Columbia Medicine House Staff Training Program

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1 Columbia Medicine House Staff Training Program Simulation Series : Advanced Cardiopulmonary Life Support A.K.A. THE CODE PRIMER

2 Course Objectives Background information on cardiac arrests Code leader / code team roles and responsibilities BLS/ACLS core concepts and algorithms Biphasic defibrillators Review scenarios

3 Resident Preparation Surveys from academic training centers 79% residents are scared 76% resident wanted more teaching 82% residents wanted more experience

4 Pre-Code Essentials Review BLS/ACLS core concepts Familiarize yourself with equipment Identify specific roles and responsibilities within the code team RELAX. you ll be great!

5 Perspective Prognosis of cardiac arrest is poor (both in hospital and out of hospital) Especially poor for those in PEA or Asystole ABCs and early defibrillation of VF/VT is key we only run to arrests so we can defibrillate VF/VT

6 VF/VT: Rapid Defibrillation is KEY!

7 The Columbia Arrest Resident Designated code residents in CCU Short call resident until 5pm Long call resident after 5pm (responds to all arrests, but care transferred to cardiology resident/night float when able) Short call resident responsible for the daily test and change of the defibrillator battery

8 Visitor/Non-Patient Arrests Arrest Team is responsible for all arrests within the hospital property or in the driveway immediately outside the hospital Call NYP EMS ( ) or hospital transport ( ) to bring patients to the ER

9 Initial steps in a Code Take a deep breath Introduce yourself as the code resident Buy yourself 15 seconds to relax by asking: Are the pads on and is the board under the patient?

10 Initial steps in a Code *CAB* Pulse? If NO compressions Rhythm? Pea/asystole vs VT/VF algorithm Shock? (only VT/VF) Access Rapid assessment Primary survey Hs and Ts

11 Circulation C = Circulation Pulse check Chest compressions Push hard and fast on the center of the chest Minimize interruptions, allow recoil 30:2 synchronous, 100/min asynchronous What is the current rhythm? Is IV access established? Does the patient need medications/volume resuscitation? Is the rhythm shockable? D = Defibrillation Early defibrillation essential during electrical phase

12 Airway, Breathing A = Airway (use oral airways if needed) B = Breathing Ventilations over 1 second TV sufficient for chest rise 30:2 with 1 breath q 5-6s Continuous with 1 breath every 6-8 s (8-10 breaths per minute) DO NOT OVERBAG!!!

13 Next Steps: Collateral history Chart Primary team Labs and other vital signs Establishing disposition / transfer Miscellaneous (attending to family members, contacting primary physician)

14 Post-Resuscitation Care Further delineate and address contributing factors EKG, Labs Continue successful anti-arrhythmics as drips Continue pressors, if applicable Ensure proper airway, ventilation Plan disposition to unit Document! Notification Consider cooling, page b.8cool

15 Termination of Resuscitation Decision must balance a respect for human dignity and clinical judgment

16 Predictors of Unsuccessful Resuscitation Unable to regain pulse after 10 minutes of ACLS Prolonged down-time prior to CPR initiation (unwitnessed) Initial rhythm other than VT/VF Advanced age and severe comorbid diseases

17 Sample Arrest Note Location: (Floor/Room Number) Primary Service: (Include resident/attending, pagers if possible) Arrest call initiated by: Arrest witnessed: (Y/N) On telemetry: (Y/N) Condition and vitals upon arrival: Initial Rhythm: Description of resuscitation: (specify medications given, defibrillation attempts/response, central line placement, advanced airway): Event times Time last seen responsive: Time arrest called: Time team arrived: Time of defibrillation (if indicated): Time pulse regained (if applicable): Impression: Disposition: Family Notified: (Y/N, specify relationship and telephone number) Attending Notified: (Y/N, specify)

18 Review o Walk in the Room Pads Pulse Board Rhythm/Shock Access Secondary Survey H s/t s Breath Sounds Heart Sounds Review Labs Story

19 Review Throughout Watching Compressions Watching Airway Timing 2 minutes Feedback Loop with Team ROSC EKG, Labs Placement Family Note

20 ACLS Review

21 ACLS Review Pulseless Arrest

22 Endotracheal Medications Naloxone Atropine Vasopressin Epinephrine Lidocaine Give times the dose

23 ACLS Review Tachycardia Bradycardia

24 Using the Defibrillator

25 Using the Defibrillator

26 Using the Defibrillator Battery Monitor Defibrillate Synchronize Pace Voltage Rate

27 Arrest Scenarios

28 Case #1 Called to bedside of 74 year old man with ESRD found unresponsive What do you do next? ABC s, call arrest and start bagging/compressions Pads on, check the rhythm

29 Case #1 What s the diagnosis? Asystole, but Check another lead (must have leads in place) What s next? Resume chest compressions Epinephrine H s & T s

30 Case #2

31 Case #2 A patient s 64 year old family member with an unknown PMH passes out in the lounge area on 6GS What do you do? ABC s Patient is unresponsive and pulseless Start bagging and chest compressions

32 Case #2 Get the pads on Rhythm: What s next?

33 Case #2 DEFIBRILLATE! Biphasic: 200J CPR x 2 minutes, rhythm check (shock again if indicated) What medications can you give? Epinephrine (or vasopressin) Amiodarone, Lidocaine

34 Case #3

35 Case #3 Called to the bedside of a 48 year old man who feels lightheaded and has had a syncopal episode. The Zoll pads are in place and the defibrillator shows the following:

36 Case #3 What s the rhythm? 3rd degree heart block What are your treatment options? Remember DaTE: Dopamine drip (Atropine) Transcutaneous pacing leads must be attached Epinephrine drip

37 Case #3 To pace: Turn defibrillator dial to Pace Set rate (70 is default) Turn up voltage until you see capture beats on monitor Don t forget sedation if patient is responsive to pain!

38 Case #4

39 Case #4 Notified by telemetry that your 79 year old patient with HTN and atrial fibrillation is tachycardic to 190. Patient is confused with a BP of 75/50 and a thready pulse.

40 Case #4 What s the rhythm?

41 Case #4 Atrial fibrillation with RVR Stable or unstable? Unstable: AMS, chest pain, hypotension What s next? Cardioversion: Biphasic: 120J and up Don t forget to **synchronize**

42 Case #5

43 Case #5 Called to bedside of 35 year old woman complaining of SOB and tongue swelling. Has PCN allergy and RN tells you she recently received ceftriaxone for PNA. Vitals: BP 80/40, HR 120, O2Sat 87% Exam: appears warm and flushed, lungs with diffuse wheezes, +lingual swelling

44 Case #5 Diagnosis? Anaphylaxis Initial management: Airway, oxygenation, ventilation Early intubation if hypoxemic, stridorous, or lingual swelling

45 Case #5 Medications: Epinephrine mg SC/IM ( mL of 1:1000 dilution) every 15-20min x3 doses May need IV infusion if poor tissue perfusion (2-10mcg/min of 1:10,000) IVF and vasopressors for circulatory support Steroids: methylprednisolone 60mg IV Q6hr Antihistamines, Beta-agonists Observe over 24 hours biphasic anaphylaxis

46 Acute Intervention/Evaluation in the Service Building: 1. First Responder: Calls for help and delegates task of calling code teams 2. Code Team: Runs code and delegates tasks to others 3. Security: Brings Banyon Bag to the gym or specified area in the service building when they hear code called in service building. 4. Call NYP EMS: (212) GYM/ Staff 5. Other Staff: Available staff halts patient flow to area. Serves to make calls and direct code team and EMS as they arrive on scene. 6. Code Team Arrives: Assumes responsibility of patient on arrival code team to assist in seamless patient care until patient transported off the floor Other staff remains available to Code team but may resume regular activities NYP EMS transport team called to transport patient to emergency department. 7. Patient Transported by NYP EMS to ED. EMS will notify ED of transport.

47 Questions?

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