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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 SURVEY  

Assessment   Action  ABCs   Help, O2, IV, Monitor  

SECONDARY SURVEY  Assessment   Action  

History, Vitals, Exam   Targeted Treatment  

CODE BLUE  Assessment   Action  Rhythm, Pulse   CPR/Defib, Epi, Hs&Ts, Team  

INTRO TO CODE BLUE

PRIMARY SURVEY

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Primary Survey Assessment Examples

Action Examples

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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Secondary Survey Assessment Action

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 Pulse Assessment Action

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 REDUCTION

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 need to know allergen if: -  Derm/Resp -  Derm/CVS

INTRO TO CODE BLUE

ANAPHYLAXIS TX

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1st LINE = EPINEPHRINE ADJUNCTS

PREVENTION OF 2nd LONG-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 octreotide (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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