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?
As others have pointed out - you and your patient survived the first "code" - so congratulations...
Seizures can be scary for a lot of nurses and even experienced supervisors / nurses. i worked on a floor with a seizure monitoring unit at some point and seizures were common occurrence and often provoked to capture the nature of the seizure and to characterize the seizure/origin/ and such. Depending on where you work, the incidents of patients who have convulsions but no EEG correlation can be found - also often called psychogenic seizures or non-electrographic convulsions (is the preferred term nowadays it seems).
The epilepsy foundation writes that as much as 25% of patients are misdiagnosed with epilepsy and actually do not have a seizure disorder
Where I worked, the number was more in the 30% range or even higher because they got referrals for a lot of folks who were not responding to regular anti seizure medication - so the neurology sends them to characterize seizures in a controlled environment where the medication is tapered off/stopped and seizure induced through lack of sleep for example.
As others pointed out - calling a code is not equivalent with starting chest compressions - but I can see how you got there because first the supervisor did not give you clear instructions beside to call a code and secondly - in a general tonic clonic seizure (generalized seizure) or even some tonic seizures, the person does not seem to breath and in fact some of them can turn quite blueish. There is a risk of sudden cardiac death with a seizure event or without event but diagnosed epilepsy
Seizures can look very violent and scary - if the person bites the tongue, bloody foam can come out of mouth/nose - there is now swallowing with the generalized seizure.
A lot of facilities and floor have a policy that a code needs to be called for a seizure event if it is a new onset or in a specific area - for example seizure in CT - they will call a code - they have to - even though you may not have to do so on a neuro floor.
But other than that key is to keep calm. Have suction on the wall with a yankauer ready in case you need it, give oxygen - if the head is shaking it is sometimes best to just turn on the oxygen more and hold the nasal canula close to nose/mouth until you are able to strap in on.
Turn the person to the side to minimize the risk of aspiration, protect their head/limps from trashing against side rails or on the floor, if you have already iv access or central line - try to ensure it stays in and does not fly out because of the convulsions...
Most often, the "seizure activity" is self-limiting - try to look at the clock to get an idea - 30 seconds of seizing can seem like 10 minutes....
As a nurse, I am not too concerned if the seizure activity is less than 2 minutes and the patient does not seem to have a cardiac arrest - meaning not turning dark shade of blue and going limp - because no oxygen also means no more convulsions and that person will not start breathing of course - in that case you do the regular CPR.
People can look very pale and slightly cyanotic lips with a generalized seizure.
In a lot of cases the seizure event does not come out of the blue and there is a history of it, or other things that are connected - somebody who is withdrawing from alcohol or drugs obviously can have a seizure. Somebody who for example was taking tegretol for a long time for pain control and for whatever reason has not taken it or had some other problem that prevented the person from getting the medication - also can have a seizure although not an epileptic.
Main thing is really to stay calm, follow the procedure in your place regarding code/rapid response, ensure the safety of the person, give supplemental oxygen, have suction available and reposition on the side. If there is already an order to give ativan for stop the seizure make sure you follow the order because some neurologists will write specific orders to only give ativan if the seizure is longer than 30 seconds, or a minute or 2 minutes - so know your orders. If you do not have orders yet and it is new - be prepared to give ativan to stop the seizure activity and can be given i.m if no access. Patient typically require telemetry after an onset of seizures, they should be on seizure precautions and fall precautions.
I am concerned when the convulsions are longer than 2 minutes, if the seizures are short but happen frequently (perhaps only 30 seconds but several an hour) , if the character of the seizures is different from before (example patient tells with admission that they had focal seizure activity in left arm which is treated with meds and now the patient has a generalized tonic clonic seizure) or the patient has a high risk for cardiac arrest.
Hint for palliation at end of life:
The prevention of seizures is important at the end-of-life. Typically, people will continue with antiseizure medication if they can swallow - some come as a liquid form - but when unable to swallow there are other possibilities. For anybody with a history of seizures at EOL it is essential to prevent. The most common way is that the MD schedules ativan every 4 hours sublingual (the 0.5 mg pills dissolve under the tongue and there is also liquid with a concentration of 2 mg/ml that can be given sublingual) sometimes low doses of 0.5 mg , sometimes 1 mg or even more depending on the overall symptoms and clinical picture. There can be orders to give additional doses sl for breakthrough symptoms at EOL. There are also phenobarbital suppositories, which are great for EOL seizure but not all hospitals carry them - it is usually not a problem with home hospice or hospice care in longterm care facility or hospice house.
There are also a variety of other other options and some depend on a compounding pharmacy - which is usually accessible for hospice but not necessarily for general acute care palliation.
Cancer patients can have seizures due to brain mets, brain tumors or other cancer related problems leading to seizures.
If somebody elects hospice care or comfort measures only in the acute care setting, it is important to prevent seizures as they are stressful for the patient but also very stressful for the family!
nutella, MSN, RN
1 Article; 1,509 Posts
As others have pointed out - you and your patient survived the first "code" - so congratulations...
Seizures can be scary for a lot of nurses and even experienced supervisors / nurses. i worked on a floor with a seizure monitoring unit at some point and seizures were common occurrence and often provoked to capture the nature of the seizure and to characterize the seizure/origin/ and such. Depending on where you work, the incidents of patients who have convulsions but no EEG correlation can be found - also often called psychogenic seizures or non-electrographic convulsions (is the preferred term nowadays it seems).
The epilepsy foundation writes that as much as 25% of patients are misdiagnosed with epilepsy and actually do not have a seizure disorder
The Truth about Psychogenic NonEpileptic Seizures | Epilepsy Foundation
Where I worked, the number was more in the 30% range or even higher because they got referrals for a lot of folks who were not responding to regular anti seizure medication - so the neurology sends them to characterize seizures in a controlled environment where the medication is tapered off/stopped and seizure induced through lack of sleep for example.
As others pointed out - calling a code is not equivalent with starting chest compressions - but I can see how you got there because first the supervisor did not give you clear instructions beside to call a code and secondly - in a general tonic clonic seizure (generalized seizure) or even some tonic seizures, the person does not seem to breath and in fact some of them can turn quite blueish. There is a risk of sudden cardiac death with a seizure event or without event but diagnosed epilepsy
SUDEP FAQ | Epilepsy Foundation
Cardiac arrest associated with epileptic seizures: A case report with simultaneous EEG and ECG
Seizures can look very violent and scary - if the person bites the tongue, bloody foam can come out of mouth/nose - there is now swallowing with the generalized seizure.
A lot of facilities and floor have a policy that a code needs to be called for a seizure event if it is a new onset or in a specific area - for example seizure in CT - they will call a code - they have to - even though you may not have to do so on a neuro floor.
But other than that key is to keep calm. Have suction on the wall with a yankauer ready in case you need it, give oxygen - if the head is shaking it is sometimes best to just turn on the oxygen more and hold the nasal canula close to nose/mouth until you are able to strap in on.
Turn the person to the side to minimize the risk of aspiration, protect their head/limps from trashing against side rails or on the floor, if you have already iv access or central line - try to ensure it stays in and does not fly out because of the convulsions...
Most often, the "seizure activity" is self-limiting - try to look at the clock to get an idea - 30 seconds of seizing can seem like 10 minutes....
As a nurse, I am not too concerned if the seizure activity is less than 2 minutes and the patient does not seem to have a cardiac arrest - meaning not turning dark shade of blue and going limp - because no oxygen also means no more convulsions and that person will not start breathing of course - in that case you do the regular CPR.
People can look very pale and slightly cyanotic lips with a generalized seizure.
In a lot of cases the seizure event does not come out of the blue and there is a history of it, or other things that are connected - somebody who is withdrawing from alcohol or drugs obviously can have a seizure. Somebody who for example was taking tegretol for a long time for pain control and for whatever reason has not taken it or had some other problem that prevented the person from getting the medication - also can have a seizure although not an epileptic.
Main thing is really to stay calm, follow the procedure in your place regarding code/rapid response, ensure the safety of the person, give supplemental oxygen, have suction available and reposition on the side. If there is already an order to give ativan for stop the seizure make sure you follow the order because some neurologists will write specific orders to only give ativan if the seizure is longer than 30 seconds, or a minute or 2 minutes - so know your orders. If you do not have orders yet and it is new - be prepared to give ativan to stop the seizure activity and can be given i.m if no access. Patient typically require telemetry after an onset of seizures, they should be on seizure precautions and fall precautions.
I am concerned when the convulsions are longer than 2 minutes, if the seizures are short but happen frequently (perhaps only 30 seconds but several an hour) , if the character of the seizures is different from before (example patient tells with admission that they had focal seizure activity in left arm which is treated with meds and now the patient has a generalized tonic clonic seizure) or the patient has a high risk for cardiac arrest.
Hint for palliation at end of life:
The prevention of seizures is important at the end-of-life. Typically, people will continue with antiseizure medication if they can swallow - some come as a liquid form - but when unable to swallow there are other possibilities. For anybody with a history of seizures at EOL it is essential to prevent. The most common way is that the MD schedules ativan every 4 hours sublingual (the 0.5 mg pills dissolve under the tongue and there is also liquid with a concentration of 2 mg/ml that can be given sublingual) sometimes low doses of 0.5 mg , sometimes 1 mg or even more depending on the overall symptoms and clinical picture. There can be orders to give additional doses sl for breakthrough symptoms at EOL. There are also phenobarbital suppositories, which are great for EOL seizure but not all hospitals carry them - it is usually not a problem with home hospice or hospice care in longterm care facility or hospice house.
There are also a variety of other other options and some depend on a compounding pharmacy - which is usually accessible for hospice but not necessarily for general acute care palliation.
Cancer patients can have seizures due to brain mets, brain tumors or other cancer related problems leading to seizures.
If somebody elects hospice care or comfort measures only in the acute care setting, it is important to prevent seizures as they are stressful for the patient but also very stressful for the family!