Extremely BAD night... - page 2

So, someone please tell me how to get past this last night shift, because I'm not sure how it's possible right now... 1st patient of the night- codes and dies.. Normally would make for a rough... Read More

  1. Visit  prep8611 profile page
    1
    Quote from Esme12
    That is a bad night....but I have a couple of questions....epi for a reaction is usually SQ.....0.1 is 0.1cc of epinepherine of a 1:1000 concentration makes the epi dose.... 0.1cc/0.1mg. 0.1mg IVP will not kill someone...per se. Could it be that the patient died from anaphalyxis and the MD needed to be more aggressive with steroids/antihistamines/histaminne blockers of that the patient just died of anaphalyxis?
    My guess is the nurse gave 1mg IV which is standard packaging for a code.
    turnforthenurseRN likes this.
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  3. Visit  Roseyposey profile page
    0
    Quote from prep8611
    My guess is the nurse gave 1mg IV which is standard packaging for a code.
    I was wondering the same thing.
  4. Visit  XmasShopperRN profile page
    2
    Quote from Esme12
    That is a bad night....but I have a couple of questions....epi for a reaction is usually SQ.....0.1 is 0.1cc of epinepherine of a 1:1000 concentration makes the epi dose.... 0.1cc/0.1mg. 0.1mg IVP will not kill someone...per se. Could it be that the patient died from anaphalyxis and the MD needed to be more aggressive with steroids/antihistamines/histaminne blockers of that the patient just died of anaphalyxis?
    I believe when administering epi IVP, the appropriate concentration is 1:10000. With SQ epi for allergic reactions, the standard adult dose is 0.3cc of 1:1000. But if the reaction is severe enough, IV is the preferred route, which would be 0.1cc of 1:10000. So if the MD ordered 0.1 of epi, he intended for IV. Sounds like the nurse used the incorrect epi concentration?
    Marshall1 and GrnTea like this.
  5. Visit  brownbook profile page
    2
    I know this is not the original point. It was a horrible shift.


    However Esme nailed it again. It did not sound like 0.1 epi would kill somebody? Scared me as I was thinking....yikes I can see myself giving that dose IV if a doctor ordered it! In a crisis it would take me 20 minutes to figure out Esme's calculations. Would 1 mg "standard packaging for a code" kill a patient? If it is standard code packaging it doesn't make sense that they would package a dose that would kill someone.

    Luckily for me and the general public I have not been in a code in over 13 years. I take ACLS per protocol every two years but as I walk out the door I immediately forget over half of what I learned!
    prnqday and anotherone like this.
  6. Visit  J.A.B.,RN profile page
    2
    Let me just tell you that I am sorry you had to witness the death of a child along with two adults. Sexual assualt of a child is more common than you would think and all I can do is pray for God's intervention in the lives of those children who are abused by some sick and twisted adult. Hugs to you..
    Marshall1 and anotherone like this.
  7. Visit  jt1o profile page
    3
    When I think of epinephrine in the emergency situation, I immediately wonder: anaphylactic or cardiac?

    In the case of anaphylaxis, epinephrine is usually given IM first, with the dose being 0.3-0.5 mg. It can be repeated every 5-15 mins for a total of 3 or 4 doses. The key to note is that the concentration is 1:1,000.

    If the pt. doesn’t respond to the IM epinephrine, then 0.1 mg IV epi can be used, but the concentration is at 1:10,000., and given slowly over 5- 10 minutes.

    I think the nurse may have thought the 0.1mg epinephrine was concentrated at 1:10,000, which if given slowly over 5-10 minutes would have likely been okay.

    The nurse may have thought the 0.1mg epinephrine was concentrated at the appropriate amount for IV.

    In ACLS, epinephrine is also concentrated at 1:10,000 and the dose is 1 mg in adults, given IV push.

    When giving a drip of IV epinephrine, it needs to be diluted with either D5W or NS. Different institutions have different protocols for IV drip epinephrine. The infusion rate depends on the pt.

    No comment on subQ epinephrine (going out of style)

    Great question to ask, btw. If you can answer the following questions correctly, you got the general points down:
    1. What is the concentration for IM epinephrine?
    2. What is the concentration for an infusion of epinephrine AND over what amount of time should it be administered?

    JCAHO doesn’t like using c.c. as it can be mistaken for “U” if poorly written.
    pseudomonas, Marshall1, and prnqday like this.
  8. Visit  VivaLasViejas profile page
    3
    Well, I've had some lousy shifts in 18 years in healthcare, but never one that even came close to yours, OP. You have my sympathies. And if you can keep going back to work after a night like that, you're a better nurse than I am!
  9. Visit  Esme12 profile page
    1
    Quote from jt1o
    When I think of epinephrine in the emergency situation, I immediately wonder: anaphylactic or cardiac?

    In the case of anaphylaxis, epinephrine is usually given IM first, with the dose being 0.3-0.5 mg. It can be repeated every 5-15 mins for a total of 3 or 4 doses. The key to note is that the concentration is 1:1,000.

    If the pt. doesn’t respond to the IM epinephrine, then 0.1 mg IV epi can be used, but the concentration is at 1:10,000., and given slowly over 5- 10 minutes.

    I think the nurse may have thought the 0.1mg epinephrine was concentrated at 1:10,000, which if given slowly over 5-10 minutes would have likely been okay.

    The nurse may have thought the 0.1mg epinephrine was concentrated at the appropriate amount for IV.

    In ACLS, epinephrine is also concentrated at 1:10,000 and the dose is 1 mg in adults, given IV push.

    When giving a drip of IV epinephrine, it needs to be diluted with either D5W or NS. Different institutions have different protocols for IV drip epinephrine. The infusion rate depends on the pt.

    No comment on subQ epinephrine (going out of style)

    Great question to ask, btw. If you can answer the following questions correctly, you got the general points down:
    1. What is the concentration for IM epinephrine?
    2. What is the concentration for an infusion of epinephrine AND over what amount of time should it be administered?

    JCAHO doesn’t like using c.c. as it can be mistaken for “U” if poorly written.
    Yes...I stand corrected...SQ is falling from favor......again. Anaphylatic shock can cause cardiac arrest......especially in the presence of IV contrast. The point I was drawing attention to is that 0.1.....whether cc/mg/ml may or may not have been the cause of death....that is the incomplete story here.
    1. What is the concentration for IM epinephrine? 1:1000 drawn up in a TB syringe(1cc syringe)
    2. What is the concentration for an infusion of epinephrine AND over what amount of time should it be administered? depending greatly on facility policy.....1-2mg of a 1:1000 concentration in 250cc of a diluent (0.9ns/D5W) titrated to effect and the bag should hang no longer than 24 hours although I have seen no longer then 12 in some studies.
    And after my analytical brain stops...OP that was a horrible night.....go home cry, grieve...talk to your peers on that night, your manager....then you have to let it go......if it really stays with you ask to go to a critical incident debriefing....I used to have them for staff after horrible nights....I must admit...your night rivals a few of mine. ((HUGS))
    Last edit by Esme12 on Mar 31, '13
    uRNmyway likes this.
  10. Visit  netglow profile page
    1
    Here's one Allergist's spin on the epi/contrast shock scenario:

    Epinephrine in the treatment of anaphylaxis
    Esme12 likes this.
  11. Visit  Nurse_ profile page
    2
    I do feel bad for your colleague. However, I find it interesting that she did not clarify the order before giving it. Also, why aren't fluids, other anti-histamines or steroids ordered in conjunction with the Epi?

    Dose for EPI for ANAPHYLACTIC SHOCK (Davis, 2012)
    Subcutaneous,
    Intramuscular (Adults): Anaphylactic reactions/asthma—0.1–0.5 mg (single dose not to exceed 1 mg); may repeat q 10–15 min foranaphylactic shock or q 20 min–4 hr for asthma.
    Intravenous (Adults): Severe anaphylaxis—0.1–0.25 mg q 5–15 min; may be followed by 1–4 mcg/min continuous infusion; cardiopulmonary resuscitation (ACLS guidelines)—1 mg q 3–5 min; bradycardia (ACLS guidelines)—2–10 mcg/min).

    I think that your colleague took the fall in a very bad situation. Though she did lapse on her duties as a nurse, it wasn't just her who let the patient down.

    As for people coding, the chances of people surviving after a code is very slim. By the time you got your hands on those patients, they are already fighting a very hard battle. Learn what you can and move forward... that's all any of us can do.
    Marshall1 and starcandy like this.
  12. Visit  neverbethesame profile page
    1
    Esme12 likes this.
  13. Visit  wannabecnl profile page
    1
    SweetMelissa, I cannot imagine the stress and grief of a shift like this, and I'm praying for you and your colleagues right now. I TOTALLY agree with the suggestions for debriefing with your unit, as well as utilizing EAP or an outside counselor. We had a code in PACU when I was a student, and I don't think there was ever a debrief. Eventually everyone just got past it, but I think it was needed. But even if your unit doesn't offer this (or take your suggestion/request for one ), you need to get someone to listen to you. Write it out in a journal. Write out how it made you feel (helpless, angry, frustrated, scared), what you observed, either as a narrative of the events if you need to or as a list of emotions or thoughts you may have had then or since.

    I'm no psychologist, but journaling helped me after our code, and seeing a counselor has helped me deal with some personal traumatic stuff that was affecting my work. I don't know how long you have been a nurse, but I'm sure you know the odds of another shift like this are pretty low. Sounds like you provide episodic care (ED?), so perhaps you can focus on THIS patient, one at a time. In PACU we have to do the same thing when something goes bad; in a way, it helps because each patient is a chance to start again.

    God bless you and bring you peace.
    SoldierNurse22 likes this.
  14. Visit  SweetMelissaRN profile page
    4
    A full mL of undiluted Epi was given and then flushed with NS. The reaction was not nearly severe enough for it. The doc wanted it SUBQ.

    To everyone who offered their support, I really REALLY appreciate it. My point was not to get a lesson on how to administer Epi and at what dilution ratio, etc. so for those of you who offered words of advice, thank you so much. It means more to me than words can say. I'm taking a week off to get my head straight, we will be debriefing in 2 days. I hope this hasn't killed my love for the ER..


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