRIMARY SURVEY

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Primar ary Survey ey Assessm ssessmen ent Exam xampl ples es Action

• n

Exam xampl ples es

Immediately life-threatening Airway: patency, secretions, obstruction Breathing: RR, O2 Sat, work of breathing, lung sounds, tracheal deviation Circulation: HR, BP, LOC, bleeding, temperature Call for help O2 Needle decompression IV Monitor Fluids

INTRO TO CODE BLUE

SECONDARY SURVEY

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Sec econ

• ndar

dary Survey ey Assessm ssessmen ent Action

• n

Systematic survey History (SAMPLE) Signs and symptoms Allergies Medications PMHx Last oral intake Events prior Vitals Head-to-toe Exam Investigations Differential diagnoses Treatments

INTRO TO CODE BLUE

ARREST RHYTHMS

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VF Pulseless VT

Only 2 “shockable” (defib) arrest rhythms

Asystole

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

PEA

Other arrest rhythms, including asystole and PEA, should NOT be defib

INTRO TO CODE BLUE

CODE BLUE ALGORITHMS

Pulseless VT, VF SHOCK SHOCK EPI

2min CPR Rhythm/Pulse 2min CPR Rhythm/Pulse

Nothing Nothing EPI

2min CPR Rhythm/Pulse 2min CPR Rhythm/Pulse

Asystole, PEA

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Shockable (Pulseless VT, VF): try 2 shocks before EPI Non-shockable (Asystole, PEA): may give EPI early 1:10,000 EPI 1mg IV q4 min

INTRO TO CODE BLUE

CODE BLUE EXAMPLE

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Rhythm Rhythm Pulse se Assessm ssessmen ent Action

• n

VT None Pulseless VT arrest Start CPR 200J shock/defib 2 minutes of CPR VF None VF arrest Resume CPR 200J shock/defib 1mg epi 1:10,000 IV 2 minutes of CPR Asystole None Asystole Resume CPR No shock/defib 2 minutes of CPR Bradycardia None PEA Resume CPR No shock/defib 1mg epi 1:10,000 IV 2 minutes of CPR No response, not breathing

INTRO TO CODE BLUE

EARLY CPR, EARLY DEFIBRILLATION

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INTRO TO CODE BLUE

Hs AND Ts

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

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INTRO TO CODE BLUE

Narrow VS Wide Complex PEA

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INTRO TO CODE BLUE

ACUTE CORONARY SYNDROME (ACS)

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O2 Nitroglycerin Morphine ASA Ticagrelor or Clopidogrel UFH or LMWH Thrombolytic PCI CABG

RISK REDUCTI TION

βB ACEi/ARB Statin Lifestyle changes

INTRO TO CODE BLUE

ANAPHYLAXIS

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57% unrecognized or not labeled in ED Multisystem syndrome Distributive shock (widespread vasodilation) Hypovolemic shock

(fluid extravasation, reduced venous return)

INTRO TO CODE BLUE

ANAPHYLAXIS 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

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2+ sBP Adults <90 Decrease 30% Exposure to allergen & either:

Do

• NOT

T need eed to

• kn

know

• w al

aller ergen gen if:

• Der

erm/R /Resp esp

• Der

erm/C /CVS

INTRO TO CODE BLUE

ANAPHYLAXIS TX

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1st

st L

LINE INE = E = EPINE PINEPHRINE PHRINE ADJU JUNCTS TS PREVENTI TION OF 2nd

nd

LONG-TE TERM

1:1000 epinephrine IM anterolateral thigh Adults: 0.3 mg Peds: 0.15 mg Shock/CVS: fluids Resp: oxygen, salbutamol Derm: H1 and H2 blocker βB: glucagon Steroids may prevent biphasic or protracted anaphylaxis Epinephrine injector Wear/carry allergy identification

INTRO TO CODE BLUE

EPINEPHRINE IS FIRST LINE

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Vasoconstriction Increased peripheral vascular resistance Decreased mucosal edema and membrane leakage

α1 β1 β2

Increased inotropy (contractility) Increased choronotropy (heart rate) 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 Alternate site: 5th ICS just anterior to mid-axillary line

INTRO TO CODE BLUE

TENSION PNEUMOTHORAX

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Chest tube: 5th ICS just anterior to mid-axillary line

INTRO TO CODE BLUE

Acute Upper GI Bleed

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Fluids, O negative blood Crossmatch (note: 1 unit = 10 Hb) Transfuse blood (if Hb < 70)

Manage Consults Early Intubation Meds

Antibiotics for cirrhotic pts. Consider PPI (ulcers) and

• ctreotide (varices), but may

not decrease mortality rate. Consider if:

• 1. Ongoing hematemesis
• 2. Altered respiratory status
• 3. Altered mental status

Consider:

• 1. GI
• 2. ICU
• 3. General Surgery
• 4. Interventional Radiology

INTRO TO CODE BLUE

ACLS EFFECTIVE TEAM DYNAMICS

Re-evaluation and summarizing*

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Closed-loop communication*

Clear messages*

Clear roles and responsibilities*

Knowing one’s limitations

Knowledge sharing Constructive intervention

Mutual respect

Slides by: Anthony Seto Cardiac Arrest Content Reviewer: Natalia Jaworska ACS Content Reviewer: Patricia Lee Anaphylaxis Content Reviewer: Kia Rokui Tension PTX Content Reviewer: Ryan Wilke UGIB Content Reviewer: Christina Yang, Niky Antony

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