Review Of Medical Emergency Procedures: Analysis Of A Code Blue Case Study

Analysis of the Medical Emergency Procedures

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The review of the given video scenario on ‘Code Blue, Full code’, it was evident that the medical practitioners applied various strategies to resuscitate the unresponsive patient, and eventually able to change the code blue status to normal by restarting the cardiac pulse. The patient was unresponsive at first with no pulse, but after the pulse, regular sinus rhythm was returned. However a closer look at the video, and an over view of the Australian Resuscitation Council (ANC) showed several aspects of underperformance and misses on the actions outlined in the guidelines. In the following essay, a review of the actions taken by the medical professionals in the given video will be analyzed to identify both the good and bad practices, and outline recommendations which can be followed to ensure better care and compliance with the guidelines of ANC.

At the starting of the video (0:13), the nurse entered the patient’s room and found him unresponsive, and could not find a pulse due to which she initiated a full code blue. After about 20 seconds of that, the code blue was initiated and in another 10 seconds, antibiotics were stopped and normal saline started. The resuscitation equipment arrived after 20 seconds of initiating code blue and the code blue team arrived about 60 seconds after the code was initiated. The actions of the nurses was according to the Guideline 2 of ANC (Managing an Emergency) showing prompt action, quick assessment and promptly asking for help. The patient was placed in a lateral position lying on the back; however, the position should have been lateral side lying recovery position (or lateral recumbent position) as per the ANC guideline, which was missed (Perkins et al., 2015; Hood & Considine, 2015; Zideman et al., 2015). Also, the ANZCOR guidelines was also not followed as the nurses did not monitor the blood saturation of oxygen (sp02), and oxygen was given without monitoring blood saturation. The verbal and tactile stimuli of the person were however checked as recommended in Guideline 3 (Recognition and First Aid management of unconscious person) (resus.org.au, 2018).

During the administration of Oxygen, the nurses ensured that the mouth of the patient is open and head was turned slightly downwards in accordance to Guideline 4 of ANZCOR (Airway), however the choking algorithm was  not checked, which was a major overlook of the Guideline 4. Signs of regurgitation and vomit were also not properly checked to see if that was causing airway obstruction, before initiation of the resuscitation of the patient. It was important that the nurses identified any upper airway obstruction according to Guideline 4 of ANZCOR (resus.org.au, 2018; Koster et al., 2010). The nurses also followed Guideline 5 to assess the breathing of the patient before initiating CPR, however, the rate of compression should have been 30:2, which was never specified to the compressor, and rescue breathing was also not given either as mouth to mouth, mouth to nose or mouth to mask, which was also a serious overlook on the part of the nurses (Na et al., 2017).

Recommendations for Improved Care

While the chest compressions were provided, it was not specified the number of chest compressions that needs to be given or the total duration (which was later mentioned to be of two minutes by the code captain). The depth of the compression also was not specified. According to the Guideline 6 (Compressions), it is advisable to give chest compressions of a depth of 5 cm, and should be provided at a rate of 100 to 120 compressions per minute, with minimum interruptions. Also, the compressors should be changed every two minutes to prevent fatigue in the compressor. The guidelines also advise the use of feedback mechanism to monitor the effect of the chest compressions and CPR regularly (resus.org.au, 2018; Perkins et al., 2015; Nichol et al., 2015; Idris et al., 2015). In the video, there were many interruptions in the chest compressions, which should have been avoided, and the depth and rate of the chest compressions should have been clearly indicated to prevent any confusion. However, the medical team did follow the guidelines by alternating the compressors to prevent their fatigue as well as provided the compression at the correct position. The team also kept on regularly checking the effect of the compression using medical equipments to monitor the heartbeat rhythm.

In the video, the defibrillation (started at 1:50) was given at 150 joules, followed by a change of compressor. Before the defibrillation, the compression was stopped to check the type of rhythm. There also was a significant delay between the arrival of the ‘Code Blue’ team and the starting of the defibrillation, as the team had to put on the pads and then noting the procedure in the chart, followed by the arrival of the code captain (Sunde et al., 2010; Soar et al., 2010). Delay in the defibrillation process should be as minimum as possible, as a delay of every minute can reduce the chance of survival by 10%, if the patient suffered from cardiac arrest due to Ventricular Fibrillation (VF). Guideline 7 (Automatic External Defibrillation in Basic Life Support) of ARC recommends that the pads be placed in anterior-lateral positions, which was followed by the medical team, and also, proper safety procedures was followed while giving the shock (resus.org.au, 2018; Finn et al., 2015; Biarent et al., 2010). Is can be suggested that the emergency response team (code blue team) should have responded along with the code captain and all the necessary equipments should have been readily available to start the defibrillation. Also the documentation could have started with the defibrillation process, instead of before it, thus causing further delay.

Use of Medication, Defibrillation, and Resuscitation Equipment

The Guideline 8 (CPR) of ARC advises that CPR should include chest compressions with rescue breathing until specialized treatment is available (Sana, 2015). The guideline also suggests that a compression: ventilation ratio of 30:2 should be maintained during the CPR. All the steps of resuscitation were also followed according to the DRS ABCD steps except for the fourth step, which was opening the airway. It is recommended that the airway should be checked for any obstruction before giving CPR. This can be considered as a serious error on the part of the present medical professionals, and it affects the efficacy of the resuscitation process, as well as breaks the DRS ABCD procedure (resus.org.au, 2018; Soar et al., 2015; Perkins et al., 2015). This shows that the guidelines were not properly followed in this process. It is advisable therefore to check of airway obstruction before starting the CPR. Also, the rate of compression should also be mentioned to ensure the correct ratio of compression to ventilation be followed, which was also not done on this video.

After the arrival of the code captain, the patient history was promptly shared with him. The patient information can be structured in the AMPLE rule, which stands for Allergies, Medications, Past Medical History, Last Meal and Event leading to the code blue. The nurse informed that the patient was 37 years old, who was admitted 2 days ago for pancreatitis, had no allergies, was diabetes (having high blood sugar), was febrile in the morning and the vital signs was also given. However, this was not entirely according to the AMPLE rule, as the last meal as well as the events leading to code blue was not mentioned. Also, the diagnosis of Pancreatitis could have been mentioned along with other medical conditions while stating the past medical history of the patient.

In the defibrillation process there was a significant deviation from the recommended energy levels for the process to what was actually administered. In the video, all the defibrillation was administered at 150 joules, which was a lot less from the recommended threshold of 360 Joules (for monophasic waveforms) or start at 200 Joules and increase the energy with every shock (Biphasic). Effective provision of shock and with adequate energy, the chances of survival can increase by 90%, which highlights the importance of maintaining adequate energy for the shock. The Guideline 11.4 (Electrical Therapy for Adult Advanced Life Support) recommends the optimal administration of monophasic shocks, each at 360 Joules (resus.org.au, 2018; Soar et al., 2015). The medical team in this video should have followed this protocol, to ensure earlier success.

Conclusion

For the administration of medication, the intravenous route was selected, which was according to the Guideline 11.5 (Medications in Adult Cardiac Arrest) of ARC. This was advisable since the patient was unresponsive and in such situations IV is the fastest route to administer medicine. The patient was administered 1mg of epinephrine through IV, after administering a defibrillator shock for 150 joules. Vasopressin was not administered, since such is not supported by strong evidence according to the ARC guidelines. The Second dose of epinephrine was administered after a gap of 5 minutes, during which 2 loops of resuscitation was completed (with 2 rounds of defibrillation), which exceeds the ARC guidelines. The recommended dosage should be at regular intervals (at every second loop). Amiodarone was also administered at 300mg following the administration of Epinephrine. It was administered through IV, as it was the most effective way. Amiodarone was administered twice in the video, after the defibrillation was done, and in both cases 300 mg was administered. This exceeded the ARC guidelines that recommend the second dose to be 150 mg followed by infusion at the rate of 15 mg/Kg for 24 hours. His was not done in the video, and could have had serious adverse effects on the success of the resuscitation. The ARC guideline recommends the administration of Calcium as it is important for the normal functioning of muscles and nerves. The usual bolus dose has been recommended at 5 to 10 ml of 10% Calcium Chloride or calcium gluconate. Lidocaine is recommended since it acts as a sodium channel blocker, and is an alternative to amidarone. Administration of Magnesium is recommended as is important for maintaining the stability of the cell membrane, and low levels of magnesium can lead to myocardial hyperexcitability. ARC recommends that it should not be routinely used, and low doses should be used for hypomagnesia. The recommended bolus should be 5mmol of magnesium. Potassium is recommended as it is an important electrolyte that is also important for membrane stability, and low levels of potassium along with digoxin therapy and low levels of magnesium can cause serious arrhythmias. The recommended dosage is a bolus of 5mmol potassium (resus.org.au, 2018; Skrifvars et al., 2004). However, none of these medication was followed in the video.

While administering oxygen, the oxygen saturation was not defined clearly. According to the Guideline 11.6 (Targeted Oxygen Therapy in Adult Advanced Life Support) 100% oxygen should be administered during cardiac arrest (resus.org.au, 2018; Kilgannon et al., 2011). However, in the video, it was never specified. Also, the blood saturation levels of oxygen were never checked before starting the resuscitation process. The blood saturation was checked after giving the first round of resuscitation and defibrillation. Equipments like glucose monitor also should have been at ready, which was not the case in the video. Fetching the glucose monitor also wasted much valuable time, which as a serious drawback, affecting the efficiency of the team.

The importance of the presence of patient’s family was addressed in the video, as the medical professionals arranged a call to the family via the social support, as a part of their hospital policy. This was in accordance to the Guideline 10.6 (Family Presence during resuscitation), which recommends that the family of the patient should have the option to be present during the resuscitation or as soon as they can. Studies have shown that the presence of family does not have any adverse effects on the process of resuscitation, and thus raises no concerns (resus.org.au, 2018).

The video showed several aspects where the medical professionals and the emergency team failed to follow the guidelines of the ARC in the resuscitation process, and highlighted several overlooks, which could have jeopardized the well being and survival chances of the patient. Thankfully, this was a mannequin study, with no real harm being done to anyone, but in a real world scenario, such overlooks and mishandling could have resulted in grave outcomes. It is therefore highly recommended that the AR%C guidelines be followed in these procedures, top ensure the optimum results.

References:

Biarent, D., Bingham, R., Eich, C., López-Herce, J., Maconochie, I., Rodríguez-Núñez, A., ... & Zideman, D. (2010). European Resuscitation Council guidelines for resuscitation 2010 section 6. Paediatric life support. Resuscitation, 81(10), 1364-1388.

Finn, J. C., Bhanji, F., Lockey, A., Monsieurs, K., Frengley, R., Iwami, T., ... & Greif, R. (2015). Part 8: education, implementation, and teams: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation, 95, e203-e224.

Hood, N., & Considine, J. (2015). Spinal immobilisaton in pre-hospital and emergency care: A systematic review of the literature. Australasian Emergency Nursing Journal, 18(3), 118-137.

Idris, A. H., Guffey, D., Pepe, P. E., Brown, S. P., Brooks, S. C., Callaway, C. W., ... & Kudenchuk, P. J. (2015). Chest compression rates and survival following out-of-hospital cardiac arrest. Critical care medicine, 43(4), 840-848.

Kilgannon, J. H., Jones, A. E., Parrillo, J. E., Dellinger, R. P., Milcarek, B., Hunter, K., ... & Trzeciak, S. (2011). Relationship Between Supranormal Oxygen Tension and Outcome After Resuscitation From Cardiac ArrestClinical Perspective. Circulation, 123(23), 2717-2722.

Koster, Sayre, M. R., R. W., Botha, M., Cave, D. M., Cudnik, M. T., Handley, A. J., ... & Morley, P. T. (2010). 2010 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations, part 5: adult basic life support. Circulation, 122(16 (Suppl. 2)), 8298-8324.

Na, J. U., Han, S. K., Choi, P. C., & Shin, D. H. (2017). Effect of metronome rates on the quality of bag-mask ventilation during metronome-guided 30: 2 cardiopulmonary resuscitation: A randomized simulation study. World journal of emergency medicine, 8(2), 136.

Nichol, G., Leroux, B., Wang, H., Callaway, C. W., Sopko, G., Weisfeldt, M., ... & Christenson, J. (2015). Trial of continuous or interrupted chest compressions during CPR. New England Journal of Medicine, 373(23), 2203-2214.

Perkins, G. D., Travers, A. H., Berg, R. A., Castren, M., Considine, J., Escalante, R., ... & Olasveengen, T. M. (2015). Part 3: adult basic life support and automated external defibrillation: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation, 95, e43-e69.

resus.org.au (2018), The ARC Guidelines, retrieved on: 13 May, 2018, from: https://resus.org.au/guidelines/

Sana, C. P. (2015). The Evolution of Nursing. International Journal of Nursing, 3(2), 1-2.

Skrifvars, M. B., Kuisma, M., Boyd, J., Määttä, T., Repo, J., Rosenberg, P. H., & Castren, M. (2004). The use of undiluted amiodarone in the management of out?of?hospital cardiac arrest. Acta anaesthesiologica scandinavica, 48(5), 582-587.

Soar, J., Callaway, C. W., Aibiki, M., Böttiger, B. W., Brooks, S. C., Deakin, C. D., ... & Morrison, L. J. (2015). Part 4: advanced life support: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation, 95, e71-e120.

Soar, J., Mancini, M. E., Bhanji, F., Billi, J. E., Dennett, J., & Finn, J. (2010). International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Part 12: education, implementation, and teams. Resuscitation, 81(Suppl 1), e288-330.

Sunde K, Jacobs I, Deakin CD, et al (2010). Part 1: executive summary: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation, 81(1), e1-e25.

Zideman DA, Singletary EM, De Buck E, et al. (2015), Part 9: First aid: 2015 International Consensus on First Aid Science with Treatment Recommendations. Resuscitation. Retrieved on 13 May, 2018 from https://www.cprguidelines.eu/assets/downloads/costr/S0300-9572(15)00368-8_main.pdf Accessed 19/11/