Code blue at my LTC and AHA guideline

billythekid · Apr 16, 2010

Sounds like you made a terrific effort :)

I believe the spirit of the AHA guideline was to encourage people to take actions that would benefit a victim, and still be within their 'comfort' limits, in the absence of appropriate medical equipment. The theory behind doing chest compressions, even without ventilations, is to circulate the existing oxygen bound to hemoglobin. While not as potentially beneficial as fully saturated hemoglobin (think oxygen dissociation curve), there is a benefit for vital organs to receive any amount of oxygen, thereby prolonging the initial 4-6 minute window to irreversible brain damage.

Understandably, a potential caregiver might balk at the concept of mouth-to-mouth, especially if the victim is a stranger, or has vomited/drooled. The revised AHA guideline seeks to sidestep this hesitation by encouraging rescuers without equipment to perform compressions rather than nothing at all.

A few years back, as I was leaving for work, I came across a crowd of people surrounding an elderly man who had collapsed while shoveling snow. He had already vomited (and likely aspirated), so I was not inclined to give mouth-to-mouth ventilations. However, I started compressions until the FDNY engine arrived with a defibrillator (almost 10 minutes during snowstorm). Once I attached it, he was in VF, and delivered one shock. EMS arrived shortly after and ran the code, but he expired at the hospital. The anecdotal point of this story is that even after being down for 3-5 minutes, followed by 10 minutes of good compressions, the pt was still in a shockable rhythm (and had a slim chance). With no compressions, he likely would have been asystolic after being down for 15 minutes with no circulation.

silverbat · Apr 16, 2010

my concern is that your LTC did not have a suction machine available. One should be on your "Crash Cart". You shuld not have hd to give the rescue breath if suction was available. If she had a pulse, compressions weren't needed. Please look into the no suction machine issue. I am glad your resident recovered.

Zookeeper3 · Apr 16, 2010

ACLS guide lines are check for responsiveness.... call for help... check for breathing if no, or agonal in your case give two rescue breaths, check carotid for a pulse...

if no pulse do 15 compressions... if there is a pulse continue rescue breaths until intubated or spontaneous breathing, place in rescue position. 2 breaths... 15 compressions. You did not say if she had a pulse or not, so compressions may or may not have been needed.

This sounds respiratory in origin, however there is way too much to rule out which the ER will.

The guide lines are there to encourage EARLY and quick compressions as the current O2 level should last for a minute or two until an airway can be secured... after the INITIAL first two rescue breaths are given, and then circulation assessed.

my concern is not suction as someone mentioned, that comes quick enough with a crash cart. My concern is with the lack or mouth/valve masks not being in the room to protect the initial responder from exposure.... YOU!

While I know nothing of long term care, these one way breathe into masks are in each room in hospital floor rooms. You've done a wonderful thing for this patient but need to follow up with your facility exposure protocol.

I am NOT in anyway judging your reaction, I gave mouth to mouth on my neighbor on the floor of her kitchen... we just make these decisions and they are ours to live with.

Just a thought for future codes, you never ever have to code in a bed, slide the patient to the floor and have at it there, it is safer for everyone's backs and shoulders and saves time, plus prevents dropping a patient during a harried lift procedure, the floor will do just fine.

You sound like a wonderful caring nurse, who responded quickly and I see you used your best judgement in the circumstances. My suggestions are just that to mill over for the future.

I'm an experienced ICU nurse and can code in my sleep, so it's easy for me to say what to do, as well as easy to just do it naturally, so I'm not knit picking you at all, just supportive suggestions. Above all, protect yourself, you can't help others if you don't protect yourself first:)

Sound to me like you did a great job, but know it's ok, to wait for protective equiptment to arrive.

silverbat · Apr 16, 2010

current AHA CPR guideline are 30 compressions to 2 breaths, not 15 to 2(except 2 man baby, and this will more than likely change to hands only before long. Some countries are doing 50 compresssions to 2 breaths.

I know that in some facilities masks are kept on med carts for easy access.

The OP stated that no suction was available. I don't like the idea of mouth-to-mouth, either, although I have done that when needs be. In ANY facility the ambu bag/mask should ALWAYS be used instead of mouth-to-mouth.

I carry a personal mask that is disposable for out of facilty use if I stop when needed at an accident or other emergency.

Kyrshamarks, BSN, RN · Apr 16, 2010

All the oxygen in the world will not help if there is no circulation in the body to get it to the brain.

tokebi · Apr 17, 2010

Oh wow, thanks for the input. I'm a fairly new member here, and I'm realizing how much helpful it can be to share here.

What I want to make clear is that when the situation first began -- when a CNA wheeled her out of the activity room and asked me to look at her -- all I saw was that she was drooling a lot more than usual and sounded like when your sinuses are impossibly stuffed up. Honestly, I wasn't that alarmed by it. With severe Parkinson's and recurrent pneumonia, her movements, her breathing, just do not appear comfortable to begin with. I asked the CNA to get her in bed and comfortable, while thinking that I'll go in to assess her and then give a call to the doctor.

In retrospect, she being an old, fragile lady, of course her respiratory muscles would give out sooner with fatigue. The surprise and panic I felt when I went into her room and saw her closing her eyes and becoming unresponsive as we shook her and called her name. That's when I asked the CNA's who were in the room to go to the station and call the code, and get the cart, oxygen, etc.

Giving mouth-to-mouth was more out of desperation than any judgement, I think. I was totally panicking at her face turning gray while waiting for the crash cart (which has the suction AND ambu bag) but unable to leave her bedside (I was the only licensed nurse there at that moment).

I only gave her one breath and the crash cart arrived as well as the RN supervisor. She commenced chest compressions immediately. I was at the head, maintaining the mask seal to the face, but I was so out of my mind that it didn't even register to me that I should check for pulse until after a couple rounds of chest compressions. When I felt strong pulse (although very tachypneic) I told her to stop compressions. But she countered that the heart would stop beating if we stop compressions -- that does not make sense to me but I was in no shape to argue with her in that situation. We only stopped when the patient opened her eyes, dazedly looking around at us.

My coworkers were making encouraging remarks and good-natured jokes even today over what happened yesterday. But I could not feel any more uncomfortable because I knew what I did was reckless and knew that they were thinking the same thing, probably. I whole-heartedly agree we cannot help anyone if we get ourselves into trouble. I think I'll get one of those disposable mask as mds1 mentioned.

I know I lack the confidence and quick-reflexes. This incident gives me quite a bad feeling over how it made me panic, because I'll be starting school again this fall and I'll be an RN after couple years. I am so-called "book-smart" but I can be quite slow in urgent situations. I've questioned often whether I really should be in this profession where so many situations require quick thinking.

For the past six years I've been an LVN, I've quietly stepped out in emergency situations because there was always someone who took the charge and I didn't want to get in the way. After two years of school, I will be the one who must take the charge. That is one heck of a scary thought...