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.

[resumecpr]

I agree with most everybody else who responded. Always look for reversible causes and treat them accordingly. Amongst all the hubub of a code. the accucheck is sometimes the last thing on everybody's mind. It is considered one of the "H's." Further. heroin and cocaine use will cause the carotid arteries to vasoconstrict so severely that a major heart attack can ensue. If the heart was already damaged (and this is totally going off the deep end), perhaps all that froth and blood you saw was from his papillary muscle rupturing. *Oops*!! But I'd like to say it was probably varices.

You also mentioned that there were not enough people to run this code. How many were there? Were their roles clearly defined? It normally takes 5 qualified staff and 1 doc to run a code. In the ED, we have a pharmacist do the med thing. A blood gas should be drawn also (it tells you so much in about 2 minutes).

Good luck for next time...use this as a learning experience.

[KatieNoelLPN]

maybe it's early and i'm tired, but what are h's and t's?

[murphyle, BSN, RN]

5H 5T - the old mnemonic for the correctable causes of asystole/PEA (5 beginning with H, and 5 beginning with T). The numbers of Hs and Ts have changed over time; common variants include adding "Hypoglycemia" to the H column, moving coronary thrombosis to the H column as "Heart attack", adding "Trauma" to the T column, and/or splitting up hyper- and hypokalemia.

H - Hydrogen (acidosis), Hyperkalemia/Hypokalemia, Hypoxia, Hypovolemia, Hypothermia, Hypoglycemia, Heart attack

T - Tamponade, Tension pneumothorax, Tablets/Toxins (overdoses), Thrombosis (pulmonary), Trauma

[Lunah, MSN, RN]

When we start running through the Hs and Ts, we usually end up giving an amp of everything. Our EMS units' protocols include an Accuchek, but they'll often give an amp of D50 anyway, along with everything else! (Bicarb, etc.)

Sounds like an ugly situation. I was thinking of pulmonary edema for your gusher issue -- I know heroin use can cause non-cardiac pulmonary edema. But if it was more blood than watery fluid, then your guess is as good as mine!

[LilgirlRN, ADN, RN]

We may not ask for a blood sugar in someone who we know their medical history. However, if we are fighting a losing battle D50 is one of the things we throw at the situation. Sort of a shotgun effect.