2. INTRO TO CODE BLUE
PURPOSE
2
Experience management of code blues Suggest plans for acute care cases
Practice leadership and teamwork skills Practice early CPR and defibrillation
3. Pengertian
3
“Suatu tanda atau sinyal yang digunakan oleh rumah
sakit untuk memberitahu bahwa seseorang
membutuhakan tindakan resusitasi, yaitu pasien yang
mengalami henti nafas dan henti jantung”
Ruang lingkup : seluruh lingkungan RS , IGD, rawat
inap, kamar operasi, ruangan intensif, rawat jalan,
tempat pemeriksaan penunjang, dll
4. TIM
4
Code blue response team atau tim code blue adalah
suatu tim yang dibentuk oleh rumah sakit yang bertugas
merespon kondisi code blue didalam area rumah sakit.
Tim ini terdiri dari DOKTER dan PERAWAT yang
sudah terlatih dalam penanganan
kondisi cardiac respiratory arrest.
6. INTRO TO CODE BLUE
KASUS-KASUS CODE BLUE
6
ACS | VF
Anaphylaxis | Asystole
Tension Pneumothorax
| Pulseless VT
Upper GI Bleed | PEA
7. INTRO TO CODE BLUE
KASUS-KASUS Code Blue
Hypovolemia Tension PTX
Hypoxia
Tamponade
Hydrogen ion Toxins
Hyper/hypokalemia Thrombosis (pulmonary)
Hypothermia Thrombosis (coronary)
7
8. INTRO TO CODE BLUE
PENILAIAN
PRIMARY SURVEY
Assessment Action
A B C Help, O2, IV, Monitor
SECONDARY SURVEY
Assessment Action
Riwayat, TTV, Pemfis Tindakan / treatment
CODE BLUE
Assessment Action
Irama, Nadi CPR/Defib, EPI
9. INTRO TO CODE BLUE
PRIMARY SURVEY
9
Primary Survey Assessment
Examples
Action
Examples
Segera, mengancam
jiwa
Airway: kepatenan,
sekresi, obstruksi
Breathing: RR, Sat.
O2, suara napas,
deviasi trakea
Circulation: HR,
tekanan darah,
perdarahan, suhu
Call for help
O2
Needle
decompression
IV
Monitor
Cairan
10. INTRO TO CODE BLUE
SECONDARY SURVEY
10
Secondary
Survey
Assessment Action
Pengkajian sistematis History (SAMPLE)
Signs and symptoms
Allergies
Medications
PMHx
Last oral intake
Events prior
TTV
PengkajianHead-to-
toe
Investigasi
Diagnosis banding
Treatments
11. INTRO TO CODE BLUE
EARLY CPR, EARLY DEFIBRILLATION
11
12. INTRO TO CODE BLUE
ARREST RHYTHMS
12
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
13. INTRO TO CODE BLUE
CODE BLUE ALGORITHMS
Pulseless VT, VF
SHOCK SHOCK
EPI 2min CPR
Rhythm/Pulse
2min CPR
Rhythm/Pulse
Nothing NothingEPI 2min CPR
Rhythm/Pulse
2min CPR
Rhythm/Pulse
Asystole, PEA
13
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
14. INTRO TO CODE BLUE
CODE BLUE EXAMPLE
14
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
We have 4 simple goals today. This is an opportunity for you to experience the management of code blues in a safe environment. You’ll also get a chance to suggest plans for select acute care cases. Leadership and teamwork skills will be practiced. And, you’ll be doing CPR and defibrillation. The take-home is that early CPR and defib saves lives; and you can make a difference if you do these early!
We have 4 simple goals today. This is an opportunity for you to experience the management of code blues in a safe environment. You’ll also get a chance to suggest plans for select acute care cases. Leadership and teamwork skills will be practiced. And, you’ll be doing CPR and defibrillation. The take-home is that early CPR and defib saves lives; and you can make a difference if you do these early!
We have 4 simple goals today. This is an opportunity for you to experience the management of code blues in a safe environment. You’ll also get a chance to suggest plans for select acute care cases. Leadership and teamwork skills will be practiced. And, you’ll be doing CPR and defibrillation. The take-home is that early CPR and defib saves lives; and you can make a difference if you do these early!
We have 4 simple goals today. This is an opportunity for you to experience the management of code blues in a safe environment. You’ll also get a chance to suggest plans for select acute care cases. Leadership and teamwork skills will be practiced. And, you’ll be doing CPR and defibrillation. The take-home is that early CPR and defib saves lives; and you can make a difference if you do these early!
Here are the cases for the simulation OSCEs. They all start off with something specific that then deteriorates into a code blue. You’ll do a primary and secondary survey to manage the acute case first, and then move onto managing the cardiac arrest. No surprises here! The goal is to focus on process and approach, as well as building a strong foundation for select acute care cases.
During arrest situations, sometimes the cause is not obvious. If someone has a heart attack or GI bleed, the cause may be obvious, in which case it would be coronary thrombosis and hypovolemia, respectively. However, sometimes there may be several reversible causes to an arrest. This can be summarized with the acronym of Hs and Ts. On the H side, we have hypovolemia, hypoxia, hydrogen ion (as in metabolic acidosis), hyper or hypokalemia, and hypothermia. For the Ts, we have tension pneumothorax, cardiac tamponade, toxins, pulmonary thrombosis, and coronary thrombosis. During downtime in code blues, team members may wish to brainstorm the possible reversible causes, using the Hs and Ts as a memory aid. We will practice the Hs and Ts method during simulations.
All simulations have an OSCE checklist with this format. Keep it simple: think of two A’s. You want to ASSESS, then you take ACTION. Under primary survey, you assess with ABCs, and your action may be calling for help, giving oxygen, establishing an IV, and hooking up the monitor. In secondary survey, your assessment is three parts: take a history, repeat vitals, and do an exam. Your action would be the targeted treatment. If a code blue happens, your assessment is always both rhythm PLUS pulse checks. Actions during code blues include CPR, defib, giving epinephrine, figuring out the possible causes through an Hs and Ts acronym, and maintaining effective team dynamics.
Primary survey is named primary, because it takes care of all the immediately life-threatening things. When we assess ABCs… for airway, we may want to assess things like if we can hear them talk, if they have secretions, or if there’s something obstructing their airway. For breathing, we want to check their vitals including resp rate and oxygen saturation. We want to see if they are in respiratory distress, listen to their lungs, and see if their trachea is deviated, in the case of a tension pneumothorax. Decompress the tension pneumothorax, if found, ASAP! For circulation, we want to check the vitals of heart rate and blood pressure. Another sign of good circulation would be if they have a good level of consciousness. If they are bleeding, we need to plug it up. Temperature of the skin may also be telling of their circulation. If there is an emergency, always get back-up. Think “IV, O2, monitor” when you walk into the room, and make sure they’re in place! Consider fluids.
Secondary survey is secondary, because, whew, you have some time. You can now take a history through the SAMPLE acronym, which stands for “signs and symptoms, allergies, medications, past medical history, last oral intake, and events prior”. Recheck the vitals at this point, to see if the condition has changed. Also, incorporate a thorough head-to-toe examination to help with the differential diagnoses and ensure you haven’t missed anything. At this point, you may want to order some investigations, consider possible causes, and offer targeted treatments.
Early CPR and early defib is very important! The Heart and Stroke Foundation notes that for every minute without CPR and defib, survival rates drop up to 10%. And, if you shock within 3 minutes of collapse, this will help increase survival rates. Minimize interruptions in CPR to <10 seconds. Continue CPR when charging the defibrillator, and resume CPR immediately after shocking!
If a person goes unconscious and doesn’t have a pulse, this is our code blue. They are either going to be in VF, pulseless VT, asystole, or PEA. VF stands for ventricular fibrillation, where the ventricles quiver and are very shakey and can’t really coordinate a good contraction to pump blood out to the body. So, you will see random squigglies for VF. This is “shockable”, meaning a rhythm you can defibrillate. You give a minimum 200 joules of an unsynchronized shock dose with the aim of stopping all the heart squigglies, so that the heart’s pacemaker will then kick in again. In VT, or ventricular tachycardia, you see a wide-complex tachycardia, because the firing focus is from the ventricles. We differentiate between pulseless VT, and VT with pulse, because the management differs. If there is no pulse, as in pulseless VT, of course we start with CPR compressions! We also give a minimum 200J unsynchronized shock, because it is a “shockable rhythm”. VF and pulseless VT are the only two shockable cardiac arrest rhythms. Remember, early CPR and early defib saves lives; so make haste! For VT with a pulse, we would do synchronized cardioversion or pharmacological cardioversion instead. Synchronized just means that the shock will be delivered at the R waves, away from relative refractory periods where it may induce VF by accident. The management of VT with pulse, along with other rhythms, is beyond the scope of this workshop. In asystole, you get your flat line. PEA stands for pulseless electrical activity. All other rhythms that is NOT VF, VT, or asystole… AND does NOT have a pulse is PEA. That means the rhythm can be bradycardia or tachycardia for example, and, if there is NO pulse, this is PEA! Asystole and PEA should not be defibrillated.
All arrest rhythms, whether it be pulseless VT, VF, asystole, or PEA, must receive immediate CPR, because there is no pulse. Since pulseless VT and VF are shockable rhythms, you also want to give a shock ASAP! Continue CPR as the defibrillator is charging! Early CPR and defib saves lives! Whereas… for the non-shockable rhythms of asystole and PEA, you don’t give shocks but give epi only.
In all cases, after every 2 minutes of CPR, you want to reassess. Do your reassessment by stopping what you’re doing, look at the monitor for the RHYTHM… and feel for a PULSE. This is also a good time to swap CPR compressors. If no pulse, continue CPR. If the rhythm is shockable, do a shock. Every 4 minutes, you can give epinephrine. This means you give epi once every SECOND rhythm and pulse check, which occurs every 2 minutes.
Let’s go over the Pulseless VT and VF algorithm (in purple). The arrows represent continuous CPR in the background. A continuous-loop to remember is “shock… shock-epi”, “shock… shock-epi”. This means you try two shocks before trying epi. And you repeat this over and over until return of spontaneous circulation (or ROSC as people may say), meaning that the person gets a pulse back. For shockable rhythms, it’s not known when to ideally time the epi dose, so it’s suggested to try 2 shocks first, since early CPR and defib are priority and the focus. Epi also increases oxygen demand and lowers subendocardial perfusion.
For asystole and PEA, think of this continuous loop (highlighted in green): “nothing… nothing-epi”, “nothing… nothing-epi”. So after every 2 rounds of doing nothing, as in NO shock, try epi. It may actually be reasonable to give epi earlier for NON-shockable rhythms, as long as you have started CPR already. In May 2014, there was a published retrospective analysis with over 100,000 people where early epinephrine for NON-shockable rhythms was associated with a higher probability of return of spontaneous circulation, survival in hospital, and neurologically intact survival. Remember, still do CPR as your priority, before the early epi administration.
Here’s an example of a patient deteriorating to a code blue, and what we would do. The patient has no response and is not breathing. Get some help! Do a code blue assessment by looking at both the monitor for the rhythm and feel for the pulse. We see VT as the rhythm, and there is NO pulse; identify this as pulseless VT arrest. Get someone to start CPR compressions. Get someone else to charge to 200J and deliver the shock, after you ensure everyone is “clear”. Resume IMMEDIATE CPR after giving the shock. Continue CPR for 2 minutes until the next reassessment.
At reassessment, we check both rhythm and pulse. Rhythm is VF and, as expected, there is no pulse. Get someone to start immediate CPR. We identify VF arrest and, since it is a shockable rhythm, we get someone to set up for a 200J shock. We deliver the shock after clearing the patient. We tried 2 shocks, and since the algorithm is “shock, shock-epi”, we now give epi. Epinephrine in cardiac arrest is a 1mg dose of the 1:10,000 concentration, IV. Continue CPR to help deliver the medication. Continue CPR for another 2 minutes until the next reassessment.
Monitor now shows asystole, and there is no pulse. For asystole, this is NOT shockable, so we do “nothing”, except continue CPR for another 2 minutes.
2 minutes later, we see bradycardia. Check the pulse; there is none. This is pulseless electrical activity. We do “nothing” because it’s not shockable, but we always continue CPR right away for pulse absence. Since the algorithm is “nothing, nothing-epi”, it is now time to give 1mg epinephrine 1:10,000 IV. We continue 2 minutes of CPR again until the next rhythm and pulse check. This continues on and on until we can get a pulse back.
This is a supplementary slide taken from the 2010 ACLS Guidelines. There is no benefit of vasopressin and amiodarone over epinephrine, so only epinephrine is introduced in ITCB. The emphasis is on early CPR/defib. Fall of 2015 will have new guidelines available, and then by 2016 the information will be rolling into the new ACLS courses.
This is another supplementary slide taken from the 2010 ACLS Guidelines. Epinephrine is suggested to be given every 3-5 minutes, but for simplicity, giving epinephrine every about 4 minutes helps you remember that after every 2nd rhythm/pulse checks, you will give epi, since you do 2 minutes of CPR before each check.
