Called a code for a seizing patient

[thesimplenurse]

Hi everyone, new grad here on my own after my first month orientation. I have not experienced a code blue before but went through a basic mock CPR during orientation.

Details: Came back from break, was doing my nursing rounds when one of my patients who was ‘stable' all morning suddenly began seizing so I quickly ran for the pt. My supervisor happened to be around and was by the bedside as well and said "pt is seizing call a code!". Pt eyes began rolling backwards, unresponsive to name and touch as she was seizing and decreased LOC. I checked for breathing and radial pulse (should've done a carotid pulse) and only felt a weak pulse. I initiated a code and began chest compressions and pt woke up after a couple of them and began vomiting blood etc. Pt never had an epileptic episode before and pt began stabilizing after medical intervention.

I am just reflecting on my nursing practice and judgment.. My question is whether we are supposed to call code blue for seizures? No one questioned my actions of calling a code and even said I did a great job. Thoughts?

[JadedCPN, BSN, RN]

A "code" is just another name for an emergency in which there is sufficient evidence to believe that a patient's aerobic metabolic requirements are suddenly and unexpectedly not being met.

It doesn't specify what kind, i.e. full arrest, uncontrolled bleeding, respiratory failure. It doesn't obligate CPR any more than some other emergency intervention that is specific to a patient's need at the time.

So, calling a "code" in this situation was the correct thing to do. CPR was not. But stuff happens and no harm, apparently, was done, so all's well.

You took the words out of my mouth. I don't have an issue with the calling a code part if that is what felt appropriate at the time - better to falsely call a code than to not call one when it is needed. However I believe starting CPR was inappropriate. The take home lesson should be just because a code is called, even if it is appropriate, doesn't mean you should automatically jump into compressions.

[CrunchRN, ADN, RN]

Seizures are scary. Next time maybe slow down a bit. You have time. You did a great job though.

[chare]

[…]

However, if they had a radial pulse it means they were stable-ish and had a systolic BP above 80. You are right though you should have checked a carotid or femoral. Was the pt still seizing when you checked it? IMO very inappropriate to start CPR.

The old rule of thumb” that a radial (femoral, carotid) pulse indicates an SPB of ≥80 (70, 60) mmHg originated from the ATLS course. This is not accurate, and using this method is generally an overestimation of the actual SBP.

[Anna Flaxis, BSN, RN]

In my experience, a Code Blue is for a cardiac or respiratory arrest, and I'm not sure why one would perform chest compressions on an adult with a pulse.

It is reasonable to call for assistance if your stable patient suddenly begins seizing.

[Anna Flaxis, BSN, RN]

The old rule of thumb” that a radial (femoral, carotid) pulse indicates an SPB of ≥80 (70, 60) mmHg originated from the ATLS course. This is not accurate, and using this method is generally an overestimation of the actual SBP.

First, please note that this is a single study with an n=20. This is not a large enough sample size to be statistically significant. Second, please note that in Group 1, the group in which radial, femoral, and carotid pulses are present, 8 out of 12 patients (67%) had an SBP >/= to 70, and 11/12 (92%) had an SPB >/= to 60.

We would need to conduct more experiments with greater sample sizes to be able to draw a reliable conclusion.

Also, please see: Accuracy of ATLS guidelines for predicting systolic blood pressure

[NurseHeart&Soul, MSN]

Thesimplenurse~

Congratulations on surviving your first code!!! This experience is now behind you. Phew! One of the most important aspects of learning is taking time for reflection, thus I commend you on being vulnerable, sharing your experience, and asking for input from others.

It sounds like there might be some confusion about what a "code" means. Simply put, it's typically a patient who could be having a rapid decline in condition and you need stat help. Often this is or respiratory or cardiac nature but could be anyone who is suddenly unstable. A code calls in more resources so all hands on deck can help stabilize the patient. Some facilities use Rapid Response Teams to help with this but not all.

In your situation it sounds like you interpreted "call a code" for start CPR. They are not synonymous. Regardless, sounds like no harm was done to the patient, resources were obtained, and things turned out okay. Experience gained, lessons learned....awesome! Enjoy your nursing journey! Congratulations on your new job!

[chare]

…Second, please note that in Group 1, the group in which radial, femoral, and carotid pulses are present, 8 out of 12 patients (67%) had an SBP >/= to 70, and 11/12 (92%) had an SPB >/= to 60.

[…]

Yes, and according to the ATLS paradigm this group of patients should have had an SBP ≥80 mmHg.

This is the second study to compare the previous ATLS guidelines equating the presence of radial/femoral/carotid pulses with SBP of 80/70/60 mmHg. The previous study (Poulton, T. J. (1988). ATLS Paradigm Fails. Annals of Emergency Medicine, 17, 107. Retrieved from http://www.annemergmed.com/article/S0196-0644(88)80538-9/pdf used manual blood pressure to evaluate the correlation between SBP in 20 hypovolemic trauma patients aged 16 – 68, with an SBP

[…]

We would need to conduct more experiments with greater sample sizes to be able to draw a reliable conclusion.

Why should any further study be done? Two studies, albeit both of them small, have shown that the previous ATLS paradigm to estimate SBP based upon the presence and location of pulses generally overestimate that actual SBP. If this evidence was sufficient for the American College of Surgeons to remove this from the ATLS curriculum, shouldn't nursing do the same?

[…]

Also, please see: Accuracy of ATLS guidelines for predicting systolic blood pressure

Even though this questions the study design, it doesn't suggest that the ATLS SBP estimation paradigm is correct, rather that Deakin & Low were incorrect in stating that this was still included in the ATLS curriculum.

ETA: http://www.annemergmed.com/article/S0196-0644(88)80538-9/pdf

[WoosahRN, MSN, RN]

I am in ICU but in our facility it is policy for the floors to call a "Code" for any new seizure or acute change in LOC. We also have a Rapid Response team and RISK nurse program but for the acute change, calling a code is appropriate.

[Loracs72]

I would like to know why the patient was seizing in the first place.

[Kuriin, BSN, RN]

Never heard of someone starting compressions on a patient while they are actively seizing...lol.

In any case, you got through your first code.

[Anna Flaxis, BSN, RN]

Why should any further study be done?

Assuming this is not a rhetorical question, to put it simply, the smaller the sample size, the less precise the information is.

Say, for example, you receive a shipment of 500 widgets, and the supplier guarantees you that no more than 10% will be defective. You can't check every single widget, so you take a sample of 10 and find two defective widgets. You could conclude that 20% of the entire shipment of widgets is defective, or you could understand that perhaps you just happened to pull out 2 defective widgets when selecting your sample.

Now, what if, instead, you select 50 widgets as your sample, and 2 of them are defective? That would be 4%, and consistent with your supplier's guarantee of 10% or less.

You can apply this principle to individual experiments as well as what we call the "body of evidence". Two studies (with small sample sizes, no less) is not a large body of evidence upon which to form a strong conclusion, it is merely a starting point for further research.

[KelRN215, BSN, RN]

In general, no. There are people with known seizure disorders who seize 100s of times/day. I think the most seizures I ever had in a day was 12 prior to my brain surgery. I was in college and didn't even call my Neurologist. A seizure that stops on its own is not a medical emergency nor does it warrant intervention. A first time seizure requires a work-up, however.

I began my career in pediatric neurology. In our experience, any floor that wasn't our floor or the ICU would call a code for a patient who seized. This basically led to any patient with a seizure history being admitted to our floor, regardless of why they were admitted. (The same rule applied to cardiac patients, as any floor outside of Cardiology would freak out at a patient with baseline sats in the 70s.) I have never seen someone requiring compressions during a seizure. Only a handful of times in my 5 years on that floor did we have to call a code during a seizure and when we did, it was because the patient needed to be intubated. In general, a cardiac arrest during a seizure would be the result of a respiratory arrest.

I remember I once transferred a patient from the pediatric floor in another hospital across town. The patient had encephalitis or meningitis and had seizures because of that. When I was getting report from the nurse, she told me of all the times the patient went back and forth to the ICU. Every time she had a seizure, regardless of how long it was, regardless of it required intervention or not, they sent her back to the ICU. We only sent our seizure patients to the ICU if they needed to be intubated or put in a medically induced coma because they were in status epilepticus. That patient never went to the ICU after she transferred to us.

Patients with known seizure disorders aren't even told to seek medical attention for seizures unless they last longer than 5 minutes.