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CODE BLUE

CODE BLUE. Dr. Hesham Amgad. PURPOSE. To provide an appropriate response to a suspected or eminent cardiopulmonary arrest or a medical emergency for an adult or pediatric patient. POLICY .

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CODE BLUE

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  1. CODE BLUE Dr. HeshamAmgad

  2. PURPOSE • To provide an appropriate response to a suspected or eminent cardiopulmonary arrest or a medical emergency for an adult or pediatric patient.

  3. POLICY • Code Blue is called for patients who do not have an advance healthcare directive indicating otherwise. • Code Blue is to be initiated immediately whenever an individual is found in cardiac or respiratory arrest. • In areas where pediatric patients are routinely admitted there should be a pediatric crash cart available. • If a Code Blue is called in an area without a pediatric crash cart, the designated response team will bring a crash cart with pediatric equipment.

  4. PROCEDURES • Code Blue team members function within their respective scopes of practice and utilize guidelines set by the American Heart Association on Advanced Cardiac Life Support. • The members perform functions that include, but are not limited to, the following:

  5. Person discovering child in cardiopulmonary arrest • Assesses patient’s airway, breathing and circulation. • Calls for help. • Initiates CPR and notes time. • Does not leave the patient.

  6. First responding physician • Assumes the role of Code Blue team leader. • Initiates direct emergency orders, as appropriate. • May transfer responsibility of team leader to attending physician or ICU department physician. • Team leader signs the Code Blue record.

  7. Personnel from department calling the Code • Initiates Code Blue per facility protocol. • Assesses patient and begins procedures to open airway, begins rescue breathing and/or initiates CPR, as indicated. • Obtains crash cart. • Attaches monitor leads. • Assumes compressions and/or ventilation until the Code Blue response team arrives.

  8. Nurse assigned to patient • Provides most recent data on the patient. • Brings chart to room and acts as information source. • Signs Code Blue record.

  9. ICU nurse with appropriate training • Responds to area/department where Code is called. • Ensures placement of cardiac monitor and assesses initial rhythm. • Establishes IV line and administers medications as ordered. • Mixes medication, solutions and labels medication during code. • Signs Code Blue record.

  10. ICU Physician • Assumes the role of Code Blue team leader. • Initiates direct emergency orders, as appropriate. • Directs and delegates code responsibilities to nursing and other personnel. • Performs ongoing evaluation of patient status. • Monitors and evaluates CPR procedures. • Orders medication according to guidelines. • Interprets EKG rhythm and defibrillates according to guidelines. • Signs Code Blue record.

  11. Anesthesiologist • Assumes ventilation responsibilities upon arrival. • Assists with intubation and obtains blood gases when needed. • Stays with patient through transport. • Signs Code Blue record.

  12. Pharmacist • Calculates drip rates and dosages. • Monitors drug administration. • Ensures medications ordered conform to guidelines. • Records all medication administered during the code. • Acts as a resource. • Signs the Code Blue record.

  13. Charge nurse • Records data on Code Blue record. • Acts as communication liaison to attending physicianand family. • Supports family members present during event. • Acts as a resource and helps coordinate Code Blue. • Assists staff in evaluation of performance during code event.

  14. Communication Service/facility operator • Voice pages Code Blue and location when notified. • Sets off pager system to appropriate Code Blue team members.

  15. Security • Coordinates necessary movement of other patients and visitors. • Manages crowd control.

  16. PALS

  17. Medications

  18. A.SUBSTRATE DELIVERY

  19. Glucose  Indications: • Documented hypoglycemia. • Empiric treatment when glucose determination is not available and the infant or child has symptoms of hypoglycemia or is at risk for developing hypoglycemia. Dose and administration: • 0.5 to 1 g/kg. intravenous; 2 to 4 mL/kg of D25W, 5 to 10 mL/kg of D10W or bolus of 10 to 20 mL/kg D5% / NS • Maximum concentration of glucose that can be administered through a peripheral vein is 10 percent dextrose in water.

  20. B.CARDIAC ARREST

  21. Epinephrine Indications: • Treatment of cardiac arrest. • Symptomatic bradycardia not responsive to oxygen and ventilation. • Hypotension not responsive to fluid administration. Dose and administration: • Intravenous: 0.01 mg/kg (0.1 mL/kg of 1 mg/10 ml solution), repeated every three to five minutes as needed. • Endotracheal: 0.1 mg/kg (0.1 mL/kg of undiluted solution), repeated every three to five minutes as needed • Optimal endotracheal drug absorption depends upon delivery of the drug as deeply as possible into the airway. The epinephrine dose should be diluted with normal saline to a volume of 3 to 5 mL and instilled into the endotracheal tube. • It also may be delivered beyond the tip of the endotracheal tube with a suction catheter followed by a 3 to 5 mL saline flush. • Several positive-pressure breaths should be given after endotracheal administration of epinephrine.

  22. C.TACHYARRHYTHMIAS

  23. Adenosine  Indication and contraindications: • Drug of choice for the acute medical conversion of SVT unresponsive to vagal maneuvers. • In children with Wolff-Parkinson-White syndrome, adenosine administration for SVT can cause atrial fibrillation with progression to ventricular fibrillation. • Adenosine should be avoided in patients with a wide QRS complex tachycardia since it can provoke severe hemodynamic deterioration in those who have ventricular tachycardia rather than an SVT. • Adenosine is also contraindicated in patients with pre-existing second or third degree heart block or sinus node disease. Dose and administration: • Initial dose SVT: 0.1 mg/kg rapid IV push (maximum first dose 6 mg) followed immediately with a 5 mL saline flush to promote drug entry into the systemic circulation. • Because the elimination half-life of adenosine is 10 seconds, it should be given in an intravenous line as close to the heart as possible. If adenosine is given too slowly or with an inadequate saline flush, then less drug may reach the heart and decrease efficacy. • The use of two syringes (one with adenosine and the other with normal saline flush) connected to a T-connector or a stopcock is a useful way of ensuring rapid and effective drug delivery. • Subsequent doses may be increased by 0.1 mg/kg to a maximum single dose of 0.3 mg/kg (maximum total single dose 12 mg). In children >50 kg, the initial adult dose of 6 mg should be given with subsequent doses being the maximum single dose of 12 mg. • The most common side effects reported after adenosine administration are flushing, chest discomfort, nausea and headache. Transient sinus bradycardia or heart block may occur, usually lasting between 10 and 40 seconds.

  24. Amiodarone Indications and contraindications: • Treating both ventricular and supraventricular arrhythmias that are resistant to other therapies. • Treatment of pulseless ventricular arrhythmias or stable ventricular arrhythmias. • Supraventricular tachycardia that is refractory to adenosine. Dose and administration: • 5 mg/kg (maximum single dose: 300 mg), repeated up to a maximum daily dose of 15 mg/kg (maximum recommended daily dose 2.2 grams).

  25. Lidocaine Indication and contraindications: • Treatment of pulseless ventricular arrhythmias that are refractory to high quality cardiopulmonary resuscitation, defibrillation, and epinephrine when amiodaroneis not available. • Lidocaine is contraindicated in patients with Wolff-Parkinson-White syndrome and those who are allergic to amide-type local anesthetics. • May also cause seizures and myocardial and circulatory depression, especially in children with poor cardiac output and those with renal or liver failure. Dose and administration: • 1 mg/kg intravenous bolus followed by an IV infusion of 20 to 50 mcg/kg/minute. • If the start of the infusion will be delayed longer than 15 minutes, a second IV bolus dose of 0.5 to 1 mg/kg may be given.

  26. Magnesium sulfate  Indications and contraindications: • Treatment of torsades de pointes (polymorphic ventricular tachycardia characterized by a gradual change in the amplitude and twisting of the QRS complexes around the isoelectric line). • Documented hypomagnesemia.   Dose and administration: • 25 to 50 mg/kg intravenous (maximum dose: 2 grams). • For torsades de pointes, magnesium sulfate should be diluted in 5 percent dextrose (D5W) to a 20 percent solution or less and given as an intravenous infusion. • Patients with pulseless arrest: infuse over 1 to 2 minutes. • Perfusing patients: infuse over 15 minutes because rapid infusion is associated with hypotension and asystole.

  27. D.LIMITED INDICATIONS

  28. Atropine Indications and contraindications: • Bradycardiacaused by increased vagal tone or primary atrioventricular block or unresponsive to oxygen, airway support, and administration of epinephrine. Dose and administration: • Intravenous: 0.02 mg/kg (max dose 0.5 mg), repeated once if needed. • Endotracheal: 0.04 to 0.06 mg/kg, repeated once . • When given endotracheally, the atropine dose should be diluted with normal saline to a volume of 3 to 5 mL and instilled into the endotracheal tube. • It may also be delivered beyond the tip of the endotracheal tube with a suction catheter, followed by a 3 to 5 mL saline flush. • Several positive-pressure breaths should be given after endotracheal administration of atropine.

  29. Calcium  Indications and contraindications: • Calcium has a very specific indication in cardiac arrests as emergency protection against the arrhythmogenic effects of hypocalcemia, hyperkalemia, hypermagnesemia, or calcium channel blocker overdose. • It is otherwise not recommended for pediatric cardiopulmonary arrest because of an observed association with decreased survival and poor neurologic outcomes after pediatric arrests. Dose and administration: • The recommended dose of elemental calcium is 5 to 7 mg/kg. • Dosing in this range can be achieved by giving 0.2 mL/kg of calcium chloride 10 percent which provides 5.4 mg/kg of elemental calcium or 0.6 mL/kg of calcium gluconate 10 percent which provides 5.6 mg/kg of elemental calcium. • The maximum single dose is 540 mg of elemental calcium. • Calcium chloride is preferred over calcium gluconate because it provides greater bioavailability of calcium but should only be given if central venous access is available because administration through a peripheral intravenous line is associated with skin necrosis and sloughing. Calcium gluconate is less irritating to the veins and may be administered by peripheral or central venous access. • Calcium chloride or calcium gluconate should be administered by slow intravenous push over 10 to 20 seconds in cardiac arrest and more slowly (over 5 to 10 minutes) in perfusing patients. • Rapid administration may cause bradycardia or asystole.

  30. Sodium bicarbonate Indications and contraindications: • The American Heart Association recommends that sodium bicarbonate be considered only in children with prolonged cardiac arrest and documented severe metabolic acidosis who fail to respond to oxygenation, ventilation, fluids, and chest compressions combined with epinephrine in recommended doses. • Sodium bicarbonate also may be considered when shock is associated with documented metabolic acidosis. • In children without cardiac arrest or shock, metabolic acidosis typically resolves with adequate volume replacement and ventilatory support. • Additional indications for the administration of sodium bicarbonate include hyperkalemia, hypermagnesemia, tricyclic antidepressant overdose, or overdose from other sodium channel blocking agents. • Sodium bicarbonate administration should not be given to children with inadequate ventilation because inadequate respiratory excretion of carbon dioxide will lead to retention and worsening respiratory acidosis. • Excess administration of sodium bicarbonate during resuscitation has been associated with hypertonicity, worsening of intracellular acidosis with impairment of myocardial contractility and extreme metabolic alkalosis with reduced oxygen delivery to the tissues, hypokalemia, and decreased plasma ionized calcium concentration. • All of these adverse effects increase the risk for cardiac arrhythmias. Dose and administration: • 1 mEq/kg (1 mL/kg of 8.4 percent solution or 2 mL/kg of 4.2 percent solution [recommended for children younger than six months of age]). • The usual maximum single dose of sodium bicarbonate is 50 mEq for a child to 100 mEq for an adult patient. • During prolonged arrests, subsequent doses of 0.5 mEq/kg each may be given every 10 minutes by slow (one to two minutes) infusion or based upon blood gas analysis. • IV tubing must be irrigated with normal saline before and after giving infusions of sodium bicarbonate to prevent inactivation of administered epinephrine or, in hypocalcemic or hyperkalemic patients, precipitation with calcium chloride.

  31. THANK YOU

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