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Code Blue
Training:
Etiology
Moving Beyond the H’s and T’s
Set up for success: determine roles in advance.
• Team/Code Lead: that’s you!
• Computer Reviewer
• Verify code status.
• Look through history, labs, medication list.
• History Taker
• Talk to family and nursing.
• If witnessed code, what happened?
• Tele Monitor Review
• Important for arrhythmic arrest
PEA: Don’t Memorize H’s and T’s
Hypovolemia Tamponade
Hypoxia Toxins
Hydrogen Ions
(acidosis)
Tension
Pneumothorax
Hyperkalemia/
Hypokalemia
Thrombosis (PE)
Hypothermia Thrombosis
(Cardiac)
Literally every abnormal
vital sign or lab value
starts with ‘H’
Just look at the card!
Which of the following is likely to cause a narrow QRS
complex pea arrest?
•Hyperkalemia
•Amitriptyline Overdose
•Pulmonary Embolism
•Ostial LAD Obstruction
Which of the following is likely to cause a narrow QRS
complex pea arrest?
•Hyperkalemia
•Amitriptyline Overdose
•Pulmonary Embolism
•Ostial LAD Obstruction
A schema is what is needed:
• PEA occurs because either:
• Heart can’t beat:
• nothing in the pump, pump being blocked
• Essentially most cases of extreme shock
• Heart won’t beat:
• signal is there but capture is not
• Electromechanical dissociation
• Muscle disrupted or out of necessary ingredients
requires a
‘mechanical’ fix
requires a medical
fix
Littman Approach
doi: 10.1159/000354195
Empiric Therapies: Focus on who is coding
• Reasonable to give without information:
• Glucose
• Narcan
• Fluids
• Give calcium if hyperkalemia plausible
• (don’t wait for labs or blood gas)
• Bicarb? No one knows, so don’t stress it
• unless TCA, Na-channel overdose
Patient Consider Do
Post-operative Opiate resp
depression, PE
Narcan
ESRD Hyperkalemia Ca, bicarb
Has a chest tube Tension pneumo Flush the tube
(needle)
Frail, DM hypoglycemia glucose
Cirrhotic Massive
hemorrhage
Fluids, blood
Etc.
Verbalize
• Verbalize your decision making!
• Very helpful to set aside time to summarize the
patient and current thought process.
• “I think this might be a pulmonary embolism
because they are post-op and not receiving
anticoagulation”
• Ask out loud for input or thoughts.
• “Does anyone have ideas we might be missing?”
Lower the power
distance
Summary Points:
• Use resources (cards, med team, code team) > memorizing
• Act despite uncertainty, focus on the big picture.
• Focus on who is coding;
Most these actions are marginal!
The BIG PICTURE is:
• Continuous CPR
• Shock if shockable

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Etiology for RRT and Code Blue Workshop.

  • 2. Set up for success: determine roles in advance. • Team/Code Lead: that’s you! • Computer Reviewer • Verify code status. • Look through history, labs, medication list. • History Taker • Talk to family and nursing. • If witnessed code, what happened? • Tele Monitor Review • Important for arrhythmic arrest
  • 3. PEA: Don’t Memorize H’s and T’s Hypovolemia Tamponade Hypoxia Toxins Hydrogen Ions (acidosis) Tension Pneumothorax Hyperkalemia/ Hypokalemia Thrombosis (PE) Hypothermia Thrombosis (Cardiac) Literally every abnormal vital sign or lab value starts with ‘H’ Just look at the card!
  • 4. Which of the following is likely to cause a narrow QRS complex pea arrest? •Hyperkalemia •Amitriptyline Overdose •Pulmonary Embolism •Ostial LAD Obstruction
  • 5. Which of the following is likely to cause a narrow QRS complex pea arrest? •Hyperkalemia •Amitriptyline Overdose •Pulmonary Embolism •Ostial LAD Obstruction
  • 6. A schema is what is needed: • PEA occurs because either: • Heart can’t beat: • nothing in the pump, pump being blocked • Essentially most cases of extreme shock • Heart won’t beat: • signal is there but capture is not • Electromechanical dissociation • Muscle disrupted or out of necessary ingredients requires a ‘mechanical’ fix requires a medical fix Littman Approach doi: 10.1159/000354195
  • 7. Empiric Therapies: Focus on who is coding • Reasonable to give without information: • Glucose • Narcan • Fluids • Give calcium if hyperkalemia plausible • (don’t wait for labs or blood gas) • Bicarb? No one knows, so don’t stress it • unless TCA, Na-channel overdose Patient Consider Do Post-operative Opiate resp depression, PE Narcan ESRD Hyperkalemia Ca, bicarb Has a chest tube Tension pneumo Flush the tube (needle) Frail, DM hypoglycemia glucose Cirrhotic Massive hemorrhage Fluids, blood Etc.
  • 8. Verbalize • Verbalize your decision making! • Very helpful to set aside time to summarize the patient and current thought process. • “I think this might be a pulmonary embolism because they are post-op and not receiving anticoagulation” • Ask out loud for input or thoughts. • “Does anyone have ideas we might be missing?” Lower the power distance
  • 9. Summary Points: • Use resources (cards, med team, code team) > memorizing • Act despite uncertainty, focus on the big picture. • Focus on who is coding; Most these actions are marginal! The BIG PICTURE is: • Continuous CPR • Shock if shockable

Editor's Notes

  1. Meaning: a schema is an approach to think through the problem. You don’t need to memorize (others can do that / help), you need to understand the situation. That way, you can integrate hints about what things are more or less likely to be going on.
  2. ABGs and VBGs can provide a lot of information. However, is this information useful? Often already addressing most things you would unveil with a gas. Depending on timing, gas results can be skewed by ongoing arrest and tissue ischemia. Bottom Line: Nice to have if you can get it as long as this does not compromise ACLS. You’re rarely going to get definitive information, so just act.
  3. -- Verbalizing allows others to correct anything that might be wrong.
  4. Verbalizing allows others to correct anything that might be wrong. An alternative framing to this might be: you are often not going to get definitive information about the cause. Therefore, the pre-assessment probabilities of various causes rules how likely they are to be present. Thus, if they have ESRD - move to address hyperkalemia rather than seeking evidence for it. If they’re post-op Sometimes questions come up on more intensive therapies. Thrombolysis for Massive PE Needle Thoracostomy with Tension Pneumothorax These diseases are usually not subtle in inpatient codes. Tension pneumo: known pneumothorax or chest tube in place. Massive PE: clots usually already found in someone admitted and not already dead. Tamponade: pre-existing effusion