SAN JOSE

STATE UNIVERSITY
4.
5.
1. Elkin, M., Perry, A., & Potter, P. (2004). Nursing interventions and clinical skills (3 rd ed., pp. 882-897 ) St. Louis, MO: Mosby.
2.
3.
Lewis, S.M., Heitkemper, M.M.., & Dirksen, S. R. (2005) Medical-surgical nursing:
Assessment and management of clinical problems (6 th ed., pp. 1845-1851).
St. Louis:
Mosby. www.americanheart.org
(website for the American Heart Association). This website has information on the new guidelines for CPR.
VT #365: Code Call: Cardiac Arrest (may be viewed in class)
Any nurse’s drug handbook.
Learning Outcomes
1. Distinguish advanced cardiac life support (ACLS) from basic cardiac life support (BCLS).
2. Define the ‘D’ in the ‘ABCDs’ of cardiopulmonary resuscitation.
3. Describe the initial assessment of a patient in cardiac arrest.
4. Describe the following roles of a code team: first responder, second responder, respiratory therapist, anesthesiologist, house officer, patient’s physician, ICU nurse, pharmacist, laboratory person
5. Discuss the importance of early defibrillation during a code.
6. Describe safety measures to follow when defibrillating the patient.
7. Identify the sequence of steps to follow in a hypothetical cardiac arrest.
8. Describe the action, indications, dose, and nursing assessments of each of the 4 primary drugs used during a code: epinephrine, lidocaine, atropine, and dopamine.
9. Identify the purpose of essential items on a crash cart.
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Learning Activities
1. What is the difference between advanced cardiac life support (ACLS) and basic life support
(BCLS)?
ACLS includes BCLS as well as: a. use of adjunctive equipment and special techniques for establishing and maintaining effective ventilation and circulation b. ECG monitoring and arrhythmia recognition c. establishing and maintaining IV access d. therapies for emergency treatment of patients with cardiac or respiratory arrest
(including stabilization post arrest) e. treatment of the patient with suspected MI
2. The ABCs of cardiopulmonary resuscitation are well known. The ABCs have now been expanded to ABC D . What does the ‘D’ stand for?
The ‘D’ stands for defibrillation.
3. You are a nurse in a local hospital. When you make rounds at the beginning of the shift, one of your patients does not rouse when you talk to him. a. What initial assessment would you perform?
Perform the “shake and shout”: shake the patient and shout “are you OK?” b. The patient does not respond. What 3 assessments are you going to perform? List them below.
1. Check for an airway
2. check for breathing
3. check for carotid pulse c. You get no response from any of these assessments. You have determined that your patient is in cardiopulmonary arrest. What will you do now? List the steps below.
1. use the hospital procedure to activate the in-house EMS system, that is, you “call a code”
2. using the ambu bag or pocket mask in the room, you initiate rescue breathing according to BCLS protocol.
3. initiate chest compressions
4. continue with chest compressions and ventilations until other members of the code team arrive and initiate advanced cardiac life support measures.
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4. Briefly describe the following roles of a code team:
First responder
This is often the nurse who discovers the patient. This individual calls the code and begins
CPR. It is helpful, as soon as the code team or other personnel arrive on the scene, for this person to turn CPR over to someone else. This nurse most likely has the best information about the patient’s diagnosis and status prior to the arrest.
Second responder
This individual should bring the crash cart. If an AED is available this person should attach the pads to the patient’s chest and activate the AED if appropriate. Otherwise this responder should assist with CPR until the code team arrives
Respiratory therapist
The respiratory therapist can provide ventilatory support, often including intubation. During the code the RT can hook up supplemental oxygen and bag the patient before and after intubation. The RT can also suction the patient’s airway if necessary.
Anesthesiologist
The anesthesiologist is often the physician who intubates the patient. The anesthesiologist can also start IV lines and direct the code.
House officer
The house officer is the physician on call for whatever service the patient is on. Many times the house officer is the first physician on the scene, and as such can direct the code and order medications until the code team arrives.
Patient’s physician
The patient’s own physician can provide information about the patient’s medical history and current medical status. However, this physician is often not adept at running a code.
ICU nurse
Code teams frequently include a nurse from ICU who is well-versed in managing codes. This individual can often respond faster than physicians on a code team and can direct the code until the team physician arrives
Pharmacist
The pharmacist brings medications in addition to those found on the crash cart. The crash cart contains drugs that are commonly used during a code. The pharmacist will bring an additional supply of these drugs, as well as other drugs that are not as commonly used.
Laboratory tech the lab tech can draw necessary bloods such as electrolytes or arterial blood gases.
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5. Current literature on emergency care emphasizes the need for initiating defibrillation as soon as possible. Why is this?
Most adults in cardiac arrest are in ventricular fibrillation. The earlier defibrillation is initiated and antidysrhythmic drugs are started, the more likely the resuscitation efforts will be successful.
6. What safety measures should be followed when defibrillating a patient?
The most important safety rule is to stand clear of the patient and bed when the patient is being defibrillated. The person defibrillating should say “clear” in a loud voice before depressing the buttons on the defibrillator paddles. This gives the rest of the team an opportunity to back away from the bed or gurney. In addition, only conductive gel or normal saline should be applied to the patient’s chest where the defibrillator paddles are placed.
Alcohol should never be used because the alcohol can catch on fire.
7. Following is a list of events during a code. Indicate the correct sequence by numbering them from first to last. You may use some steps more than once.
___3_Call a code
___6_Establish an IV line
___8_Provide ventilatory support (intubation)
___4_Initiate CPR
___5_Defibrillate
___7_Administer medications (keep in mind that many of the drugs used during a code can be given intracardiac or intratracheal and may be given before the patient has an IV access).
___1_Determine DNR status
___2_Shake and shout
8. Identify the purpose of the following essential items on a crash cart.
IV tubing
A variety of IV tubing is provided, most of which has a drop factor of 60gtt/ml (microtubing).
Micro tubing allows more precise titration of medications.
Over-the-needle IV catheters
A variety of IV catheters in addition to the over-the-needle variety is provided on the code cart. This may include central venous catheters as well, along with large bore catheters and equipment needed to perform a cut down.
IV solutions
The code cart usually has several different kinds of IV solutions, such as normal saline and lactated ringer’s. Normal saline is compatible with most drugs used during a code, and lactated ringer’s is useful for patients in acidosis, a common occurrence during cardiac arrest.
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Chest board
This is positioned under the patient’s chest to provide a hard surface on which to perform chest compressions. Generally, the head of most hospital beds also slides off, and can also be used as a chest board.
Laryngoscope
The laryngoscope is used to visualize the vocal cords and aid in endotracheal intubation of the patient.
Endotracheal/tracheal tube
Intubation is often required during a code in order to adequately ventilate the patient.
Adequate ventilation and oxygenation is essential; it is very difficult to resuscitate and anoxic heart.
Code drugs
A variety of drugs is generally available in the code cart, including the most common ones; epinephrine, lidocaine, atropine, and dopamine.
Defibrillator
As the name indicates, this is used for the purpose of defibrillating patients. The paddles act as electrodes and provide a visual read out of the patient’s rhythm, as well as defibrillating shock.
Oxygen mask
Sometimes the patient does not require intubation or ventilation with an ambu-bag, but is able to ventilate. A mask provides a means of delivering extra oxygen to facilitate the resuscitation efforts.
EKG electrodes
These are essential and are applied to the patient’s chest, then attached to the EKG monitor so that the patient’s cardiac rhythm can be determined. Treatment the patient receives is generally determined by the cardiac rhythm.
EKG monitor
This provides a readout of the patient’s cardiac rhythm. Most of the time, the defibrillator also serves as the EKG monitor and eliminates the need for an extra piece of machinery at the already-crowded bedside.
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