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INTRO TO CODE BLUE

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INTRO TO CODE BLUE

PURPOSE

!  Experience management of code blues

!  Suggest initial management plans of acute care cases

!  Practice leadership, communication, collaboration, and interdisciplinary teamwork skills

!  Practice effective CPR and early defibrillation

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INTRO TO CODE BLUE

OBJECTIVES By the end of Intro To Code Blue (ITCB), medical students will be able to:

!  Demonstrate an approach to the assessment of an acute care patient (i.e. ABCs) !  Suggest initial management plans for select acute care patient presentations

(ACS, anaphylaxis, tension pneumothorax, and UGIB) !  Demonstrate an approach to the management of cardiac arrest cases !  Discuss the importance of early CPR and defibrillation in cardiac arrest cases !  Demonstrate effective CPR and BVM techniques !  Demonstrate accurate dosing and frequency of epinephrine administration in

cardiac arrest cases !  Select the appropriate defibrillation dose for cardiac arrest cases !  Recognize the following rhythms: VF, VT, PEA, asystole !  Demonstrate the management of VF and pulseless VT !  Demonstrate the management of asystole and PEA !  List causes of cardiac arrest, using H’s and T’s as a mnemonic !  Describe and demonstrate the ACLS elements of effective team dynamics !  Discuss the roles of the interdisciplinary health care team in cardiac arrest cases

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INTRO TO CODE BLUE

CASES

①  ACS | VF

②  Anaphylaxis | Asystole

③  Tension Pneumothorax | Pulseless VT

④  Upper GI Bleed | PEA

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INTRO TO CODE BLUE

SIM AND DEBRIEF LOGISTICS !  22.5 minutes per SIM session

!  15 minute SIM

!  5 minute debrief

!  2.5 minute transition / preparation

!  Each learner will be a team leader once

!  Roles: team leader (e.g. doctor), airway (e.g. RT), compressor (e.g. nurse), meds/defib (e.g. nurse)

!  The facilitator will act as another role, the recorder 6  

!  Assessment | Primary Survey !  ABCs

!  Action | Primary Survey !  Help, O2, IV, Monitor

!  Assessment | Secondary Survey !  SAMPLE, Vitals, Head-to-toe

!  Action | Secondary Survey !  Targeted tx

!  Management | Code Blue !  Quality CPR, Early Defib, Hs and Ts, Teamwork

INTRO TO CODE BLUE

OSCE FORMAT

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INTRO TO CODE BLUE

PRIMARY SURVEY !  Primary = immediately life-threatening

!  Assessment !  Airway: patency, secretions !  Breathing: RR, O2 Sat, work of breathing, lung sounds !  Circulation: HR, BP, LOC, bleeding, temp

!  Action !  Call for help !  O2 !  IV !  Monitor !  Fluids

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INTRO TO CODE BLUE

SECONDARY SURVEY !  Assessment

!  SAMPLE !  Signs/symptoms !  Allergies !  Medications !  PMHx !  Last oral intake !  Events prior

!  Vitals !  Head-to-toe

!  Action !  Investigations, differential diagnoses, treatments

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INTRO TO CODE BLUE

CODE BLUE MANAGEMENT

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INTRO TO CODE BLUE

ARREST RHYTHMS

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VF

Pulseless VT

2 shockable (defib) rhythms

Asystole

Everything else with NO pulse is PEA (Pulseless Electrical Activity) PEA

INTRO TO CODE BLUE

CODE BLUE ALGORITHMS

Pulseless VT, VF

SHOCK SHOCK EPI 2min CPR Rhythm Check

2min CPR Rhythm Check

Nothing Nothing EPI 2min CPR Rhythm Check

2min CPR Rhythm Check

Asystole, PEA

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INTRO TO CODE BLUE

CODE BLUE EXAMPLE

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Monitor   Pulse   Assessment   Ac0on  

VF   None   VF  arrest   Start  compressions  200J  shock/defib  2  minutes  of  CPR  

VT   None   Pulseless  VT  arrest   Start  compressions  200J  shock/defib  

1mg  epi  1:10,000  IV  2  minutes  of  CPR  

Bradycardia   None   PEA   Start  compressions  No  shock/defib  2  minutes  of  CPR  

Asystole   None   Asystole   Start  compressions  No  shock/defib  

1mg  epi  1:10,000  IV  2  minutes  of  CPR  

No response, no pulse " start 2 minutes of CPR

INTRO TO CODE BLUE

CPR / CCR

!  “CCR” = Cardio-Cerebral Resuscitation

!  Compressions " #CCP " #survival

!  Less time b/w compression & shock " #survival

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INTRO TO CODE BLUE

Early CPR, Early Defib

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INTRO TO CODE BLUE

Hs and Ts

Hypovolemia Tension PTX

Hypoxia Tamponade

Hydrogen ion Toxins

Hyper/hypoK Thrombosis (pulmonary)

Hypothermia Thrombosis (coronary)

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INTRO TO CODE BLUE

ACS ①  Anti-anginal

!  O2, nitroglycerin, morphine

②  Anti-platelet !  1st: ASA (162mg PO chewable) !  2nd: P2Y12 inhibitor (clopidogrel, ticagrelor, or prasurgrel – not if hx stroke/TIA) !  3rd: glycoprotein IIb/IIIa inhibitor (consider at PCI)

③  Anti-coagulation !  If fibrinolytics: UFH, LMWH, or fondaparinux !  If PCI: UFH, bivalirudin, or UFH+bivalirudin

④  Revascularization !  Fibrinolytics (TNK), PCI, or CABG

⑤  Risk factor reduction !  Beta-blocker, ACEi/ARB, and Statin !  Aldo antagonist (e.g. eplerenone): on BB/ACEi, either sx HF or DM, and EF<40% !  Quit smoking

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INTRO TO CODE BLUE

ACS DOSES FOR SELECT MEDS Drug Load Maintenance Duration ASA 162mg PO 81mg/day Lifelong

Clopidogrel 600mg pre-PCI 300mg lytics <24h

75mg > age 75

75mg/day 1 year

Ticagrelor 180mg 90mg BID 1 year Heparin IV bolus weight

based IV infusion

(Goal 1.5-2x PTT) 48h or until

revascularization LMWH IV bolus weight

based SC injections Up to 8 days or until

revascularization ACEi - - Lifelong

Beta-blocker - - Lifelong Statin - - Lifelong

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INTRO TO CODE BLUE

ANAPHYLAXIS !  57% unrecognized or not labeled in ED as anaphylaxis

!  Multisystem syndrome

!  Distributive shock (widespread vasodilation) and hypovolemic shock (fluid extravasation, reduced venous return)

!  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

Exposure to allergen and either:

!  Low BP (e.g. sBP<90 in adults or sBP decreased by 30%)

!  2 or more systems involved (i.e. multisystem syndrome): !  Derm !  Resp !  CVS !  GI

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INTRO TO CODE BLUE

ANAPHYLAXIS TX

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!  1st line: epinephrine 1:1000 IM anterolateral thigh !  0.3mg adults !  0.15mg pediatrics

!  Adjuncts !  CVS: fluids !  Resp: oxygen, salbutamol !  Derm: H1 and H2 blocker

!  Prevention of biphasic or protracted reaction !  Steroids (controversial)

!  Long-term !  Epinephrine injector !  Wear/carry allergy identification

INTRO TO CODE BLUE

EPINEPHRINE IS FIRST LINE

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!  Alpha-1 !  Vasoconstriction !  Increased peripheral vascular resistance !  Decreased mucosal edema and membrane leakage

!  Beta-1 !  Increased inotropy (contractility) !  Increased choronotropy (heart rate)

!  Beta-2 !  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

!  Chest tube !  5th ICS just anterior to midaxillary line

INTRO TO CODE BLUE

Acute Upper GI Bleed

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!  Pre-Scope !  IV fluids and blood !  Assume PUD (most common, threatening, treatable)

!  Empiric PPI bolus (e.g. IV pantoprazole 8mg) !  Assume variceal bleed (threatening, treatable)

!  Empiric octreotide (e.g. 50mcg IV then 50mcg/h) !  Consults: GI, surgery, interventional radiology !  Intubate early: lower aspiration risk !  Balloon tamponade if still bleeding

!  Post-Scope !  Add abx for varices (ceftriaxone or fluoroquinolone) !  Add PPI infusion for PUD (e.g. IV pantoprazole 8mg/h)

INTRO TO CODE BLUE

ACLS EFFECTIVE TEAM DYNAMICS !  Closed-loop communication

!  Clear messages

!  Clear roles and responsibilities

!  Knowing one’s limitations

!  Knowledge sharing

!  Constructive intervention

!  Re-evaluation and summarizing

!  Mutual respect

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