Cardiopulmonary Resuscitation

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1 Cardiopulmonary Resuscitation CEm Introduction Cardiopulmonary resuscitation (CPR) can be attempted on any individual in whom cardiac or respiratory function ceases. Such events are inevitable as part of dying and thus, CPR can theoretically be used on every individual prior to death. It is therefore essential to identify patients for whom cardiopulmonary arrest represents a terminal event in their illness and in whom CPR is inappropriate. It is also essential to identify those patients who do not want CPR to be attempted and who completely refuse it. Definition Cardiac Arrest: is the sudden and complete loss of cardiac function. It may be due to ventricular fibrillation, asystole or electromechanical dissociation. Respiratory arrest: is the sudden and complete cessation or inefficient of breathing. Cardio pulmonary Resuscitation: refers to the prompt diagnosis and treatment that is essential in the event of a cardiac or respiratory arrest to prevent irreversible brain damage and death. Irreversible brain damage will occur unless some circulation of oxygenated blood can be achieved within two or three minutes. Basic Life Support (BLS): comprises the elements: initial assessment, announcing Blue or White code, then airway maintenance, expired air ventilation (rescue breathing), and chest compression. Basic life support implies that no equipment is employed; where a simple airway or facemask for mouth to mouth ventilation is used. In charge physician: The last physician who is the leader of the team responsible for the patient Page of Hospital Director: Dr Parviz Afshar Date: Version:

2 Team Leader: The leader of the team is a person with the following ranking and he/she is in charge:. Nurse before arriving the GP. GP. Anesthesiologist 4. Cardiologist (pediatrician in neonate and children) Cardiologist has the highest priority and the nurse has the lowest. In the presence of cardiologist he/she is the leader of the team and in charge of the CPR process irrespective of he/she is the treating physician or not. CPR teams: there are three different teams for the CPR in Iranian Hospital.. Adult CPR. Neonate & Children CPR. Operation room CPR Team member: are the members of each CPR team for children, adult and in operation room. Procedure. Announcing for resuscitation should followed by diagram in Appendix CEm. The technical process for CPR in Iranian Hospital should be done based on the latest American Heart Association (AHA) guidelines.. All nursing personnel will be currently BLS and all nurses in wards are ACLS certified and will attend CPR recertifica on workshop every two () years. 4. Nursing personnel currently certified in BLS/ACLS may initiate CPR when appropriate. 5. Emergency crash cart, supplies and defibrillator must be checked at the beginning of every shift for completeness and function. Page of Hospital Director: Dr Parviz Afshar Date: Version:

3 6. A cardiopulmonary resuscitation report must be check and completed by the recorder (nurse) following each arrest immediately. In charge physician (Leader of the team) should check the report and add additional note to this report before signature. 7. Documentation before, during and after CPR is very important and should be followed as follow: 7.. Throughout cardiopulmonary resuscitation measures, an assigned nurse will document: 7... Medications being administered, with dosage and time 7... Defibrillation, with amount of watts discharged 7... Other procedures being performed (i.e., intubation, arterial blood gases by anesthesiologist, cutdown) Patient's response (i.e., state of consciousness, respiration, pulse, cardiac rhythm, blood pressure, skin color) Name of the person who present in CPR team and time of their arrival 7.. Record on Nurses Notes: 7... Patient's condition and/or activities prior to arrest 7... Time of arrest 7... Time of start and end of CPR Patient reaction to all measures given Heart action, if any, including samples of tracings Nurse's signature 7.. Cardiopulmonary Resuscitation Report: 7... Cardiopulmonary Resuscitation Report form is to be filled out by the register nurse and physician, immediately following an arrest. Report will be distributed as follows: 7... Original in patient s medical record 7... One copy sent to medical director Page of Hospital Director: Dr Parviz Afshar Date: Version:

4 7... One copy to Pharmacy. At the same time request for medicine which used during CPR to refill crash code 8. Staffs that are expected to be competent in undertaking Basic Life Support will be provided with training to a recognized international standard at induction and biennial up dating. Those staffs who could involve in children care through the course of their practice should also receive training in pediatric life support. 9. A full record must be made in the medical and nursing notes immediately following the resuscitation attempt. 0. For announcing the CPR request every staff will call the 700 and inform them about the adult or child CPR and the place and from the phone center they should use the color codes based on code in Emergency Paging Codes, AEn6, policy and procedure.. The phone center MUST document the name of the person who informed them and the exact time of her/his call and her/his request. They should use hospital paging system based on Emergency Paging Codes, AEn6, policy and procedure and after that inform the other members of the team who are out of the range of paging system by their phone. The name of these persons will be informed by the supervisor in the beginning of each shift to phone center.. The aging classification of the patient, by their file or their appearance, for COLOR CODE are:.. Under month is neonate.. Equal or under years old consider as child.. More than years old consider as adult. Team members for adult CPR:.. Cardiologist.. Anesthesiologist specialist.. GP (ER Ward).4. Treating physician (in case of inpatient or previously admitted patient).5. Supervisor Page 4 of Hospital Director: Dr Parviz Afshar Date: Version:

5 .6. CCU in charge nurse.7. ICU in charge nurse.8. ER in charge nurse.9. Ward in charge nurse (in ER, CCU, ICU cases the second nurse).0. Anesthesiologist technician 4. Team members for Neonate & Children CPR 4.. Pediatrician or neonatologist 4.. Anesthesiologist specialist 4.. GP (ER Ward) 4.4. Treating physician (in case of inpatient or previously admitted patient) 4.5. Supervisor 4.6. ER in charge nurse 4.7. In charge nurse of nursery 4.8. In charge nurse of pediatric ward 4.9. Anesthesiologist technician 4.0. Ward in charge nurse (in ER, pediatric and nursery ward cases the second ER nurse) 5. Duties of team members: 5.. Team leader, leading the team 5.. Supervisor, coordinator 5.. CCU in charge nurse (In charge nurse of nursery), in charge of medicine and lab 5.4. ICU in charge nurse (In charge nurse of pediatric ward), second in charge of monitoring and DC shock 5.5. ER in charge nurse, chest compression. Page 5 of Hospital Director: Dr Parviz Afshar Date: Version:

6 5.6. Ward nurse (in ER cases the second ER nurse), recording the exact time of all activities like arrival of team members, medication times and time and power of CD shock and exact time of dead Anesthesiologist technician, patient breathing. 6. The position of each members of team MUST be arranged by head of nursing department for each shift and it MUST check by supervisor just at the beginning of each shift. 7. Supervisor MUST contact all team members at the beginning of each shift to be sure all team members available in the hospital and ready for code. 8. With coordination of supervisor the position of team members could be changed (especially for the cardiac massage and breathing in prolong CPR). 9. After the hemodynamic situation of the patient being stable the cardiologist will decide to transfer patient to ICU or CCU and he/she will decide to transfer patient to other services based on underlying disease or main problem or he/she will continue to take care of the patients. He/she must write his/her idea about this transfer in the patient s file. The same cardiologist will follow the cardiovascular problem of the patient even after transfer to the other services based on Inpa ents Interdisciplinary Medical Consulta ons (CMe4). 0. The cardiologist will announce the termination of CPR and ward nurse should document the exact time and date and loudly announce it to the other team members.. Death on arrival (DOA):.. In the case of death on arrival CPR should start and continue for 5 minutes and if the second assessment confirms the DOA the CPR will con nue for 0 minutes but no need to call team members who are out of hospital.. Issuing of death certificate should be under the rules and regulation of UAE.. Death certificate: For DOA and other patients who arrive in ER or under observation in ER the death certificate should be issued by the team leader who declares death of the patient. It could be GP or any specialist. 4. For inpatients even if the cardiologist is the leader of the team, the treating physician who admitted the patient should issue the death certificate. Page 6 of Hospital Director: Dr Parviz Afshar Date: Version:

7 5. In cases which multidisciplinary team involves in treatment process, the leader of that team will issue the death certificate. (Like general surgeon in multiple trauma cases). In ambiguous situation the medical director of hospital makes decision 6. The places for crash code trolleys in Iranian Hospital are attached (Appendix CEm ). 7. The specification of crash codes trolleys comes is attached (Appendix CEm ). 8. After each CPR, supervisor will arrange a meeting during one week after the CPR date, to discuss about the CPR and check for weakness or any required improvement in the team or equipment. The MOM of this meeting should be kept in the documentation of ER team. Page 7 of Hospital Director: Dr Parviz Afshar Date: Version:

8 Appendix CEm Page 8 of Hospital Director: Dr Parviz Afshar Date: Version:

9 Appendix CEm ADULT EMERGENCY MILCARE CART Drawer Adult Medications Phenytoin 50 Indral mg Aminophilline 50 mg Adenosine 6mg/ml vial Amiodarone 50mg/ml ampule Epinephrine mg/ml Magnesium Sulfate 50% Nitroprusside 50mg vial Norepinephrine Procainamide Verapamil 40 mg Phenobarbital 65 Protamin sulfate 50 mg TNG 5 mg Lasix 0 mg Ephedrine 50 mg Hydrocor son 00 mg Isoprel mg Digixin 0.5 mg Dexamethazon 8 mg Diazoxide 00 mg / 0 Diazepam 0 mg Sodium chloride 0.9% Dopamine vials 00mg Dobutamine vials 50mg Atropine 0.5mg Gluconate Calcium 0% Dextrose 50% 50ml syringe Lidocaine % Sodium Bicarbonate meq/ml Page 9 of Hospital Director: Dr Parviz Afshar Date: Version:

10 Drawer Breathing and Airway (large drawer) Ambu bag with mask (can attach to cart if bottom shelf needed) O Nasal cannula O Flow meter with adapter (xmas tree) Oral airways: one each -- 0 mm, 9 mm, 8 mm Intubation tray (laryngoscope handle, straight and curved blade, 0 cc syringe, lubricant) Stylet C cell batteries Laryngoscope light bulbs Padded tongue blades Roll adhesive tape or pre-made ET tube holder Skin prep wipes or benzoin pr. exam gloves Yankauer suction catheter #4 suction catheters Salem sump tube, 6 Fr Lubricant Straight connector Toomey syringe Endotracheal tubes, each size: 6.0, 7.0, 7.5, 8.0, 8.5, 9.0 Tracheostomy tubes, each size: Adult Shiley Blue Box: #4, #6, #8 Inner Cannulas, size each: Shiley #4, #6, #8 (Portex is discontinued unless special order for a patient) End-tidal CO Detector Page 0 of Hospital Director: Dr Parviz Afshar Date: Version:

11 Drawer Circulation: IV supplies (small drawer) Angiocaths, each: 4G, 6G, 8G, 0G, G Way stopcocks Blood tubes: SST, lt. blue, lavender ABG kits, heparinized aspirators Needles: 6 8G, 6 0G, 6 G, 5G Alcohol swabs Tape Bu erflies, each: G, G, 5G IV start kits Syringes: TB, 6 cc, 6 5cc, 6 0cc, 0cc, 50cc Non coring Huber Needles each: ga inch, 0ga inch Drawer 4 Circulation: IV solutions and tubing (large drawer) Lactated ringers 000 ml Normal saline 000 ml Normal saline 50 ml D5W 500 ml D5W 50 ml IV Tubing: Macrodrip Microdrip Horizon casse es Page of Hospital Director: Dr Parviz Afshar Date: Version:

12 Extension tubing (needless) Buretrol Blood pump tubing Armboards: long, short Drawer 5 Cardiac, Chest Procedures (large drawer) 6 EKG electrodes Restraints Sterile gloves, pair each size: small, medium, and large Masks with face shields or masks and eye protec on Scalpels with blades Dressings: 4x4 0 pk, 4X4, 4X4 drain sponge, X Betadine solution Sutures, each: 000 silk with needle, 0 silk with needle Cardiac needle 0 G Sterile towels Petroleum gauze Cutdown tray lumen CVP catheter kit Chest tubes, each: 8 Fr, Fr Page of Hospital Director: Dr Parviz Afshar Date: Version:

13 PEDIATRIC EMERGENCY MILCARE CART Drawer Pediatric Medications Adenosine 6mg/ml vials Calcium Chloride 0% (gm/0ml) vials Calcium Gluconate 0% (998mg/0ml) vials Diphenhydramine 50mg/ml vial Dobutamine 50mg/0ml vial Dopamine 00mg/5ml vial Epinephrine mg/ml ampules Epinephrine mg/ml 0ml MDV Flumazenil 0.5mg/5ml vial Methylprednisolone 40mg vial Naloxone 0.0mg/ml ml ampule Naloxone 0.4mg/ml ml ampule Norepinephrine 4mg/4ml ampule Sodium Chloride 0.9% vial 0ml flush SDV Atropine 0.5mg/5ml syringe Calcium Chloride gm/0ml syringe Dextrose 50% 50ml syringes Epinephrine mg/0ml syringes Lidocaine 00mg/5ml syringe Sodium Bicarbonate meq/ml 0ml syringe Sodium Bicarbonate meq/ml 50ml syringe 4 Drawer Breathing and Airway (small drawer) Pedi paddles for those units using Lifepack 6 Endotracheal tubes each:.5,.0,.5, 4.0, 4.5, 5.0, 5.5, and 6.0 Endotracheal tube each uncuffed: 6.5 Endotracheal tube each cuffed: 7.0, 7.5, 8.0, and 8.5 peds intuba on tray adult intuba on tray Page of Hospital Director: Dr Parviz Afshar Date: Version:

14 peds stylet adult stylet Yankauer roll tape C ba eries Laryngoscope Replacement Bulbs Magill Forceps can stomahesive spray Drawer Airway/Breathing (large drawer) Tracheostomy tubes (Shiley) each size: NEO:.0,.5 each size: PED:.5, 4.0, 4.5, 5.0, 5.5 Adult & Pedi AMBU bags: each Oxygen flowmeter Suc on Catheters: each size: 6 Fr., 8 Fr., 0 Fr., 4 Fr. Yankauer suc on Nasal airways each size: 6mm, 8.5mm Oral airways each size: 5cm, 6cm, 7cm, 8cm 4 K Y Gel packets Bu erfly (needle aspira on) kits () kit includes each: Ga. Bu erfly Stopcock 0 cc syringe Betadine swab Page 4 of Hospital Director: Dr Parviz Afshar Date: Version:

15 Drawer 4 Circulation (small drawer) Intraosseous (I.O.) needles Angiocaths each size: 4 Ga., Ga., 0 Ga., 8 Ga. T connectors (old style) Horizon tubing Buretrol I.V. filter 60 cc syringes Extension tubing each size: 0 inch and 60 inch packets X gauze packets 4X4 gauze Other I.V. start items: stopcock, clave, tourniquet, alcohol swabs, betadine Tegaderm inch tape Assorted syringes 4 each: 0cc, 5cc, cc, cc Non coring Huber Needles each size: ga ¾ inch, 0 ga inch Drawer 5 Circulation/Special (small drawer) I.V.Fluids each: Lactated ringer s 000cc, Normal Saline 000cc Nasogastric Tubes each size: 0fr., fr., 4fr. Toomey syringe Feeding tubes each size: 5 Fr., 8 Fr. (both 4 inch length) 4 Packets K Y gel Flashlight Page 5 of Hospital Director: Dr Parviz Afshar Date: Version:

16 D cell ba eries Special sterile instruments: Wirecu ers Zoll internal paddles ( sizes) Intracardiac needles Drawer 6 Invasive Procedures (large drawer) Cutdown Tray 4 Fr., 8 cm double lumen CVL 5 Fr., 8 cm double lumen CVL Transvenous pacing set up Betadine bottle Packages of sterile O.R. towels Sterile gloves each size: 6, 6/, 7, 7/, 8 Blades each size: #0, #, #5 Silk suture each size:.0, 4.0 Chest tube clamps Bottom shelf Large Trays PICU Cardiac arrest trays Rib Spreaders: large, small Zoll cable (sterile) for internal paddles Suction set up Temporary pacing wires Page 6 of Hospital Director: Dr Parviz Afshar Date: Version:

17 Top of Cart Zoll paste Multifunction cable EKG cable Pacer cable Multi function pads each size: adult & pedi (IMPERATIVE: check expira on dates) packs EKG leads (NOT the prewired pediatric leads) O sat (SpO) probe Rolls Zoll paper Oxygen wrench Page 7 of Hospital Director: Dr Parviz Afshar Date: Version:

18 NEWBORN INTENSIVE CARE MILCARE CART Drawer Neonatal Medications Adenosine 6mg/ml vials Calcium Chloride 0% (gm/0ml) vials Calcium Gluconate 0% (998mg/0ml) vials Diphenhydramine 50mg/ml vial Dobutamine 50mg/0ml vial Dopamine 00mg/5ml vial Epinephrine mg/ml ampules Epinephrine mg/ml 0ml MDV Flumazenil 0.5mg/5ml vial Methylprednisolone 40mg vial Naloxone 0.0mg/ml ml ampule Naloxone 0.4mg/ml ml ampule Norepinephrine 4mg/4ml ampule Sodium Chloride 0.9% vial 0ml flush SDV Atropine 0.5mg/5ml syringe Calcium Chloride gm/0ml syringe Dextrose 50% 50ml syringes Epinephrine mg/0ml syringes Lidocaine 00mg/5ml syringe Sodium Bicarbonate meq/ml 0ml syringe Sodium Bicarbonate meq/ml 50ml syringe 4 Drawer Respiratory, Airway (small drawer) Endotracheal Tubes 4 each:.5,.0,.5, 4.0, and 4.5 Style e Oral Airways each: infant, neonatal CPAP mask: neonate, infant, pediatric CPAP bag and manometer each Page 8 of Hospital Director: Dr Parviz Afshar Date: Version:

19 4 Laryngoscope bulbs Feeding tube 8 French Feeding tube 5 French Drawer Circulation, Umbilical Catheter Supplies (small drawer) Umbilical Artery Catheters each:.5, 5.0, and 8.0 Sutures each: 4 0 silk, 0 silk, 4 0 chromic, 0 chromic, 5 0 prolene Way stopcocks umbilical tape Drawer 4 Circulation, IV Supplies (small drawer) Syringes: 0 TB, 5 x cc, 5 x 5cc, 5 x 0cc, 0 x 0cc, 4 x 60cc Bu erfly Needles: 8 x 5G /4, 4 x G /4 Angiocaths 4 each: 4G 5/8, G, 0G /4, 8G /4, 6G, 4G Needles: 8 x 5G, 8 x G /, 8 x 0G /, 8 x 8G /, 8 x 9G filter needle 5 Extension Set (T Connectors) Arm boards short Betadine swabs Alcohol wipes roll cloth tape Intraosseous needle way stopcocks Hospital Director: Dr Parviz Afshar Page 9 of Date: Version:

20 I.V. Fluids each: D5W 00 cc, NaCl 00cc Drawer 5 Breathing and Airway (large drawer) Gloves each: 6 /, 7, 8 4X4=s, X=s Betadine Heimlich valve Sterile water 4 oz. 4 Transparent dressing/bioclusive Roll adhesive tape Mini-vol. extension set Straight connectors Y- Connectors Thoracic Catheters: x Fr, 4 x 0 Fr, 4 x 8 Fr Petroleum Gauze Suture removal kit Bottom Shelf Specialized Procedure Trays UAC Neonatal thoracotomy Pedi Pack Peds Cutdown Neonatal tray Page 0 of Hospital Director: Dr Parviz Afshar Date: Version:

21 Water Seal chest drain Sterile Gowns Sterile Towels Top of Cart Zoll Paste Multifunction Cable EKG Cable Pacer Cable Pedi Mul func on Pads (IMPERATIVE Check expiration date) Zoll Paper Oxygen tank wrench (On E cylinder) Page of Hospital Director: Dr Parviz Afshar Date: Version:

22 OPTIONAL PEDIATRIC/NEWBORN SUPPLIES FOR ADULT AREAS Pediatric Ambu bag Pediatric intubation tray Pediatric stylet Nasal cannulas: infant and peds Non breather mask Oral airways: child, infant Endotracheal tubes, each:.0,.5, 4.0, 4.5, 5.0 Suc on catheters: 4 Fr. 0 Fr, 8 Fr, 6Fr. Feeding tubes: x 8 Fr, x 5 Fr Syringes: 4 x TB, x 0cc Intraosseous needles 5G 4 Angiocaths: x G, x 4G Bulb Syringe blankets Cord Clamp Page of Hospital Director: Dr Parviz Afshar Date: Version:

23 Appendix CEm Table of Crash Card Trolleys in Iranian Hospital Labor Female ward Pediatrics ward ICU ER OR Endoscopy Nursery Male ward Medical ward CCU Cath lab Exercise test Poly clinic Radilogy Page of Hospital Director: Dr Parviz Afshar Date: Version:

Commercial Ambulance Services. Annual Renewal & Inspection Application Packet NEONATAL SERVICE INFORMATION

Commercial Ambulance Services. Annual Renewal & Inspection Application Packet NEONATAL SERVICE INFORMATION Maryland Institute for Emergency Medical Services Systems Office of Commercial Ambulance Licensing & Regulation 653 West Pratt Street Baltimore, MD 21201-1536 Office: (410) 706-8511 - Fax: (410) 706-8552