Bad code

[sk8rn]

Any thoughts,

Right before the end of shift last night we got a code by private vehicle, 40 something yo, 240ib, heroin OD (dime bag injection, per hooker) down for approx 15-20min still warm. Cpr to room from carport, flatline, hard iv, io,then iv,narcan, 3 rounds of meds, et was placed which yeilded bloody mucus; then a water fountain (really) of pulsing, warm blood out of the ET tube. Tube replaced with no blood return, 30mins of cpr. Flatline and called it. Took a sugar postcode because of a bad feeling/ bsg 37.

No doubt we will add accuchecks to all code situations but it still takes some time to free up somebody for that task.

Does anybody start coding with nacan and d50 right out of the gate?

Noted some relation with heroin od and hypogylcemic state in some research? We don't see much heroin, maybe 3 in 10 years, any tips or tricks?

I'm guessing this et tube bleed out was do to varices in the intubated esophagus? Never seen it before and I was not sure were to go with it; our MD was new to the ER and was no doubt suprised and wanted to put a c02 monitor over the gusher (anybody ever see a lacerated trach from tube placement?)

Thanks for any tips.

[Penelope_Pitstop, BSN, RN]

Hi sk8rn. Welcome to AllNurses! Are you a skateboarder?

Anyway, I'm not an ER nurse. I work MedSurg, and, yes, we do Accuchecks during each and every code. If nothing else it gives us something else to push when we're not sure what to do! It's probably good practice, but isn't necessarily going to make or break a code.

I doubt it was the blood sugar.

Heroin is an ugly, ugly drug and if it's cheap, it's usually not pure. So who knows what delectable stuff was in this patient's veins. (And a dime bag of Heroin? Crikey - that's scary!)

I think Narcan off the bat would have been a good idea, but if the patient had anything aside from the opiods, it wasn't going to make too much of a difference.

I live in a Heroin-filled area myself. Here the stuff is readily available and really really pure. A few years ago the popular thing was to cut it with Fentanyl. These were the ODs that featured the patient with needle still in arm, it was that quick.

A lot of times it's not the Heroin itself but what goes along with it...a speedball kills you because it's Heroin AND Cocaine.

As for the blood from the tube, I've only seen that with varices myself. And who usually has varices? That's right, alcoholics. So perhaps this patient was drinking and using smack.

[ER_JEN_RN]

NO stat labs with a blood glucose included? I work for IHS so our ER serves 99% native american population, for this reason accuchecks are a first line check during code situations, we've had people come in full arrest with a BS of 11 AFTER an amp of D50.....I can see how it might not be first thought during a code if you have a large diabetic population, and no doubt he had many other significant problems leading to his situation, but ACLS does mention reversible factors and blood sugar is one of them. Easy to miss though.

[ER_JEN_RN]

Lol sorry for my typos, its early in the morning still :-) I meant to say I can see how you might not think to check blood suger if you DONT have a large diabetic population in your area :-)

[aCRNAhopeful]

I'm not an ER nurse but isn't that part of every code? What I mean is ruling out the H's and T's or whatever. I'm not criticising you in the least bit either I'm just thinking out loud. It would stand to reason that if you have a patient coding and coming into the ER that you should probably always rule out hypoglycemia. Now if it's in the ICU or on the floor it certainly wouldn't be a high priority unless there was some reason to suspect it, but in the ER you are in a situation where you have to secure the ABC's and then rule out a whole long list of H's and T's that could be possible on a patient that no one knows.

[JustinAllen]

I'm wondering...did you use Mag Sulfate in your round of medications? I have been a medic for years (just starting nursing school this summer, yea!) and sometimes in round 2 of the ACLS meds dosage I like to throw that on-board, especially in suspected heron OD's.

[marty6001, EdD, EMT-P, APRN]

We dont routinely do a BGM during a code, although if I have any suspicion I will just order an amp (history, part of H/T, etc). I've seen blood via an ETT when compressions have ruptured something, varcies, or even with an UGIB. Also, pulmonary hemmorhage could cause this. Ask your ED attending if he saw blood in the airway or not.

[PatMac10,RN, RN]

Wow a lacerated Trachea? Those drugs sure aren't anything to play with.

[glasgow3]

I wouldn't over think that one too much.....you KNEW the primary correctable cause (per the hooker) and he was flat lined/asystole/pulseless for who knows long, likely the better part of the 15-20 minutes he was down.

Now granted, there could be concomitant causes for this man's "condition" (being dead), in fact, that IS the LIKELIHOOD according to the research; but as a couple of posters have suggested indirectly, by far the most likely of these is other CNS drugs...etoh, barbs etc. Not saying that hypoglycemia couldn't ever be another possibility, but it wouldn't be the direction I would be drawn to. On the other hand if the guy was wearing a diabetic alert bracelet I suppose an argument could be made that he should get the D50 without even waiting to get a blood sugar just because the consequences of not getting adequate glucose in quick could be catastrophic.

Out in the field a decade ago they used to give a mixture of D50, narcan, thiamine, and romazicon right off the bat for comatose patients. That was determined to be a bad idea after a while....wasteful, and in the case of D50, potentially harmful since there is a potential to cause brain tissue damage via the lactic acid buildup.

Anyway, I'm not sure how being dead with a substantial blood loss (from the "fountain" the OP described)affects the accuracy of accucheck type devices...that 37 reading might not have been accurate.

[himilayaneyes]

well, i work on cardiac telemetry (step-down) and we do accuchecks during every code. the only thing i can say is that now you know for next time...a lesson learned.

[medic182]

First things first. You can only do much with a code like this, so congrats on doing what you can do. Let's tackle one thing at a time. Difficult IV access. Gotta love the IV drug users with no veins, then with nothing circulating only makes things worse. IO was definately a good idea here. I have 10+ years as a pre-hospital medic and almost a year as an ER RN. The Narcan is the first thing I would have done, followed by epi and atropine. I would have considered hypoglycemia possibly late in the arrest, but it would not have been one of the first things I would have checked. It possible that the patient, and actually likely, was hypoglycemic secondary to respiratory depression s/p opiate overdose. The body was trying to get energy from anywhere and would burn glucose in the process. But be reminded, that though a blood glucose level of 37 is low, it is not likely to cause aystole. As far as blood from the ETT, it could be anything. If it was a bad intubation and in the belly then varcies is likely. If it was in the lungs then a pulmonary injury could have been the cause. I agree with someone who asked did the attending see blood in the airway, that would be a key piece of information. Well there is my two cents. Sounds like it was a bad code, but unfortunately with greater than 10 minutes of downtime without CPR, that patient was dead before they hit your back door. Keep you chin up, you did fine.

Donnie

[taz628, BSN, RN]

we don't bother with finger sticks during a code... the docs usually do some sort of lab draw (fem stick) and we ALWAYS run an iStat for codes (from the few I've actually witnessed anyway). The BS shows up on the iStat, so that's what we tend to go by.