Unit III (c) Code

Management

Facilitator:
Tanzeel Ul Rahman
Nursing Instructor
BSN, RN, M.Phil Public health

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 1

 Acknowledgement
• Institute of Learning Emergency Medicine ( ILEM)
University of Health Sciences (UHS)
• Dr Hadja Hadjirul Brown
• Mr. Nickson Subestion Anthony
• Mr. Farhan Mukhtar
• Mr. Minhas Ahmed
• Ms. Priskila Samual
• Mr. Sunil Sadiq

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 2

 Copyright Disclaimer
Copyright © 2017 by Tanzeel Ul Rahman

All rights reserved. This Presentation or any portion

thereof may not be reproduced or used in any manner
whatsoever without the proper acknowledgment of the
owner.
Tanzeel Ul Rahman
Nursing Instructor
BSN, RN, M.Phil Public health
Mr.Tanxeel@Gmail.com

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 3

Objectives

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 5

 Code Management

Code, code blue, code 99, and Dr. Heart are

terms frequently used in hospital settings to refer
to emergency situations that require lifesaving
resuscitation and interventions. Codes are called
when patients have a cardiac and/or respiratory
arrest or a life-threatening cardiac dysrhythmia
that causes a loss of consciousness
• Code Brown
• Code Red

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 6

 Code Blue

Code Blue is the term used to describe the

emergency situation when the patient’s heart
rate and/or breathing cease and there is an
immediate need to resuscitate the patient to
maintain life .

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 7

 Code Management

• Code team is an organized approach to

managing cardiopulmonary arrest.
• Need a system for notifying team members.
• All team members should be trained in ACLS
protocols.
• While the team manages the code, other staff
members on the unit should attend to the other
patients.

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 8

Need of Cardiopulmonary in Critical Care
Unit

Patients in the critical care unit are at particularly high

risk for experiencing cardiopulmonary arrest during
the course of their hospitalization. Early recognition of
a patient’s deterioration in clinical status and rapid
initiation of treatment can prevent some cases of
cardiopulmonary arrest

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 9

Keep in Mind!!

When a patient is determined to be in

cardiopulmonary arrest, seconds matter. Unless
definitive action is taken within 4 to 6 minutes, the
patient will experience irreversible brain injury.
Prompt intervention is necessary if the patient is going
to have a chance of survival.

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 10

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 11
Cardiopulmonary Resuscitation

Cardiopulmonary resuscitation is a combination of

oral resuscitation (mouth-to-mouth) breathing, which
supplies oxygen to the lungs and external cardiac
massage (chest compression) which intended to
reestablish cardiac function and blood circulation and
to return the patient to baseline neurological
function.

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 12

CPR is also Referred to as BCLS

• BCLS is the foundation for saving lives following

cardiac arrest
• Fundamental aspects of BCLS that include
immediate recognition of a sudden cardiac arrest
(SCA) and activation of the emergency response
system, early CPR and rapid defibrillation
• Initial recognition and response to heart attack is
also considered part of BCLS

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 13

Indications for CPR

A. CARDIAC ARREST

B. RESPIRATORY ARREST

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 14

A. Cardiac Arrest
A cardiac arrest is the cessation of cardiac function;
the heart stops beating. Often a cardiac arrest is
unexpected and sudden. When it occurs, the heart no
longer pumps blood to any organ of the body.
Breathing then stops and the persons becomes
unconscious and limp. Within 20 to 40 minutes of a
cardiac arrest, the lack of oxygen supply to the brain
causes permanent and extensive damage.
The person’s skin appears pale or grayish and feels
cool. Cyanosis is evident when respiratory function
fails prior to heart failure.

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 15

Cardiac Arrest
Cardiac arrest is caused when the heart's electrical
system malfunctions. In cardiac arrest death results
when the heart suddenly stops working properly. This
may be caused by abnormal, or irregular, heart
rhythms (called arrhythmias).

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 16

Heart Attack
He term "heart attack" is often mistakenly used to
describe cardiac arrest. While a heart attack may
cause cardiac arrest and sudden death, the terms
don't mean the same thing. Heart attacks are caused
by a blockage that stops blood flow to the heart. A
heart attack (or myocardial infarction) refers to death
of heart muscle tissue due to the loss of blood supply,
not necessarily resulting in the death of the heart
attack victim.

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 17

The 3 cardinal signs of a cardiac arrest are:

Apnea
Absence of a carotid and femoral pulse
And dilated pupils

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 19

 The Four Arrhythmias That Cause Cardiac
Arrest Are:

Ventricular Fibrillation (VF)

Ventricular Tachycardia (VT)
Asystole
Pulseless Electrical Activity (PEA = rhythm on
monitor, without detectable pulse)

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 20

 Ventricular Fibrillation (VF)
VF – An abnormal irregular heart rhythm whereby
there are very rapid uncoordinated contractions of
the lower chambers (ventricles) of the heart. there is
irregular undulations of varying shapes and
amplitude. This represents the firing of multiple
ectopic foci in the ventricle. Mechanically the
ventricle is quivering and no effective contraction,
and consequently no CO, occurs.

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 21

 Ventricular Tachycardia (VT)
VT- An abnormally rapid heart rhythm that originates
from a ventricle. One of the lower chambers of the
heart. Although the beat is regular, VT is life
threatening because it can lead to a dreaded
situation.
This occurs when an ectopic focus or foci fire
repetitively and the ventricle takes control as the
pacemaker.

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 22

•Asystole –A dire form of cardiac arrest in which the
heart stops beating--- there is no systole--- and there
is no electrical activity in the heart. The heart is a total
standstill. However, in 2004 people with asystole were
reported three times as likely to survive if they are
given in an injection of hormone called vasopress in
than they receive adrenaline alone.
•Occasionally the P waves can be seen. No ventricular
contraction occurs because depolarization does not
occur. Patients are unresponsive, pulseless and
apneic.

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 23

 Pulseless Electrical Activity
PEA – describes a situation in which electrical
activity can be observed in the ECG, but there no
mechanical activity of the ventricles and the patient
has no pulse. Prognosis is poor unless the underlying
cause can be identified and quickly corrected.

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 24

 B. Respiratory Arrest

A respiratory arrest (pulmonary arrest) is the

cessation of breathing. It often occurs as a result of a
blocked airway, but it can occur following a cardiac
arrest and for other reasons. A respiratory arrest is
preceded by short, shallow breathing. The breathing
becomes increasingly labored. Then the person
becomes flushed and disoriented and experiences
suffocation.

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 25

 B. Respiratory Arrest
When the primary respiratory arrest occurs, the heart
and lungs can continue to oxygenate the blood for
several minutes and the oxygen will continue to
circulate to the brain and other vital organs. Such
patients initially demonstrate signs of circulation.
When respiratory arrest occurs or spontaneous
respirations are inadequate, establishment of a patent
airway and rescue breathing can be lifesaving because
it can maintain oxygenation and may prevent cardiac
arrest.

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 26

 Causes Of A Cardiorespiratory Arrest:

A useful way to remember the 12 most common

causes of cardio respiratory arrest is to remember
that Six start with H and Six start with T.

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 27

Find the Cause
and Treat it.
11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 29
 Hypovolaemia
Hypovolaemia becomes critical when the patient
loses so much of their circulating volume that they
have an inability to carry oxygen. If the haemoglobin
is reduced below 8 mmol/l there will be an intolerable
oxygen deficit at cellular level.
The most common causes of severe blood loss are:
Trauma
Surgical procedure
Gastrointestinal mucosa erosion
Oesophageal varices
Peripheral vessel erosion ( by tumor)
Clotting abnormality

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 30

 Hypoxia
Most common are:
Acute respiratory
Acute lung injury failure
Airway difficulties
Severe Anemia
Neuromuscular disorders
For healthy cell metabolism the body requires a
constant supply of oxygen. When this interrupted for
more than 3 mins. In most situations (except when
there is severe hypothermia) cell death occurs,
followed by lactic acidosis and very rapidly cardio
respiratory arrest
11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 31
 Hypothermia

When the core body temperature falls below

approximately 30C there is a resultant shift in the pH
of the blood. This alteration in the pH severely affects
cell metabolism and results in a rapid progression to
cell death and lactic acidosis. Such severe
hypothermia is usually associated with being exposed
to severe weather conditions or near drowning. The
treatment is to gently warm the patient at a rate of a
degree an hour by using warming blankets.

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 32

 Hypo/Hyperkalemia
Because potassium is so closely linked with muscle
and nerve excitation any imbalance will affect both
the nervous conduction and the muscular working of
the heart. Therefore a severe rise or fall in potassium
can cause arrest arrhythmias.
The causes of hypokalemia are:
Gastrointestinal fluid loss
Urinary fluid loss
Drugs that affect cellular potassium, eg. Anti- fungal
agents such as amphotericin.

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 33

 Hypo/Hyperkalemia
The immediate treatment for hypokalemia which
has resulted in an arrest is to give concentrated
boluses of potassium while carefully monitoring the
serial potassium measurements. Check ABG’s
Causes of hyperkalemia:
Renal failure
The immediate treatment for hyperkalemia is to give
intravenous calcium. This binds to the potassium and
removes it from the cell. from the body.

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 34

 Hydrogen Ions (Acidosis)
Accumulation of acid and hydrogen ions or decrease
of alkaline reserve (bicarb) in the blood and body
tissues, decreasing pH

Effective Interventions:

•Ventilation
• Sodium bicarb bolus

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 35

 Thromboembolism
Myocardial infarction is the most common cause of
cardiac arrest, accounting for approximately 60% of
cases. Pulmonary embolism is less common but it of
concern in certain patient groups, for example after
major surgery or in patients who have a pelvic
malignancy.

Interventions:
•Surgical Embolectomy
•Fibronilytics

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 36

 Tension Pneumothorax
A tension pneumothorax is the sudden collapse of a
lung, usually under pressure, which results in a severe
change in intra thoracic pressure and cessation of the
heart as a pump.

Common causes are:

•Trauma
•Acute lung injury
•Mechanical ventilation of the newborn

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 37

 Tamponed

This is where there is an acute effusion of fluid in

the pericardial space and as it enlarges, the heart is
splinted and finally cannot beat. The fluid is usually
blood but can be malignant or infected fluid. The
most common cause for a sudden cardiac tamponade
is trauma. The immediate treatment is to relieve the
pericardial compression by aspirating the blood.-
Cardiac surgery.

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 38

 Toxicity-drug Or Metabolic
In this case the heart or its control mechanism (the
CNS) has been directly affected by a noxious
stimulant. This toxin may be external or endogenous
to the body. Examples of external toxins are drugs
used with therapeutic intent or recreationally. Internal
toxins might be lactic acid, diabetic keto-acidosis or
thyrotoxicosis. The treatment is to administer an
antidote where possible or to reverse the cause.

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 39

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 40
11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 41
11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 42
11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 43
11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 44
 Code Team
• Leader usually MD skilled in ACLS/ BLS
• 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
• Anesthesiologist/anesthetist intubation
• Respiratory therapist manages airway, sometimes intubates
• Pharmacist prepares medications in some settings
• Chaplain
• ECG technician
• Other personnel to run errands

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 45

 Emergency Equipment
• Crash cart • Bag-valve-mask device
• Backboard • Airway supplies/suction
• Monitor/defibrillator/ • Medications
pacemaker • IV supplies
– AED • Nasogastric tube
– Transcutaneous patches
• BP cuff

Copyright © 2017 by .Tanzeel Ul Rahman 47

Copyright © 2017 by Tanzeel Ul Rahman
 Emergency Equipment
1.Emergency equipment must be maintained in good
working order and assessed regularly to ensure
effective management of emergency situations
2.The use, maintenance, supply of emergency
equipment and checking of the crash cart is the
responsibility of the nurse but collaboration and
effective services from other departments are required
(Bio-medical departments and Material Management
Department) to ensure efficiency

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 49

 Emergency Equipment
Emergency cart Observations will include:
1. The entire content of supplies and equipment
checked against the list
2. Defibrillator is demonstrated to function
3. Oxygen supply is demonstrated to have sufficient
pressure and functioning
4. Suction has appropriate tubing attached
5. The expiry dates will be inspected once a week and
replaced as needed
Review Table 11-1

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 50

 Crash Cart
• Crash carts are labeled as to contents of drawers.
• Most carts have equipment stored on top and in several
drawers.
• Equipment such as backboards and portable suction
machines may be attached to the cart. Larger equipment is
stored on the top of the cart or in a large drawer; smaller
items, such as medications and IV equipment, are in the
smaller drawers.
• Nurses should familiarize themselves with contents of the
cart on their unit. Checking the cart and defibrillator assists
nurses in becoming familiar with equipment.

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 52

To achieve a maximum Response and
Outcome during a Code Blue, all Nurses
must meet the following criteria:
•All nursing staff must be familiar with the emergency
equipment and medications stored in the crash cart in
their respective department
•All nursing staff must be certified competent in BCLS
• Nursing Staff must be certified competent with
BCLS/ACLS and their competency must be renewed
every 2 years
• All Nursing Staffs must be familiar with the Code Blue
procedures and any special considerations in their unit

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 53

Responsibilities of Nurse in Code Blue

6Nursing Team will assist the resuscitation team by:

• Remaining on the scene, assisting as necessary
•Initiating CPR
•Performing CPR
•Providing supplies/equipment needed in the Code Blue
• Checking vital signs
•Inserting Cannula’s if not in place
• Preparing medications
• Administering medications
• Documentation

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 54

 Basic Cardiac Life Support
The Sequence Of Cardio- Pulmonary
Resuscitation

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 55

 2010 AHA Guidelines for CPR
• 2010 – THE American Heart Association (AHA) released new
guidelines about the re-arrangement of the THREE steps of CPR
• The first step is doing chest compressions instead of first
establishing the airway and then doing the mouth-to –
mouth resuscitation
• The new guidelines apply for adults, children and infants but
exclude newborns
• The old way was A-B-C for Airway, Breathing and
Compressions
• The new way is C-A-B for Compressions, Airway and
Breathing

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 56

 Key Changes

• Look, listen and feel is removed form the BLS

Algorithm
• Hands-only (Chest Compressions ) for lay rescuer
• Sequence change from ABC to CAB
• Continue emphasis on PULSE CHECK

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 57

 The American Heart Association
(AHA)/Emergency Cardiac Care
(ECC) Chain of Survival

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 58

 Push Hard, Push Fast

Full Chest Recoil

Minimize
Interruption
30 : 2
Until Intubated
When intubated:

Do not Hyperventilate
Ambu every 6 – 8 seconds
Copyright © 2017 by Tanzeel Ul Rahman
 Always Pulse + ECG
Every 2 minutes

Pulse + ECG
= =

CPR? SHOCK?

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 60

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 61
 CPR Guidelines for Adult Patients
One Rescuer
Age: 14 years and above

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 62

 Scene Safety
• Self
• Scene
• Survivor
Scene Assessment
 Fire, Wires
 Chemical
 Traffic
 Farm

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 63

 Phone Call
In Pakistan In Europe, You Can dial 112 or 9
Edhi 115 99 from a Mobile
• Without entering a Code
Rescue 1122 • Without taking the Lock off
Or your Local Hospit • If the SIM Card is missing
al / Emergency Med • Even if you have no Credit
ical Services Phone
Number
From a Mobile or
Land Line
11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 64
 Emergency Services 115 /1122
Always Give the Following Information:
• Name & telephone number
• Give exact location with accurate directions
• Type of incident
• Seriousness of incident
• Number of patients
• Age, sex and condition of patients
• Number of dead people
• Any hazards
• Don’t hang-up until you are told to do so
• Don’t keep your phone engaged
11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 65
 STEP 1 : Check Airway
• Assess for unresponsiveness
• Determine unresponsiveness (tap or
gently shake the victim and shout
“ARE YOU OK?
• If the victim is unresponsive but with normal
breathing, place the patient in a recovery position, so
that fluids can drain out from mouth

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 66

Recovery Position

67
Copyright © 2017 by Tanzeel Ul Rahman
•If unresponsive with absence of
breathing:
• Position the victim in supine and on
firm/flat surface

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 68

 STEP 2 : Check Pulse
•Studies have shown that both lay rescuer and
healthcare providers have difficulty detecting a pulse
• Lay rescuer ---- NO need to check pulse Assume
cardiac arrest if an adult collapse or unresponsive
• Health care provider------ CHECK pulse no more than
10 seconds, if no pulse, START with Chest Compressions

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 69

 STEP 3 : Chest Compressions
• These compressions create blood flow by
increasing intrathoracic pressure and directly
compressing the heart
• This generates blood flow and oxygen delivery
to the myocardium and brain
• To provide effective chest compressions, push
hard and push fast at a rate of 100 compressions
per minute

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 70

• If there is no sign of circulation begin chest
compressions:
• Place your fingers on the lower margin of the
victim’s rib cage on the side near you
• Slide your fingers up to the rib cage to the notch
• Place one heel of one hand on the lower half of the
sternum and the other hand on top of the first

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 71

• Lock your elbows in position, with arms straight.
Position your shoulders directly over your hands so that
the thrust for each chest compression is straight down
on the sternum
• Perform 30 chest compressions and 2 breaths (push
hard and fast)
• Minimize interruptions in compressions
• Depress the chest (at least 2 inches (5cm))

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 72

 STEP 3 : Rescue Breathing
1. Open Airway
• Place the patient on supine position in a firm
surface area
• Open airway using head-tilt-chin lift maneuver or
jaw thrust (if suspecting spinal or neck injury)

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 73

2. Clear the Airway
1. Check for foreign body airway obstruction (FBAO),
clear airway by finger swipes

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 74

3. Mouth- to- mouth rescue breathing
• If the patient is unresponsive and not breathing
• GIVE 2 SLOW BREATHS by
• Pinch the victims nose, then deliver 2 rescue
breathing

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 75

 NOTE:

• Perform 5 complete cycle of 30 compression and 2

ventilation, then re-assess the victim

• Continue until ACLS Team/Providers take over and or

victim start to move

• Once the patient is intubated, ventilations can be

performed at a rate of 8-10 breaths per minute without
pausing for compressions

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 77

 Pediatric Basic Life Support
Age
1 year to adolescent
(12-14 years)

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 78

 CHEST COMPRESSIONS TECHNIQUE IN
CHILDREN’S
• Because children and rescuers can very widely in
size, rescuers are no longer instructed to use a
single hand for chest compression of all children,
instead the rescuer is instructed to use 1 hand or
2 hands ( as in adult) as needed.
• Depress the chest ( 1-1 ½ inches or about 2
inches (5cm) for children

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 79

 Cardiac Arrest (Child)
• Safety (Self, Survivor and Scene)
• Standard Precautions
• Check for Response
• If No Response, get help and get an AED
• Open Airway and scan Chest for Breathing
• In No Breathing or NOT Breathing normally, Call for
Help
• Check for Carotid Pulse for at least 5 seconds and
NOT more than 10 seconds
• If no pulse or if it is <60, Start Chest Compressions,
just below the Nipple Line

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 80

 Cardiac Arrest (Child)
• Deliver 30 Compressions @ 100 per minute
• Insert the right size OPA
• Give Two effective slow breaths
• After 5 cycles of CPR, change ration to 15:2 if 2nd rescuer is av
ailable
• Continue until help or AED arrives or the victim becomes respo
nsive

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 81

 CPR Guidelines for Infant
Age : < 1 year old

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 82

 Cardiac Arrest (Infant)

• Safety (Self, Survivor and Scene)

• Standard precautions
• Check responsiveness
• Shout for help
• Open Airway
• Sniffing position
• Check for Breathing
• Look, Listen & Feel

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 83

 Cardiac Arrest (Infant)
• Two Effective Breaths
• Check Brachial Pulse, if its Absent or < 60, start 30
chest Compressions just below the nipple line
• This is followed by Two effective Breaths
• Change to 15-2 if 2nd Rescuer is arrives
• After 5 cycles Call for help if not already done, contin
ue until help arrives or infant becomes responsive

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 84

 Cardiac Arrest (Infant)
• Make good seal over infant’s nose & mouth with y
our own mouth
• Give 2 Effective breaths in max. 5 attempts
• If your mouth is too small to go over mouth and nos
e of the baby, you can blow through nose while keep
ing the mouth closed
• Remember: If Pulse rate is < 60 with poor perfusio
n, Continue CPR

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 85

 Similarities & Differences
in Adult, Child & Infant CPR
CPR Protocols Adult Child > 1 yr Infant
14 year or olde And < 14 yrs Up to 1 Year
r
Check for Respon By Tapping of Shou By Tapping of Shou By Tapping of
siveness lders lders Feet
Early Access Call for help Call for Help Shout for Help
Opening the Airw Head Tilt, Head Tilt, Sniffing
ay Chin Lift Chin Lift Position
Inserting the OP Invert & Rotate Direct / Straight Direct / Straight
A
Giving Two Effect Mouth to Mouth Mouth to Mouth Seal Mouth over N
ive Breaths Nose Pinch in two a Nose Pinch, in Max. ose & Mouth, in Ma
ttempts Five attempts x. Five attempts
Volume of Air Give normal breath Give normal breath Puff of Air
Look for chest rise Look for chest rise Look for chest rise
Ventilation Durat 1 second 1 second 1 second
ion 86

Pulse Check Carotid Carotid Brachial

 Similarities & Differences
in Adult, Child & Infant CPR
CPR Protocols Adult 14 year Child - > 1 year L Infant
or older ess than 14 years Up to 1 Year
Compression Both Hands One or Two Fingers
Both Hands Two Thumbs with
Two Rescuers
Compressions At least 2 Inche About 2 Inches 1/3 AP Diameter
Depth s / 5-6cm 5 cm of chest or 4 cm
Compression:
Ventilations Si 30:2 30:2 30:2
ngle Rescuer
Compression: 30:2 15:2 15:2
Ventilations
Two Rescuers
Compression R 100 per minute 100 per minute 100 per minute
ate (Speed)
AED protocol Shock when ad Shock when advised Used in Hospital
vised Use Child protocol settings 87
 Advances Airway and
Respiratory Arrest Situations

One breath every 6-8 seconds

(8-10 breaths/min)
Asynchronous with chest compressions
One breath after 5-6 seconds
10-12 breaths / min in Adults
One breath after every 3-5 seconds
12-20 breaths / min in Children / infants for Respiratory
Arrest situations

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 88

 When to STOP(s) CPR

S – Patient Starts Breathing and has a pulse

T - The patient is Transferred to another person trained i
n BLS, ALS
O - You are Out of Strength or too tired to continue
P – Physician gives direction to discontinue CPR
S - The Scene becomes unsafe

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 89

 Complications

• Rib fracture (13 -97%)

• Sternal fracture (1-43%)
• Bleeding in anterior mediastinum
• Heart contusion
• Hemopericardium
• Abdominal viscus – laceration of liver and spleen
• Fat emboli
• Pulmonary complications includes pneumothorax,
hemothorax and lung contusions

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 90

 Post-resuscitation Care
• The post resuscitation period is often marked by hemodynamic
instability as well as laboratory abnormalities
• Every organ system is at risk during this time, and patients may
ultimately develop multi-organ dysfunction.
Complete recovery from cardiac arrest does not happen
immediately, The patient may require between 12 to 24 hours of
mechanical ventilation after cardiac arrest
1. Check the patient by assessing airway breathing,
circulation, blood pressure and urine output
2. Check ABG’s and electrolytes
3. Monitor patient’s cardiac rhythm
4. Chest x-ray should be taken
5. Continue respiratory therapy

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 91

11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 92
 FBAO
 Foreign

 Body

 Airway

 Obstruction
93

Copyright © 2017 by Tanzeel Ul Rahman

 Foreign Body Airway Obstruction
Mild or Partial Obstruction
Patient Responsive
 Ask are you Choking?

Patient can
• Speak
• Make sounds
• Cough loudly
• Encourage casualty to Cough
• Advise to go to hospital if needed
94
Copyright © 2017 by Tanzeel Ul Rahman
 FBAO (Adult)
Severe or Full Obstruction
Patient Responsive
 Ask are you Choking?

 Reassure

 Give up to Five Back Blows

 Perform Five Abdominal Thrusts

until object comes out or Casualty
goes Unresponsive
95
Copyright © 2017 by Tanzeel Ul Rahman
 FBAO (Adult)
Patient Unresponsive
1. Call for Help
2. Start CPR with 30 Chest Compress
ions
3. Open mouth wide and Remove Ob
ject if you can see it
4. Continue CPR
5. Each time open the mouth to see
obstructing Object, Try to remove
it and provide two ventilations 96
Copyright © 2017 by Tanzeel Ul Rahman
 FBAO (Child)
Mild or Partial Obstruction
Responsive
• Ask are you choking?
The Child Can
• Speak
• Make Sounds
• Cough loudly
• Encourage casualty to Cough
• Advise to go to hospital if needed
97
Copyright © 2017 by Tanzeel Ul Rahman
 FBAO (Child)
Severe or Full Obstruction
Patient Responsive
 Ask are you Choking?

 Perform five Back Slaps

 Followed by five Abdominal Thrusts
 Continue until object comes out or casual
ty goes Unresponsive

98
Copyright © 2017 by Tanzeel Ul Rahman
 FBAO (Child)
Unresponsive Child
1. Call for Help
2. Place on flat surface
3. Open Airway, look for the obstructi
ng object and try to remove if poss
ible
4. Try to ventilate
5. Continue CPR

99
Copyright © 2017 by Tanzeel Ul Rahman
 FBAO (Infant)
Mild or Partial Obstruction
The Infant Can
 Make Sounds

 Cough loudly

 Let Infant Cough

 Advise to go to Hospital if needed

100
Copyright © 2017 by Tanzeel Ul Rahman
 FBAO (Infant)
Severe or Full Obstruction
Infant Responsive
1. Cannot Breathe
2. Cannot make a Sound or Cry

3. Has high pitched noisy Breathing

4. Begin Five back Slaps and Five chest comp

ressions until Object comes out or infant g

oes Unresponsive

101
 FBAO (Infant)
Infant Unresponsive
1. Call for Help
2. Place on flat surface
3. Open Airway, Look into the mouth for obstr
ucting object and try to remove it if you find
one
4. Try to ventilate (max five attempts)
5. Start chest compression
Continue steps 3-5 until help arrives or object comes ou
t

102
 S-A-M-P-L-E
 S – Signs & Symptoms

 A – Allergies (Food, Medicines)

 M – Medications

 P – Past / Pertinent Medical History

 L – Last Oral Intake

 E – Events leading to present condition

103
Copyright © 2017 by Tanzeel Ul Rahman
 O.P.Q.R.S.T.A
 O – Onset – Sudden, gradual
 P – Provocation – Aggravated / relieved by
 Q – Quality – Stabbing, colicky, burning
 R – Region / Referral / Recurrence / Relief
 S – Severity – On a scale of 1-10
 T – Time of Onset of symptoms
 A – Associated Symptoms: Nausea, Vomiting

104
Copyright © 2017 by Tanzeel Ul Rahman
 S-T-A-B-L-E
 S – Sugar (Hypo/hyperglycemia)
 T – Temperature
 A – Airway
 B – Blood Gases
 L – Lab Works
 E – Empathy

105
Copyright © 2017 by Tanzeel Ul Rahman
• At the end of this presentation we will be
able to
• Define ACLS.
• Explain Algorithms.
• Enumerate the steps of ACLS.
• Describe Procedure of defibrillation.
• Identify the Drugs and Airways used in
ACLS.
• Explain Post cardiac arrest care.
• Discuss Nursing responsibilities.
Copyright © 2017 by Tanzeel Ul Rahman
Advanced cardiac life support or advanced
cardiovascular life support (ACLS) refers to a set
of clinical interventions for the urgent treatment
of cardiac arrest, stroke and other life-threatening
medical emergencies.

Copyright © 2017 by Tanzeel Ul Rahman

 ACLS: Airway and Breathing

Figure 10-3. Rescue breathing with bag-mask device. (Reprinted with permission,
Cleveland Clinic Center for Medical Art & Photography © 2011-2016. All rights reserved.)

Copyright © 2017 by Tanzeel Ul Rahman 109

 ACLS: Airway and Breathing
(Cont.)

Figure 10-4. Ventilation with a bag-valve device connected to endotracheal tube.

(Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography ©
2011-2016. All rights reserved.)
Copyright © 2017 by Tanzeel Ul Rahman 110
 ACLS: Airway and Breathing
(Cont.)

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. (Reprinted
with permission, Cleveland Clinic Center for Medical Art & Photography © 2011-2016. All rights reserved.)
Copyright © 2017 by Tanzeel Ul Rahman 111
 ACLS: Circulation
• Large-bore IVs
• Biggest veins
• May insert central line if IV access is difficult

Copyright © 2017 by Tanzeel Ul Rahman 112

 Defibrillation
• The only effective treatment for VF and pulseless VT is
defibrillation.
• Monophasic waveforms deliver current in one direction.
• Biphasic waveforms deliver current that flows in a positive direction
for a specified duration and then reverses and flows in a negative
direction. As a result, fewer joules are needed for defibrillation.
• Important to know what equipment is on the unit’s crash cart. Most
newer defibrillators are biphasic type.
• Completely depolarize the heart
• Allow for the resumption of rhythm
• Safety is essential
• Complications
– Skin burns
– Damage to heart muscle
11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 113
1. Apply defibrillator pads to the patient with conductive
medium (gel)
2. Turn on defibrillator.
3. Set the number of joules (J):
Monophasic device: 360 J
Biphasic device: 120 or 200 J, depending on device
4. Ensure that personnel are not touching the patient
or bed. (say “I’m clear, you’re clear, everyone clear,
oxygen clear”)
5. Deliver shock.
6. Continue cardiopulmonary resuscitation (CPR).
7. Prepare to deliver subsequent shocks
Copyright © 2017 by Tanzeel Ul Rahman
• Current recommendations are to attempt
defibrillation using one shock, with
immediate resumption of CPR. Following
this first shock, five cycles of CPR are
performed. If the patient remains in a
shock able rhythm, then a second shock is
delivered. After each subsequent shock,
five more cycles of CPR are performed
before determining whether the patient is
in a shockable rhythm
11/1/2017 Copyright © 2017 by Tanzeel Ul Rahman 115
Defibrillation

Copyright © 2017 by Tanzeel Ul Rahman 116

Defibrillation (Cont.)

117
Copyright © 2017 by Tanzeel Ul Rahman
 AED
 Automated

 External

 Defibrillator
118
Copyright © 2017 by Tanzeel Ul Rahman
 AED Protocol
 Clear the patient’s Chest
 Put left and right pads on patients bare
chest at correct position
 If shock advised, Shout to warn the pe
ople to stay ‘Clear’
 Deliver Shock by pressing the button
 Immediately restart CPR with 30 chest
compressions

119
Copyright © 2017 by Tanzeel Ul Rahman
 AED Special Situations, Check
for “P’s”
Pacemaker Perspiration
Pendants Patches

Piercing Pani (H2O)

Pregnancy

120
Copyright © 2017 by Tanzeel Ul Rahman
 Cardioversion
•Cardioversion is the delivery of a shock that is
synchronized with the patient’s cardiac rhythm.
• Lower joules (e.g., 50)
• Synchronized delivery on R wave (prevents
“shock on T”)
• The purpose of cardioversion is to disrupt an
ectopic pacemaker that is causing a
dysrhythmia and to allow the sinoatrial node
to take control of the rhythm.
Copyright © 2017 Elsevier Inc. All rights reserved. 121
• A set of instructions that are followed to
standardize treatment, and increase its
effectiveness. These algorithms usually come
in the form of a flowchart, incorporating
'yes/no' type decisions, making the algorithm
easier to memorize.

Copyright © 2017 by Tanzeel Ul Rahman

Cardiac Arrest Algorithm
Acute Coronary Syndromes Algorithm
PEA/Asystole Algorithm
VF/Pulseless VT Algorithm
Bradycardia Algorithm
Tachycardia Algorithms
Respiratory Arrest Algorithm
Opioid Emergency Algorithm
Suspected Stroke Algorithm

Copyright © 2017 by Tanzeel Ul Rahman

Drugs

Copyright © 2017 by Tanzeel Ul Rahman

 `

Copyright © 2017 by Tanzeel Ul Rahman

• Following successful conversion to a perfusing rhythm, the
patient may be hemodynamically unstable and require
continuous intensive monitoring.
-Vasoconstrictors may be administered to maintain an adequate
blood pressure. If the patient was placed on a transcutaneous
pacemaker during the cardiopulmonary arrest, then a
transvenous can be placed.
-Induced therapeutic hypothermia (32° to 34° celsius) may
benefit unconscious adult patients.
- During cardiac arrest, blood flow to the brain is compromised,
and even prompt interventions may not counteract the
deleterious effects of this hemodynamic compromise.
-Studies have shown that cooling the patient after cardia arrest
may preserve neurological function by reducing the cerebral
metabolic rate for oxygen (CMRO2).
Copyright © 2017 by Tanzeel Ul Rahman
Transcutaneous Pacing

Copyright © 2017 by Tanzeel Ul Rahman

Copyright © 2017 by Tanzeel Ul Rahman
 Documentation of Events
• Assign someone to document events during the
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

Copyright © 2017 by Tanzeel Ul Rahman 130

 Supporting the Family
• Should they be present during a code?
– Providing information
– Active communication
– Visitation after a code
– Support from staff

Copyright © 2017 by Tanzeel Ul Rahman 131

 Supporting Other Patients
• Remove from the situation
• Talk with them
• Assess their feelings
• Continue their care

Copyright © 2017 by Tanzeel Ul Rahman 132

 VF and Pulseless VT
• ABCD with Initiate CPR
• Shock, CPR, shock, CPR, shock
– 120, 200 (biphasic), 360 (monophasic) joules
• IV access
– Epinephrine or vasopressin
• Intubate if unable to effectively manage
airway and ventilate patient

Copyright © 2017 Elsevier Inc. All rights reserved. 133

 VF and Pulseless VT
(Cont.)
• Drug-shock continues
– Epinephrine repeated as needed; vasopressin is
given only once
– Consider antidysrhythmic drugs
• Amiodarone (drug of choice)
• Lidocaine
• Procainamide
– Magnesium if level is low or torsades is present
– Sodium bicarbonate (only if severely acidotic)

Copyright © 2017 Elsevier Inc. All rights reserved. 134

 Pulseless Electrical Activity (PEA)
• Rhythm without pulse
• Airway, oxygen, intubate, IV access
• ABCD with CPR
• Treat cause
• Epinephrine

Copyright © 2017 Elsevier Inc. All rights reserved. 135

 Asystole
• ABCD with CPR
• Airway, oxygen, intubate, IV access
• Confirm in two leads
• Treat cause
• Epinephrine
• Transcutaneous pacemaker

Copyright © 2017 Elsevier Inc. All rights reserved. 136

 Symptomatic Bradycardia
• ABCD with CPR
• Airway, oxygen, IV access
• Atropine
• Consider cause
• Transcutaneous pacing
• Dopamine or epinephrine

Copyright © 2017 Elsevier Inc. All rights reserved. 137

 Unstable Tachycardia
• ABCD
• Airway, oxygen, IV access
• Identify the unstable tachycardia
• Sedation
• Cardioversion
• Reassess patient and rhythm

Copyright © 2017 Elsevier Inc. All rights reserved. 138

Overview of Medications

Copyright © 2017 Elsevier Inc. All rights reserved. 139

 Epinephrine
• Potent vasoconstrictor
• Alpha- and beta-adrenergic effects
• Ventricular fibrillation (VF), pulseless ventricular tachycardia
(VT), asystole, and PEA
• 1 mg IV push every 3 to 5 minutes
• Can also be given via intraosseous or ETT
(through the ETT the dilution is 2 to 2.5 mg
diluted in 19 mL of NS or sterile water).
• Continuous infusion begun at 1 mcg/min (1 mL in 250 or
500 mL of D5W or NS); infuse at 2-10 mcg/min and titrate as
needed.

Copyright © 2017 Elsevier Inc. All rights reserved. 140

 Vasopressin
• Nonadrenergic vasopressor/alternative to
epinephrine
• Intense vasoconstriction at high doses
• May be as effective as epinephrine
• Onetime dose of 40 units IV for VF/pulseless
VT
• Can be given via ETT (dilute in 10 mL of NS)

Copyright © 2017 Elsevier Inc. All rights reserved. 141

 Atropine
• Decreases vagal tone
• Symptomatic bradycardia
– 0.5 mg every 3 to 5 min IV push
– Maximum of 3 mg
• Can be given via ETT (2-3 mg diluted in 10 mL
of NS or sterile water
• External pacemaker on standby
• Atropine is no longer given in PEA or asystole
Copyright © 2017 Elsevier Inc. All rights reserved. 142
 Amiodarone (Cordarone)
• Reduces membrane excitability
• Prolongs the action potential and retards the
refractory period; thus facilitates the termination
of VT and VF
• Alpha-adrenergic and beta-adrenergic blocking
properties
• Does not have the same prodysrhythmic
properties of other antidysrhythmics
• During cardiac arrest 300 mg IV/IO loading bolus

Copyright © 2017 Elsevier Inc. All rights reserved. 143

 Lidocaine
• Antidysrhythmic
• Suppresses ventricular ectopy
• Bolus 1 to 1.5 mg/kg; additional bolus 0.5 to 0.75
mg/kg every 5 to 10 minutes up to 3 mg/kg
• Follow with infusion at 2 to 4 mg/min (1 g in 250
mL 5% dextrose in water)
– Concentration: 1 mg/min = 15 mL/hr
• Assess for lidocaine toxicity
• Can be administered via ETT tube (2-4 mg/kg
diluted in 10 mL of NS or sterile water)

Copyright © 2017 Elsevier Inc. All rights reserved. 144

 Adenosine
• Slows conduction through AV node
• Primary use for paroxysmal supraventricular
tachycardia
• Rapid IV push through port nearest insertion site
of IV followed by rapid flush of 20 mL NS
• The initial dose is a 6 mg IV push over 1 to 3
seconds, followed by a 20-mL rapid saline flush.
Expect short pause in rhythm after administration
• A second and third dose of 12 mg may be given 1
to 2 minutes later
Copyright © 2017 Elsevier Inc. All rights reserved. 145
 Magnesium
• Refractory VF, torsades de pointes (type of VT)
• Known deficiency of magnesium
• When VF/pulseless VT cardiac arrest is associated
with torsades de pointes, 1 to 2 g of magnesium
sulfate diluted in 10 mL of D5W is given IV/IO over
5 to 20 minutes.
• In nonarrest situations, a loading dose of 1 to 2 g
mixed in 50 to 100 mL of D5W is given over 5 to
60 minutes. IV bolus followed by infusion titrated
by magnesium levels

Copyright © 2017 Elsevier Inc. All rights reserved. 146

 Torsades de Pointes

Figure 10-14. Torsades de pointes. The QRS complex seems to spiral around the isoelectric line. (From
Urden LD, Stacy KM, Lough ME. Critical Care Nursing: Diagnosis and Management. 6th ed. St. Louis:
Mosby; 2010.)

Copyright © 2017 Elsevier Inc. All rights reserved. 147

 Sodium Bicarbonate
• According to ABGs
• Treatment of metabolic acidosis
• Do not mix with other medications
(precipitate)
• Initial dosage of sodium bicarbonate is 1
mEq/kg by IV push.

Copyright © 2017 Elsevier Inc. All rights reserved. 148

 Dopamine
• Symptomatic hypotension
• Vasoactive (vasoconstrictor) to increase BP
• Continuous drip
– 2 to 5 mcg/kg/min (learn calculations)
– Dose is dependent on blood pressure control
– In doses greater than 20 mcg/kg/min, marked
vasoconstriction occurs
• Effects dose related
– Moderate doses = cardiac doses
– Higher doses = vasopressor doses
• Consider need for fluids versus dopamine

Copyright © 2017 Elsevier Inc. All rights reserved. 149

• Thanks...