Called a code for a seizing patient

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?

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. :-)

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.

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

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!

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.

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.

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!