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Rapid Response Guide

RAPID

Flow of a rapid response:

  1. Introduce yourself and your role loudly
  2. Stand at the foot of the bed
  3. Eyeball patient quickly – ABC’s, if unresponsive ask if there is a pulse
  4. Intro Timeout
    • Team introductions – roles and names
    • Primary nurse sign out (SBAR: Situation, Background, Assessment, Recommendation)
  5. Interventions
  6. Determine disposition
  7. Debrief with the team
  8. Identify one learning point

Trouble shooting:

  1. Diagnostic pause and shared mental model – helpful once situation has been ongoing or if you feel stuck
    • Review what you are thinking and what interventions have been done
    • Think out loud
    • Ask team: is there anything else?
  2. Closed loop communication
  3. Call for backup if needed – you can always call MICU, hospitalist on call, pharmacy, etc.
  4. If tenuous – assign someone to keep a finger on the pulse
  5. Use the Rapid Response ordersets created by Amanda Tosi

Rapid Response Scenarios

Atrial Fibrillation
  • Irregularly irregular rhythm
  • Narrow complex UNLESS has repolarization abnormality — can see AFib RVR with aberrancy. Compare to prior ECGs to assess for this.  If in doubt, assume wide complex rhythm is not supraventricular.
Assess/mitigate triggers
  • Starling curve — too little or too much fluid
  • ACS
  • Sepsis
  • PE
  • Sympathetic surge (surgery, sepsis, hyperthyroidism)
  • Electrolyte abnormalities
Acute therapies for Afib with RVR
  • IV metoprolol 5 mg up to 3x — contraindicated in severe lung disease
  • IV diltiazem 10 mg up to 3x — contraindicated in HFrEF
  • IC amiodarone 150mg over 10 minutes, followed by drip. Can take some time to work. Side effects include acute hypotension. Can cause stroke if converts to sinus rhythm and patient not anticoagulated.
  • Esmolol drip (0.5 mg/kg IV over 1 minute load, then 0.05 mg/kg/min)— has to be reconstituted by pharmacy, can only give in certain hospital units.
  • Synchronized cardioversion (120-200 Joules) — if unstable or refractory to above. Can consult cardiology to help with this, but if unstable should not delay. Consider versed/morphine prior to administering if still responsive, should not delay in an emergent situation.
Acute Hypoxemia
Underlying causes of acute hypoxemia
  • Volume overload
  • Acute flash pulmonary edema (hypertensive urgency, ACS, valvular disease)
  • PE
  • Aspiration
  • Pneumothorax
  • Pneumonia (typically more subacute)
  • Pleural effusion (typically more subacute)
  • Respiratory depression (narcotic overdose, acute stroke, seizure)
Acute therapies for flash pulmonary edema 2/2 hypertensive emergency
  • Nitroglycerin paste (0.5 inch)
  • Nitroglycerin drip (starting dose 5 mcg/min) — typically want an arterial line in place
  • Furosemide, bumetanide, torsemide — depends on diuretic tolerance of patient and renal function
  • CRRT/HD
Afterload reduction: arterial dilation
  • Labetalol (20mg IV)
  • Hydralazine (10mg IV) — least preferred, less predictable, can have significant hypotension leading to stroke or acute MI, especially with carotid stenosis, CAD
  • Nitroprusside drop (starting dose: 0.25-0.5 mcg/kg/min) — typically want an arterial line in place
Oxygen Delivery Methods