Extremely BAD night...

Esme12, ASN, BSN, RN · Mar 30, 2013

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 night in itself right? It gets worse...
Later in the shift, 4yr old CPR in progress on the way from EMS.. Broken neck caused by step parent.. Suspected sexual assault (turned into obvious sexual assault)... Didn't make it... HORRIBLE NIGHT... Oh, it gets worse..
My colleague has a pt react to contrast, says "give 0.1 of Epi" says the doctor... Nurse (for some crazy reason!) gave it IV not IM and NOT diluted... Causes pt to have an MI and after 3 hrs of working on them, dies...
How is it possible for a shift to go THAT BAD!!!!! I left work feeling completely defeated... Someone please help me to cope with this bc everything feels surreal right now...

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?

prep8611 · Mar 30, 2013

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.

Roseyposey · Mar 30, 2013

My guess is the nurse gave 1mg IV which is standard packaging for a code.

I was wondering the same thing.

XmasShopperRN, ASN, RN · Mar 30, 2013

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?

brownbook · Mar 30, 2013

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!

EaglesWings21, ASN, RN · Mar 31, 2013

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..

jt1o · Mar 31, 2013

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.

Long Term Care Columnist / Guide · Mar 31, 2013

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!

Esme12, ASN, BSN, RN · Mar 31, 2013

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))

netglow, ASN, RN · Mar 31, 2013

Here's one Allergist's spin on the epi/contrast shock scenario:

Epinephrine in the treatment of anaphylaxis

Nurse_ · Mar 31, 2013

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.

neverbethesame · Mar 31, 2013

http://mitss.org/clinicians_home.html

http://www.info-trauma.org/flash/media-e/mitchellCriticalIncidentStressDebriefing.pdf