The 25th Asia Pacific Symposium

on Critical Care and Emergency Medicine 2018

SCA - CODE BLUE WORKSHOP

INTRODUCTION
Tri Wahyu Murni
Depart of Cardio Thoracic Surgeon of Hasan Sadikin Hospital
School of Medicine of Pajajaran University Bandung
Discovery Kartika Plaza Hotel – Kuta – Bali
1 Agustus 2018 1
 Introduction
- Sudden Cardiac arrest (SCA) is a serious community health problem
and now is a third leading cause of death.

- Prevalence of SCA:
- Indonesia nearly 300.000 – 350.000/ year with survival rate 9.5% -12 %.
- Japan more than 100.000/ cases/ year with survival rate 20%.
- Singapore with more than 1.000 cases/ year with surival rate 2,7%.
- USA more than 350.000/ year with mortality rate 8%-40%.

- Out of hospital sudden cardiac arrest about 50% of all cardiovascular

death.
- Incidence of cardiac arrest of out of hospital about 20-140/ 100.000
people in United states, survival ranges from 2%-11%

Survival from cardiac arrest not only depend on early

recognition and immediate response but also
depend on of quality CPR delivered.
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 What is SCA

- Sudden Cardiac arrest (SCA) is a sudden stop the effective blood

flow due to failure or the condition in which the heart suddenly and
unexpectedly stop beating.
- CA refers to abrupt hemodynamic collaps due to rapid degradation.

SCA occurs suddenly and often without warning. It is triggered

by an electrical malfunction in the heart that causes in irreguler
heart beat.

- With is pumping action disrupted. SCA can occur after a heart

attack or during recovery. Most heart attack do not lead to sudden
cardiac arrest, but when SCA occurs, heart attack is a common
cause.
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 What does the science say ?
- The reports data about 30% - 40% the fatality due to Ventricular
fibrilation (VF) and pulseless ventricular tachycardia (VT) with low
survival rate 1-2%.

- According USA Occupational Safety and Health Adiministration (OSHA),13%

off all fatalities in workplace from SCA

- Out of Hospital cardiac arrest actually is treatable and outcomes can be

improved if in communities equiped and trained about CPR and how to use
AED (Automated External Defibrillators).

- Resuscitation Outcome Consortium (ROC) out of hospital cardiac

arrest victims had a increase chance of survival after the first shock
delivered using an AED.
- These CPR component its an important to ensure the contribution the
blood flow and adequate oxygenation in myocard and brain.

- Monitoring the patient; survival after CPR is depend on adequate myocardial

oxygenation and blood flow during CPR.
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 The chain of survival
- The chain of survival with the good outcome in Emergency medical services
(EMS) its depend on a life saving procedures of out of hospital intervention.

- The chain of surival depend on:

1. Early access,
2. Early CPR (time to CPR, Community CPR training, Quality of CPR),
3. Early defibrillation (time to defibrillation, interaction of CPR and
defibrillation),
4. Early advanced care (type of EMS system),
5. Early post resuscitation care (hypothermia).

- Why the outcome of survival for SCA its to low, ussually treatment its too late
and ineffective.
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Chain of survival 1. Immediate recognition and activation
of the emergency response system
2. Early CPR with an emphasis on chest
compressions
3. Rapid defibrillation,
4. Effective advanced life support and
5. Integrated post-cardiac arrest care.

1 2 3 4 5

April_Surabaya
BLS ALS POST C.A
CARE
 Out-Of-Hospital Cardiac Arrest
− CPR is indicated for any person who is unresponsive without
breathing or who is only breathing in occassional agonal gaps,
as it is most likely that they are in cardiac arrest.
− CPR may succeed in inducing a heart rhythm which may be
shockable.

− CPR is generally continued until the patient has a return os

spontaneous circulation or is decleared dead.

If a person still has a pulse , but is not breathing (respiratory

arrest) artificial respirations may be more appropriate.

CPR guide lines recommended that the lay person should not be
instructed to check the pulse

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 Charaecteristic of SCA

− SCA can occur after a heart attack or during recovery.

− Most heart attack do not lead to sudden cardiac arrest, but when
SCA occurs, heart attack is a common cause.

− WHO criteria classify deaths within 24 hours of the onset of

symptoms as “sudden”.

− In the overwhelming majority of cases, sudden death is the results of

a cardiovascular abnormality.

− Cardiac arrest divide as:

− Shocakable and
− Non Shockable,
the different depend on cardiac rhytm on electrocardiogram
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 Updated CPR guidelines
− The AHA & International liason commitee on resuscitation updated CPR
guidelines.
− The importance of high quality CPR (sufficient rate and depth without
excessivelly ventilating).

− The order of interventions was change for all groups except newborn.
(ABC-CAB).
− An exception to this recommendation is for those who are believed to be
in respiratory arrest (drowning).
− AHA guidelines 2010 define a Basic Life support (BLS) is the foundation for
saving lives following cardiac arrest.

Fundamental aspects of adults BLS include

1. Recognition of SCA and activation of the emergency
response system,
2. Early performance of high quality CPR
3. Rapid defibrillation when apopriate.
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 Consensus Guidelines

The major contributor for ILCOR

Resuscitation Council of
Southern Africa (RCSA)

Inter American Heart Foundation

Resuscitation Council of ASIA
(IAHF) (RCA) 11
 ERC – AHA - ILCOR
ERC Guidelines 2015
HEAD TILT – CHIN LIFT
AHA Guidelines 2015
Since 2010 The 2010 Guidelines
were most notable for the
re-orientation of the universal
sequence from A-B-C
(Airway, Breathing, Compressions)
to C-A-B
(Compressions, Airway, Breathing)
to minimize time to initiation of
chest compressions.
"Look, Listen, and Feel" is no
longer recommended
ERC 2015 = ILCOR 2015
"Look, Listen, and Feel"
is recommended 12
April_Surabaya
ERC Guidelines 2015

HEAD TILT – CHIN LIFT

LOOK – LISTEN – FEEL

ILCOR 2010
3 – 5 seconds

April_Surabaya 13
 2015 - The new guide line
− A universal compression to ventilaton ratio of 30:2 is recommended,
− Children, if at 2 trained rescuers are present a ratio of 15:2 is prefered.
− Newborn rate of 3:1 is recommended unless a cardiac cause is known,in
which care a 15:2 ratio is reasonable

− Recommended compression depth: adult 5 cm (2 inches) and children

4 cm (1,5 inches).

− Pulse check has been removed for lay providers and should not be
performed more than 10’ by health care providers.

Compression only without artificial respiration, it is recommended as the

method of choice for the untrained rescuer, as it easier to perform.
In adult pre hospital cardiac arrest with compression only has a higher
succes rate than standard CPR.

The exception are cases of drowning, drug overdose and arrest in

children.
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 Adjunct devices
− These device can be,

1. Timing devices (asisst the corect rate, timing reminders for

performing compressions, changing operator and breathing),
2. Assist the rescuers to achieve the correct technique,
3. Over all adjunct device improve the CPR technique.

− CPR is only effective if commenced within 6 minutes after

the blood flow stop (after 6 minute the cells unable to
survive with reintroduction of oxygen in a traditional
resuscitation).
− Research 79,4% survive with new method compare 15% with
traditional method
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 In hospital Cardiac Arrest
Initial mangement of in hospital cardiac arrest as
follow :

1.Ensure personal safety such as used gloves as soon as

possible or other personal protective equipment (PPE).
2. Check the patient for a response
(collapse, unconscious or responsive).
a). If the patient responds, required medical assessment
(using the ABCDE approach), calling the resuscitation
team or Emergecy medical team
b). If the patient not respond ,shout for help, open & clear
airway, look – listen - feel to determine is breathing
normally and assess the carotid pulse at the same time,
heck the skin colour.
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 .....................In hospital Cardiac Arrest
3. a). if there are signs of life or a pulse, required urgent
medical assessment.
b). if there are no signs of life or no pulse, start CPR, call
the resuscitation team (code blue team), use whatever
equipment available immediately for airway and
ventilation, add suplementar oxygen (avoid mouth to
mouth ventilation in clinical setting).
c). Tracheal intubation by competent and experienced
personal, used the defibrilator and rapid assessemnt the
heart rhytm about every 2 minute, use the protocol and
communcation tool for handover.
d). if the patient is not breathing and has a pulse (respiratory
arrest), ventilate the patient and check a pulse every 10
breath, the diagnose can be made
.
5. If the patient has monitored and witnessed cardiac arrest,
rapidly check for rhytm change, use ALS algorhytm.
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 What is a code blue ?
− CODE BLUE, is one of emergency code in hospital (Hospital
emergency code), thats code use to indicate patient requiring
immediate resuscitation (emergency code messages to be
announced).

Hospital and staff action in hospital cardiac arrest depend on

1. The location (out patient department, ward, non clinical area such as
car park),
2. Skill staff who respond,
3. Number of responders (day and night) and equipment available
(including the defibrilator).

Its important things to manage the Code Blue

1. to diagnose of cardiac arrest,
2. High quality of CPR,
3. Defibrilation strategy
4. Hospital reviewed or audited.
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 Update Code Blue Guideline

The guidelines 2015 does not include any major changes in core in
hospitalresuscitation intervention since the previous guidelines
published in 2010.

The key change 2010∞(2015) are:

1. Continuing use of rapid response systems for care deteorating

patient
and prevention of in-hospital cardiac arrest,
1. Continued on providing minimally interrupted high quality chest
compression throughout CPR,
2. Chest compression are paused briefly only to enable specific
inteventions.
3. This include minimising interruptions in chest compressions to
attempt defibrillation.
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Practice to stay prepared.
The “beautiful” chance
suddenly appears in front
of you

No time to think twice,

just do it.... or
the chance will be gone 20