ACLS algorithms

WindwardOahuRN, RN · Dec 8, 2009

Ask yourself if you would be more frightened by having someone double check a drug dosage that they were not 150% sure of versus them relying solely on their memory in a stressful situation that for some of the readers of this forum is likely not an everyday, or even every month situation and likely giving your loved one the wrong medication? The fact is, people make mistakes in codes quite frequently. This is actually something that has been studied extensively and we know that patients get the wrong med, or the wrong dose, at the wrong time, around 10-30% of the time. Deviations from practice guidelines happen a lot. Many readers of this forum will read that and think they couldn't possibly be responsible for a med error, but it happens are patient outcomes not doubt suffer for it. I was not describing a situation where the code leader is clueless about what to do, and stares blindly at a algorithm, card like it was the first time they've seen one. But get serious, you got 2 minutes of compressions before the next action. Why not take a deep breath; look at your card; double check that dosage; make sure you aren't forgetting anything; ask your team members if they have any ideas? I don't think it adds anything to the discussion to scoff at someone who is humble enough to make use of an available tool, to ensure that they are adhering the best available scientific data as they attempt a resuscitation. Quick: what's the max dose of lidocaine you should give a 79 kg man in refractory v-fib? If you think you might have even a shadow of a doubt what the answer is in the heat of a code with the pressure cooker on high, why not make sure you know where your little flip book is? Because if you get it wrong, it will likely be by a factor of 10. That can't be good.

Sorry, but if you are a member of the Code Blue Team you SHOULD know those things by heart. And if you do screw up the relatively simple stuff (like the max doses of code meds) you shouldn't be on that team.

"Two minutes of compression before the next action"? Ah, what a luxury. Two minutes to browse through cards, maybe catch up on a little light reading, perhaps some meditation, a few stretching exercises. PDX, either you said this tongue-in-cheek or you haven't worked many codes. Those two minutes are often spent inserting lines, chest tubes, doing ABG's, grabbing labs, dealing with the concerns of the family members, making sure whoever is recording is recording correctly, preparing gtts.

Tools are fine, tools are good. But, IMHO and IME, you simply cannot count on them as a resource during an active code.

The standard meds for codes are rather easy to memorize. Dosages, max doses---not terribly difficult. Years ago we actually had more of a buffet of drugs that we used during codes, drugs that required escalating weight-based dosages (bretylium, for example) that we don't use anymore. Standard code drugs and their actions, doses, maxes---epi, atropine, amiodarone, vaso, etc---are relatively easy to park in your memory bank. The preparation of gtts should also be firmly planted in your brain too---for both peripheral and central administration.

Yep, if my loved one was coding and the leader was thumbing through a stack of laminated cue cards as he or she worked the code I would be concerned.

And BTW, it is standard practice to interact with your fellow team members and the floor nurses during a code. Standard practice for even a cardiologist to turn to us and ask if we have any suggestions, any ideas, or if we think we should continue with a code that appears futile. But no, we don't refer to cue cards before we answer.

If a person is not comfortable working a code or feels that they're not ready to do so it is nothing to be ashamed of. In our ICU it used to be a requirement that the nurses working there would be expected to be part of the Code team eventually. When it became apparent that it was a terrifying experience for some and they couldn't function well during a code the requirement was dropped. Now only those who are comfortable AND function well are part of the team, which is as it should be IMHO.

So just accept that you have to learn this stuff if you are going to step in and participate. That's just the way it is and the way it should be.

And as far as "not doing these things every day" there should always be SOMEONE designated to respond to codes who DOES know what they are doing. AKA the "leader." There should never be a code where there is no one responding who is not very sure of ACLS protocols and algorithms.

If a nurse who is ACLS trained and who is carrying that card cannot at least start the proceedings and keep things going until a leader arrives than they should hand back that card and take the course again. Think of the very first things you do as a first responder. Relatively easy, no? But you do have to do them quickly---seconds count. No time for card-checking....sorry.

This is about lives, people, not protecting the egos of those who are not ready to participate in a code. Surely, with practice and study and guidance, you will be someday. It takes time, exposure, and the opportunity to merely observe and absorb before one can be expected to function in such a high-pressure situation. It's unrealistic and dangerous to expect otherwise.

PDX_RN · Dec 9, 2009

my point is actually really simple and can be summarized in three sentences. 1: deviations from standard clinical practice guidelines during in-hospital arrest are a very common occurrence - to simply say "not me"; "not my team"; "not my institution" is too live outside reality. 2: a major responsibility, perhaps the major, responsibility of the code leader is to make sure that the algorithms are being carried out correctly and optimally. 3: there are tools available, including the aha algorithm cards, which can be helpful to in some situations to assist the code leader in helping keep everything running smoothly.

i think if anyone who has been to very many codes has seen some that frankly were not run well. the evidence demonstrates that happens way too often. and like 'em or not, when we deviate from the guidelines, we are not giving are patients the best chance for survival.

WindwardOahuRN, RN · Dec 9, 2009

Of course we see codes that would not be considered "run well" if the ACLS police were in the room. Main reason? We are working with real patients with many co-morbidities that get in the way of "neatness." In situations where the designated code leader (sometimes a resident who is given the job as a learning experience) calls for something that is not appropriate someone else will simply say "ummm....you probably don't want that now---why don't we go with this______?" and the "leader," recognizing his limitations, defers. And learns.

And sometimes we are working with real docs (sometimes old-school cardiologists) who insist on going out of protocol because this is what they know and this is what they want. Not bad practice but not current practice. Most of the time, LOL, their old protocol procedures work quite nicely. Over decades of ACLS I've seen the protocols change and many of the new protocols discarded after a few years. The fantastic new and improved versions were proven to be not only ineffective but sometimes counterproductive. So who can blame the old docs for sticking with what they know has worked for years and going with it.

When the kim chee truly hits the fan no laminated cue card is going to straighten things out. In a room full of practitioners, including physicians, nurses, RT's, and CRNA's, SOMEONE (and very likely more than one person IN MY EXPERIENCE) is going to be able to pull things together with a combination of knowledge and experience.

If the code is way out of control and someone calls for something that is patently ridiculous I will just refuse to prepare it and tell them why. Yes, this crap does happen and egos be damned, we advocate for the patient.

Honestly, except for the occasional med student standing in the corner with an ACLS pocket guide, I've never seen anyone refer to a cue card during an adult code.

Different scenario---peds code, where the Broselow tape may be used. Because of the tremendous variation of doses, max doses, and sizes of the pediatric code patient population this is a useful tool to have available in case we are confronted with a pediatric code. Many peds code carts are arranged according to the Broselow tape protocols which is wonderful but for those who are faced with a pediatric code without a color-coded Broselow cart and are unfamiliar with peds codes it is a great device. But you still have to know PALS algorithms when using the Broselow tape---it's not a "what do I do now??" reference. It's very simple to use and a wonderful tool that has undoubtedly saved the lives of many pediatric code patients. Just establish the color group to which the child belongs with the tape and your ETT size and med dosages are calculated for you on the tape. If you do have the Broselow pediatric code cart (and most places do these days) you just pull open the color-coded drawer and all your appropriately-sized equipment and calculated-dosage meds are there for you. Great stuff.

RN-BS1972 · Dec 10, 2009

I so agree!!!!!!!!

celclt · Dec 10, 2009

rock it out windward!