MOCK CODE
PREPARATION
Janet McCarthy, MSN, MBA, RN
MSN 377
Early Identification and Treatment
■ Rapid response teams – or early medical emergency
teams
– Documented reductions in cardiac arrest
– Improved patient outcomes
Cardiac Arrest
■ Ventricular fibrillation (VF) --> defib, CPR
■ Ventricular tachycardia (Vtach) – pulseless
defib
■ Pulseless electrical activity (PEA) rhythm
tracing and no pulse
■ Asystole
CPR
■ Primary – good CPR, early defib for VT & VF
■ Witnessed arrest:
– Check for pulse – if no pulse,
– Begin CPR
■ Continue cycles of 30 compressions/2 breaths
■ Check for pulse & rhythm every 5 cycles (2 minutes)
■ During early stages of CPR, chest compressions are more
important than breaths
■ Do not provide excessive ventilation – increases
intrathoracic pressure, decreases venous return
■ Use barrier device or bag/mask
CPR- Key Points
■ Once intubated, ventilate at rate of 8-10 breaths/min – do
not synchronize with chest compressions
■ Confirm placement of ETT – bilateral chest expansion,
exhaled CO2, auscultation, CXR
■ Chest compressions at 100/minute (hard & fast!)
■ Depress sternum 1.5 to 2 inches - allow chest to recoil
after each compression
■ Risk of gastric inflation if breaths given too forcefully
■ Compressor should be relieved every 2 minutes to avoid
fatigue (& less effective compressions)
■ No longer than 10 seconds to check for pulse
■ Avoid compression interruptions (e.g. IV insertion)
Defibrillation - Key Points
■ Goal of defibrillation: reset electrical conduction system
by depolarizing a critical mass of myocardial cells
■ Defibrillation (unsynchronized shock): Ventricular
fibrillation (VF) & pulseless Ventricular tachycardia (VT)
■ Cardioversion (synchronized shock): used for Vtach with
pulse & other arrhythmias (e.g. Afib)
Defibrillation
■ First Defibrillation:
– 120 – 150 - 200J for biphasic defibrillator
– 200 – 300- 360J for monophasic defibrillator
– If unknown, shock at 200J
■ Continue CPR while defibrillator charges
■ After shock - 5 cycles of CPR beginning with compressions
■ Check rhythm & pulse after 5 cycles CPR
Cardiac Arrest - Key Points
■ IV access (central line allows faster circulation of drug)
■ If unable to get IV access, may use intraosseous (into
marrow of long bones)
■ Last resort: endotracheal administration - administer
2 – 2.5 times the amount of drug
■ Follow peripheral drug administration with bolus of about
20 cc of IV fluid & elevate extremity
■ Administration of epinephrine (1 mg) may improve
effectiveness of defibrillation (repeat q 3-5 minutes)
■ Use of vasopressin (40U) may or may not be helpful
■ Administer drugs ASAP after rhythm check
Cardiac Arrest - Medical Management
■ If VF or pulseless VT persists after 2-3 shocks plus
vasopressor (epinephrine or vasopressin), consider
antiarrhythmic: amiodarone
■ Amiodarone suppress ventricular irritability
– 150 - 300mg IV once, then 150mg
■ Consider Magnesium for torsades (polymorphic) de pointes
– IV mag
Asystole and PEA
■ Pulseless Electrical Activity – electrical activity present without
palpable pulse, poor survival rate
■ Survival rate very poor for asystole 9cant shock, cpr or drugs)
■ Check asystole in 2 leads – may be fine VF
■ Defibrillation offers no benefit
■ Focus on good CPR
■ May administer vasopressor (epi or vasopressin)
Look for possible causes…
H’s (6):
■ Hypovolemia
■ Hypoxia
■ Hydrogen ion (acidosis)
■ Hypo- or hyperkalemia
■ Hypoglycemia
■ Hypothermia
T’s (6):
Toxins
Tamponade (cardiac)
Tension pneumo
Thrombosis - coronary
Thrombosis - pulmonary
Trauma
Interventions not supported by research
■ Pacing for asystole
■ Procainamide for VF or pulseless VT – can infiltrate veins
■ Norepinephrine (during arrest)
■ Precordial thump – vtach, vfib
■ Administration of electrolytes
(except for magnesium for torsades de pointes)
■ Routine IV fluids
Meds for Cardiovascular Support
■ Used to support cardiac output
– Improve heart rate (chronotropic)
– Improve myocardial contractility (inotropic)
– Improve arterial pressure (vasoconstrictive)
– Reduce afterload (vasodilation)
■ Many adrenergic drugs are not selective
– May increase or decrease HR & afterload
– May induce arrhythmias
– May increase myocardial O2 demand
Meds for Cardiovascular Support
■ Epinephrine (Adrenalin) – increases perfusion to brain &
coronaries during CPR
■ Vasopressin (Pitressin) – may cause coronary & renal
vasoconstriction
■ Norepinephrine (Levophed) – inotrope & potent
vasoconstrictor; used for severe hypotension; central line
(extravasation)
■ Dopamine (Intropin) – dose dependent effects:
– .5-2 mcg/kg/min: dopaminergic (renal perfusion)
– 2-10 mcg/kg/min: inotropic
– >10mcg/kg/min: vasoconstriction
Additional Meds
■ Dobutamine (Dobutrex) – synthetic catecholamine & potent
inotrope; severe systolic heart failure
■ Inamrinone – inotropic, vasodilator of vascular smooth muscle;
heart failure
■ Calcium – for hypocalcemia, calcium channel blocker toxicity
■ Digitalis – inotrope: afib, aflutter
■ Nitroglycerin – relaxes vascular smooth muscle; CHF, HTN
■ Nitroprusside (Nipride) - potent peripheral vasodilator; HTN
Research
■ Hypothermia therapy
– Current guidelines recommend cooling to 32-34C for
patients in a coma after cardiac arrest from VF
– Cardio- and neuro- protective effects
– Cool by large volume ice cold IV fluids, cooling blankets
■ Coenzyme Q10– Neuroprotectant – improve neurological outcome??
Ethics
All patients should be provided CPR except:
■ The patient has a valid Do Not Attempt Resuscitation
(DNAR) order
■ The patient has signs of irreversible death (e.g. rigor
mortis, decapitation, decomposition)
■ No physiological benefit can be expected because vital
functions have deteriorated despite maximal therapy (e.g.
progressive septic or cardiogenic shock)
Withdrawal of Life Support
■ A recent meta-analysis of 11 studies involving 1,914 patients
documented 5 clinical signs that were found to strongly predict
death or poor neurological outcome, with 4 of the 5 predictors
detectable at 24 to 72 hours after resuscitation:
– Absent corneal reflex at 24 hours
– Absent pupillary response at 24 hours
– Absent pain withdrawal response at 24 hours
– No motor response at 24 hours
– No motor response at 72 hours
Emotional Support of Family
■ Should family members be allowed to remain in room
during code?
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