TOPIC OUTLINE o QRS shape and duration = usually
normal, but be regularly abnormal
I. Introduction
II. ECG
III. Code Management based on Potter & Perry
IV. Code Management based on ACLS
INTRODUCTION
• Cardiac arrests are emergency where there is
cessation of circulating blood flow that
eliminates O2 transport and perfusion
• Many cardiac arrest are caused by
dysrhythmias (due to electrolyte imbalance,
heart damage, medications)
• In addition to initiating CPR, you must know
pre-arrest indications (tachycardia,
hypotension, tachypnea, decreased O2 sat
<90% despite O2 therapy, and decease UO of
<50 mL in 4 hrs.
• GOAL = to provide resuscitation in a timely
manner and to restore cardiopulmonary
function thus avoiding poor neurologic
outcomes or death.
• ALL who respond to cardiopulmonary arrests
should follow a standardized approach that is
simple to understand.
ECG
• Electrocardiogram (ECG/EKG)
• The end product of viewing electrical impulse
that travels through the heart by means of
electrocardiography
• Obtained by placing electrodes on the body at
specific areas
“Snow over Trees, Smoke of Fire, and
Chocolate in the stomach”
Normal Sinus Rhythm
• Occurs when the electrical impulse starts at a
regular rate and rhythm in the SA node and
travels through normal conduction pathways.
• Indicative of good cardiovascular health
• Includes the ff characteristics:
o Ventricular and atrial rate = 60-100
bpm (adult)
o Ventricular and atrial rhythm = regular
4NUR4 THESIS GROUP 5
o P wave = consistent; always in front of
the QRS
o PR interval = consistent interval
between 0.12 and 0.20 seconds
o P:QRS ratio → 1:1
Common Cardiac Dysrhythmias
Sinus Tachycardia
• Impulse at a faster than normal rate
• Regular rhythm, rate 100-180 beats/min,
normal P wave, and QRS complex
• Rate increase is often normal response to
exercise, emotion, or stressors
• Some patients with heart disease are unable to
increase their heart rate to meet increased
oxygen demands
• One must correct underlying factors and
discontinue drugs producing the side effect.
MANAGEMENT:
• Synchronized Cardioversion
• Otherwise, vagal maneuvers
o Carotid sinus massage
o Gagging
o Bearing down against a closed glottis
(as if having a bowel movement)
o forceful and sustained coughing
o applying a cold stimulus to the face
MEDICATIONS:
• Administration of Adenosine (if QRS is
monomorphic and the ventricular rhythm is
regular)
• Administration of Amiodarone (if QRS is wide
with tachycardia)
Sinus Bradycardia
• Impulse at a slower than normal rate
• Regular rhythm, rate less than 60 beats/min,
normal P wave, PR interval, and QRS complex.
• Rate decrease is normal response to sleep,
diminished blood flow to SA node, vagal
stimulation, hypothyroidism, increased
intracranial pressure, or pharmacologic agents
• No clinical significance unless associated with
s/sx of reduced cardiac output such as
dizziness, syncope, or presence of chest pain
 • Bradycardia with hypotension and decreased First dose: Adenosine 6 mg
cardiac output is treated with atropine or even a rapid IV push follow with NS
pacemaker if necessary. flush
Second dose: Adenosine 12
MEDICATIONS: mg if required
• Administration of 0.5mg of Atropine IV bolus • WITHOUT PULSE:
repeated every 3-5 mins until maximum dosage o Defibrillation and CPR
of 3 mg is given.
Ventricular Fibrillation
• Rarely if bradycardia is unresponsive to
atropine, dopamine or epinephrine are given.

Atrial Fibrillation (A-Fib)

• Uncoordinated electrical activity.
• No identifiable P, QRS, or T wave.
• Causes include sudden cardiac death,
electrical shock, acute myocardial infarction,
• Chaotic, irregular atrial activity resulting in an drowning, or trauma.
irregular ventricular response resulting in an • Acute loss of pulse and respiration.
irregular cardiac rate and rhythm • Immediate chest compressions and
• No identifiable P waves. defibrillation are required.
• The conduction of the multiple atrial impulses
across the atrioventricular (AV) node MANAGEMENT:
determines the rate. • Early defibrillation
• Caused by aging, calcification of the sinoatrial • Cardiopulmonary Resuscitation (CPR) until
(SA) node, or changes in myocardial blood defibrillation is available
supply. MEDICATIONS:
• There is loss of the atrial kick, pooling of blood • Administration of Amiodarone and epinephrine
in the atria, and development of micro emboli. after defibrillation
• The patient often complains of fatigue, a
fluttering in the chest, or shortness of breath Asystole/ PEA
• common in older adult

Ventricular Tachycardia

• Flat line, no waves

• Usually led by severe bradycardia
MANAGEMENT:
• Rhythm slightly irregular, rate 100-200
• IV / IO access
beats/min,
• Consider advance airway
• Absent P wave and PR interval
• CPR every 2 mins then reassess cardiac
• QRS complex wide and bizarre,
rhythm
• Caused by changes in the normal pacemaker
• DO NOT SCHOCK
of the heart such as decrease in blood flow,
MEDICATIONS:
ischemia, or embolus.
• Acute loss of pulse and respiration • Administration of Epinephrine 1mg every 3-5
• Immediate chest compressions and mins
defibrillation are required
CODE MANAGEMENT (POTTER & PERRY)
MANAGEMENT: • Initially, a code is managed by the first
responder by notifying help from resuscitation
• WITH PULSE:
or code team then initiate performing CPR
o Identify if stable or unstable?
• The following assessment/intervention must be
(Hypotension? Acutely altered mental
done, C(circulation), A(airway), B(breathing),
status? Signs of shock? Ischemic chest
D(early defibrillation)
discomfort? Acute heart failure?)
o Stable • The first responder must continue until the code
First dose: Amiodarone 150 team arrives
mg SIVP over 10 minutes. • The team consists of Team leader, CPR nurse,
Repeat as needed. Followed Substitute for CPR nurse, Airway manager, IV/
by maintenance infusion of 1 Med nurse, and Recorder (based on lectures)
mg/min for first 6 hrs • The response team consists of a first
o Unstable responder, physician, intensive care nurse,
Synchronized Cardioversion respiratory therapy personnel, anesthesiology
personnel, and possibly radiology and
laboratory technologists (based on the book)

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 • The skill of code management cannot be
• Depth: 5-6 cm (2-2.4 inch)
delegated to nursing assistive personnel (NAP)
unless he/she is certified in basic life support
Child • Begin if no pulse or pulse
(BLS) and can use AED
(1-8 y/o) <60/min
• Early CPR and defibrillation delivered
• Lower half of sternum, between
enhances heart and brain function → higher
nipples
chance of survivability
• Heel of 1 hand on top of the other
CRASH CART • Depth: At least ⅓ of chest (5cm)
• Equipment may be readily available at the Infant (<1) • Begin if no pulse or pulse
bedside or in a designated area of the hospital
<60/min
unit.
• Just below nipple line
• The CRASH CART consists of the ff:
• 2 finger, 2 thumbs (encircling
o Clean and sterile gloves, gown,
hands)
protective eyewear
o Oxygen source
o Bag-mask device or resuscitation bag
o Oral airways STEP-BY-STEP PROCEDURE WITH RATIONALE
o Laryngoscope, handle, and
laryngoscope blades, straight and
curved STEPS RATIONALE
o Endotracheal tubes, various sizes (5-
to-9 mm for adults; 0-to-4 mm for 1. Determine if px is To confirm if the px
pediatrics) unconscious by shaking is truly
o Carbon dioxide detector to confirm ET him/her and saying unresponsive and
tube placement “Hey! Hey! Are you not intoxicated,
o Tape or commercial ET tube holder ok?” sleeping, or hearing
o Backboard impaired, etc.
o AED and/or manual defibrillator with
Assess for
AED/defibrillator pads
unresponsiveness NOTE: If an
o Intravenous (IV) needles (sizes for
unresponsive
adults and pediatrics)
person has
o Central vascular access kit
adequate
o IV tubing and fluids (NS and D5W)
respirations and
o Syringes
pulse, remain until
o Laboratory specimen tubes
further assistance is
o Arterial blood gas kit
present and place
o Emergency medications
the patient in a
o ACLS guidelines or algorithms
modified lateral
o Suction source and suction equipment
recovery position.

2 Check carotid pulse on Carotid pulse is

adult or child; use brachial easily accessible
or femoral pulse in an and located in
infant. Also check the adults and children
breathing of the px

Palpate for no more than

10 seconds
Cardiopulmonary Resuscitation (CPR)
If no pulse and no This is to notify
Technique Chest Compression: Push hard and breathing, ACTIVATE
fast to allow complete recoil other healthcare
CODE BLUE by saying team members for
• 100-120/min “Code blue! Code blue! help to provide
• (30:2) compressions to rescue Activating the proper intervention
breaths ratio emergency response for the px.
team!“
Adult • Begin if no pulse
• Lower half of sternum, between 3 Place px on a hard This is to provide
nipples surface (if available, put external
• Heel of 1 hand on top of the other compression to the

4NUR4 THESIS GROUP 5

 back board) and must be heart. (compressed 10 If cardiac rhythm is
flat. between sternum “shockable,” continue
and spinal CPR while assist code
Logroll victim to flat, vertebrae), team is preparing manual
supine position. defibrillation
Energy is delivered
A. Turn on the
in prescribed
4 Initiate CPR until the This is to provide defibrillator and select the
doses. Manual
code team arrives and proper circulation proper energy level
biphasic devices
take note the time you until the code team following agency policy
deliver shocks at a
started arrives. 30 and equipment directions.
lower level (200
compressions : 2 B. Apply conductive
joules);
breaths gel or gel pads to the
monophasic
patient’s chest where
waveforms use 360
defibrillator paddles will
joules.
be placed
5 Open airway Done because C. Place paddles or
A. Head tilt–chin tongue is the most pads on the patient's Good skin-to-
lift (if px has spontaneous common cause of chest wall. paddle / pad
respirations) blocked airway in D. Verify that no one contact ensures
unresponsive is in physical contact with appropriate
patients. patient, bed, or any item discharge of current
contacting patient during and decreases
defibrillation by saying chance of skin
“Okay, I am going to burns
shock / defibrillate the
B. Jaw thrust (if patient. I am clear, you Ensures
cervical trauma is are clear, everybody is appropriate
suspected) Prevents head discharge of
clear. Shocking in 3, 2,
extension and neck current.
1”
movement to avoid
further injury to the
Prevents accidental
neck. Apply
delivery of shock or
cervical collar and
injury to personnel
immobilize px to
reduce further injury

6 Attempt to ventilate Slow breaths to

patient with slow breaths reduce gastric
distention

7 Once the team arrived, Information is

briefly report on the critical in selection 11 If no IV access available, Provides a route for
condition of the px and of appropriate establish IV access with rapid drug
events performed. treatment for large-bore IV needle (14- administration and
patients. to 22-gauge) and begin access for blood
infusion of 0.9% NS samples and fluid
8 Team leader delegates Essential to meet administration
the tasks as appropriate critical needs of
while the core group patient in timely 12 Continue CPR until Interruptions in
continues with manner relieved, until victim CPR are planned
resuscitation efforts. regains spontaneous and organized.
pulse and respiration They usually occur
Attach manual Cardiac rhythm during change of
defibrillator / monitor to monitor devices If the team was CPR personnel,
patient using ECG provide immediate successful, the team defibrillation, and
electrodes, quick-look rhythm display for leader will say intubation. An
paddles with gel pads, or analysis without “Congratulations team, interruption
“hands-off” defibrillation disruption of rescue we have achieved a should not exceed
electrode to visualize breathing and chest return of spontaneous 10 seconds
cardiac rhythm compression. circulation! Please
prepare for post cardiac
9 After 5 cycles of chest Every 2 mins, one arrest care ”
compression, begin must assess if the
rhythm analysis and px’s condition is
check for pulse/breathing improving

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 CODE MANAGEMENT BASED ON ACLS
7 Continue CPR for 2 Amiodarone via IV/IO
• ACLS = Advanced Cardiovascular Life Support minutes and route
administration of • 1st dose = 300
CODE MANAGEMENT/ ALGORITHM Amiodarone or mg
lidocaine • 2nd dose = 150
STEPS NOTES mg

Lidocaine via IV/IO

1 START CPR - Also give O2 and route
attach px to the cardiac
• 1st dose = 1-
monitor and defibrillator
1.5 mg/kg
- minimize interruptions
• 2nd dose = 0.5
- change CPR nurse
- 0.75mg/kg
every 2 minutes or if
exhausted
8 IF Return of This is known as the
Spontaneous Initial stabilization
2 After 2 mins / 5 Biphasic DEFIB
Circulation (ROSC), phase
cycles, assess - recommended initial
go to Post-Cardiac
rhythm and check for dose of 120-200 J
Arrest Care to Airway Management
pulse and breathing. - if unknown, use
maximumly available
manage airway, • Waveform
respiratory capnography
- subsequent shocks
parameters, and • Capnometry to
must be equivalent.
hemodynamic confirm and
Higher charges may be
parameters. May also monitor
considered
obtain 12 lead ECG endotracheal
Monophasic DEFIB
- 360 J tube placement

3 If VF / pVT These rhythms are Manage Respiratory

= SHOCK shockable. while Parameters
Asystole or Pulseless • Titrate FIO2, for
electrical activity (PEA) SpO2, 92%-
are NOT shockable 98%;
• start at 10
4 Continue CPR for 2 Epinephrine via IV/IO breaths/min:
minutes and route • titrate to Paco2
administration of • 1mg every 3-5 of 35-45 mm Hg
epinephrine every 3- mins Manage Hemodynamic
5 mins. May also Parameters:
consider advanced - if an advanced airway • Administer
airway, capnography is inserted, give 1 crystalloid
breath every 6 seconds and/or
(10 breaths/min) with vasopressor or
continuation chest inotrope
compressions • This is get
systolic blood
5. After 2 mins / 5 pressure = 30
cycles, assess mmHg or mean
rhythm and check for arterial
pulse and breathing. pressure >65
mmHg
6 If VF / pVT For asystole/PEA,
= SHOCK administer Epinephrine 9 After obtaining 12- This is known as the
immediately(and every lead ECG, consider continued mgt and
3-5 mins) and start CPR for emergent cardiac additional emergent
for 2 mins. Also intervention if activities
consider inserting • (+) STEMI
advanced airway. After • Unstable If the px is not following
2 mins, re-assess cardiogenic commands
rhythm if shockable or shock • start Targeted
not. If still not • Mechanical Temp
shockable, Continue to circulatory Management
provide CPR and support (TTM) by
epinephrine required beginning at

4NUR4 THESIS GROUP 5

 32C-36C for
24hrs
• obtain brain CT
• monitor EEG
• and other
critical care mgt

4NUR4 THESIS GROUP 5