Rapid Responses and Codes
Disclaimer: the clinical information on this site is only meant to serve as a reference. Please consult with your team for individual diagnostic and treatment decisions.
Code Blue: Pulseless VT/VF/PEA/Asystole
- Causes: 6H’s (hypovolemia, hypoxia, hypothermia, hypoglycemia, hypo/hyperkalemia, hydrogen acidosis) or 6T’s (thrombosis, tachycardia, trauma, tension pneumothorax, tamponade, toxins)
- If no pulse: start CPR x 2 minutes, bag valve mask ventilation, place defibrillator pads, and get IV access
- Both scenarios can get pulse/rhythm checks every 2 minutes, epinephrine 1mg IV every 3-5 minutes, and treatment of reversible causes
- If pulseless VT or Vfib go ahead then defibrillate (unsynched) and continue defibrillating during pulse/rhythm checks. Pulseless VT or Vfib can get amiodarone 300mg bolus, second dose can be 150mg.
- If PEA arrest or asystole do not defibrillate.
- ROSC (return of spontaneous circulation): if has a mental status then do not cool, if does not have mental status then do head CT to ensure no bleed and consider hypothermia protocol
- Get EKG first to see if sinus bradycardia or heart block
- Sinus bradycardia with hypotension/shock, loss of consciousness: atropine 0.5mg IV then 0.5mg-1.0mg in 3-5 min then 0.5mg-1.0mg in 3-5 min, dopamine (2-10 mcg/kg/min or epinephrine (2-20 mcg/kg/min) infusion; transcutaneous pacing (with fentanyl/midazolam)
- First degree heart block (PR interval > 200) or second degree heart block Mobitz type 1 (PR intervals get longer then dropped beat): no intervention
- Second degree heart block Mobitz type 2 (PR intervals are unchanged then dropped beat) or complete heart block (PR intervals variable because P and QRS are not synched): directly to transcutaneous pacing (with fentanyl/midazolam)
- First question: narrow complex QRS (Afib/SVT/sinus tachycardia) or wide complex QRS (VT/Vfib).
- Second question: pulse (Afib/SVT/sinus tachycardia/VT) or no pulse (pulseless VT, Vfib, PEA, asystole)
- See above for code situation tachyarrhythmias
- Sinus tachycardia is usually gradual on telemetry where as Afib/SVT/VT/Vfib are usually sudden on telemetry
- Stable = relatively normal respirations, normal mental status, normal blood pressure, no severe chest pain: treat medically
- Unstable = agonal/severely tachypneic, depressed mental status, hypotensive, or chest pain: shock right away
- Stable atrial fibrillation with rapid ventricular response (stable Afib with RVR): give metoprolol 5mg IV every 5 min up to 3 times, then can give diltiazem 10-20mg IV every 5 min up to 3 times (careful in CHF patients). If resolves, start PO of metoprolol or diltiazem, whichever broke the Afib RVR. Goal HR<110. If persistent, give amiodarone IV bolus 150mg and start amiodarone drip 1mg/min.
- Unstable atrial fibrillation with rapid ventricular response (unstable Afib with RVR): proceed directly to synched cardioversion
- Stable supraventricular tachycardia (stable SVT): try vagal maneuver (blow into syringe, cold water towel over face, bear down like a bowel movement), then try carotid massage (only one side at a time, no collaterals), if unsuccessful then place backboard and push adenosine (1st dose 6mg, 2nd dose 12mg, 3rd dose 12mg) with warning to patient they will feel flushed/nauseous/impending doom. If no response then synched cardioversion. Suppress future SVT with PO metoprolol. If refractory consider amiodarone 150mg bolus and drip at 1mg/min.
- Unstable supraventricular tachycardia (unstable SVT): proceed directly to synched cardioversion
Chest Pain/Acute Coronary Syndrome
- Differential for chest pain (most common): cardiac (angina/acute coronary syndrome, pericarditis, aortic dissection, aortic stenosis), pulmonary (pneumonia, pleuritis, pulmonary embolism), GI (esophagitis, GERD, ulcer, esophageal spasm or rupture, pancreatitis, cholelithiasis), musculoskeletal (costochondritis), dermatologic (herpes zoster), or psychiatric (anxiety)
- If ST elevations/depressions or dynamic T wave changes: compare with prior EKG and call Cardiology
- If unstable angina/NSTEMI/STEMI: aspirin 324mg (chewable 81mg x 4), Plavix (clopidogrel) 300-600mg (based on proximity to left heart catheterization timing, careful if patient has IDDM and may need surgical CABG instead of stent), pain control (nitroglycerin preferred over morphine), heparin bolus and drip (re-bolus with every subtherapeutic PTT and check PTT in 6 hours), beta blocker (metoprolol tartrate to HR 50-60), high dose statin (atorvastatin 80mg or rosuvastatin 40mg), ACE inhibitor (usually at end of hospital stay, can use enalapril or lisinopril). Keep HR 50-60, BP ~120/80 to minimize excess oxygen demand.
- Differential: 5P’s (pulmonary embolism, pneumothorax, pneumonia, pulmonary edema, pleural effusion) or 5A’s (asthma/COPD, anaphylaxis, atelectasis, aspiration, ARDS)
- Oxygen modalities: room air, 6L NC, Ventimask, nonrebreather, high flow nasal cannula, BiPAP, bag valve mask, intubation, FiO2/PEEP changes, paralysis, recruitment maneuvers, proning, ECMO (exact order depends on situation)
- Consider: stat CXR, ABG, listen to both lungs, suctioning/chest PT, diuresis, IV methylprednisolone 125mg, antibiotics, IM epinephrine, CT PE protocol, thoracentesis, Flolan (epoprostenol)
- Hypovolemic: from dehydration, bleeding; treat with fluids or blood
- Obstructive: from cardiac tamponade or pulmonary embolism; treat with fluids, pericardiocentesis, tPA/heparin or thrombectomy
- Cardiogenic: from CHF (can be ischemic or rupture event); treat with diuresis, dobutamine/dopamine/epinephrine cardiac pressor drips, intra-arterial balloon pump, possibly CABG if ischemic
- Distributive: from septic shock (treat with antibiotics/source control, fluids, Levophed/norepinephrine then vasopressin then epinephrine septic pressor drips), anaphylactic shock (treat with IM epinephrine), or adrenal insufficiency (treat with hydrocortisone IM 100mg IV x 1 and every 8 hours thereafter)
GI Bleed: Exsanguination Protocol
- Blood bank: 215-662-3448 / 215-662-3449 at HUP, 215-662-8336 at PPMC
- First round: 10 units RBCs, 6 units FFP, 1 unit platelet of uncrossed blood
- For massive transfusions consider calcium gluconate after the 4th RBC to counteract hypocalcemia due to citrate in packed RBCs and also giving RBC:FFP:platelets in a 4:2:1 ratio (4:1:1 in surgical data) due to dilutional coagulopathy/thrombocytopenia
- Differential: stroke (ischemic or hemorrhagic), sepsis, hypoglycemia, cardiac arrhythmia (check pulse), seizure, medication side effect, hypercarbia, delirium
- Consider: finger stick, head CT/MRI, infectious workup, telemetry, medication list review, Ativan (lorazepam) and Keppra (levetiracetam) IV load, or ABG