HHS CPO Code Blue

OPA Indications

• Unconscious (absent gag reflex)

• Breathing or non-breathing patient

• Bite block (seizures)

NPA Indications

• OPA insertion not possible (i.e. facial trauma, jaw wiring, seizures)

• Pt with intact gag reflex

• Frequent suctioning

Indications for Advanced Airway

• Ventilation

• Obstruction relief

• Protect airway

• Secretion removal

Intubation Equipment

• PPE

• Oxygen source and flowmeter

• BVM

• Suction equipment

• Laryngoscope with appropriate blade

• ETT (#7.5, 8.0, 8.5)

• Stylet

• 10 ml syringe

• Lubricant

• ETCO2 detector

• Tape

• Stethoscope

Cricoid Pressure (Sellick’s Maneuver)

Compresses esophagus to prevent regurgitation

ETT Placement Confirmation

• Auscultate stomach, lungs

• Visible bilateral chest rise

• Verify colour change on ETCO2 detector

• Monitor for condensation in ETT

• VS improvement

• Confirm placement on CXR

ETT Suctioning

• 120-150 mmHg suctioning

• Preoxygenate with 100% O₂

• Suction to resistance, pull back 2cm

• Continuous suction with slow withdrawal

• 10-15 sec maximum

Code Blue Team Members

• Team captain

• Medical resident

• Anesthesia resident

• Critcal care RNs

• RT

• Porter

Modified Code Blue Team Members

• Physician

• Critical Care RNs (2)

• RRT (2)

• Security

Access for Medication

• 18g IV

• If not established in 90 sec → IO

Epinephrine Indications

• VF

• pVT

• Asystole

• PEA

Epinephrine Effects

Increased BP, coronary/cerebral blood flow, force of myocardial contraction, O₂ consumption

Epinephrine Dosing

1mg IV/IO q3-5 min

Lidocaine Indications

• VF

• pVT

• Wide complex tachycardia

• Torsades de Pointes refractory to amiodarone

Lidocaine Effects

Suppresses ventricular activity (decreases automaticity, shortens refractory period)

Lidocaine Dosing

1-1.5 mg/kg IV/IO push

• May repeat 0.5-0.75 mg/kg in 5-10 min

• Maximum dose → 3 mg/kg

Amiodarone Indications

• Atrial and ventricular arrhythmias

• VF

• VT

• SVT

Amiodarone Effects

Decreases excitabiity of myocardial cells → slows rate, irritability

Amiodarone Dosing (VF/pVT)

1. 300mg IVP with 10-20ml NS flush over 1-3 min

2. 150mg IVP with 10-20ml NS flush over 1-3 min

Adenosine Indications

• SVT

• VT (regular, monomorphic)

Adenosine Effects

Slows AV conduction and interrupts reentry pathways

Adenosine Dosing

Peripheral line → 6mg over 1-3 sec, repeat once 12mg over 1-3 sec PRN

Central line → 3mg over 1-3 sec, repeat once 6mg over 1-3 sec PRN

Procainamide Indications

• SVT

• Atrial Flutter

• VT with pulse

Procainamide Dosing

15 mg/kg IV/IO over 30-60 min followed by maintenance infusion (1-4 mg/min)

Atropine Indications

Symptomatic bradycardia

Atropine Dosing

1mg q 3-5 min up to max of 3 mg

Dopamine Indications

Inotrope → increase CO, BP

Dopamine Dosing

0.05-3 mcg/kg/min infusion → vasodilation, inc blood flow to coronary, renal, mesenteric, cerebral beds

3-10 mcg/kg/min infusion → inc myocardial contractility, HR, SVR

10-20 mcg/kg/min infusion → inc vasoconstriction, myocardial oxygen demand

Magnesium Sulfate Indication

Torsades de Pointes

Magnesium Sulfate Dosing

1-2 g IVP slowly over 1-2 min

• May give up to 5-10 g total by infusion

Naloxone - Opiate-Induced Resp Depression

0.1mg IV q 3 min, up to 0.4mg total

Naloxone - Known or Suspected OD

0.4-2mg IV q 2-3 min, max 10mg

Norepinephrine Indications

Temporary maintenance of BP

Norepinephrine Dosing

8-16 mg in 250 D5W (preferred) or NS

0.1-0.5 mcg/kg/min (70 kg adult 7-35 mcg/min) titrate to MAP or SBP

Endotracheal Administration

Lidocaine

Epinephrine

Atropine

Naloxone

Acute Coronary Syndrome

MONA if needed

• Morphine - IV if not relieved by nitro

• Oxygen - 4L SpO₂ over 90%

• Nitro SL, spray or IV

• Aspirin - 160-325 mg

12-lead ECG

STEMI → fibrinolysis or PCI

NSTEMI → monitor, angiogram/angioplasty 24-48h

Symptomatic Bradycardia

• Maintain airway

• Oxygen if hypoxemic

• Cardiac monitor (BP, SpO₂, tele), patent IV access

• Prep for transcutaneous pacing (TCP)

• Atropine 1mg IV q 3-5 min (max 3 min) until paced

• Epinephrine 2-10 mcg/min or Dopamine 5-20 mcg/kg/min

Transcutaneous Pacing Indications

• Symptomatic bradycardia (hemodynamic compromise, aLOC, angina, pulm edema)

• 2nd Degree AV Block Type II

• 3rd Degree AV Block

• New L/R BBB

• Early witnessed asystole

5Hs

Hypovolemia

Hydrogen Ion Imbalance

Hypothermia

Hyper/hypokalemia

Hypoxia

5Ts

Tamponade (Cardiac)

Tension pneumo

Toxicity/tablets

Thrombosis (coronary)

Thromosis (pulmonary)

Hypovolemia Treatment

• IV fluids

• Volume expanders

• FFP

• pRBCs

Hydrogen Ion Imbalance (Acidosis) Treatment

• High quality CPR

• Possibly NaHCO₃

• Correct ABG/VBG

Hypothermia Treatment

• Warm blankets, Bair Hugger, warmed IV fluids

• Intravascular temp management

• Green blanket

• Warm bladder irrigation

• Bypass machine in OR

Hyperkalemia Treatment

• IV Calciu, NaHCO₃, Insulin+D50W, furosemide

• Kayexalate enema

• Emergency dialysis

• Nebulized salbutamol

Hypokalemia Treatment

• Potassium boluses max. 20 mmol over 1h

• Some concentrations must go through CVAD

• Supplemental potassium in IV fluids

Hypoxia Treatment

• O₂ ± intubation

• Fix ABG/CBG via vent setting, CPAP/BiPAP

• Correct metabolic derangement

Tamponade Treatment

• Pericardiocentesis

• Open chest to relieve pressure

Tension Pneumothorax Treatment

• Chest tube insertion

• Needle decompression

Toxicity Treatment

Antidote if available

Coronary Thrombosis Treatment

• Thrombolytics (TNK, streptokinase)

• PCI

• Coronary bypass sx

Pulmonary Thrombosis Treatment

• O₂ ± intubation

• Anticoagulations (Heparin gtt, subcut, warfarin PO)

Therapeutic Hypoxemia

Limit anoxic brain injury d/t low flow state in cardiac arrest (32-36)