CODE BLUE Flashcards
First drug to use in pulseless cardiac arrest (asystole/PEA)
* Dose and Route
1 mg every 3-5 min
- 0.1 mg/ml 10 ml syringe
- No max amount of epi during a code
Anaphylaxis
- 3 to 0.5mg IM every 5 minutes
* 1mg/ml (vial) or auto-ready devices
* If anaphylaxis refractory to IM admin, may give 0.1 mg IV over five min (FURTHER DILUTED IN 9 ML OF NS)
Bradycardia - if atropine is ineffective, what do you give next?
Atropine 0.5mg -1mg q 3-5min, give 1mg if severe bradycardia. Max of 3mg.
Epinephrine
- IV infusion
- 2 to 10 mcg/min
- 2mg/100 ml NS or 10mg/500 ml NS (conc 2mcg/ml or 0.02 mg/ml)
Hypotension or septic shock
epinephrine
- IV infusion
- 0.1 to 0.5 mcg/kg/min
- 2mg/100 ml NS or 10mg/500 ml NS (conc 2mcg/ml or 0.02 mg/ml)
VTach/Vfib
- IVP/IO
- 1 mg every 3 to 5 min
- 0.1mg/ml 10ml syringe
- *same as ASYTOLE/PEA
Side effects of epinephrine and what to monitor
epinephrine’s B-1 receptor effects can result in myocardial ischemia and potentially fetal arrhythmias. Monitor during administration for tachycardia and HTN
* Epi is not compatible with sodium bicarb and may not be as effective in acidotic states
MOA of Epinephrine during a code
Acts as a peripheral vasoconstrictor and coronary artery vasodilator
For reture of spontaneous circulation during cardiac arrest - which one is the first choice epinephrine or vasopressin
epinephrine
- vasopression (antidiuretic) is non-inferior to epinephrine in improving return of spontaneous circulation during cardiac arrest, it has been removed for the simplicity.
- vasopressin may work better than epinephrine in acidotic and low oxygen states **
When do you use vasopressin during a cardiac arrest?
- Following return of spontaneous circulation, the prescriber may request a vasopressin drip to help decrease infusions of adrenergic agonists
- ** vasopressin may work better than epinephrine in acidotic and low oxygen states **
For VTach/Vfib that is unresponsive to two prior cycles of CPR/shock/epinephrine, what do you use?
*dose and route
- Amiodarone 300 mg IV push
- If still unresponsive give 2nd dose at 150 mg iv push. flush the line afterwards with 10 ml ns
- after pt has recovred spontaneous circulation, start an amiodarone iv infusion at a rate of 1mg/min x 6 hrs, then decrease to 0.5 mg/min x 18 hrs for a total infusion duration of 24 hrs
Massive Pulmonary Embolism
Obtain 100 mg alteplase if the pateint has an acute PE and any of the following: hypotension and profound bradycardia (<40 beats per min)- cardiac arrest
For respiratory failure (intubation): For Induction
- prefer *Etomidate 0.3 mg/kg IV (max 20mg)
- Propofol 1.5 mg/kg once (continuous infusion may be started if sedation is required)
- Ketamine 1.5 mg/kg IV
Etomidate: onset 60 secs, duration 3-5 min, may cause myoclonic activity, lower sz threshold in pt with known seizures
Propofol: may cause hypotension
Ketamine:
- 100 mg/ml must be diluted w/equal part NS if given IV
- Might cause hallucinations
- drip may be used to lower narcs
Agents for induction: etomidate, ketamine, midazolam, propofol
For respirator failure (paralytics):
- Succinylcholine 1-2 mg/kg IVP (common dose in ER 100mg = 5 ml)
onset 30-60 sec, duration 30-60 min - Rocuronium 0.6-1.2 mg/kg (common dose 60-100mg = 6-10 ml)
- Vecuronium 10 mg vial: 0.1-0.25 mg/kg ivp. Reconstitute with 10ml NS = 1mg/ml. Common dose in ER 10 mg = 10 ml. Onset 2.5-5 min, duration 30-40 min
St. Joe Hospital paralytics (2 step process if pt is transport to CT)
- ) Intubation: Rocuronium 1-1.2 mg/kg IVP
2) for trans to CT: half the dose of the original dose 0.5-0.6 mg/kg ivp
For respiratory failure (intubation): Sedation
- Loading dose fentanyl: 1.0 mcg/kg IVP
- Infusion dose: fentanyl 1 mcg/kg/hr IV gtt (consider increase if opioid tolerant)
3. Loading dose: Versed 2mg IVP
4. Infusion dose: Versed 2mg/hr IV gtt
For respiratory failure (intubation): Consideration for Neurotrauma patients once pt returned from CT. If a neurosurgen is requiring a critical sensitive neurologic exam. _____ medication can be considered, but ONLY when the ___ is present and a decision is being made to take the patient to the OR or not.
- Sugammadex (Bridion)
- Neurosurgeon
Sugammadex: reveral of rocuronium or vecuronium- induced blockade (2-4mg/kg). Readministration of rocuronium or vecuronium - wait 24 hours or use cisatracurium
The pt has vTach/vFib and has not responded to epi and amiodarone. Which other medication can be tried?
Lidocaine 2% (20mg/ml) syringe
- Initial dose: 1 to 1.5 mg/kg IV/IO
- After 5 to 10 minutes, may repeat half the dose 0.5 to 0.75 mg/kg
- Max 3 mg/kg
- After spontaneous circulation returns, start drip at 1-4 mg/min
- May be given down endotracheal.
- Even with titration drip, levels will likely drop below therapeutic levels - injected boluses of 0.5mg/kg lidocaine may be given to avoid breakthrough arrhythmias.
- Lidocaine is sometimes added to amiodarone for refractory ventricular arrhythmias - amio slow down the metabolism of lidocaine
Treatment of torsades de pointes (polymorphic Vtach associated with prolonged QT interval)
Magnesium sulfate
* Initial dose: 1 to 2 g IV/IO over 5 to 20 min (mix with 10 ml NS)
- Cuase: low magnesium
- SE to monitor while administering magnesium - hypotension associated with rapid administration
A male patient has just fainted. A code blue is announced and you respond as part of the code team. He is breathing on his own, but bradycardia is noted on the EKG with heart rate of 45. What medication should be given first? If he doesn’t respond to first-line medication, what medication should be tried next?
1) Atropine 0.5mg rapid iv push, then 1mg, total max of 3mg.
2. If atropine does not work, perform pacing or initiate dopamine (2 to 10 mcg/kg/min) or epinephrine (2 to 10 mcg/min) drip.
