Chapter 10

Rapid Response Teams and

Code Management

Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
 Cardiopulmonary Arrest
 Most codes filled with panic and pandemonium
 Best options
 Prevent
 Plan
 Practice

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 Rapid Response Teams
 “Failure to rescue” is important concept to
address
 RRT established to address concerns
 Call BEFORE the cardiac/respiratory arrest
 Recommended by The Joint Commission and
Institute for Healthcare Improvement to
implement systems to request assistance for
worsening conditions

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 RRTs (continued)
 Call any time a staff member is concerned about
changes in a patient’s condition including:
 Heart rate, systolic blood pressure
 Respiratory rate, oxygen saturation
 Mental status
 Urinary output
 Laboratory values
 Some institutions empower family members to
activate the RRT

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 RRT Effectiveness
 RRT reduces:
 Cardiac arrests
 Critical care unit length of stay
 Incidence of acute illness, such as respiratory failure,
stroke, severe sepsis, and acute kidney injury
 Recent review of literature and meta-analysis of
1.3 million patients
 RRT was not associated with lower hospital mortality
rates in hospitalized adults

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 Codes
 Code, code blue, code 99, Dr. Heart
 Cardiac and/or respiratory arrest
 Lifesaving resuscitation and intervention needed
 BLS/AED
 ACLS

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 Code Team
 Notification system
 Members vary within setting
 Better patient management
 Care according to ACLS protocols
 Other healthcare workers manage other patients

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 Team Members
 Leader usually MD skilled in ACLS
 Nurses (usually ICU or ER)
 Primary nurse knows patient
 Second nurse gives medications and gets equipment
from crash cart
 Another nurse records events
 Nursing supervisor provides traffic control and
secures ICU bed (if needed)

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 Team Members (continued)
 Anesthesiologist/anesthetist intubation
 Respiratory therapist manages airway,
sometimes intubates
 Pharmacist prepares medications in some
settings
 Chaplain
 ECG technician
 Other personnel to run errands

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 Critical Thinking Challenge
 Who has observed resuscitation efforts?
 What observations were made?
 What perceptions of care were noted?

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 Equipment
 Crash cart  Bag-valve-mask
 Backboard device
 Monitor/defibrillator/
 Airway
pacemaker supplies/suction
 AED  Medications
 Transcutaneous  IV supplies
pacemaker  Nasogastric tube
 BP cuff

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Equipment (continued)

Figure 10-1. A typical crash cart.

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 Things to Know
 Your cart
 Where it is located?
 How do you unlock it?
 How do you check it per unit protocol?
 Your equipment
 O2 and suction
 Is child-sized equipment available if needed (e.g.,
ED)?

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 Sequence of Events: BLS
 Advance directives or living wills
 Airway open
 Breathing
 Mouth to mask
 Bag-valve-mask device
 Circulation: chest compressions
 May do open chest compression in trauma patients or
after cardiac surgery

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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 15
 ACLS: Airway and Breathing
 Airway management
 Manual ventilation
 Intubation
• Isolate airway and keep open
• High concentration of oxygen
 Delivery of tidal volume
• Protect airway
• Suction
• Administer selected medications

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 ACLS: Airway and Breathing
(continued)

Figure 10-2. Head-tilt/chin-lift technique for opening the airway. A, Obstruction by the tongue. B,
Head-tilt/chin-lift maneuver lifts tongue relieving airway obstruction.

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 ACLS: Airway and Breathing
(continued)

Figure 10-3. Rescue breathing with bag-mask device. (Reprinted with permission,
Cleveland Clinic Center for Medical Art & Photography © 2011-2012. All rights
reserved.)
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ACLS: Airway and Breathing
(continued)

Figure 10-04. Ventilation with a bag-valve device

connected to endotracheal tube.

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 ACLS: Airway and Breathing
(continued)

Figure 10-5. End-tidal carbon dioxide detector connected to an endotracheal tube. Exhaled
carbon dioxide reacts with the device to create a color change indicating correct endotracheal
tube placement.
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 ACLS
 Primary survey
 ABCD (early defibrillation)
 Use of automatic external defibrillator (AED)
 Secondary survey
 Advanced skills
 Differential diagnosis

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 ACLS: Circulation
 Large-bore IVs
 Biggest veins
 May insert central line or intraosseous cannula if
IV access is difficult

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 ACLS (continued)
 Administer medications via ETT if needed
 Lidocaine
 Epinephrine
 Vasopressin
 Defibrillation
 Differential diagnosis

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 Logical Flow of Events
 BLS  Crowd control
 ACLS/AED  Notification of family
 Ongoing assessment and communication
 Pulse oximetry  Family presence in
 ETCO2 code
 Pulse checks  If successful code,
 ABGs transfer to ICU
 Lab work

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 ACLS Summary
 Treat patient, not monitor
 CPR throughout
 Early defibrillation essential
 Use ETT as needed for medication
administration
 Provide treatment according to algorithms

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 Circulation

Figure 10-6. Defibrillator. (Courtesy Philips Healthcare, Andover,

Massachusetts.)
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 Dysrhythmia Management
 Algorithms
 Early defibrillation
 Public access defibrillation encouraged
 AED used in field
 AED may be used during in-hospital codes; newer
defibrillators have built-in AED

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 Defibrillation

Figure 10-7. Paddle placement for defibrillation.

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 Defibrillation (continued)

Figure 10-8. Anteroposterior placement of adhesive electrode pads for defibrillation or

transcutaneous pacing.

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 Defibrillation (continued)

Figure 10-10. Approximate location of the vulnerable period. (From Conover MB.
Understanding Electrocardiography. 8th ed. St. Louis: Mosby; 2003.)
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Dysrhythmia Management
(continued)

Figure 10-11. Monitor/defibrillator demonstrating marked R waves for

cardioversion. (Courtesy Zoll Medical, Burlington, Massachusetts.)

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Dysrhythmia Management
(continued)

Figure 10-12. Transcutaneous pacemaker-defibrillator. (Courtesy Philips

Healthcare, Andover, Massachusetts.)
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 VF and Pulseless VT
 ABCD, initiate CPR
 Shock, CPR, shock, CPR, shock
 200 (biphasic), 360 (monophasic) joules
 IV access
 Epinephrine or vasopressin
 Intubate if unable to effectively manage airway
and ventilate patient

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 VF and Pulseless VT
(continued)
 Drug-shock continues
 Epinephrine repeated as needed; vasopressin is
given only once
 Consider antidysrhythmic drugs
• Amiodarone (drug of choice)
• Lidocaine
• Procainamide
 Magnesium if level is low or torsades is present
 Sodium bicarbonate (only if severely acidotic)

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 Pulseless Electrical Activity (PEA)
 Rhythm without pulse
 Airway, oxygen, intubate, IV access
 ABCD with CPR
 Treat cause
 Epinephrine

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 Pulseless Electrical Activity
(continued)
 Hypoxia  Tablets (overdose)
 Hypovolemia  Tamponade (cardiac)
 Hypothermia  Tension
 H+ ions (acidosis) pneumothorax
 Hypokalemia or
 Thrombosis
hyperkalemia (coronary)
 Thrombosis
(pulmonary)

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 Asystole
 ABCD with CPR
 Airway, oxygen, intubate, IV access
 Confirm in two leads
 Treat cause (see PEA)
 Transcutaneous pacemaker
 Epinephrine

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 Quick Quiz!
The patient is in asystole with a blood pH of 6.95
and has lost the IV access. The nurse knows to
administer which drug via the ET tube first?

A.Atropine
B.Epinephrine
C.Vasopressin
D.Sodium bicarbonate

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 Symptomatic Bradycardia
 ABCD with CPR
 Airway, oxygen, IV access
 Atropine
 Consider cause
 Transcutaneous pacing
 May need sedation/analgesia
 Dopamine or epinephrine
 No lidocaine

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 Unstable Tachycardia
 ABCD
 Airway, oxygen, IV access
 Identify the unstable tachycardia
 Sedation
 Cardioversion
 Reassess patient and rhythm

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 Defibrillation
 Primary treatment for VF and pulseless VT
 Monophasic waveform
 Electrical current
 200 to 360 joules

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 Defibrillation
(continued)
 Completely depolarize the heart
 Allow for the resumption of rhythm
 Safety is essential
 Complications
 Skin burns
 Damage to heart muscle

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 Defibrillation
(continued)
 External paddles (traditional)
 External “hands-off” defibrillation with
multipurpose pads (ECG, pace, defib)
 Paddle/pad placement
 Transverse/anterior
 Anterior-posterior

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 Defibrillation
(continued)
 Internal paddles
 “Spoons”
• Cardiac surgery
• Open-chest CPR
 Lower joules

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 Defibrillation
(continued)
 Automatic implantable cardioverter-defibrillator
(AICD)
 Recognizes ectopy
 Delivers countershock
 Prevents episodes of sudden death

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 Procedure for Defibrillation
 Paddle or defibrillation pad placement
 Good contact with skin (protect from burns)
 Conductive medium with paddles
 Charge defibrillator to desired setting
 “I’m clear, you’re clear, everyone clear, oxygen
clear”
 Adequate pressure with paddles
 Shock
 Continue CPR 2 minutes, then assess rhythm
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 Automated External Defibrillation
(AED)
 External defibrillator with rhythm analysis
capabilities
 For cardiac arrest
 Procedure
 Place two adhesive pads
 Analysis by AED
 Shock advisory

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 Cardioversion
 Electrical current
 Lower joules (e.g., 50)
 Synchronized delivery on R wave (prevents
“shock on T”)
 Disrupts ectopic foci

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Defibrillation Versus Cardioversion
 No pulse—defibrillation
 Symptomatic tachycardia—cardioversion (can
also do overdrive pacing)

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 Transcutaneous Pacemaker
 Symptomatic bradycardia
 External pads/anterior-posterior placement
 Demand mode
 Adjust mAs to initiate a paced rhythm
 Assess rhythm for proper functioning
 Sedation and analgesia as needed

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 Paced Rhythm

Figure 10-13. Electrical capture of transcutaneous pacemaker. Note the pacemaker spikes followed by a
wide QRS complex and a tall T wave.

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Overview of Medications

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 Oxygen
 Treat hypoxemia
 Improve tissue oxygenation
 Delivered via mouth to mask or bag-valve device
(BVD) to mask or ETT
 During a cardiopulmonary arrest 100% oxygen
(15 L/min via BVD)

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 Epinephrine
 Potent vasoconstrictor
 Alpha- and beta-adrenergic effects
 Ventricular fibrillation (VF), pulseless ventricular
tachycardia (VT), asystole, and PEA
 1 mg IV push every 3 to 5 minutes
 Can be given via ETT
 Infusion if needed

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 Vasopressin
 Nonadrenergic vasopressor
 Intense vasoconstriction at high doses
 May be as effective as epinephrine
 One-time dose of 40 units IV for VF/pulseless
VT

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 Atropine
 Decreases vagal tone
 Symptomatic bradycardia
 0.5 mg to 1.0 mg every 3 to 5 min IV push
 Maximum of 0.03 to 0.04 mg/kg

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 Atropine
(continued)
 Can be given via ETT; 2 to 3 mg in 10 mL
normal saline
 External pacemaker on standby
 Atropine is no longer given in PEA or asystole

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 Amiodarone (Cordarone)
 Reduces membrane excitability
 Prolongs the action potential and retards the
refractory period; thus facilitates the termination
of VT and VF
 Alpha-adrenergic and beta-adrenergic blocking
properties
 Does not have the same prodysrhythmic
properties of other antidysrhythmics

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 Lidocaine
 Antidysrhythmic
 Suppresses ventricular ectopy
 Bolus 1 to 1.5 mg/kg; additional bolus 0.5 to
0.75 mg/kg every 5 to 10 minutes up to 3 mg/kg
 Follow with infusion at 2 to 4 mg/min (250 mL
5% dextrose in water with 1 g)
 Concentration: 1 mg/min = 15 mL/hr
 Assess for lidocaine toxicity

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 Adenosine
 Slows conduction through AV node
 Primary use for paroxysmal supraventricular
tachycardia
 Rapid IV push through port nearest insertion site
of IV
 Expect short pause in rhythm after
administration
 Half-life 10 seconds; duration 1 to 2 minutes

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 Adenosine
(continued)

FIGURE 10-15. Atrioventricular block after intravenous administration of adenosine. (From Paul, S.,
& Hebra, J. D. (1998). The nurse’s guide to cardiac rhythm interpretation: Implications for patient
care. Philadelphia: W. B. Saunders.)

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 Magnesium
 Refractory VF
 Torsades de pointes (type of VT)
 Known deficiency
 IV bolus followed by infusion titrated by
magnesium levels

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 Torsades de Pointes

Figure 10-14. Torsades de pointes. The QRS complex seems to spiral around the isoelectric line. (From
Urden LD, Stacy KM, Lough ME. Critical Care Nursing: Diagnosis and Management. 6th ed. St. Louis:
Mosby; 2010.)

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 Sodium Bicarbonate
 According to ABGs
 Treatment of metabolic acidosis
 Rarely given

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 Dopamine
 Vasoactive (vasoconstrictor) to increase BP
 Continuous drip
 2 to 20 mcg/kg/min (learn calculations)
 Up to 50 mcg/kg/min can be given
 Effects dose related
 Moderate doses = cardiac doses
 Higher doses = vasopressor doses
 Consider need for fluids versus dopamine

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 Documentation of Events
 Assign someone to document during code and
record rhythm strips
 Time started
 Actions taken and patient’s response
• Defibrillation
• Medications
• Procedures
• Pacemakers
 Intubation and airway management
 Vital signs
 Team members present
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Example of Paper Documentation

Figure 10-15. Sample of a code record used for documenting activities during a code.
(Courtesy Cleveland Clinic, Cleveland, Ohio.)

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 Post-Resuscitation
 Goals
 Optimize cardiopulmonary function
 Transport to critical care unit
 Determine cause of arrest to prevent
 Management of patient care continues

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 Post-Resuscitation
(continued)
 Airway placement
 Maintenance of blood pressure and oxygenation
 Control of dysrhythmias
 Advanced neurological monitoring
 Capnography

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 Capnography

Figure 10-16. Waveform capnography. A, Normal waveform indicating adequate ventilation pattern
(ETCO2 35 to 40 mm Hg). B, Abnormal waveform indicating airway obstruction or obstruction in breathing
circuit (ETCO2 decreasing).

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 Post-CPR Interventions
 12-lead ECG
 Arterial line
 Pulmonary artery catheter
 Indwelling urinary catheter for hourly output
 NG tube if bowel sounds are absent or if patient
is mechanically ventilated
 Serial neurological exams

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 Post-CPR Care
 Palliative comfort care
 Pain management
 Sedation
 Anxiety management
 Head CT scan and EEG if comatose
 Blood glucose levels (may be hyperglycemic)

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 Supporting the Family
 Should they be present during a code?
 Providing information
 Active communication
 Visitation after a code
 Support from chaplain and nursing staff

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 Supporting Other Patients
 Remove from the situation
 Talk with them
 Assess their feelings
 Continue their care

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 Therapeutic Hypothermia
 Fever from brain injury increases the level of
neurological damage post-CPR
 Increased length of stay
 Lower body temperature is associated with
better recovery

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 Hypothermia
 Optimal temperature is not known
 Firm guidelines have not been developed

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 Methods of Hypothermia

Figure 10-17. Arctic Sun 5000. Figure 10-18. Thermagard XP.

(Courtesy Medivance, Louisville, (Courtesy Zoll, Chelmsford,
Colorado.) Massachusetts.)
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Nursing Care During Hypothermia
 Monitor core body temperature
 Bladder catheter with a temperature probe
 Esophageal thermometer
 Pulmonary artery catheter
 Axillary, tympanic, and oral probes do not
measure core body temperature and should not
be used

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 Monitoring with Hypothermia
 Shivering
 Increase oxygen consumption
 Increases body temperature
 Controlled with
 IV sedatives
 Analgesics
 Neuromuscular blockade medications
 Drugs can mask seizure activity
 Continuous EEG monitoring

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 Complications
 Bleeding
 Infection
 Metabolic and electrolyte disturbances
 Hyperglycemia

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 Nursing Care
 Infection prevention
 Handwashing
 VAP prevention
 Hyperglycemic management
 IV insulin
 Monitor electrolytes
 During cooling, K+, Mg+, phosphate, and Ca+ may
decrease
 During rewarming, K+, Mg+, phosphate, and Ca+ may
increase
 Rewarm after 24 hours very slowly

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 Quick Quiz!
The nurse is caring for a patient being treated with
therapeutic hypothermia post-CPR. Which order
should the nurse question?

A.Draw serum electrolytes stat

B.Measure blood glucose every 2 hours
C.Continuously monitor EEG and ECG
D.Record tympanic temperature every hour

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 Quick Quiz!
A 56-year-old female patient reports feeling
fatigued with sudden nausea and lightheadedness.
The nurse immediately chooses to take which
action?

A.Call the charge nurse

B.Get the patient an antiemetic
C.Call the attending physician
D.Notify the rapid response team

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