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Called a code for a seizing patient

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…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.

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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

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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?

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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

Edited by chare
Corrected link

WoosahRN, MSN, RN

Specializes in PICU. Has 10 years experience.

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

Specializes in OB/GYN, Home Health, ECF. Has 40 years experience.

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

Kuriin, BSN, RN

Specializes in Emergency. Has 5 years experience.

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

Has 14 years experience.

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

Specializes in Pedi. Has 10 years experience.

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.

Creamsoda, ASN, RN

Specializes in ICU.

its not wrong to call a code. Like others have said, if you felt a weak radial pulse, compressions not necessary, but like you said there maybe was some doubt, so its totally fine. You can also justify (if you ever had to, some people can be rude about it) that due to the seizure they are having a resp. arrest. Essentially they are. People who have seizures turn blue because theyre not breathing. When the seizure stops they breath again. If thats the fastest way to get help in your hospital, calling a code is not wrong. If you have a rapid response team, that also could have been implemented. A code is for a full on cardiac arrest, and or just a plain resp arrest. They may still have a pulse, but if they stop breathing, then that warrants BLS/ ACLS- hence calling a code. Sure when the code team arrives, usually the seizure is done and the patient is coming around, but at that moment, the right thing to do is call a code.

KelRN215, BSN, RN

Specializes in Pedi. Has 10 years experience.

People who have seizures turn blue because theyre not breathing. When the seizure stops they breath again.

This is a generalization that is not typical of most seizures. Most people don't stop breathing during a seizure. During my 5 years of being a pediatric neurology nurse and 10 years volunteering at a camp for children with epilepsy, I can count on 1 hand the number of times I witnessed someone stop breathing during a seizure. When it happens, it is an emergency.

If someone turns blue and stops breathing during a seizure, they minimally need to be bagged and a code should be called. We always instructed our patients' parents to call 911 if the child stopped breathing, turned blue or had a seizure that lasted longer than 5 minutes.

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

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I understand, and agree with everything that you have said in both of your previous posts. If we are going to continue to teach this paradigm, then yes, further study should be done.

The problem is this. No one seems to know where this came from, and why it was originally included in the ATLS curriculum as there is zero evidence to support it. Nor does anyone seem to know why it was removed. Unfortunately, both medicine and nursing continue to believe, and teach it.

And thus the intent of my previous post. Don't you think that there should be some evidence behind what we teach and practice?

Edited by chare

Anna Flaxis, BSN, RN

Has 14 years experience.

And thus the intent of my previous post. Don't you think that there should be some evidence behind what we teach and practice?

Of course, just as I think that when citing evidence to make a point, one should verify that such evidence is reliable. :-)

RNNPICU, BSN, RN

Specializes in PICU. Has 13 years experience.

Since you felt a pulse, I don't think I would have started compressions until I had them on a monitor. Calling a code does not mean you automatically start compressions. I would have wanted to make sure I had an Ambu bag ready in case they stopped breathing and need oxygen and breaths. If the patient was known to have seizures I might not have called the code if the seizures were part of the medical history and was a known occurrence unless something was different. Did the physician say to start compressions. I know your Charge stated to call a code, but calling a code does not equate immediately start compressions. Now if no pulse, no respirations, YES start CPR.

cjcsoon2bnp, MSN, RN, NP

Specializes in Emergency Nursing.

To the OP, as you mentioned you are a new nurse and you get the gist from these posts that calling a code was fine but starting CPR wasn't appropriate in this situation. Don't beat yourself up over it but instead use it as a teaching moment and take some time to further your education on BLS, rapid response/emergency situations, and seizure management.

Many users have mentioned that "calling a code" is basically a way to quickly get more help from the multidisciplinary team because of an emergent condition. Not every nurse would have called one for this particular situation (it depends on your experience level and the setting where you work), but your decision to call the code was justified and supported by the supervisor. Regarding CPR, you know that for the next time you would check a carotid pulse and if the patient was actively seizing you would assist them to a supportive position, maintain the airway, check the SP02 and blood glucose, and apply supplemental oxygen as needed. If you have a palpable pulse then you should focus on airway, breathing, circulation (ABC) and oxygenation until the patient regains consciousness. One thing to note, in PALS (for pediatric patients) if you have a HR of

Best of luck and keep your head up OP!

!Chris :specs:

OP, I agree with what many of the other posters have said. Overall, you did a good job! You got help when it was needed and worked to stabilize your patient. The appropriateness of starting chest compressions depends on your patient population (peds with a pulse

One thing I would suggest is to also seek feedback from your manager/educator on your unit. They will be familiar with what happened and can give you feedback on your interventions, critical thinking, delegation, and even on your documentation. They will be familiar with the criteria for calling a rapid response vs calling a code at your hospital and can guide you as to when each one is most appropriate (however- don't be afraid to call either if you feel it is warranted!!). As well, discussing this incident with your management shows that you have been reflecting on it and are seeking to hone your practice. They are lucky to have a nurse who is self-reflective and open to feedback!

EaglesWings21, ASN, RN

Specializes in Medical Surgical.

I would not have called a code; I would have called a Rapid Response. I also would not have started chest compressions but would have turned the patient on their side and protected their airway. In the process of waiting for the RR nurse I would have got vital signs. If the patient maintained a pulse throughout the event I would have administered Ativan via verbal order from the RR nurse. If the patient lost a pulse I would have started compressions and called a code. If the lost their airway but had a pulse I would have administered O2 via Ambu bag and called a code. Hope this helps.

I started nursing back in the dark ages when there were very few seizure meds available and it seemed like every seizure patient was med non-compliant because of the side effects. Back then, seizures were pretty much weekly and we reacted like cavemen when a patient experienced one - jumped on top of them, held down arms and legs, jammed a tongue depressor in their mouth and put a thin, cheap hospital pillow under their head. I'm surprised we didn't kill them with our "care." Seizures are scary when they happen if you're not used to them. I think the OP did a great job (except starting compressions). But from a lot of the comments here, it sounds like epilepsy and seizure disorders are as misunderstood now as they were back when we were pinning the patients to the floor. It's important to remember that most seizures are NOT medical emergencies, so there's no need to panic. Assess the patient and initiate care based on what you find. And it's also important to observe the patient during the post-ictal period and remember, sometimes patients coming out of a seizure are confused and violent, so always be careful. I've seen post-ictal patients knock staff into next week and not even remember doing it.

AlwaysLearning247, BSN

Has 6 years experience.

At my work we would call a rapid response. I also would not have done chest compressions. When I had a patient seize I made sure they were safe and kept track of how long it lasted. I work on a medical-surgical/cardiac floor.

5 years Level 1 Trauma/ 1 year flight nurse....here is my take

You did the right thing. When in doubt, be over prepared. Especially when you are new. Would much rather call a code and not need it than to NOT do something for fear of being wrong, and trying to explain why you didn't act. No one will ever fault you for being OVER prepared.

You handled that just right.

A lot of medical professionals are saying it's ok what you did...

If I were in the pts condition, I would want you to follow the rules from the AHA.

Please don't start compressions on me if I have a pulse... Radial, brachial carotid or even ped... Rescue breathing would be great tho.

Thank you in advance.