Code Blue

Ah, Bravo! Bull! The crowd roars!

The bull goes, he comes,

He comes and strikes again!

Shaking his dart-stabbed neck,

Full of fury, he runs!

The arena is full of blood!

They save themselves, they pass the gates

It is your turn now. Let’s go!

En guard! Let’s go! Let’s go! Ah!

Toreador, en guard! Toreador, Toreador!

And dream away, yes, dream in combat,

That a black eye is watching you,

And that love awaits you,

Toreador, Love awaits you!

Escamillo's Aria from Bizet's Carmen

1805:  A 50 year old man is brought in by EMS with complaints of difficulty breathing and generalized weakness.   He has a history of cardiomyopathy with EF 15%, CHF, ascites, and diabetes.   

1815:  He is placed on the monitor and oxygen is continued at 4L/min via mask.   His initial oxygen saturations are 96%.   An IV is established, a 20 gauge in the right AC, and labs are obtained”  TNI, BNP, Chemistries, CBC, DDimer, PT/INR, PTT,  Liver enzymes.  On the monitor, he is in a AV paced rhythm with a rate in the 80s.   BP 86/72.    Blood sugar 124.

He is lethargic but awakens to verbal stimuli.  While awake, he is anxious, restless.  Follows commands.  PERRL- briskly.   MAEs but has generalized weakness with weak bilateral grips.  Has difficulty moving his arms and is unable to lift his legs.    Respirations are rapid, deep.   Lung sounds diminished in the bases.   Abdomen round, firm in all quadrants.   Peripheral pulses are weak.   Skin cool and dusky. 

1835: Twenty minutes after his arrival, he puts on his call light and complains of increased shortness of breath.   You go to the room to check on him and he not responsive.   His respirations are agonal and his peripheral pulses are absent.   A code blue is called.

1836:  CPR with positive pressure ventilations are initiated.   Placed on defibrillator monitor.  

1837:  CPR with positive pressure ventilations in progress.  Epinephrine 1mg IV given.

CPR rhythm

1840:  CPR followed by a rhythm check.  Fluid bolus with NS.  

CPR rhythm

1841:  Epinephrine 1mg IV given.

1843  Weak femoral pulse present.  Confirmed pulse with doppler.  BP 72/33.  Dopamine infusion started at 5 mcg/kg/min.   Continuing positive pressure ventilations.   Preparing to intubate. 2nd IV site in left AC.  

1847:  Pulse absent.   Resumed CPR

CPR rhythm

1849:  Epinephrine 1mg IV given.   Intubated with 7.5 orally ET tube.   Positive bilateral breath sounds present with symmetrical chest rise.  Positive end tidal CO2 reading.   ET tube secured.

1851: CPR continues.   Positive pressure ventilations via ET tube.  Remains pulseless and apneic. 

1855:  Epinephrine 1mg IV.   

1857:  Lab called with critical serum potassium of 8.0 mEq/L

Sodium Bicarbonate 1 amp given

Calcium chloride 10% 1 amp given

Dextrose 50% 1 amp given

Insulin 10 units IV given

1900:  Epinephrine 1mg IV given.  Bicarbonate repeated, suspected metabolic acidosis.

1904:  CPR continues

1906:  Epinephrine 1mg IV given

1910:  Rhythm check.  

Strong femoral pulse present.   Continuing positive pressure ventilations.   Placed on portable ventilator.   BP 89/46.  Oxygen saturation 98%.  Continuing to monitor.   

1940

Transferred to intensive care.