RRT and Code Management 2021 PDF

Chapter 10 RAPID RESPONSE TEAMS AND CODE MANAGEMENT Objectives 2  Compare roles of caregivers in rapid response teams (RRTs) and managing cardiopulmonary arrest situations.  Identify equipment used during a code.  Differentiat...

Chapter 10 RAPID RESPONSE TEAMS AND CODE MANAGEMENT Objectives 2  Compare roles of caregivers in rapid response teams (RRTs) and managing cardiopulmonary arrest situations.  Identify equipment used during a code.  Differentiate basic and advanced life-support measures used during a code.  Identify medications used in code management, including use, action, side effects, and nursing implications.  Discuss treatment of special problems that can occur during a code.  Describe special concerns related to the geriatric population during a code.  Identify information to be documented during a code.  Describe care of patients after resuscitation.  Identify psychosocial, legal, and ethical issues related to code management. Cardiopulmonary Arrest 3  Most codes filled with panic and pandemonium  Best options  Prevent  Plan  Practice  RRT another option Rapid Response Teams 4  “Failure to rescue” is important concept to address Assess pt deterioration.  RRT established to address concerns  Call BEFORE the cardiac/respiratory arrest  Recommended by The Joint Commission and Institute for Healthcare Improvement to implement systems to request assistance for worsening conditions RRTs (continued) 5  Call any time a staff member is concerned about changes in a patient’s condition including:  Heart rate, systolic blood pressure  Respiratory rate, oxygen saturation  Mental status  Urinary output  Laboratory values  Some institutions empower family members to activate the RRT RRT Effectiveness 6  RRT reduces:  Cardiac arrests  Critical care unit length of stay  Incidence of acute illness, such as respiratory failure, stroke, severe sepsis, and acute kidney injury  Recent review of literature and meta-analysis of 1.3 million patients  RRT was not associated with lower hospital mortality rates in hospitalized adults Codes 7  Code, code blue, code 99, Dr. Heart  Cardiac and/or respiratory arrest  Lifesaving resuscitation and intervention needed  BLS/AED  ACLS Code Team 8  Notification system  Members vary within setting  Better patient management  Care according to ACLS protocols  Other healthcare workers manage other patients Team Members 9  Leader usually MD skilled in ACLS  Nurses (usually ICU or ER)  Primary nurse knows patient  Second nurse gives medications and gets equipment from crash cart  Another nurse records events  Nursing supervisor provides traffic control and secures ICU bed (if needed) Team Members 10 (continued)  Anesthesiologist/anesthetist intubation  Respiratory therapist manages airway, sometimes intubates  Pharmacist prepares medications in some settings  Chaplain  ECG technician  Other personnel to run errands Equipment 11  Crash cart  Bag-valve-mask device chest  Backboard better  Airway supplies/suction compressions -  Monitor/defibrillator/pac  Medications emaker  IV supplies  AED  Nasogastric tube  Transcutaneous pacemaker  BP cuff  Things to Know 12  Your cart  Where it is located?  How do you unlock it?  How do you check it per unit protocol?  Your equipment  O2 and suction  Is child-sized equipment available if needed (e.g., ED)? Sequence of Events: BLS 13  Advance directives or living wills  Airway open  Breathing  Mouth to mask  Bag-valve-mask device  Circulation: chest compressions  May do open chest compression in trauma patients or after cardiac surgery  ABC became CAB in 2010 guidelines ACLS: Airway and 14 Breathing  Airway management  Manual ventilation  Intubation  Isolate airway and keep open  High concentration of oxygen  Delivery of tidal volume  Protect airway  Suction  Administer selected medications Naloxone approved to Atropine go down ET Vasopressin Epinephrine tube (higher doses DT Lidocaine going in lungs) ACLS: Airway and 15 Breathing (continued) Figure 10-2. Head-tilt/chin-lift technique for opening the airway. A, Obstruction by the tongue. B, Head- tilt/chin-lift maneuver lifts tongue relieving airway obstruction. ACLS: Airway and Breathing 16 (continued) Stop CPR for brea,ths 30 : 2 Figure 10-3. Rescue breathing with bag-mask device. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2011-2012. All rights reserved.) ACLS: Airway and 17 Breathing (continued) Advanced airway ① stop CPR I breath 96-8 sec Figure 10-04. Ventilation with a bag-valve device connected to endotracheal tube. ACLS: Airway and 18 Breathing (continued) Figure 10-5. End-tidal carbon dioxide detector connected to an endotracheal tube. Exhaled carbon dioxide reacts with the device to create a color change indicating correct endotracheal tube placement. ACLS 19  Primary survey  ABCD (early defibrillation)  Use of automatic external defibrillator (AED)  Secondary survey  Advanced skills His & T's  Differential diagnosis ACLS: Circulation 20  Large-bore Ivs/Biggest veins  May insert central line or intraosseous cannula if IV access is difficult  Administer medications via endotracheal tube (ETT) if needed  Lidocaine  Epinephrine  Vasopressin  Defibrillation  Differential diagnosis Logical Flow of Events 21  BLS  Crowd control  ACLS/AED  Notification of family and communication  Ongoing assessment  Pulse oximetry  Family presence in code  ETCO2  If successful code, transfer to ICU  Pulse checks  ABGs  Lab work ACLS Summary 22  Treat patient, not monitor  CPR throughout  Early defibrillation essential  Use ETT as needed for medication administration  Provide treatment according to algorithms Circulation 23 Figure 10-6. Defibrillator. (Courtesy Philips Healthcare, Andover, Massachusetts.) Dysrhythmia 24 Management  Algorithms  Early defibrillation  Public access defibrillation encouraged  AED used in field  AED may be used during in-hospital codes; newer defibrillators have built-in AED Reverse Causes: H’s & T’s 25  Hypoxia  Tablets (overdose)  Hypovolemia  Tamponade (cardiac)  Hypothermia  Tension pneumothorax  H+ ions (acidosis)  Thrombosis (coronary)  Hypokalemia or  Thrombosis (pulmonary) hyperkalemia Defibrillation 26 Figure 10-7. Paddle placement for defibrillation. Defibrillation (continued) 27 Figure 10-8. Anteroposterior placement of adhesive electrode pads for defibrillation or transcutaneous pacing. VF and Pulseless VT 28 Defibrillated  ABCD, initiate CPR -  Shock, CPR, shock, CPR, shock  200 (biphasic), 360 (monophasic) joules  IV access  Epinephrine or vasopressin -  Intubate if unable to effectively manage airway and ventilate patient VF and Pulseless VT 29 (continued)  Drug-shock continues  Epinephrine repeated as needed; vasopressin is given only once  Consider antidysrhythmic drugs  - Amiodarone (drug of choice) 1) 300 mg ↳  Lidocaine caronlybe 2) 150mg amiodaro e  Procainamide  Magnesium if level is low or torsades is present  Sodium bicarbonate (only if severely acidotic) Pulseless Electrical Activity 30 (PEA) defibrillate *  Rhythm without pulse  Airway, oxygen, intubate, IV access  ABCD with CPR  Treat cause  Epinephrine Asystole 31 * defibrillate  / with CPR ABCD  Airway, oxygen, intubate, IV access  Confirm in two leads  Treat cause (see PEA)  Epinephrine Symptomatic Bradycardia 32  ABCD with CPR  Airway, oxygen, IV access  Atropine Img total of 3 doses possible  Consider cause Box 11. 3  Transcutaneous pacing SISX of -  May need - sedation/analgesia symp, brady  Dopamine or epinephrine  No lidocaine Unstable Tachycardia 33  ABCD  Airway, oxygen, IV access  Identify the unstable tachycardia  Sedation T  Cardioversion to prevent Ron T  Reassess patient and rhythm Defibrillation 34  Primary treatment for VF and pulseless VT  Monophasic waveform vs. Biphasic  Electrical current  200 to 360 joules vs. 120 joules to 200 joules Defibrillation 35 (continued)  Completely depolarize the heart  Allow for the resumption of rhythm  Safety is essential  Complications  Skin burns  Damage to heart muscle Defibrillation 36 (continued)  External paddles (traditional)  External “hands-off” defibrillation with multipurpose pads (ECG, pace, defib)  Paddle/pad placement  Transverse/anterior  Anterior-posterior Defibrillation 37 (continued)  Internal paddles  “Spoons”  Cardiac surgery  Open-chest CPR  Lower joules Defibrillation 38 (continued)  Automatic implantable cardioverter-defibrillator (AICD)  Recognizes ectopy  Delivers countershock  Prevents episodes of sudden death Procedure for Defibrillation 39  Paddle or defibrillation pad placement  Good contact with skin (protect from burns)  Conductive medium with paddles  Charge defibrillator to desired setting  “I’m clear, you’re clear, everyone clear, oxygen clear”  Adequate pressure with paddles  Shock  Continue CPR 2 minutes, then assess rhythm Automated External 40 Defibrillation (AED)  External defibrillator with rhythm analysis capabilities  For cardiac arrest  Procedure  Place two adhesive pads  Analysis by AED  Shock advisory Cardioversion 41  Electrical current  Lower joules (e.g., 50)  Synchronized delivery on R wave (prevents “shock on T”)  Disrupts ectopic foci Dysrhythmia Management 42 (Cont.) Defibrillation Versus 43 Cardioversion  No pulse—defibrillation  Symptomatic tachycardia—cardioversion (can also do overdrive pacing) Documentation of Events 44  Assign someone to document during code and record rhythm strips  Time started  Actions taken and patient’s response  Defibrillation  Medications  Procedures  Pacemakers  Intubation and airway management  Vital signs  Team members present Ex. of Paper Documentation 45 Figure 10-15. Sample of a code record used for documenting activities during a code. (Courtesy Cleveland Clinic, Cleveland, Ohio.) Post-Resuscitation 46  Goals  Optimize cardiopulmonary function  Transport to critical care unit  Determine cause of arrest to prevent  Management of patient care continues Post-Resuscitation 47 (continued) SBP  Airway placement MAP365 190  Maintenance of blood pressure and oxygenation Ou sat >96 %  Control of dysrhythmias  Advanced neurological monitoring q4 neurochecus  Capnography  Capnography 48 Figure 10-16. Waveform capnography. A. Normal waveform indicating adequate ventilation pattern (ETCO2 35 to 40 mm Hg). B. Abnormal waveform indicating airway obstruction or obstruction in breathing circuit (ETCO2 decreasing). Copyright © 2017 Elsevier Inc. All rights reserved. Post-CPR Interventions 49  12-lead ECG identify D event if oracute MI  Arterial line BP monitoring  Pulmonary artery catheter  Indwelling urinary catheter for hourly output  NG tube if bowel sounds are absent or if patient is mechanically ventilated  Serial neurological exams Risk of seizures Post-CPR Care 50  Palliative comfort care  Pain management  Sedation  Anxiety management  Head CT scan and EEG if comatose Lack of blood flow to brain  Blood glucose levels (may be hyperglycemic) possible damagie Catecholamines Supporting the Family 51  Should they be present during a code? yes  Providing information  Active communication  Visitation after a code  Support from chaplain and nursing staff Supporting Other Patients 52  Remove from the situation  Talk with them  Assess their feelings  Continue their care Therapeutic Hypothermia 53  Fever from brain injury increases the level of neurological damage post-CPR  Increased length of stay ⑤  Lower body temperature is associated with better recovery ↓ metabolic rate and O2 consumption  Optimal temperature is not known  Firm guidelines have not been developed Methods of Hypothermia 54 Figure 10-17. Arctic Sun 5000. Figure 10-18. Thermagard XP. (Courtesy Medivance, (Courtesy Zoll, Chelmsford, Louisville, Colorado.) Massachusetts.) Nursing Care During 55 Hypothermia  Monitor core body temperature  Bladder catheter with a temperature probe  Esophageal thermometer  Pulmonary artery catheter Swan  Axillary, tympanic, and oral probes do not measure core body temperature and should not be used 32-34 % 24 hrs after Rosc & code and don't wave up per AHA Monitoring with 56 Hypothermia  Shivering  Increase oxygen consumption  Increases body temperature  Controlled with  IV sedatives  Analgesics  Neuromuscular blockade medications  Hyperglycemia IV insulin drip a hr fingerstices  Drugs can mask seizure activity  Continuous EEG monitoring versed propofol Complications 57  Bleeding control first  Infection  Metabolic and electrolyte disturbances  Hyperglycemia Bradycardia coagulopathy Nursing Care 58  Infection prevention  Handwashing  VAP prevention  Hyperglycemic management  IV insulin  Monitor electrolytes  During cooling, K+, Mg+, phosphate, and Ca+ may decrease  During rewarming, K+, Mg+, phosphate, and Ca+ may increase  Rewarm after 24 hours very slowly 0. 25-0 5/hr. Rapid rewarming vasodilation hypotension & shock