Code Blue

Question 1

Goals of a resuscitation

Answer 1

1. Re-establishing spontaneous respiration and circulation
2. Maintaining and preserving function of vital organs

Question 2

What to do before arrival of the code team

Answer 2

1. Monitor pt complaints
   - breathless: administer oxygen, assess pain, check BP
2. Pt goes unconscious:
   - double check pt no response
   - activate code blue
   - lower bed rails, flatten bed
3. Check airway, breathing and circulation (pulse)
   - head tilt chin lift, feel for presence of carotid pulse?
   - any breathing from mouth?
4. Start CPR:
   - 30 compressions, 2 breaths

Question 3

Assessment for signs of early deterioration

Answer 3

look, listen, feel ABCDE

A (Airway);
- Assess for signs of airway obstruction (look listen feel)
- Perform head tilt chin lift or jaw thrust
- Place patient on the side
- Insert artificial airway (e.g. OPA)
- Perform suctioning

B (Breathing):
- Count RR
- Assess breathing pattern (regularity/depth)
- Assess chest movement
- Check for cyanosis
- Measure spO2
- Auscultate chest for breath sound
- Place patient in head-up position
- Initiate oxygen
- Titrate oxygen (keep spO2>94, for COPD, keep 90-92% or baseline)

C (Circulation):
- Count PR
- Palpate carotid pulse (regularity and strength)
- Measure BP
- Check for peripheral skin (colour, temp, moisture)
- Measure capillary refill time (normal <2 seconds)
- Measure temp
- Check urine output (oliguria<0.5ml/kg/hr)
- Lower pt head of bed position
- Establish IV access
- Prepare or administer IV NS 0.9%
- Attach cardiac monitor, perform 12 lead ECG

D (Disability):
- Assess LOC (GCS/AVPU)
- Examine pupil (size, equality, reaction)
- Monitor blood glucose

E (Exposure/examine):
- Expose body for physical examination (inspection, palpation, percussion, auscultation)
- Examine invasive catheter/tube/lines/drainage
(any bleeding, discharges, infection, inflammation from dressing, wound sites, IV lines)
- Examine pain (COLDSPA)
- Examine pt’s notes (e.g. history, baseline, trend)
- Examine prescribed medications
- Examine investigations result

Question 4

What do do upon arrival of code team

Answer 4

1. Inform other nurses on pt status
   e.g. Pt complained of breathlessness, suddenly turned unresponsive, no pulse, no breathing, just started CPR first cycle
2. Delegating duties
   - nurse to continue CPR
   - Nurse 1: Airway and breathing
   - Nurse 2: (Circulation nurse) ECG rhythm and drugs

Question 5

Role of airway nurse

Answer 5

1. Pull bed out and remove headboard
2. Assemble Air Viva
3. Check oral cavity and insert OPA
4. Work with compression nurse, start BVM (after 30 compressions, 2 breaths)
5. Prepare for ETT intubation, alert Dr once prepared
6. Perform suctioning to clear secretions, remove OPA
7. Hand laryngoscope to Dr’s non-dominant hand
8. Hand ETT tube to Dr’s dominant hand
9. Once ETT placement is confirmed by Dr, ventilate pt at 10-12 breaths/min (5-6 seconds/breath)

Question 6

How to assemble Air Viva? How to BVM?

Answer 6

1. Oxygen reservoir bag connect to air viva, connect to oxygen supply
2. BVM with C grip on mask and pt chin
3. Prepare and assist in intubation

Question 7

How to insert OPA?

Answer 7

1. Check size (curving towards tragus of the ear)
2. Insert in with curved side pointing towards you (and pt upper jaw), once inserted, turn 180 degrees

Question 8

How to prepare and assist in ETT intubation?

Answer 8

1. Gather logistics
   - Glove size
   - Tube size (Female: 6.5-7.5, Male: 7.5-8.5)
   - Laryngoscope size
2. Prepare logistics
   - Confirm w Dr ETT size before opening
   - Open ETT package using ANTT, leave the tube within the package
   - Use 10mls syringe to inflate ETT cuff, while keeping it within package
   - Observe cuff inflation to test for leakage, afterwards, remove the air
   - Open stylet package and lubricate lower 1/3 of stylet
   - Insert lubricated stylet into ETT while keeping ETT within package (tip of stylet must be 1-1.5cm away from distal end of ETT to avoid trauma to trachea)
   - Bend top end of stylet, while keeping ETT in package
   - Open bottom package of ETT and lubricate lower 1/3 of ETT, while keeping it in package
   - Bend and shape ETT to “Hockey stick” shape
   - Attach laryngoscope blade to handle, check light is working
   - Prepare 2 strips of durapore tape to form “trousers”, tape it to side of table
   - Prepare suctioning equipment and attached Yankauer suction tip
   - Prepare IV bolus neuromuscular blockades & sedatives as ordered to ensure smooth intubation
   - Prepare environment
3. Implementation
   - Insert OPA (if unconscious), choose correct face mask size, connect to Air Viva and oxygen source (15L of 100% oxygen)
   - Ensure a firm seal over face
   - Hyperextend pt neck/jaw thrust, pre-oxygenate using BVM to achieve SpO2>95%
   - Continuous monitoring of VS
   - Oral suctioning if necessary
   - Pass laryngoscope to Dr’s NON-DOMINANT hand
   - Pass ETT with stylet to Dr’s DOMINANT hand
   - Remove stylet from ETT once ETT placement confirmed
   - Inflate ETT cuff with 5-8mls of air
   - Connect ETT to AirViva with ETCO2 detector, ventilate at 12 breaths/min
   - Dr confirm ETT placement through auscultation (epigastric, left and right basal lung field, left and right apical lung field)
   - Note colour change of ETCO2 from purple to yellow
   - Once placement confirmed, slide ETT to corner of mouth, secure with durapore, apply durapore around ETT, each at opposite direction and secure to pt’s cheek, measure lip marking
   - Check ETT cuff pressure (20-30)

Question 9

Role of circulation nurse (up till ROSC)

Answer 9

1. Stand at the side opposite the compression nurse
2. Apply 3-lead ECG. Once done, instruct “STOP CPR”. Analyse cardiac rhythm, identify what kind of arrhythmia, check for pulse
   e.g. Identified VT, continue to check for pulse (not more than 10 seconds) —- no pulse: Pulseless VT
3. Instruct “PLEASE CONTINUE CPR”. Prepare for defibrillation
4. Establish IV access, initiate IV NS 0.9%
5. Report event to Dr using ISBAR
6. Dr will instruct: Prepare for defibrillation 150 joules, prepare for intubation (for airway nurse)
7. Before administering shock, repeat “defib set at 150 joules, now i will administer the first shock”, “STAND CLEAR”, ensure ALL HANDS OFF PATIENT BEFORE delivering shock, “Continue CPR”
8. After 2 mins (5 cycles) of CPR, analyse cardiac rhythm, “PLS STOP CPR”
   e.g. VF identified
9. Dr instruct nurse to prepare IV adrenaline 1:10,000
   - repeat to confirm order with Dr “I repeat, IV Adrenaline 1:10,000 bolus to be administered to pt now”
   - prepare 1mg/ml Adrenaline, 9 mls of Nacl 0.9%
   - check back IV med with Dr “this is 1mg/1ml of Adrenaline diluted in 9mls of NS”
10. Administer IV Adrenaline
    - verbalise administration “I’m giving 1st dose of IV Adrenaline 1:10,000 to (Pt) now at (time)”
    - swab first, connect syringe, turn to open stopcock, inject in adrenaline, afterwards, flush with 10-20mls of NaCl 0.9%
    - afterwards, verbalise completion of administration “Dr, first dose of IV Adrenaline 1:10,000 has been given to pt at (time)
    - keep ampoules used in tray for verification
11. After intubation, analyse rhythm
    e.g. If cardiac rhythm still shows VF after failed 1st shock, this is refractory VF
12. If refractory VF: Prepare for second dose of shock, prepare IV Adrenaline and IV Amiodarone
    - IV Adrenaline 1mg every 3-5mins with
    - IV Amiodarone 300mg, repeat at 150mg if necessary
    - repeat Dr order “IV Adrenaline 1:10,000, IV Amiodarone 300mg”
    - prepare and check back medications with Dr
    - Verbalise the time and dose of IV medication administered once done
    - Continue CPR when drugs are being administered
13. Analyse rhythm after drugs administered
14. If sinus rhythm, check for presence of carotid pulse
15. Keep track of cardiac rhythm, CPR cycles, drug administration and defibrillation (joules delivered)

Question 10

How to report event to Dr using ISBAR

Answer 10

I: Identify
- Pt name, age, ward & bed no.

S: Situation
- e.g. Complained of sudden chest pain, turned unresponsive (no pulse, no breathing)
- e.g. CPR initiated 2 mins ago

B: Background
- e.g. pt admitted for unstable angina, history of HTN, HLD

A: Assessment
- e.g. IV access is established, running NS 0.9%
- e.g. 5 cycles of CPR completed

R: Recommendation
- e.g. suggest that we analyse rhythm now

Question 11

How to initiate IV NS 0.9%

Answer 11

1. Swab opening of IV
2. Connect to prepared NS
3. Turn stopcock

Question 12

Placement of ECG Leads (3 lead)

Answer 12

Red electrode: Under RIGHT clavicle, near right shoulder, within rib cage frame

Yellow electrode: Under LEFT clavicle, near left shoulder, within rib cage frame

Green electrode: LEFT side below pectoral muscles, lower edge of left rib cage

Question 13

How to defibrillate patient?

Answer 13

1. Apply defib pad to protect pt’s skin (right upper below collar bone, left lower)
2. Before applying ECG electrodes, check and remove any:
   - metal (jewellery)
   - flammable gas/air
   - moisture (wipe away sweat)
   - hair and medicine patch

Question 14

Role of compression nurse

Answer 14

1. Continue CPR, DON’T stop

Question 15

Role of scribe

Answer 15

1. Record the number and time of shock
2. Record e-drugs given to patient and time

Question 16

What to do upon Return of Spontaneous Circulation (ROSC)?

Answer 16

1. Stop CPR
2. Monitor vitals
3. Prepare to transfer patient to ICU
   - A: BVM, portable ventilator, portable suction pump
   - B: Oxygen tank
   - C: Defib + e drugs + portable VS monitor
   - D: Documents and Drs (pt’s notes and charts)
   - E: Check pt’s env, pt’s belongings
   - F: Inform family members
4. Clean/replace equipment/consumables used in resuscitation
5. Nurses’ debrief and reflection

Question 17

What are the 4 types of arrthymias?

Answer 17

1. V fib
2. Pulseless VT
3. Pulseless electrical activity
4. Asystole

Question 18

General cycle of VF/Pulseless VT management (Algorithm 1)

Answer 18

1. Analyse rhythm
2. IF VF: SHOCK
   IF VT, CHECK PULSE, IF NO
   PULSE, SHOCK
3. Continue CPR 2 mins WHILE:
   - ETT intubation
   - BVM to receive 10-12 breaths/min
   - establish IV access, administer adrenaline 1mg, flush with NS 0.9%, note time and dosage given
4. Analyse rhythm again after 2 mins CPR
5. If failed 1st shock, if still VF/VT (recurrent or refractory), deliver another shock
6. Continue CPR 2 mins WHILE:
   - administering IV Adrenaline 1mg and IV Amiodarone 300mg
   - Flush line with normal saline 10-20mls after each drug
   - Note time and dosage given
7. Analyse rhythm again after 2 mins
8. If return to sinus rhythm, return to post cardiac care

Note: Follow the sequence “Shock–CPR, Shock—CPR”

Question 19

General cycle of Asystole/PEA (Algorithm 2)

Answer 19

1. Analyse rhythm
2. If PEA or ASYSTOLE
3. Continue CPR for 2 mins WHILE:
   - establish IV access
   - administer IV adrenaline 1mg every 3-5mins, ETT insertion, BVM 10-12 breath/min
4. Analyse rhythm again

Question 20

What to do in post cardiac arrest care

Answer 20

1. Gather information, ensure proper documentation
2. When ROSC is restored, liaise and arrange for transfer to ICU
   - prepare for safe transportation: portable defib monitor, portable oxylog ventilator, E-kit
3. Condition for transfer: SBP stabilised ot above 90mmHg for continuous 15mins
4. Speak to family members

Question 21

What to monitor during post cardiac arrest care, when ROSC is established?

Answer 21

1. Keep SpO2 between 94-99%, avoid hyperoxia (which may cause re-perfusion injury)
2. IV therapy to maintain adequate hydration to optimise BP, HR and urinary output
3. Administer anti-arrthymics as continuous infusion (infusion pump) if required
4. Monitor VS, maintain SBP>90mmHg
5. Perform 12 lead ECG after ROSC if required (to rule out coronary involvement
6. Keep temp between 33-36deg (to lower metabolism and allow VS to stabilise)

Question 22

What drugs are used for cases of VF/Pulseless VT?

Answer 22

1. Adrenaline
2. Amiodarone
3. Lignocaine
4. Magnesium

Note: Drugs are used to start the heart, preserve coronary and cerebral circulation

Question 23

What drugs are used for PEA?

Answer 23

1. Adrenaline
2. Others e.g. Potassium, calcium, antidotes

Question 24

What drugs are used for asystole?

Answer 24

1. Adrenaline

Question 25

Assess ECG

Answer 25

1. Ventricular Fibrillation (VF) - uncoordinated myocardial electrical activity, uncoordinated electrical impulses - heart is quivering rather than contracting - no pulse generated - Appearance on ECG: Messy waves, extremely irregular rhythm 2. Pulseless Ventricular Tachycardia - rapid, coordinated myocardial electrical activity, with absence of myocardial mechanical activity - heart is generating rapid, coordinated electrical impulses from left ventricle, however no pulse present - Appearance on ECG: regular "M" shaped big waves 3. Pulseless Electrical Activity (PEA) - non-VF/VT and non-asystole rhythm - rhythm unable to generate any cardiac output, pt is pulseless - try to find and treat any reversible causes (6 Hs and 6 Ts) 4. Asystole - complete cessation of both electrical and mechanical activity - heart not generating any electrical impulses or a pulse

Question 26

Common Reversible Causes of PEA (6Hs and 6Ts)

Answer 26

6Hs: 1. Hypovolemia - treatment: fluid resus 2. Hypoxia - treatment: ventilation 3. Hydrogen ion-acidosis - treatment: sodium bicarbonate 1mEq/kg 4. Hyperkalemia - treatment: remove potassium/dialysis 5. Hypokalemia - treatment: replace potassium 6. Hypothermia - treatment: warm patient 6Ts 1. Tablets (overdose, accidents) - treatment: antidote 2. Tamponade cardiac - treatment: pericardiocentesis 3. Tension pneumothorax - treatment: needle compression of chest 4. Thrombosis coronary (ACS) - treatment: resuscitation, revascularisation, PCI 5. Thrombosis pulmonary - treatment: thrombolytics/surgery