Codes-ACLS drugs-reasons for the code

[vampireslayer]

Don't ya hate when you have to ask a question that you KNOW you should know already? Well, here's another one.

I've been in a lot of codes, been in the ER over a year now. They don't scare me, I can be secondary nurse (the "do-er") or primary (the writer) with no qualms. So that's a huge improvement. But here's the thing...I know the ACLS drugs, I know to ask the paramedics before they leave how many rounds of epi/atropine they've given, what rhythms they've seen, if they lost the pulse, what time did that happen, etc.

But then, one time I asked the doc if he wanted to give another round of atropine, we hadn't done the max of 3 rounds...and he answered something like "well, no, I don't think heart rate is a problem".

In ACLS they teach us the drugs, they teach us the max doses, etc...but they don't teach us WHY we're giving them! There's an ER101 post that I just read, and it's a good beginning reference, but I still don't think I totally get why we give certain drugs, and why that doc would say "no" to the atropine. Every single other code I've ever worked, we give the epi/atropine rounds until the atropine's maxed out. I never even thought to look at heart rate, we just give it cuz ACLS says you can give 3 (although I have given atropine in other situations, so I should KNOW that).

And that leads me to my next question...aren't we supposed to be looking to see if there's a reason for the code? My real concern is that I have a diabetic child, and I've seen him go REALLY low before, but he's never lost consciousness. So what if it's a severe hypoglycemia? Or some other treatable cause, that causes the unresponsiveness...that led to respiratory arrest and/or cardiac arrest? Most of our codes, we never even bother to collect blood. We look at times, how long has he been down? If he's been down a long time, we know there'll be no brain function left, so we usually do the obligatory epi/atropine, maybe some bicarb, calcium, whatever, then we call it. I've only ever seen ONE nurse ask for a d-stick, no blood was ever collected.

Is that how everyone else handles the codes? Aren't there reversible reasons (like severe hypoglycemia?) that could have caused the code? If they're coming in the door from EMS already in full arrest, is it too late to deal iwth any of the possible causes?

I feel like I know how to "do", but not to "think" about the codes. But I feel like I should KNOW this. How could I have been working many many codes by now, and not know this stuff?

Thanks!

VS

[rjflyn, ASN, RN]

As ACLS has been just recently been revised I am told that there is more emphasis on good CPR and less on drugs.

In your example the doctor based on his experence chose not to give more atropine. Why- could be a number of reasons such as the first 2 doses didnt do anything so most likely another wont either.

As far as hypoglycemia a cause for a code it is entirely possible. As for an amp of d50 magically improving things not likely. My first code back when I was a medic 18 yrs ago the patient was diabetic, BS in the 30's and not successful. D50 made no difference. And actually if you do successfully resusitate someone you dont want an excessively high blood glucose as it can and does cause further brain issues.

Rj

[km5v6r, EdD, RN]

Ok, you really need to go back to your drug book from school and look up these meds. Every med in a Code is given for a specific reason. To give meds and not know why they are given is not a good situation. Every single action in a Code is a direct response to the heart rythmn on the monitor and the physical assesment of the pt; not because the protocol said to. No the instructors in the 2 day ACLS class did not go over the rationale behind every drug. It is in the pharmacology chapters in the ACLS book. The assumption made is that the person taking the class has already read the book and knows this information.

So the doc didn't want to give another dose of atropine. Atropine works by blocking the vagus nerve of the parasympathic system of the heart. Basically Atropine increases the heart rate. If the heart rate is slow and ineffective; say 20-30's or slow PEA; Atropine may raise the rate to a more effective rate; 80-100+. If the heart's electrial activity is already fast enough; say above 60; making it go faster doesn't mean it will be more effective. A heart rate of 160 without a pulse is no better then 60 without a pulse.

As far as looking for the reason for the arrest; in adults unless you are dealing with PEA the reason doesn't matter. Something like hypoglycemia is not going to cause V-fib. Until the electrical activity of the heart is restored nothing else matters. PEA is different because the electrical activity still exist, the heart is still trying to beat but mechanically can't. Also remember asystole is a terminal rythmn. You can't jump start a heart.

[sirI, MSN, APRN, NP]

And that leads me to my next question...aren't we supposed to be looking to see if there's a reason for the code?

Exactly and a good observation on your part.

New ACLS changes include looking for the cause of the arrest in every situation. This includes V-fib/bradycardia/SVT and not only PEA/asystole. This is something that should have been taught all along.

ACLS EP (experienced provider) is an excellent course as well. It takes the individual "pre-arrest" and helps to identify and implement interventions that can intervene before the arrest.

[RunningWithScissors]

It's called critical thinking skills.

[vamedic4, EMT-P]

QUOTE: As far as looking for the reason for the arrest; in adults unless you are dealing with PEA the reason doesn't matter. Something like hypoglycemia is not going to cause V-fib.

:wakeneo: Ummm, yes, it can. Hypoglycemic patients code frequently.

QUOTE: Until the electrical activity of the heart is restored nothing else matters. PEA is different because the electrical activity still exist, the heart is still trying to beat but mechanically can't. Also remember asystole is a terminal rythmn. You can't jump start a heart.

Not entirely true either, it's both we can't live without, but it's the MECHANICAL activity of the heart that we live on.

We are taught to look for reasons for particular rhythms :

for PEA we remember PATCH4 -pulm. embolism, acidosis, cardiac tamponade, hypovolemia, hypoxia, hyperkalemia, hypothermia.

You should always be thinking about "How" this patient could have gotten in this situation...was it drug related? Accident/trauma? hypoxia due to asphyxia?? Every detail you know alters your treatment plan, and helps you better take care of your patient.

Next time you're in a code, think to yourself...OK...he's in asystole - what have we done so far...what could it be?? What's left to try??

And let's hope it never gets that far.

vamedic4;)

And no, while we don't "jumpstart" the heart, we do attempt to "restart" it in the correct rhythm, with either manual (CPR), electrical (defibrillation) or pharmacological (epi, atropine, adenosine) interventions.

[km5v6r, EdD, RN]

Ummm, yes, it can. Hypoglycemic patients code frequently.

In 23 yrs of CCU nursing I have never seen a pt go into V-fib from hypoglycemia. And if they have, a dose of D50 is not the immediate answer. Even the TPN dependent pt who went through 6+ hours of OR with NS only and came to the room with a BS of 16 didn't have arrthymias. He suffered massive brain damage and siezed for days but his rythmn was always stable.

To go back to the OP the person works in ER and was questioning why things like a BS were not a priority check on a pt coming into the ER in what I assume was PEA or terminal VF. The OP did not know what rythmn was being treated, why the code was stopped or why the meds were being given. Pretty hard to know which protocol to follow and drugs to give if you don't know what you are treating. I still contend that until the heart is beating in an organized manner with a perfusing pulse the cause of the VFib is moto. The only treatment for PEA is to treat the underlying cause of the PEA if it is treatable.

New ACLS protocols called for more pre-code assesment and prevention. We don't have a lot of luck with long term survival if the condition deteriorates to the point of full arrest. Someone who rolls into ER in full arrest doesn't give alot of opportunity for pre arrest assesment and intervention. ACLS protocols have also changed. You can not apply the standards of today to a situation from even 6 months ago. The ACLS I began teaching 15+ yrs ago is not the same ACLS taught today. I started teaching when Bicarb was one of the first things given and large amounts were given. We don't even name the rythmns the same. Remember EMD?

[angel337, MSN, RN]

it is the nurses responsibility to know the MOA of all drugs and the reason why they are given. you can kill a patient if you just follow orders and protocols. i have been an ED nurse for 3 years and there have been many times that we have not given all 3 rounds of epi/atrop because of various factors...such as the rhythm, heart rate, the PATIENT and their condition. i'm glad that you posted this question, because i do believe alot of people don't know why and just push drugs because they are told to. i know that i am not a MD, but before i give ANYTHING, i must be comfortable with why i am giving it.

[Jennifer, RN]

In ACLS, you are being taught the drugs and WHY you push them d/t the algorthyms being addressed. If you are not sure of why you are pushing a certain drug for asytole, PEA, V fib or SVT, then you need to learn your drugs. Read up on them before you push them. Not just emergency drugs, but drugs like K runs too. I don't know how many times I have come on to a nurse giving a K run by gravity. Some drugs are diluted with certain diluents, some are given over a certain amt of time. LOOK UP YOUR DRUGS!!! It is your license!!! If you are still not sure of why a doc didn't give a drug, or gave an order for a different one, ask the doctor why. ER docs are usually very receptive to teaching. At least where I work they are.

[Nurse Beachbum]

This website should be used to help each other. Not to make the person asking the question feel stupid.

[Nurse Beachbum]

it's called don't get an attitude....help each other!

[nghtfltguy, BSN, RN]

i was not there during that code.... you have to do what you think is right.... and as many others have said... it is your license on the line....i run codes a lot.... but that is just cause i have that kind of experience.... the doctors do not question me... they let me run the show... just do what you think is right when it comes to a code.... use your ACLS... and if your shy... listen to the docs.... my docs don't question me.... they know. im smarter than them..... :)