Code Management
The goals of any code are to restore the patient’s spontaneous heartbeat and respirations and also to prevent hypoxic damage to the brain and other vital organs. Fulfilling these goals requires a team approach. Ideally, the team should consist of health care workers trained in advanced cardiac life support (ACLS), although health care workers trained in basic life support (BLS) may also be a part of the team. Sponsored by the American Heart Association (AHA), the ACLS course incorporates BLS skills with advanced resuscitation techniques. BLS and ACLS should be performed according to the 2010 AHA guidelines.
In most health care facilities, ACLS-trained nurses provide the first resuscitative efforts to cardiac arrest patients, often administering cardiopulmonary resuscitation (CPR) and performing defibrillation before the doctor’s arrival. Ventricular fibrillation commonly precedes sudden cardiac arrest; initial resuscitative efforts should focus on early CPR, rapid recognition of arrhythmias and, when indicated, defibrillation. If monitoring equipment isn’t available, you should simply perform BLS measures. Of course, the scope of your responsibilities in any situation depends on your facility’s policies and procedures and your state’s nurse practice act.
A code may be called for patients with absent pulse, apnea or inadequate breathing, ventricular fibrillation, ventricular tachycardia, and asystole. Family members may be present during a code if your facility’s policy supports it. The Emergency Nurses Association supports the option of family presence during invasive procedures and CPR in its 2005 position statement.1
According to the 2010 AHA guidelines for CPR and emergency cardiovascular care, ACLS interventions build on the foundation of basic life support, which includes immediate recognition and activation of the emergency response system, early high-quality CPR, and rapid defibrillation to increase the patient’s chance for survival. The recommended priority of the 2010 AHA guidelines is performing high-quality CPR chest compressions of adequate rate and depth that allow complete chest recoil after each compression, with minimal interruptions and avoiding excessive ventilation.
To prevent a delay in chest compressions, the AHA changed the sequence of CPR in the 2010 guidelines from “A-B-C” (airway, breathing, and compressions) to “C-A-B” (compressions, airway, and breathing), which gives the highest priority to chest compressions when resuscitating a patient in cardiac arrest. In addition to high-quality CPR, the only rhythm-specific therapy known to increase survival is defibrillation. As such, defibrillation remains of primary importance in the CPR cycle when a rhythm check reveals ventricular fibrillation or ventricular tachycardia. Establishing vascular access, administering medications, and inserting an advanced airway are important, but they shouldn’t cause significant interruptions in CPR or delay defibrillation.2
Equipment
Oral, nasal, and endotracheal (ET) airways ▪ one-way valve masks ▪ oxygen source ▪ oxygen flowmeter ▪ intubation supplies ▪ handheld resuscitation bag ▪ suction supplies ▪ end-tidal carbon dioxide detector ▪ nasogastric (NG) tube ▪ goggles, masks, gloves, other personal protective equipment as indicated by the patient’s condition ▪ cardiac arrest board ▪ peripheral IV supplies ▪ central IV supplies ▪ IV administration sets (including macrodrip and microdrip) ▪ IV fluids (normal saline and lactated Ringer’s solutions) ▪ electrocardiogram (ECG) monitor and leads ▪ automated external defibrillator (AED), if available ▪ cardioverter-defibrillator (monophasic or biphasic) ▪ defibrillator pads ▪ cardiac drugs, including adenosine, amiodarone, atropine, calcium chloride, dobutamine, dopamine, epinephrine, isoproterenol, lidocaine, procainamide, sodium bicarbonate, and vasopressin ▪ tape ▪ marker ▪ Optional: transcutaneous pacemaker, percutaneous transvenous pacer, cricothyrotomy kit, and waveform capnography.
Preparation of Equipment
Because effective emergency care depends on reliable and accessible equipment, the equipment, as well as the personnel, must be ready for a code at any time. You also should be familiar with the cardiac drugs you may have to administer. (See Common emergency cardiac drugs, pages 182 and 183.)
Always be aware of your patient’s code status as defined by the doctor’s orders, the patient’s advance directives, and family wishes. If the doctor has ordered a “no code,” make sure the doctor has written and signed the order. If possible, have the patient or a responsible family member cosign the order.
For some patients, you may need to consider whether the family wishes to be present during a code. If they do want to be present, see if another nurse, social worker, or clergy member can remain with them.
Implementation
If you’re the first to arrive at the scene of a code, tap the patient on the shoulder and shout, “Are you all right?” If the patient is unresponsive, check to see if the patient is apneic or only gasping.2
If the patient is unresponsive and apneic or only gasping, assume the patient is in cardiac arrest and immediately activate the emergency response system.2
Take no longer than 10 seconds to check for a pulse; if you don’t feel a pulse within that time (or are unsure of a pulse), begin chest compressions. Depress the adult sternum at least 2″ (5 cm), allowing the chest to completely recoil after each compression. Perform compressions at a rate of at least 100 compressions per minute.2 After 30 compressions, provide 2 ventilations.
When a second person arrives with the emergency equipment, have that person apply the AED. In many facilities, the AED is a function of the defibrillator. Follow the directions provided by the AED. Then have the second person assist with placing the cardiac arrest board under the patient and with providing CPR.
The second person should get into position on the other side of the patient and begin chest compressions at a rate of at least 100 compressions per minute. You provide ventilations after every 30 compressions. After 5 cycles of compressions and ventilations,
switch roles. The switch should take fewer than 5 seconds because interruptions in chest compressions can compromise vital organ perfusion. The compressor should be relieved every 2 minutes to prevent rescuer fatigue that could lead to inadequate compression rates or depth.2
Ask the nurse assigned to the patient to relate the patient’s medical history and describe the events leading to cardiac arrest.
A third person, either a nurse certified in BLS or a respiratory therapist, will then attach the handheld resuscitation bag to the oxygen source.
Ideally, a fourth person will be available to open the patient’s airway and seal the mask to the patient’s face. After the mask is in place, the other person will squeeze the resuscitation bag to deliver 2 ventilations (each over 1 second) during a brief pause after 30 compressions. Both people will watch for the chest to rise. If a fourth person isn’t available, the other person will open the patient’s airway, seal the mask to the patient’s face using one hand and then, with the other hand, squeeze the resuscitation bag to deliver 2 ventilations during a brief pause after 30 compressions.2
When the ACLS-trained nurse arrives, she’ll expose the patient’s chest and apply defibrillator pads if not already in place. The patient’s cardiac rhythm will appear on the defibrillator monitor. If the patient is in ventricular fibrillation, ACLS protocol calls for defibrillation as soon as possible with 360 joules (monophasic energy) or 120 to 200 joules (biphasic energy) according to the manufacturer’s recommendations. Be sure to continue CPR while the defibrillator is charging. Then resume CPR immediately after the shock is delivered. Perform a rhythm check after five cycles of CPR; if a rhythm is detected, perform a pulse check. The ACLS-trained nurse will act as code leader until the doctor arrives.2
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