Few seconds later, the soundof the rolling E-Kart fills thehallway and you see thehospital code team; clad inface masks, rapidly take offrunning to the scene.
As a new nurse, you are awarethat a medical emergency isbeing unfolded right at thatmoment. You dream to be in thatscene, taking part of theresuscitative measures andhelping to direct the manyinterventions that will beemployed during the event.
This course gives you anoverview of your functions asa nurse in an emergencysituation and an outline of thenursing skills, detrimental inthe management of a CODE.
THE CODE TEAM• Physician• Critical Care Nurse• Respiratory Therapist• Nurse Supervisor• Nursing Aide• Security Officer
The Code Team shall be responsible for:•Responding immediately to all Code alerts.•Conducting the code according to currentAdvanced Cardiac Life Support (ACLS)protocols.•Recording any pertinent data on the patient’srecord.
The nursing unit, clinic, and/ordepartment on which the Code occurs,shall be responsible for initiating BasicLife Support (BLS) until the CodeTeam can respond.
Responsibilities of the Physician1. Informing the patient’s family of the situation.2. Making arrangements for an ICU bed if needed.3. Completing the medical record if the patient expires,documenting the events leading up to the patient’sdeath, cause of death, date and time of death,coroner’s case, autopsy requested, and physiciansignature.
Responsibilities of the Code Team Nurse• Managing the E-Kart• Administration of medications• Assisting in Endotracheal Intubations• Defibrillation• Reviewing documentations post code and follow up toensure complete documentation
Responsibilities of the Charge Nurse1. Overseeing traffic control on the unit.2. Ensuring that emergency equipment is brought to thebedside.3. Delegating duties to appropriate personnel to ensure theunit’s continued function.4. Serving as the recorder for the resuscitation efforts ordelegating an appropriate person to do so.5. Carrying out orders by physician.6. Documenting and completing the chart.7. Contacting the admitting office if the patient needs to betransferred to a critical care bed.8. Evaluating the situation to see if additional personnel areneeded to ensure that the Patient Care Area continues tofunction.
CODE 82Responds toMedicalEmergenciesat theSpeed of Life…Because everysecond counts.
THE CHAIN OF SURVIVAL1. Early Access to Care.2. Early Cardiopulmonary Resuscitation (CPR)3. Early Defibrillation.4. Early Advanced Care.These 4 steps can increase survival as much as 90% if initiated within the first minutes after sudden cardiac arrest. Survival decreases by about 10% each minute longer.
WHEN TO CALL A CODE?• Primary Survey •Assess for RESPONSIVENESS •Assess for BREATHING •Assess for CIRCULATION• Secondary Survey •Pre and Post RESUSCITATION MEASURES
Assess ResponsivenessResponsive Not Responsive> vital sign > call for help fast> assess/inform AP > position> document > open airway
Assess BreathlessnessBREATHING NOT BREATHING> recovery position > Rescue Breath> vital sign ( facemask/> assess/inform AP resuscitation bag)> Document> Continously Monitor
Assess Circulation(+) Pulse (-) Pulse> continue pressure > Activate the ventilation Code Team support > Perform cardiac compression
Primary Survey Activate Code 82 Start CPR Prepare for Intubation PostAssist Code 82 Team Resuscitation Activities
Activities During a Code CPREndotracheal Intubation Defibrillation Administration of Medications
CPR•When the heart stops, the absence of oxygenatedblood can cause irreparable brain damage in only afew minutes. Death will occur within eight to 10minutes. Time is critical when youre helping anunconscious person who isnt breathing.•CPR does not restart a heart that hasstopped, but it can keep a victim aliveuntil more aggressive treatment canbe administered.
ENDOTRACHEAL INTUBATIONEndotracheal intubation is performed toestablish and maintain a patent airway,facilitate oxygenation and ventilation,reduce the risk of aspiration, and assistwith the clearance of secretions.
Nursing Responsibilities in Endotracheal Intubation• Assembling materials needed• Proper patient and bed positioning• Ensuring O2 source and suction equipment• Ensuring ET is secured• Proper collection of ETA specimen and sending to laboratory• Chest X-ray post intubation
DEFIBRILLATIONIt is the administration of electric shockfor a patient on cardiac arrest when thepresenting rhythm is pulseless VT or VF.
Ventricular FibrillationA turbulent, disorganised electrical activity of the heart in such away that the recorded electrocardiographic deflectionscontinuously change in shape, magnitude and direction.
VENTRICULAR TACHYCARDIAA fast rhythm that originates in one of the ventricles of the heart.This is a potentially life-threatening arrhythmia because it may leadto ventricular fibrillation and sudden death.
DEFIBRILLATION METHOD1. Verify cardiac arrest. Ensure ongoing & effective BLS [CPR and airway management]2. Ensure the ECG monitor is properly connected.3. Identify VF or pulseless VT. Ensure all patient and device movement is eliminated.4. Gel the entire metal surface of both paddles.5. Place the paddles on the chest wall. The sternum pad is placed to the right of the sternum just below the right clavicle (not on the clavicle or sternum). The apex pad is placed at the level of the apex of the heart in the area of the anterior.6. Charge the defibrillator or paddles to the desired energy level.7. “Verbally and visually clear the patient!” In simple terms, make absolutely sure that no one is in electrical contact with the patient.1. Provide firm, downward pressure (25 pounds of force) onto the chest2. Discharge the selected energy by pressing 2 buttons simultaneously.
The administration of medications is achief responsibility of a nurse in anevent of a code.• Anticipation of the drug to beadministered• Dosage & Route of administration •When to use an agent (indications) •Why an agent is used (actions) •How to use an agent (dosing) •What to watch out for (precautions)• Obtain a patent IV access• Announce the drug and dosagebefore and after administration
CESSATION OF CODE ACTIVITIESCriteria for stopping the Code activities:1 – When sinus rhythm is detected on the ECG, Vital Signs inacceptable limits2 – When code lasted for more than 30 minutes with no signof sinus activity on the ECG.3 – When patient’s immediate and significant family memberverbally stops the activities and agreed to sign waiver / DNR.4 – When flat ECG tracings are seen despite 15-20 minutesof continued CPR and “maximum” dose of Epinephrine isadministered.
POST RESUSCITATION ACTIVITIES1. Obtaining 12-Lead ECG2. Obtaining Chest X-Ray3. Request for Laboratory workups4. Inserting NGT5. Inserting Foley Catheter6. Coordinating with Admitting section for transfer to ICU7. Coordinating with ICU Nurse for plan of transfer8. Coordinating with Respiratory Services for VR parameters9. Coordinating with Dietary Division10.Patient preparation and coordination with relatives11.Documentation12.Transfer of patient13.Pharmacy and CSSR reconciliations
DOCUMENTATIONCode Team Leader-Written orders-Code notes-Transfer referralsCharge Nurse-All pertinent data pertaining to the event-Medications administered-Completing the Chart-Nurse’s notes / Charting
NURSES’ NOTES07/16/07 F -Cardiopulmonary Arrest 9:40am D -Patient’s relative rushed to station and reported of patient’s unconsciousness, stating, “Patay na yata ang tatay ko!” -Seen on bed unresponsive, with hands cupped over chest -Breathing ( - ), Pulse ( - ) 9:40am A -Activated Code 82 immediately. -Positioned flat on bed immediately and initiated CPR, ambubagging at 10L O2 flow. 9:41am -Code team arrived and assisted with intubation. 9:45am -Defibrillation administered by code team at three episodes, noted sinus activity after third shock.
(cont.)A -Emergency medications administered by member of code team / MTR -12-lead EKG done, tracings seen by AP10:14am -Chest X-Ray requested, plate seen by AP -Laboratory specimen for ETA G/S, C/S sent10:14am -Requested Lab for Trop-T, CPK-MB, Na, K, BUN, Crea -Coordinated with relatives of MICU transfer, conveyed support and gave reassurance10:30 -NGT inserted, Consent Form duly signed by relatives10:40 -Informed Dietary Dept of change in diet & MICU bed -IFC inserted, Consent Form duly signed by relatives10:40 -IV Fluids regulated accordingly10:40 -Coordinated with Admitting Section for MICU transfer -Coordinated with MICU NOD for transfer
(cont.) A -Coordinated with SRS personnel of VR parameters10:55am -Transfer Notes completed by AP -Placed on stretcher and prepared patient for transfer -Patient’s dentures and wristwatch endorsed to relatives11:00am R -Successful resuscitation lasting for about 20 min11:10am -Wheeled to MICU accompanied by AP -On ambubagging per ET @ 15 LPM, unconscious, with latest VS; BP 160/90, CR 142/min, Temp 36.4ºC O2 Sat 94% -Endorsed to MICU receiving nurse accordingly BC A. Co, RN
Normally, the family is quickly escorted away from the scene, presumably for the following reasons:1. The family’s outpouring emotions may be disruptive2. The family interferes with the resuscitation efforts3. The family tends to scrutinize the activities and interventions for signs of incompetence4. Code team considers to protect the family members from irreparable psychological harm from witnessing the event
Dispelling the Myths…Terry L. Tucker’s study, (Critical Care Nurse) Baltimore, USA•It has been observed that families are rarely disruptive•Family members rarely interrupt code activities, don’treally scrutinize the activities of the code team for signsof incompetence•Family members feel they provide an element ofemotional and psychological support for the patient.•Families of patients who don’t survive the event feel alevel of comfort in knowing that everything that could bedone to save the patient was done, thereby facilitatingthe grieving process.
Dispelling the Myths…Terry L. Tucker’s study, Baltimore, USA•No report of significant psychological damage fromwitnessing the attempted resuscitation of a loved one.•Most families believe it’s their right to be present andthat their presence is important to the patient.•Provides the family member or significant other anopportunity to say goodbye, relay their love, apologizeor reconcile their relationship, or simply give permissionbefore the patient takes leave.