Latest Comments by Lev <3

Lev <3, BSN, RN 45,369 Views

Joined Jun 3, '11 - from 'Another planet'. Lev <3 is a ED Registered Nurse. She has '4' year(s) of experience and specializes in 'Emergency - CEN, upstairs, troll bashing'. Posts: 2,752 (53% Liked) Likes: 5,094

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  • 6

    I think his actions are bordering on harassment.

  • 0

    My old ED- Very busy, >100k visits/year, frequently 50+ people waiting - we had a microphone on the wall and a number system.

  • 0

    I just switched jobs and haven't actually started on the floor at my new one, but I can speak to my old job. Fast track opened at 630am and stayed open no later than 130pm. Sometimes closed at 11pm, sometimes earlier, depended on staffing. Fast track saw 4s and 5s with a PA only. If there happened to be a physician available, fast track also saw "soft" threes. I have had up to 9 patients at a time in the fast track area. That left the main ED open to take the 1s, 2s, and 3s at a 4:1 ratio, up to 5:1 (we switched to team nursing). Sometimes at 230am we would take the remaining 4s and 5s in the main ED, at a 4:1 ratio too.

  • 13
    Swellz, Stellababy, mharzi, and 10 others like this.

    Initial Response:

    Oh no! Your patient has gone unresponsive on you. First thing to do is a quick pulse check of their carotid artery.

    If you do not detect a pulse within five to ten seconds and your patient wishes to be resuscitated, call for help. Send one person to call the code blue and another to grab the crash cart and defibrillator. Then flatten the bed (max inflate the mattress if you know how) and "jump on their chest" and start compressions. The current Advanced Cardiovascular Life Support (ACLS) guidelines from the American Heart Association call for a compression rate of 100 to 120 compressions per minute.

    (If your patient has a pulse, but is not breathing or is breathing very slowly or ineffectively, call for help (code blue) and start providing rescue breaths with a bag valve mask device or “ambu bag" at a rate of one breath every five to six seconds. Give each breath over one second.)

    Getting help - time for some delegation!

    Make sure your charge nurse and the patient’s doctor or provider is aware. Once help arrives, quickly place the patient on the backboard. One staff member should start manually bagging the patient with a bag valve mask device at a compression to ventilation ratio of 30 compressions to two breaths. The other person should hook the patient up to the defibrillator. While your coworker is getting the pads on, continue compressions or switch off with someone if you are tired. In general, someone should switch off doing compressions every two minutes.


    There are two popular methods of placing defibrillator pads. The method seen most publicly is anterior-lateral placement. This is usually the method illustrated on the package of the defibrillator pads seen in AEDs. Anterior-lateral placement is great for defibrillation but not for pacing. Anterior-posterior placement is ideal for both pacing and defibrillation, but requires the patient to be turned to place the second pad under the left scapula. When placing the pads, try to avoid nipples. Quickly shave the chest if chest hair is preventing the pads from making contact with skin. Avoid placing the pads over a pacemaker site to avoid damaging the pacemaker.

    The defibrillator located on inpatient units generally has two modes. There is the automatic external defibrillator (AED) mode - which is similar in functionality to the AEDs used in the public setting. These defibrillators recognize a fatal arrhythmia and advise a shock if indicated. The other mode is manual where a person who is competent at cardiac arrhythmia recognition recognizes a shockable arrhythmia (either ventricular fibrillation (VF) or “V-fib” or ventricular tachycardia (VT) or “V-tach.”). Follow your unit and institutional policies and standards for energy selection if your unit uses defibrillators in manual mode. If using a defibrillator in AED mode, pause compressions while the defibrillator is analyzing the rhythm and then resume compressions until the “all clear” is given before a patient is shocked. As soon as the patient is shocked, compressions should be restarted for a full two minutes. When using a defibrillator in manual mode, compressions need only be paused for the shock and then resumed immediately after defibrillation.

    Lots of things to do:

    Before the resuscitation team arrives there are a couple things that can be taken care of.

    1) Make sure that there is suction set up in the room. It is good practice to have suction set up in your rooms at the beginning of the shift.

    2) Get a second and ideally third IV line and draw blood if possible. Have a liter of normal saline hanging and ready at the bedside. It is helpful to have running IV fluids to help flush medications and to make sure the IV is patent. It is also helpful to have some flushes ready.

    3) Check a finger-stick blood glucose level. Hypoglycemia is one of the causes of cardiac arrest.

    4) Have the patient’s labs, previous vital signs, medications, and past medical history at easy access.

    When the resuscitation team arrives:

    The “code” team is made up of critical care staff and may include nurses, a physician assistant or nurse practitioner, a respiratory therapist, an attending physician/hospitalist and/or a resident physician.

    The respiratory therapist should take over bagging the patient. In some hospitals respiratory therapists routinely intubate while in others they just assist with intubation.

    The PA or doctor may recommend a 1mg dose of epinephrine. Epinephrine or Adrenaline is a poten vasoconstrictor which is a naturally occurring catecholamine in the body, responsible for the “fight or flight” response of the sympathetic nervous system. Per ACLS protocols, a dose of epinephrine can be given every three to five minutes. The lower concentration of epinephrine (1:10,000) is used for cardiac arrest contrary to the epinephrine in epi pens used for anaphylaxis.

    The team will try to find and reverse the possible causes of the cardiac arrest. These are known as the "Hs and Ts."

    Other medications given during codes:

    Narcan - given to counteract opioid overdose.

    Sodium bicarbonate - given for hyperkalemia and acidosis.

    Calcium gluconate/calcium chloride - given for hyperkalemia or hypocalcemia or suspected calcium channel blocker/beta blocker overdose.

    Magnesium sulfate - given for hypomagnesemia, hypokalemia, V-tach, or Torsades de Pointes.

    Dextrose - given for hypoglycemia.

    Amiodarone - antiarrythmic sometimes given after the first shock for V-fib or V-tach arrest.

    TPA - may be given in the setting of known embolism, pulmonary or otherwise.

    Lidocaine - not part of ACLS algorithms, but still given at times for wide complex tachyarrythmias such as V-tach.

    IV fluids - given for hypovolemia/support hemodynamics.

    Note: When a patient does not have a pulse, there is no need to inquire about a patient’s blood pressure. Without a perfusing rhythm, there is no self regulated blood pressure. Effective compressions can create a good blood pressure but any blood pressure measured while the patient is pulseless is really a waste of time.


    The patient may be intubated with an endotracheal (ET) tube during or after the resuscitation attempt. Once the patient is intubated, tube verification is done by listening for breath sounds in both lungs and by listening to the stomach to make sure no gurgling is heard (indicating esophageal intubation). Watch for abdominal distention which can indicate esophageal intubation.

    Tube placement should also be verified through some sort of carbon dioxide (CO2) detection - either through waveform capnography on the monitor which shows end tidal carbon dioxide (EtCO2) or through a clip attached to the tube and bag valve mask which changes color when it detects carbon dioxide after the patient is bagged a couple times. EtCO2 measures the amount of carbon dioxide present at the end of exhalation and is normally 35 to 45 mmHg. Sometimes it is monitored during resuscitation attempts to gauge the quality of compressions and to help determine if spontaneous circulation returned indicated by a sharp increase in EtCO2.

    Link to a video about end tidal CO2 for those interested

    Once intubation occurs, the patient should continue to be bagged at a rate of six breaths per minute until the ventilator is attached. If the patient survives the resuscitation attempt, final verification of ET tube placement will be done by chest x-ray.


    Note: Effective compressions can look a lot like the V-tach shown in the first rhythm video below. Make sure to pause compressions before analyzing the rhythm.

    Ventricular Tachycardia (VT) - Rate >100 usually >120, can have pulse, must shock immediately if no pulse or unresponsive.

    Torsades de Pointes “Torsades” - A type of VT, no pulse, give magnesium IV push

    Ventricular Fibrillation (VF) - No pulse, must shock immediately


    After the code:

    Most patients do not survive resuscitation attempts. Some survive but with very diminished brain function. Do not expect your patient to wake up after CPR. The ones more likely to wake up right away are those who were successfully shocked immediately after the occurrence of a fatal shockable rhythm like ventricular tachycardia.

    To give the patients the best chance of consciousness after cardiac arrest, patients are cooled temperature of 32 to 36 degrees Celsius. The cooling process, also known as targeted temperature management (TMM), is usually initiated in the ICU.

    A debriefing process, either directly after the code, a couple hours after the code, or scheduled for another day is a good way to help staff members deal with any feelings they have after the resuscitation and to allow staff members to ask questions.

    Sources for information and BLS and ACLS algorithms:

    Adult Basic Life Support and Cardiopulmonary Resuscitation Quality

    Adult Advanced Cardiovascular Life Support

    Here is the link to a good code blue simulation video. I watched several of these and found this one to be the most accurate and informative. Many videos had lapses or delays in compressions that made me cringe. LINK

  • 8

    I have dealt with many "Jakes" and I will dilute their pain medicine and push it over the recommended minutes.

  • 0

    A nursing only class may focus on PICCs, ports, and central lines because only nurses can draw from those lines.

  • 0

    What was her BP before intubation?

    Most patients do fine with just Propofol for sedation. If they have PRN agitation, an extra bolus of Propofol or some Fentanyl can fix that as the Propofol is being titrated up. For those who cannot be sedated with Propofol, Precedex usually does the trick. I have also seen Ketamine used for this purpose.

  • 0

    You are still on orientation presumably? Save your judgments for when you are a year in. Meanwhile, keep up the respect and friendliness.

  • 0

    Sounds like you made your choice. Neuro patients can be frustrating and it is slow progress (if any).

    However, there are other variables to consider such as the unit environment, staffing, and support.

  • 1
    cocoa_puff likes this.

    Wow! Is Masters in Biomedical Science a biomedical engineering major? Was just looking that up last night as something I was interested in pursuing over NP (no doctorate degree required). (NP does not require a doctorate degree but many programs have switched over to a doctorate degree and those programs have lost me).

  • 6

    LOL, I will be on the lookout, thousands of miles away from Texas! Consider attaching a colorful patient wristband to the stethoscope in the future. I favor "elopement" bands for my scissors.

  • 0

    The same thing happened to me and I treated it as a needlestick.

  • 0

    Whoops! Generally PO contrast should be finished at least 45 minutes before CT and longer (2 hours) if highly suspicious of something like appendicitis.

  • 0
  • 1
    al3x117 likes this.

    Triage generally requires some ED experience (usually about 2 years, unless the hospital is so short staffed that they let just about anyone do triage) as well as some pediatric knowledge (cross training) if the nurse only works in the adult ED. Triage decides who needs to be seen sooner than others and where treatment can take place (fast track vs main ED vs psych). Some hospital's EDs are trauma centers, so once a nurse gets some ED experience they can train to work with the trauma patients.