Exam 2 PPT Transcripts - Lecture notes Lecture 4-6 PDF

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Rapid Response Teams and Code Management Dark Green: Footer Notes

Cardiopulmonary Arrest •

Codes can fill with panic and chaos

•

Best options o

Prevent-assessing the client, anticipating needs, activating rapid response team

o

Plan-know how to activate the rapid response team/code team and what to expect

o

Practice-go to educational simulation courses

•

Rapid response teams (RRTs) help to prevent a code situation.

•

Planning and teamwork maximize effectiveness of RRT calls and codes.

•

Anticipate!

Rapid Response Team Concept •

Identification of clinical deterioration that triggers early notification of a specific team of responders (neuro, vital signs, labs)

•

Rapid intervention by the response team that includes both personnel and equipment that is brought to the patient, and

•

Ongoing evaluation through data collection and analysis to improve prevention and response.

Rapid Response Teams •

“Failure to rescue” is important concept to address

•

RRT established to address concerns

•

Call BEFORE the cardiac/respiratory arrest

•

Recommended by The Joint Commission and the Institute for Healthcare Improvement to implement systems to request assistance for worsening conditions

•

Failure to recognize changes in a patient’s condition until major complications, including death, have occurred is referred to as “failure to rescue.”

•

Rapid response teams (RRTs) have recently been implemented to address changes in a patient’s clinical condition before a cardiac and/or respiratory arrest occurs.

•

The Institute for Healthcare Improvement and The Joint Commission National Patient Safety Goals require hospitals to implement systems that enable health care workers to request additional assistance from a specially trained individual(s) when the patient’s condition appears to be worsening.

•

The goal of the RRT is to ensure that interventions are available quickly when patient conditions become unstable before an actual cardiac arrest.

RRTs (Cont.) •

Call any time a staff member is concerned about changes in a patient’s condition, including: o

Heart rate, systolic blood pressure**

o

Respiratory rate, oxygen saturation**

o

Mental status**

o

Urinary output**

o

Laboratory values**

•

Some institutions empower family members to activate the RRT

•

Criteria to facilitate early identification of physiological deterioration help nurses determine whether the RRT should be called for a bedside consultation.

RRT Effectiveness •

•

RRT reduces: o

Cardiac arrests

o

Critical care unit length of stay

o

Incidence of acute illness, such as respiratory failure, stroke, severe sepsis, and acute kidney injury

Recent review of literature and metaanalysis of 1.3 million patients o

Conflicting studies with results showing or not showing lower hospital mortality rates in hospitalized adults (Why? Think about the patient condition at the time, comorbidities & multiple hospitalizations)

o

In researching, some recent studies have shown otherwise

Codes •

Code, code blue, code 99, Dr. Heart

•

Cardiac and/or respiratory arrest

•

Lifesaving resuscitation and intervention needed

•

o

BLS/AED

o

ACLS

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 Team •

Notification system

•

Members vary within setting

•

Better patient management

•

Care according to ACLS protocols

•

Other health care workers manage other patients

•

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.

Team Members •

Leader usually MD skilled in ACLS

•

Nurses (usually ICU or ER)

o

Primary nurse knows patient

o

Second nurse gives medications and gets equipment from crash cart

o

Another nurse records events

o

Nursing supervisor provides traffic control and secures ICU bed (if needed)

•

Team is led by a physician.

•

Every team member has a role.

•

Only essential personnel are in the room.

•

See Table 10-1.

•

Chaplains can support the family or friend during the code.

Team Members (Cont.) •

Anesthesiologist/anesthetist intubation

•

Respiratory therapist manages airway, sometimes intubates

•

Pharmacist prepares medications in some settings

•

Chaplain

•

ECG technician

•

Other personnel to run errands

•

Table 10-1 (Cont.)

•

See pages 221-223 for complete listing of responsibilities.

Equipment •

Crash cart

•

Backboard

•

Monitor/defibrillator/ pacemaker o

AED

o

Transcutaneous pacemaker

•

Bag-valve-mask device

•

Airway supplies/suction

•

Medications

•

IV supplies

•

Nasogastric tube

•

BP cuff

•

See Table 10-2.

•

See page 209 for complete listing of contents.

•

Backboard for adequate compressions.

Things to Know 

Your cart



o

Where it is located?

o

How do you unlock it?

o

How do you check it per unit protocol?

Your equipment o

O2 and suction-risk of aspiration

o

Is child-sized equipment available if needed (e.g., ED)?



The nurse can become familiar with the location of items on the cart by being responsible for checking it.



Management of the code is more efficient when the nurse knows where items are located on the crash cart, as well as how to use them.



Many institutions require nursing staff to participate in periodic “mock” codes to assist in maintaining skills.

Sequence of Events: BLS 

Advance directives or living wills



Airway open



Breathing



o

Mouth to mask

o

Bag-valve-mask device

Circulation: chest compressions o

May do open chest compression in trauma patients or after cardiac surgery



The code team should be alerted to the patient’s code status.



The goal of basic life support (BLS) is to support or restore effective circulation, oxygenation, and ventilation with return of spontaneous circulation. Early CPR and early defibrillation with an AED are stressed.



The 2010 AHA Guidelines for CPR recommend a change in the BLS sequence from ABC (airway, breathing, circulation) to CAB (chest compressions, airway, breathing) and determining need for early defibrillation.



Table 10-3

ACLS: Airway and Breathing 

Airway management



Manual ventilation



Intubation



o

Isolate airway and keep open

o

High concentration of oxygen

Delivery of tidal volume o

Protect airway

o

Suction

o

Administer selected medications



See Figure 10-2, 10-3 and 10-4 for airway management strategies.



Also refer to sections in Chapter 9 related to intubation.

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.

Figure 10-3. Rescue breathing with bag-mask device •

Ventilation of the patient with a bag-valve-mask device requires that an open airway be maintained. Frequently, an oral airway is used to keep the airway patent and to facilitate ventilation.

•

The bag-valve-mask device is connected to an oxygen source set at 15 L/min. The face mask is positioned and sealed over the patient’s mouth and nose after opening the airway.

•

Personnel should be properly trained to use the bag-valve-mask device effectively.

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

The bag-valve-mask device should have a reservoir and be connected to an oxygen source to deliver 100% oxygen while providing a tidal volume of 6 to 7 mL/kg.

•

Chest compressions are not stopped for ventilations. Chest compressions are delivered continuously at a rate of 100 per minute.

•

Ventilations are delivered one breath every 6 to 8 seconds or approximately 8 to 10 breaths per minute.

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. 

Once a patient is intubated with an endotracheal tube, placement is verified with an end-tidal CO 2 detector device and confirmed by chest x-ray.

ACLS •

•

Primary survey o

ABCD (early defibrillation)

o

Use of automatic external defibrillator (AED)

Secondary survey o

Advanced skills

o

Differential diagnosis

•

Primary and secondary surveys are integral parts of code management.

•

The ACLS Secondary Survey takes you through the advanced assessment and actions you need to accomplish for a patient in respiratory arrest. Your assessment guides you in finding the answers and taking appropriate next steps

•

Does the patient need an advanced airway?

•

If yes, use the airway that is appropriate to your skill level. King Airway System™, LMA, Combitube™, and or endotracheal intubation.

•

Is the patient breathing?

•

Is the advanced airway device placed properly?

•

Confirm correct placement of advanced airway device by observing the patient, confirming the presence of lung sounds in at least 4 lung fields and using waveform capnography

•

42mmhg

•

Capnography is the monitoring of the concentration or partial pressure of carbon dioxide (CO 2) in the respiratory gases

•

Is the advanced airway device secured correctly?

ACLS: Circulation •

Large-bore IVs

•

Biggest veins

•

May insert central line or intraosseous cannula if IV access is difficult

•

Important to have good IV access.

•

Intraosseous access is also effective if unable to get IV access.

•

As last resort, a few medications can be given through the ETT.

ACLS (Cont.) •

Administer medications via endotracheal tube (ETT) if needed

•

Lidocaine

•

Epinephrine

•

Vasopressin

•

Defibrillation

•

Differential diagnosis

•

Medications that can be administered through the ETT until IV access is established are epinephrine, lidocaine, and vasopressin (ACLS guidelines).

•

IO is preferred over ETT drug administration because ETT absorption is not consistent.

•

Other drugs that can be given through the ETT include atropine and naloxone (Narcan), but they are not included in the ACLS protocol.

Logical Flow of Events •

BLS

•

ACLS/AED

•

Ongoing assessment

•

Pulse oximetry o

ETCO2

o

Pulse checks

o

ABGs

o

Lab work

•

Crowd control

•

Notification of family and communication

•

Family presence in code

•

If successful code, transfer to ICU

ACLS Summary •

Treat patient, not monitor

•

CPR throughout

•

Early defibrillation essential

•

Use ETT as needed for medication administration

•

Provide treatment according to algorithms

Dysrhythmia 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

•

Dysrhythmia management is an integral part of code management.

•

Nurses, team members, and lay people must be instructed in application of AED.

VF and Pulseless VT •

ABCD, initiate CPR

•

Shock, CPR, shock, CPR, shock o

•

200 (biphasic), 360 (monophasic) joules

IV access o

Epinephrine or vasopressin

•

Intubate if unable to effectively manage airway and ventilate patient

•

The most common initial rhythms in witnessed sudden cardiac arrest are VF or pulseless VT.

•

Treatment for VF and pulseless VT is the same.

•

Initiate the BLS survey. Begin CPR. Defibrillate as soon as possible.

•

Give one shock and resume CPR.

•

If a biphasic defibrillator is available, use the dose at which that defibrillator has been shown to be effective for terminating VF (typically 120 joules [J] to 200 J). If the dose is not known, use the maximum dose available.

•

If a monophasic defibrillator is available, use an initial shock of 360 J and use 360 J for subsequent shocks.

•

If VF/VT persists, continue CPR, charge the defibrillator, and obtain IV/IO access.

•

Alternate cycles of CPR, shock, and medication.

VF and Pulseless VT (Cont.) •

Drug-shock continues o

Epinephrine repeated as needed; vasopressin is given only once

o

Consider antidysrhythmic drugs 

Amiodarone (drug of choice)



Lidocaine



Procainamide

o

Magnesium if level is low or torsades is present

o

Sodium bicarbonate (only if severely acidotic)

•

CPR-shock-drug cycle continues.

•

Epinephrine can be used frequently; one dose of vasopressin can be tried instead of epinephrine.

•

Antidysrhythmics may be needed; amiodarone is the drug of choice.

Pulseless Electrical Activity (PEA) •

Rhythm without pulse

•

Airway, oxygen, intubate, IV access

•

ABCD with CPR

•

Treat cause

•

Epinephrine

•

Pulseless electrical activity is treated as asystole since there is no cardiac output.

•

Key is to assess and treat the cause of the PEA.

Pulseless Electrical Activity (Cont.) •

Hypoxia

•

Hypovolemia

•

Hypothermia

•

H+ ions (acidosis)

•

Hypokalemia or hyperkalemia

•

Tablets (overdose)

•

Tamponade (cardiac)

•

Tension pneumothorax

•

Thrombosis (coronary)

•

Thrombosis (pulmonary)

•

Identify and treat causes of PEA: H’s and T’s for remembering these.

•

See Box 10-2.

Asystole •

ABCD with CPR

•

Airway, oxygen, intubate, IV access

•

Confirm in two leads

•

Treat cause (see PEA)

•

Transcutaneous pacemaker

•

Epinephrine

•

Asystole is the absence of electrical activity on the ECG and has a poor prognosis.

•

For resuscitation efforts to be successful, it is essential to search for and treat reversible causes of asystole.

Symptomatic Bradycardia •

ABCD with CPR

•

Airway, oxygen, IV access

•

Atropine

•

Consider cause

•

Transcutaneous pacing o

May need sedation/analgesia

•

Dopamine or epinephrine

•

No lidocaine

•

Symptomatic bradycardia is any heart rhythm that is slow enough to cause hemodynamic compromise.

•

See Box 10-3.

•

Treatment is to maximize cardiac output through medications, such as atropine, and mechanical means, such as a transcutaneous pacemaker.

Unstable Tachycardia •

ABCD

•

Airway, oxygen, IV access

•

Identify the unstable tachycardia

•

Sedation

•

Cardioversion

•

Reassess patient and rhythm

•

Unstable tachycardia occurs when the heart beats too fast for the patient’s clinical condition.

•

Treatment involves rapid recognition, and that the signs and symptoms are caused by the tachycardia.

•

Synchronized cardioversion and antidysrhythmic therapy may be needed.

Defibrillation •

Primary treatment for ...