Blanchard Valley Hospital Pharmacy Code Blue Overview Adapted from Gary Spanik, RPh Edited by Kate Reeves, Pharm D, RPh Jon Manocchio, Pharm D, RPh
Pharmacist Responsibilities Be aware of basic ACLS tenets Be aware of ACLS Core Case drug indications Have basic knowledge ACLS drug pharmacology Dose ranges Calculations Be aware of crash cart contents and locations Understand standard emergency drip regimens concentrations and compatibilities and how to prepare them provide IV pump administration rates in ml/hr
Watch and Listen Take control of the drug tray You are the drug expert Remain calm and alert Nurses will look to you for support Request clarification when needed Codes not in CCU/ER tend to be crowded and hectic Make sure someone is recording Keep drug tray free of debris RL3 and label all syringes/drips accurately Be aware of location of refrigerated drugs Anticipate stock replacement needs
Basic ACLS Tenets A = Airway B = Breathing C = Circulation D = Defibrillation Priorities during cardiac arrest are high quality CPR and early defibrillation. Drug administration is of secondary importance
Routes of Drug Access IV: Peripheral IV is preferred because of ease of access Due to possible delay of drug entry to the central circulation Give by bolus injection Follow with 20ml bolus of IV fluid Elevate the extremity for 10-20 seconds. IO: Intraosseus route is safe and effective if IV access is unavailable Can be established in all age groups Can be achieved in 30-60 seconds Any drug or fluid given IV can be given IO
Routes of Drug Access ET: Endotracheal is less preferred Optimal ET drug dose is unknown Typical ET dose is 2 2 ½ times the IV route dose Drugs known to be effective via ET Naloxone, Atropine, Vasopressin, Epinephrine and Lidocaine. Dilute the dose in 5 10ml of water or NS and inject directly into the trachea quickly
ACLS Core Cases VF/Pulseless VT Respiratory Arrest Pulseless Electrical Activity (PEA) Asystole Acute Coronary Syndrome (ACS) Unstable angina, non-st segment elevation MI, ST-segment elevation MI, and sudden cardiac death Bradycardia Unstable Tachycardias A. Fib/Flutter, Re-entry SVT, Mono/Polymorphic VT, Wide-Complex Tachycardia Stable Tachycardias Narrow (SVT)/Wide QRS Complex, Regular/Irregular tachycardias Acute Stroke
ACLS Drug Classification Control heart rate and rhythm Improve cardiac output, blood pressure, affect peripheral vascular tone, and inotropic and chronotropic forces
Blood Pressure Paradigm BLOOD PRESSURE = CARDIAC OUTPUT X PERIPHERAL RESISTANCE Be mindful how the pharmacologic actions of ACLS drugs affect blood pressure based on their affect on heart rate (Atropine/Beta blockers) or peripheral resistance such as vasoconstrictors (Phenylephrine) or vasodilatory drugs (Nitroprusside), as well as potential compensatory mechanisms.
Medications in ACLS Lidocaine: Antiarrhythmic Amiodarone: Antiarrhythmic Procainamide : Antiarrhythmic Beta Blockers: Rate Control Atropine: Bradycardia Isoproterenol: Sympathomimetic/Inotrope Calcium Channel Blockers: Myocardial Ischemia Adenosine: Nucleotide, PSVT Magnesium : Torsades de Point, hypomagnesiemia
Medications in ACLS Epinephrine: Catecholamine, cardiac stimulant Phenylephrine: Alpha-1 vasopressor Vasopressin: Pituitary Hormone, Cardiac Arrest/PEA/Vent Asystole Norepinephrine: Vasoconstrictor/Inotrope Dopamine: Adrenergic agonist/vasopressor/inotrope Dobutamine: Inotrope/Chronotrope/Vasodilator Inamrinone: Inotrope in CHF Nitroglycerin: Vasodilator/Antianginal Nitroprusside: Vasodilator
Medications in ACLS Diuretics: Reduce fluid volume Natrecor: Natriuretic Peptide/Decompensated CHF/Inotrope Thrombolytics: GP IIB/IIIA Antagonists Miscellaneous Oxygen Morphine IV Fluids Sodium Bicarbonate
Autonomic Nervous System Review The sympathetic nervous system accelerates the body s response to stress. It innervates the myocardium through adrenergic fibers for excitatory effect. A. Alpha Adrenergic Receptors - Alpha 1 - Vasoconstriction - Positive inotrope and negative chronotrope - Alpha 2 - Decreased Vascular tone in the heart, kidneys, and periphery - Lower resistance - Blood pressure reduction B. Beta Adrenergic Receptors - Beta 1 - Beta 2 - Positive chronotrope and increased myocardial contractions - Vasodilation and relaxation of smooth muscle
Adult Crash Cart Contents DRAWER 1 Lidocaine 2gm Premix (1) Dopamine 400mg Premix (1) Atropine PFS (4) Lidocaine PFS (6) Vasopressin (2) Amiodarone 150mg vial (3) Epinepherine PFS (6) 0.9% NS PFS (10) Dextrose PFS (2) DRAWER 2 Sodium Bicarbonate PFS (2) Norepinephrine vial (4) Succinylcholine vial (2) Metoprolol (3) Epinephrine (2) Adenosine (5) Phenytoin (3) Propofol (1) Etomidate (1) Magnesium Sulfate (2) Flumazenil (1) Furosemide (2)
Adult Crash Cart Contents DRAWER 2 Ephedrine amp (1) Calcium Cl 10% PFS (2) Vecuronium (2) Naloxone amp (5) Bacteriostatic NaCl (1) Neo Synephrine (1) Dobutamine Premix (1) DRAWER 3 Needles, Syringes, adapters DRAWER 4 Batteries, Blades, Tubes DRAWER 5 Tubing, Masks, Sterile Water DRAWER 6 IV Solutions, Gauze, Dressings
Dosage Regimens Reopro : 0.125 mcg/kg/min (max 10mcg/min-filter) Amiodarone : 1mg/min x 6hr, then 0.5mg/min x 18hr (Glass after initial dose) Diltiazem : 5 15 mg/hr Dopamine : 1-20 mcg/kg/min (Beware renal dosing) Dobutamine: 2.5 20mcg/kg/min Epinephrine : 1-10mcg/min Integrilin: 2mcg/kg/min Furosemide: 5mg/hr up to 4GM/Hr Inamrinone: 5-10mcg/kg/min Isoproterenol: 1-20mcg/min Norepinephrine: 2-30mcg/min
Dosage Regimens Natrecor: 0.01mcg/kg/min Lidocaine: 1-4mg/min Labetalol: 2-8mg/min Milrinone: 0.375-0.75mcg/kg/min to max 1.13mg/kg/24Hr Nitroglycerin: 5-200mcg/min(non-PVC Tubing, Glass) Nitroprusside: 0.3-10 mcg/kg/min (PFL) Norepinepehrine: 2-30mcg/min (PFL) Phenylephrine: 100-180 mcg/min (PFL) Vasopressin: 0.01-0.04 units/min Procainamide: 2-6 mg/min
Information Required Dosing Patient approximate weight Dose needed Dosing regimen Final concentration IV pump setting in ml/hr Quick and accurate dosing calculations are cruicial Become comfortable calculating dosages
Conclusion Pharmacists play an important role in Code Blue Work as a team Closed-loop communication Provides confirmation Double check medications Request clarification when needed