Question about a code we had last night

turnforthenurse, MSN, NP · Jan 16, 2012

Doesn't sound "normal" to me. What was the patient's PMH? The frank blood could be coming from GI or the lungs, perhaps some sort of UGIB or varices? or a PE...I'm still relatively new with limited "code experience" but that's what I would think.

Guest2010 · Jan 16, 2012

1) NOT normal

2) What was the pt in rehab from/for?

3) PMH needed

4) cardiac hx? Pulmonary HTN? Varices?

5) was intubation CORRECTLY PLACED?

6) what was outcome?

TheCommuter, BSN, RN · Jan 16, 2012

Is it "normal"?

Frank bleeding is never, never normal.

Kittypower123, BSN, RN · Jan 16, 2012

He has a history of CHF, CVA, CAD, DM, HTN, can't remember everything else. Has a PEG tube with continuous feedings, MRSA in wound in R great toe, lost L great toe (DM), no pulmonary HTN that I know of, no history of PE or MI. In rehab for PT/OT for weakness following illness and treatment of toe wound. As far as intubation, paramedics confirmed placement with a stethoscope. He had a pulse when they took him to the ER, but don't know about after that - hopefully will get an update when I go in this afternoon. I'm really not expecting him to make it. Honestly, probably shouldn't have been full code to begin with.

Guest2010 · Jan 16, 2012

"...As far as intubation, paramedics confirmed placement with a stethoscope. Honestly, probably shouldn't have been full code to begin with."

Confirm placement with steth? Interesting. Must mean they didn't hear ABD sounds.

This is why I advocate for COMPLETED Advance Directives.

nurseprnRN, BSN, RN · Jan 18, 2012

might have had an aberrant blood vessel in the bronchial tree, or might have been a more traumatic intubation than they thought. only times i've ever seen frank blood in lg amounts coming out of a trachea was when a trach tube balloon eroded through a vessel (patient died despite immediate very heroic efforts from the best team in the hospital who just happened to be making rounds outside her icu door when it happened) or with iatrogenic acute te fistula+esophageal varices (h***uva mess, also died)

troop742 · Jan 18, 2012

And how did they confirm placement? Capnography is the standard, even an esophageal detector would have been OK. How many attempts were made to intubate? If the skills were not up to snuff, there could have been trauma to the airway. Another poster had a point, also, were there advanced directives in place?

Pediatric Critical Care Columnist · Jan 18, 2012

We've suctioned frank blood from both mouth and trachea in patients during codes. It's not uncommon for patients with cardiovascular disease to have pulmonary hemorrhage secondary to anticoagulation either as the precipitating event or as a result of compressions. Aspirin therapy is a potent antiplatelet agent and most adults with any kind of cardiac issue will be taking it. This patient had CHF, CAD and HTN, all of which are significant here. And he'd had a CVA... so the likelihood of him also being anticoagulated is quite high. That would be my best guess - not that the intubation was traumatic or incorrect. I'd also suspect that the EMTs checked placement with a disposable ETCO2 detector, which is pretty much standard practice.

This sort of resus is always a traumatic experience for the people involved in the effort. The images tend to stick in one's brain for a long time. Hopefully the details will start to blur a bit for you soon.

Kittypower123, BSN, RN · Jan 18, 2012

He didn't make it (not that I expected him to). Unfortunately, he was full code - no DNR, wife didn't want one (not sure why). Since I'm not experienced with codes, they could have used a disposable ETCO2 detector, but I'm not really sure, I only noticed the stethescope (granted there was a quite a bit going on). I have to say, I'm a big fan of DNRs for certain patients (like the 103 year old lady whose family seems to think she can live forever).

Pediatric Critical Care Columnist · Jan 18, 2012

Most out-of-hospital codes end with death. And that's probably a blessing... since the odds of full recovery are so very poor. But people believe that what they see on TV is real. You know what I mean - comatose-for-months patient arrests, has a couple dozen compressions, a jolt or two from the defibrillator, no intubation, no drugs but miraculous ROSC, then wakes up and is talking, walking and going home in a matter of days. So OF COURSE Daddy's a full code! If only the general public could see the chaos, the mess, the blood, hear the bones break... maybe they'd reconsider.

This is what a disposable ETCO2 detector looks like. It's popped onto the endotracheal tube right after the stylet is pulled. If the tube is in the detector changes colour. It only takes one breath to assess. Then the Easycap is taken off and tossed, the bagger is attached and hand-ventilation goes on. Unless you were watching specifically to see if this check was done, you definitely would have missed it. No shame there.

TheCommuter, BSN, RN · Jan 18, 2012

Unfortunately, he was full code - no DNR, wife didn't want one (not sure why).

Many members of the public, especially people who are not healthcare workers, have misconceptions about the things that take place during code blues. They have certainly watched exciting codes on television shows such as ER where the patient always survives and miraculously discharges from the hospital without any scrapes.

On the other hand, most people do not have a clue about what really goes on during codes, or the low success rates seen after a certain age.