RRT, Code Blue, Organ Donation

Critical Care Study Notes

Material to Cover

  • Rapid Response Team
  • Code Blue Management
  • Organ Donation

Rapid Response Team

  • Definition and Purpose (Chapter 11)
    • The Rapid Response Team (RRT) is implemented to address changes in a patient's clinical condition before a cardiac or respiratory arrest occurs.
    • It is designed to improve the recognition and response to clinical deterioration in patients, ensuring that interventions are available quickly before actual cardiopulmonary arrest.
    • The inability to recognize changes in a patient’s condition until significant complications have occurred is referred to as “failure to rescue.”
    • Goal: Improve patient outcomes and decrease hospital mortality.

Conditions Associated with “Failure to Rescue”

  • Acute Respiratory Failure (ARF)
  • Acute Cardiac Failure
  • Acute changes in level of consciousness
  • Hypotension
  • Dysrhythmias
  • Pulmonary Edema
  • Sepsis
    • Statistic: 80% of these patients will have instability changes to their heart rate (HR), blood pressure (BP), and/or respiratory status in the 24 hours leading up to a cardiac arrest.

RRT Concept (Page 231)

  • Identification of clinical deterioration triggers early notification of a specific team of responders.
  • Rapid intervention by the RRT includes both personnel and equipment brought to the patient.
  • Ongoing evaluation through data collection and analysis to improve prevention and response.

RRT Role

  • Resource Team
    • Called at any time to assess patients outside of a critical care unit.
    • Supports and educates nursing staff (specifically critical care nurses).

RRT Activation

  • Criteria for patient activation:
    • Early warning score system triggered by deterioration of:
    • Heart rate
    • Blood pressure
    • Respirations
    • Pulse oximetry
    • Mental status
    • Urinary output
    • Laboratory values
    • An RRT can be activated by any staff member concerned about changes in patient condition, and in some institutions, family members are also empowered to activate the RRT.

RRT Respondents

  • Critical Care Nurses
  • Respiratory Therapist
  • Physician (sometimes)
  • Clinical Nurse Specialist or Mid-Level Practitioner

RRT Equipment

  • Equipment Brought by RRT:
    • RSI box
    • ECG monitors
    • Vital Signs equipment
    • IV supplies
    • O2 therapy apparatus
    • Blood draw supplies, including Arterial Blood Gas (ABG), blood sugar, and other labs
    • Medications
    • ACLS algorithms, standing medical orders, evidence-based protocols

Benefits of RRTs

  • Reduction in:
    • Cardiac arrests
    • Length of hospital stay
    • Incidence of acute illness
    • Respiratory failure cases
    • Stroke occurrences
    • Severe sepsis
    • Acute kidney injury

Code Blue Management

  • Adult Basic Life Support Algorithm for Healthcare Providers:
    1. Verify scene safety.
    2. Check for responsiveness.
    3. Shout for nearby help, activate emergency response system via mobile device if appropriate.
    4. Get AED and emergency equipment, or send someone to retrieve them.
    5. Monitor until emergency responders arrive while checking for normal breathing, and checking pulse simultaneously.
    • If normal breathing and pulse are felt, continue monitoring.
    1. If no breathing or only gasping, check for pulse:
    • If pulse is felt, provide rescue breathing (1 breath every 6 seconds or approximately 10 breaths/min).
    • Check pulse every 2 minutes; if there is no pulse, start CPR.
    • If opioid overdose is suspected, administer naloxone if available per protocol.
    1. If no pulse is felt, start CPR:
    • Perform cycles of 30 compressions and 2 breaths.
    • Use AED as soon as it is available.
    • Check rhythm upon AED arrival:
      • If shockable rhythm, deliver a shock and resume CPR immediately for 2 minutes until prompted by the AED for another rhythm check.
      • If non-shockable rhythm, continue CPR until ALS providers take over.

Adult Cardiac Arrest Algorithm

  • VF/PVT:
    • Start CPR and give oxygen.
    • Attach monitor/defibrillator.
    • Check rhythm:
    • If shockable, deliver shock and continue CPR for 2 minutes, then reassess rhythm and follow protocol for medication (Epinephrine every 3-5 minutes, consider advanced airway).
    • If asystole or PEA, administer Epinephrine ASAP, begin CPR, and provide IV/IO access.

Team Roles in Code Blue

  • Code Team:
    • Members Include: Physician, Critical Care Nurse or ER Nurses, Nursing Supervisor, Nurse Anesthetist/Anesthesiologist, Respiratory Therapist, Pharmacist/Pharmacy Technician, ECG Technician, Chaplain.
    • Works with the primary nurse and physician to manage the code.
  • Code Leader: Usually a physician; responsible for directing the code, making diagnosis and treatment decisions, and needing detailed patient information.
  • Code Nurses:
    • Includes a primary nurse, tasked with relaying information, administering medications, starting IVs, and drawing blood.
    • A secondary nurse coordinates the code cart, while a third nurse records details of the code.

Documentation

  • An example of documentation for code situations is available on page 251.

Post Code Blue Management

  • Return of Spontaneous Circulation (ROSC):
    • After a successful resuscitation, it is important to determine the cause of the cardiac arrest (H's and T's of ACLS).
    • Targeted Temperature Management (TTM):
    • It involves maintaining a lower body temperature (32-36 degrees Celsius) for 24 hours post-arrest to optimize neurological recovery.
    • Rapid induction of target temperature is important, with slow rewarming monitored for potential complications like shivering or increased O2 consumption.

Organ Donation (Chapter 5)

  • Brain Death:
    • Defined as absent cerebral and brainstem function due to nonsurvivable head injury.
    • Determined based on neurological criteria rather than circulatory death criteria.
    • Methods for Brain Death Diagnosis include:
    • Comprehensive clinical evaluation and neurological testing such as EEG, cerebral angiography, and ensure confounding factors are accounted for before diagnosis.
    • Criteria to Rule Out Brain Death Test Interference:
      • Conditions like hypothermia, CNS depressants, or massive drug ingestion must be reversed first.

Organ Procurement and Management

  • Organ Procurement Organizations (OPOs): Non-profit entities responsible for recovering organs from donors for transplant purposes. E.g., Donate Life Florida, LifeLink.
  • Types of Organ Donation:
    • Living Donor:
    • Organs such as kidney, lobe of lung, etc.
    • Brain Death Donor: Consent required from the individual or legal representative.
    • Circulatory Death Donor: Donation occurs after cardiac death in an ethically monitored timeframe.
  • Complications in Donor Management: Include hypotension, electrolyte imbalances, and hormonal dysregulations post-brain death.
  • Management Focus:
    • Maintain hemodynamic stability, ensure normal laboratory parameters, manage nutrition, and fluid status for viable organ recovery.

Medications Frequently Used in Code Management

  • Common medications include:
    • Epinephrine, Amiodarone, Atropine, Lidocaine, Adenosine, Sodium Bicarbonate, and others.
  • Specific protocols outline dosages and administration routes for each medication in different emergency situations.