Code Blue Flashcards
Goals of a resuscitation
- Re-establishing spontaneous respiration and circulation
- Maintaining and preserving function of vital organs
What to do before arrival of the code team
- Monitor pt complaints
- breathless: administer oxygen, assess pain, check BP - Pt goes unconscious:
- double check pt no response
- activate code blue
- lower bed rails, flatten bed - Check airway, breathing and circulation (pulse)
- head tilt chin lift, feel for presence of carotid pulse?
- any breathing from mouth? - Start CPR:
- 30 compressions, 2 breaths
Assessment for signs of early deterioration
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
What do do upon arrival of code team
- Inform other nurses on pt status
e.g. Pt complained of breathlessness, suddenly turned unresponsive, no pulse, no breathing, just started CPR first cycle - Delegating duties
- nurse to continue CPR
- Nurse 1: Airway and breathing
- Nurse 2: (Circulation nurse) ECG rhythm and drugs
Role of airway nurse
- Pull bed out and remove headboard
- Assemble Air Viva
- Check oral cavity and insert OPA
- Work with compression nurse, start BVM (after 30 compressions, 2 breaths)
- Prepare for ETT intubation, alert Dr once prepared
- Perform suctioning to clear secretions, remove OPA
- Hand laryngoscope to Dr’s non-dominant hand
- Hand ETT tube to Dr’s dominant hand
- Once ETT placement is confirmed by Dr, ventilate pt at 10-12 breaths/min (5-6 seconds/breath)
How to assemble Air Viva? How to BVM?
- Oxygen reservoir bag connect to air viva, connect to oxygen supply
- BVM with C grip on mask and pt chin
- Prepare and assist in intubation
How to insert OPA?
- Check size (curving towards tragus of the ear)
- Insert in with curved side pointing towards you (and pt upper jaw), once inserted, turn 180 degrees
How to prepare and assist in ETT intubation?
- Gather logistics
- Glove size
- Tube size (Female: 6.5-7.5, Male: 7.5-8.5)
- Laryngoscope size - 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 - 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)
Role of circulation nurse (up till ROSC)
- Stand at the side opposite the compression nurse
- 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 - Instruct “PLEASE CONTINUE CPR”. Prepare for defibrillation
- Establish IV access, initiate IV NS 0.9%
- Report event to Dr using ISBAR
- Dr will instruct: Prepare for defibrillation 150 joules, prepare for intubation (for airway nurse)
- 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”
- After 2 mins (5 cycles) of CPR, analyse cardiac rhythm, “PLS STOP CPR”
e.g. VF identified - 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” - 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 - After intubation, analyse rhythm
e.g. If cardiac rhythm still shows VF after failed 1st shock, this is refractory VF - 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 - Analyse rhythm after drugs administered
- If sinus rhythm, check for presence of carotid pulse
- Keep track of cardiac rhythm, CPR cycles, drug administration and defibrillation (joules delivered)
How to report event to Dr using ISBAR
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
How to initiate IV NS 0.9%
- Swab opening of IV
- Connect to prepared NS
- Turn stopcock
Placement of ECG Leads (3 lead)
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
How to defibrillate patient?
- Apply defib pad to protect pt’s skin (right upper below collar bone, left lower)
- Before applying ECG electrodes, check and remove any:
- metal (jewellery)
- flammable gas/air
- moisture (wipe away sweat)
- hair and medicine patch
Role of compression nurse
- Continue CPR, DON’T stop
Role of scribe
- Record the number and time of shock
- Record e-drugs given to patient and time
