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ACLS MEGACODE 2O1O

GUIDELINES
CODE TEAM MEMBERS:
TEAM LEADER (TL) AIRWAY MANAGER (AM) CHEST COMPRESSOR (CC) ELECTRICAL THERAPIST (ET) IV THERAPIST (IVT) RECORDER CASE SCENARIO: In the Medical-Surgical Floor, you are evaluating Mr. Magdar, a 70 year-old man complaining of palpitations. He has a history of coronary artery disease and had a stent in the past. His vital signs are: HR 170, BP 110/70, RR 16. Suddenly, the patient becomes unconscious. Team Leader: a. Establish unresponsiveness Hey! Hey! Are you OK? Hey! Hey! Are you OK? and do sternal rub The patient is unresponsive. b. Call for help. Activate Mega Code. Code Blue! Code Blue! (Codes may vary depending on the institution) c. Assess for circulation by checking carotid pulse for less than 10 sec. d. While waiting for the Code Team, insert CPR board and initiate CPR by starting 30 chest compressions followed by 2 ventilations. IV LINE: IV Therapist, can you please start an IV line? IVT: IV line initiated at left brachial vein, 1L PNSS at KVO PATCHES: patches. Kindly apply the defibrillator Team Leader: Can somebody take over Chest Compressions? *Team Leader assumes the team leaders role and starts to command using HEAD-TO-TOE pattern following M-I-P (Monitor-IV Line-Patch) pattern based on priority. (Head) Start and provide 2 VENTILATIONS every after 30 compressions. (Trunk) Continue COMPRESSIONS at 30 is to 2 ratios. (*at this stage, all team members should have already donned their pair of clean gloves) MONITOR: Attach the patient to the cardiac monitor

Once everything (MIP) is already attached or once patient is already attached to the monitor, team leader can start organizing the team and command the S-A-S pattern -------------------2 MINUTES----------------------SStop COMPRESSION A (Ill) Analyze the rhythm

S Switch roles Page

Code Team arrives.

*(Team Leader analyzes the ECG Rhythm)

TL: The patient is on__________________. (The presenting Tachycardia) rhythm is Ventricular

IVT: Epinephrine 1mg via IV push given and flushed with 10cc of NS

TL: Check for the pulse please. Is there a PULSE? CC: Negative PULSE!

NOTE: For VFib, no need to check for pulse after rhythm check. Immediately start compressions and prepare for defibrillation. No checking of pulse afterSHOCK. Remember minimize compression interruption. Resume ventilation and compression immediately after shock

2 SHOCKABLE RHYTHMS PULSELESS VENTRICULAR TACHYCARDIA VENTRICULAR FIBRILLATION


TL: Start compression and prepare defibrillate the patient at 200 Joules. to

ET: Im going to defibrillate the patient at 200 Joules.(Select energy level of 200 joules) ET: Charging at 200 Joules. (While pressing the CHARGE button) a. 1 Im CLEAR! b. 2 Are you CLEAR? (referring to AIRWAY MANAGER) c. 3 Is everybody CLEAR? (referring to ALL TEAM MEMBERS) ALL: CLEAR!!! ET: Shocking! (While pressing the SHOCK button) ET: Shock delivered! TL: Team Leader COMMAND: uses HEAD TO TOE

While waiting for 2 minutes and the patient do not have an advanced airway in place, patients o2 Saturation is less than 90%, the Team Leader considers Endotracheal Intubation and commands airway manager to INTUBATE the patient within 15-30 seconds. Airway Manager follows the Intubation Procedure. If patient is not intubated successfully, withdraw intubation process and resume usual ventilation ratio. Attempt for reintubation should be done on the next 2 minutes.

INTUBATION PROCEDURE:
TL: Stop Ventilation, Stop Compression. Kindly intubate the patient. AM: Attempts to intubate the patient. a. Position the head using HEADTILT-CHIN-LIFT maneuver. b.Insert OPA to maintain patent airway. c.Hyperoxygenate the patient using BVM attached to 100% oxygen until O2 Saturation is greater than 92%. d.Successfully INTUBATE the patient within 15-30 seconds.

(Head) Continue VENTILATION. (Trunk) Continue COMPRESSION. Lets give MEDICATION (except for first shock) TL: Give epinephrine 1mg via IV push and flush with 10cc of NS

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TL: the patient is intubated. Can you please check for EQUAL BILATERAL AIR ENTRY? (Referring to CC to auscultate air sounds using FIVE POINTS OF AUSCULTATION, while AM delivers breath through BVM while CC presses the stethoscope diaphragm as he auscultates.) CC: Positive Equal Bilateral Air Entry! AM: Intubated with a depth of_____ using French_______ (If correct placement of ET tube is confirmed, AM inflates the pilot balloon of ETT therefore inflating the cuff to secure the tube in place. Commercial Securing Device or any securing tape can be used to secure the tube in place and avoid dislodging the tube. This is done without waiting for any command from the team leader.) TL: Team leader uses HEAD TO TOE COMMAND Resume Ventilation at a rate of 1 breath every 6-8 seconds. Resume Compression continuously over 2minutes asynchronous with ventilation Code Recorder: 2 MINUTES! (If previous rhythm is without pulse, team leader commands using SASpattern, e.g. VFib, Vtach pulseless, or Asystole)

CC: Positive PULSE! TL: Team Leader COMMAND: uses HEAD TO TOE

(Head) Continue VENTILATION. (Trunk) Standby COMPRESSION.

STABLE
TL: Let us give medication________. give amiodarone 150mg via IV push and flush with 10cc of NS

UNSTABLE
TL: Sedate the patient and prepare for CARDIOVERSION at 100J! ET: Sync mode ON. Im going to cardiovert the pt at 100J! Charging at 100Joules. (While pressing the CHARGE button) a. 1 Im CLEAR! b. 2 Are you CLEAR? c. 3 Is everybody CLEAR? ALL: CLEAR!!! ET: Shocking! (While pressing the SHOCK button) ET: Shock delivered! TL: Continue VENTILATION. Well wait for 2 minutes

SStop COMPRESSION A (Ill) Analyze the rhythm

S Switch roles

*(Team Leader analyzes the ECG Rhythm) TL: The patient is on VENTRICULAR TACHYCARDIA TL: Is there a PULSE?

NOTE:Give only External Chest Compression if the patient is PULSELESS. Stop compression if patient has already pulse. Ventilation should still be provided continously but at a different rate (1 breath every 5 seconds).

Code Recorder: 2 MINUTES!

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(If previous rhythm is with pulse, team leader commands ANALYZE THE RHYTHM, e.g. AFib, ATach, VTach with pulse, Aflutter, Sinus Bradycardia, and Sinus Tachycardia.) SStop COMPRESSION A (Ill) Analyze the rhythm

UNSTABLE
TL: Sedate the patient and prepare for CARDIOVERSION at 100J! ET: Sync mode ON. Im going to cardiovert the pt at 100J! Charging at 100Joules. (While pressing the CHARGE button) a. 1 Im CLEAR! b. 2 Are you CLEAR? c. 3 Is everybody CLEAR? ALL: CLEAR!!! ET: Shocking! (While pressing the SHOCK button) ET: Shock delivered! TL: Continue VENTILATION. Well wait for 2 minutes

S Switch roles

*(Team Leader analyzes the ECG Rhythm) TL:Thepatient is on ____________________. *If rhythm is ATRIAL FLUTTER, ATRIAL FIBRILLATION, or ATRIAL TACHYCARDIA TL: Is there a PULSE? (Team leader commands to check for pulse because the patient may be manifesting PULSELESS ELECTRICAL ACTIVITY OR PEA. PEA is any rhythm that is not accompanied by palpable pulse except for VFib and VTach. If such rhythm is presented, the patient should be treated using the algorithm for ASYSTOLE) CC: Positive PULSE!

TEAM LEADER: (If previous rhythm is without pulse) SStop COMPRESSION A (Ill) Analyze the rhythm

S Switch roles (If previous rhythm is with pulse)

TL: Team Leader COMMAND:

uses

HEAD

TO

TOE A Analyze the rhythm

(Head) Continue VENTILATION. (Trunk) Standby COMPRESSION.

*(Team Leader analyzes the ECG Rhythm) TL: The patient is on ASYSTOLE TL: Are all electrodes in place? ET: (checks for electrode placement)

STABLE
TL: lets give medication________. give amiodarone 150mg via IV push and flush with 10cc of NS

All electrodes are in place! TL: Is there a pulse?

Patient is pulseless!

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CC: (checks for pulse)

TL: maximize ECG size! ET: (maximizes ECG size) TL: Confirmedasystole TL: Team Leader COMMAND: uses HEAD TO TOE

TEAM LEADER: (If previous rhythm is without pulse) SStop COMPRESSION A (Ill) Analyze the rhythm

S Switch roles (If previous rhythm is with pulse) A Analyze the rhythm

(Head) Continue VENTILATION. (Trunk) Continue COMPRESSION. Lets give MEDICATION__________ TL: Give epinephrine 1mg via IV push and flush with 10cc of NS IVT:Epinephrine 1mg via IV push given and flushed with 10cc of NS *(Team Leader analyzes the ECG Rhythm) TL: The patient is on Sinus bradycardia.

TREAT REVERSIBLE
TL: Positive chest wall rise during ventilations? (to rule out Hypoxia and Hydrogen acidosis) TL: Positive pulse during chest compressions? CC: No pulse during chest compression TL: Auscultate muffled heart sound (to rule out Cardiac Tamponade) TL: Positive flail chest? Positive lung asymmetry? (to rule out Tension pneumothorax) TL: If negative for Cardiac Tamponade and Tension pneumothoraxpositive for Thrombosis TL: Is he cold to touch? (to rule out Hypothermia) TL: Inspect left and right sides of patients body for asymmetry (to ruke out Trauma) TL: Draw blood sample for cardiac enzymes, electrolytes, and for drug level. (to rule out Hypo/Hyperglycemia, Hypo/hyperkalemia, and Drug toxicity)

TL: Is there a Pulse? CC: Positive Pulse TL: Team leader uses HEAD TO TOE COMMAND Continue Ventilation (1 breath every 5 seconds interval). Stop Compression.

CAUSES

UNSTABLE
TL: Give Atropine 0.5mg IV push and flush with 10cc of NS IVT: Atropine 0.5mg IV push and flush with 10cc of NS given TL: Is TCP Available? Set to PACER MODE SET the PACER RATE to 80bpm SET the PACER OUTPUT starting at5mA with increments of 5 until it is already PACING and CAPTURING. TL:Lets check the patients BP CC:Patients systolic BP <90! TL:Start Dopamine Drip, via piggyback, 400 mg diluted in 250ml D5W at 5mcg/kg/min. IVT:Dopamine drip started at_________ml/hr.

CODE RECORDER: 2 MINUTES!

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STABLE
POST CARDIAC CARE

REMEMBER:
IV therapist carries out every order of the team leader for medications while the recorder documents every order carried out by any of the team member. To maintain closed loop communication, any order from the team leader should be echoed while carrying out by the team member assign to the task, after the team member has carried out the order, recorder echoes again the order while documenting it. Compressor and airway manager switch roles every after 2 minutes. If presented with pulseless rhythm.

POSTCARDIAC CARE TL: The patient is on____________________. (the presenting rhythm in NORMAL SINUS RHYTHM, SINUS TACHYCARDIA, SINUSBRADYCARDIA) TL: Kindly check for the pulse. Is there a pulse? AM: The patient has a good pulse TM: Kindly check for Blood Pressure CC: Patients systolic BP >90. TL: Patient has stable BP. Kindly check patients O2 Saturation____ a. Continue ventilations by replacing BVM with Non-rebreather mask @ 15LPM 100% Oxygen. (If with advanced airway attach patient to Mechanical Ventilator connected to 100% oxygen) b. Insert NGT c. Attach 12-lead EKG d. Secure STAT chest x-ray e. Draw blood for ABG analysis and other blood works f. Insert Foley Catheter g. Somebody call the ICU nurse for proper endorsement TL: CONGRATULATION REVIVED THE PATIENT TEAM WE HAVE

Elements of Effective Resuscitation Team Dynamics:


1. 2. 3. 4. 5. 6. 7. 8. Closed-loop communication Clear messages Clear roles and responsibilities Know ones limitation Knowledge sharing Constructive intervention Re-evaluation and summarizing Mutual respect

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CARDIOPHARMACOLOGY
VENTRICULAR FIBRILATION AND PULSELESS VENTRICULAR TACHYCARDIA

DRUG

INITIAL DOSE 1mg 40 units 300mg 1-1.5 mg/kg

SUCCEEDING DOSE 1 mg NONE 150mg 0.5-0.75 mg/kg

INTERVAL 3-5 minutes NONE 10 minutes 5-10 minutes

MAXIMUM DOSE NONE 40 units 2.2g in 24 hrs 3 mg/kg

E PINEPHRINE V ASOPRESSIN A MIODARONE L IDOCAINE

VENTRICULAR TACHYCARDIA WITH PULSE


DRUG

A DENOSINE
(monomorphic V.TACH)

INITIAL DOSE 6 mg 150 mg 1-1.5 mg/kg 20 mg / min

SUCCEEDING DOSE 12 mg 150 mg 0.5-0.75 mg/kg Depends on pt. response

INTERVAL 2 minutes 10 minutes 5-10 minutes 17 mg/kg

MAXIMUM DOSE 3 doses 2.2 g in 24 hrs. 3 mg/kg

A MIODARONE L IDOCAINE P ROCAINAMIDE

ATRIAL TACHYCARDIA / SVT


DRUG

ADENOSINE

INITIAL DOSE 6 mg

SUCCEEDING DOSE 12 mg

INTERVAL 2 minutes

MAXIMUM DOSE 3 doses

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ATRIAL FIBRILATION / ATRIAL FLUTTER


DRUG

V ERAPAMIL I NDERAL D ILTIAZEM

INITIAL DOSE SUCCEEDING DOSE 2.5 5 mg 5 10 mg O.1 mg/kg divided in 3 doses 15 20 mg 20 25 mg

INTERVAL 15 30 minutes 2 minutes 15 30 minutes

MAXIMUM DOSE 20 mg 3 doses 5 15 mg/hr IV infusion

ASYSTOLE AND PEA


DRUG

E PINEPHRINE

INITIAL DOSE 1 mg

SUCCEEDING DOSE 1 mg

INTERVAL 3 5 minutes

MAXIMUM DOSE NONE

SINUS BRADYCARDIA
DRUG

ATROPINE DOPAMINE DRIP

INITIAL DOSE 0.5 mg 5 mcg/kg/ min.

SUCCEEDING DOSE 0.5 mg 5 mcg/kg/ min.

INTERVAL MAXIMUM DOSE 3 5 minutes 3 mg Depends on patient response

HYPOTENSION
DRUG

DOPAMINE DRIP
400 mg in 250 ml D5W

INITIAL DOSE 10 mcg/kg/ min.

SUCCEEDING DOSE 5 mcg/kg/ min.

INTERVAL MAXIMUM DOSE Titrate depends on patient response

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