Code Blue Pharmacys Role Pharmacists To recognize and participate - PDF document

Objectives Code Blue Pharmacy’s Role • Pharmacists – To recognize and participate in the treatments of bradycardia, tachycardia, cardiac arrest and New Mexico Society of Health-System Pharmacists help facilitate post cardiac arrest care 2014 Balloon Fiesta Symposium – To identify medication classification, October 6 th , 2014 mechanism of action, dosages, pharmacokinetics, and adverse reactions – Practice following ACLS algorithms using case Juan S. Rodriguez, PharmD, RPh Jason Summers, RN scenarios and simulation Inpatient Staff Pharmacist REACT Team RN Lovelace Medical Center Lovelace Medical Center Objectives Code Blue • Each hospital decides how to designate • Pharmacy technicians emergencies – Practice medication preparation and dosage • Common for “Code Blue” to be the designation calculations for cardiopulmonary arrest – Know how to utilize the medication drug tray • Cardiopulmonary arrest – Practice working with the pharmacist and the – Abrupt cessation of spontaneous and effective code team during a cardiopulmonary arrest ventilation and circulation – Usually follows a cardiac or respiratory event • Heart attack, Pulmonary Embolism, Sepsis, drug overdose Code Blue Basic Life Support • What is our goal during cardiopulmonary 1. Check responsiveness – “Are you all right?” arrest? – Look for chest movement – Return of spontaneous circulation (ROSC) 2. Activate the emergency response system and • Basic Life Support (BLS) get an AED • Cardiopulmonary resuscitation (CPR) 3. Circulation • Automatic external defibrillator (AED) – Check the carotid pulse, take no longer than 10 • Advanced Cardiovascular Life Support (ACLS) seconds – If no pulse within 10 seconds, start CPR – Minimize hypoxic damage to vital organs • Post cardiac arrest care 1

Basic Life Support Basic Life Support • 4. Defibrillation CPR – – Attach and turn on the 30 chest compressions to two breaths AED – Center of the chest – Check for a – Hard and fast shockable rhythm – – Depth of at least 2 inches Provide shocks as indicated – Allow complete chest recoil – Follow each shock – Minimize interruptions in compressions with CPR – • Switch providers every 2 minutes Begin with compressions – Avoid excessive ventilation Code Blue: Key Members Code Blue • ACLS is a team approach • Pharmacy – Pulmonologist – Maintenance of drug trays for crash carts – Emergency Physician – Prepare medication – Registered Nurse (RN) – Drug information – Respiratory Therapist (RT) – Make recommendations and suggestions based on the situation – Emergency Medical Technician (EMT) – Help document medication administration – Pharmacist and/or Pharmacy Technician Crash Cart Med Tray How to assemble a syringe 1.Open the syringe box from the side indicated 2.Let the two parts fall out into your hand 3.Flip off the plastic end-caps using both hands 4.Attach the medication half to the plunger half with a push and a twist until resistance is met 2

Code Blue Code Blue • Normal Sinus Rhythm • Normal Sinus Rhythm – Heart Rate between 60-100 beats/min – One P wave precedes each QRS – QRS usually narrow with upright P waves – Normal Blood pressure • Systolic Blood Pressure: 90-120 • Diastolic Blood Pressure: 60-80 – Normal Respiratory Rate: 12-18 breaths/min – Normal O2 saturation: > 90% Bradycardia Bradycardia • Heart Rate less than 60 beats/min • Symptoms – Common in young athletes, asymptomatic – Chest discomfort or pain – Usually sinus node dysfunction in the elderly – Shortness of breath • Caused by heart disease and/or normal aging – Decreased level of consciousness process – Weakness – Symptomatic Bradycardia – Light-headedness • Heart rate< 50 beats/min – Presyncope or syncope Bradycardia Bradycardia • Signs • Does the patient have signs or symptoms – Hypotension of poor perfusion caused by bradycardia? – Orthostatic hypotension – Diaphoresis – If perfusion seems adequate and the patient – Pulmonary congestion, congestive heart failure or is responsive and answers questions edema appropriately, then observe and monitor – Frequent premature ventricular complexes or – If the patient has signs and symptoms of poor Ventricular Tachycardia perfusion, then administer atropine 3

Bradycardia Tachycardia • Atropine • Abnormally fast heart rate of greater than 100 beats/min – Anticholinergic Agent • Regular rhythm • Blocks the action of acetylcholine at parasympathetic sites • Often a response to increased cardiac output • Increases cardiac output demand or reduced stroke volume – 0.5 mg rapid IV bolus • Treatment is aimed at correcting the underlying • every 3 to 5 minutes, up to 3 mg total cause – Side effects • Increased myocardial oxygen demand Tachycardia Tachycardia – Sympathetic activation • Correct the underlying causes – Decreased parasympathetic activity – If fever, then antipyretic and/or antibiotics – Fever – If pain, then analgesics – Hyperthyroidism – If hypotensive, then fluids – Pain – If hypoxic, then oxygen – Increased metabolism • If stable and no other correctable causes – Hypotension • Vagal maneuvers – Hypoxia • Consider giving adenosine Tachycardia Tachycardia • Adenosine • Adenosine cardioversion of SVT – Antiarrhythmic Agent • Slows conduction time through the AV node, interrupting the re-entry pathways, restoring normal sinus rhythm – Initial dose: 6 mg rapid IV bolus • If ineffective, then 12 mg may be given • May repeat 12 mg once more • Follow each dose with 20 ml normal saline flush – Side effects • Flushing, chest pain, brief asystole, bradycardia 4

Cardiac Arrest Cardiac Arrest 1. Ventricular Fibrillation Ventricular Fibrillation (VF) • Rapid uncoordinated rhythm • Ventricular quivering 2. Pulseless Ventricular Tachycardia • Ineffective ventricular contraction • Pulseless • Unconscious patient 3. Asystole / Pulseless Electrical Activity (PEA) • Often associated with myocardial ischemia and infarction Cardiac Arrest VF / Pulseless Ventricular Tachycardia Pulseless Ventricular Tachycardia Management • Three or more consecutive ventricular 1.High Energy Shock complexes 2.CPR • Regular rhythm with rate > 100/min 3.High Energy Shock (if indicated) • Causes 4.CPR plus epinephrine – Drug toxicities, myocardial ischemia, reentry pathways, electrolyte abnormalities 5.High Energy Shock (if indicated) • Tendency to transition into VF 6.CPR plus amiodarone VF / Pulseless Ventricular Tachycardia VF / Pulseless Ventricular Tachycardia • Epinephrine • Amiodarone – Alpha and beta agonist – Antiarrhythmic • Stimulates adrenergic receptors • Prolongs action potential and refractory period • Cardiac stimulation • Decreases AV conduction and sinus node function – 1 mg IV every 3 to 5 minutes – First dose: 300 mg IV bolus – Side effects – Second dose: 150 mg IV • Myocardial ischemia – Side effects • Increase myocardial oxygen demand • Hypotension • QT prolongation 5

Cardiac Arrest Asystole / Pulseless Electrical Activity (PEA) • Asystole / Pulseless Electrical Activity • Management (PEA) 1. CPR – Absence of impulse initiation in the heart 2. Epinephrine – Zero cardiac output 3. Rhythm check – Causes • If not a shockable rhythm then continue CPR • Hypovolemia, hypoxia, electrolyte abnormalities, 4. CPR thrombosis, toxins 5. Epinephrine 6. Rhythm check Post Cardiac Arrest Care Asystole / Pulseless Electrical Activity (PEA) • Epinephrine • Optimize ventilation and oxygenation – Placement of an advanced airway – 1 mg IV every 3 to 5 minutes • Sedatives and analgesics • Vasopressin (antidiuretic hormone) – Etomidate, Midazolam, Fentanyl, Propofol, Precedex • Neuromuscular blocking agents – May replace the first or second dose of – Rocuronium, succinylcholine, cisatracurium epinephrine – Direct vasoconstrictor • Treat hypotension – 40 units IV – IV bolus – Side effects – Vasopressor infusion • Increased peripheral vascular resistance, may provoke • Epinephrine, Dopamine, Norepinephrine cardiac ischemia 6