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Discussion

? about coding the post Open Heart pt???

this question is only concerning the first 24 hour period. do you deviate from ACLS protocols or do you give 1 mg epi q3-5 mins? anyone use calcium chloride ?

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this question is only concerning the first 24 hour period. do you deviate from ACLS protocols or do you give 1 mg epi q3-5 mins? anyone use calcium chloride ?

from my experience still follow acls protocols but no chest compression attach pt to external pacer using the pericardial wire then get you IABP ready for they might insert it

I agree with most of the other posters....been working CVICU 10 years. If patient is asystole I'd be doing compressions unless I had a surgeon standing there opening the chest. No compressions means no circulation so you can push as many drugs as you want without any response and how do you explain that to a jury when asked why chest compressions werent done? I'd rather deal with the complications that might occur if compressions are done on a fresh open heart patient then explain to the family why the patient is dead.

that is a very good point for a client that is already flatlining then chest compression is a must

Our facility's practice is to do compressions lateral to the sternotomy site utilizing two people

from my experience still follow acls protocols but no chest compression attach pt to external pacer using the pericardial wire then get you IABP ready for they might insert it

With no compressions?? How are you circulating your drugs? By the time the IABP is inserted or chest opened..pt has already been anoxic.

We do chest compressions on our open hearts. We do them from the side (toward the heart, from the sternum) and we do them hard and fast. Our CV Surgeon REALLY does them hard and fast. Even the time it would take to prep for a sternotomy the pt would have been pulseless and anoxic. Even if you had an open chest cart in every room. We have had to take someone back to evacuate a hematoma and do a stat echo on all pts after compressions. We are usually having the echo tech look for tamponade all at the same time.

PLEASE do chest compressions on ME!!!:uhoh3:

And we give bicarb and calcium chloride routinely..when they are crashing.

Very Good point.

Unfortunately, pacers wont help in certain situations/arrests.

Do you mean you withhold compressions in all patients with wires??

they meant trying to pace and get capture first rather than immediately starting compressions. you'd be surprised how often peope forget about their wires. Though oftentimes you wont capture anyway :/

To not do compressions on a pt. with a non-perfusing rhythm is assinine. CPR can be done on a sternotomy pt, it just needs to be done differently.

There are very few cases in which you're gonna do a re-entry at the bedside, and hopefully the surgeon is smart enough to take them back before it gets to that point.

Why would acls be any different on a fresh heart? If anything its more liberal.

Compressions!!! Always, if the pt has a non-perfusing rhythm--otherwise all of your other efforts will be futile.

Had an open chest code today and compressions were done until the surgeon was at the bedside to open the patient up.

We do regular (i.e. aggressive) compressions on our open hearts until the surgeons arrives. Does anyone know of anything is the literature re: coding open hearts? Does the red cross have a set of recs? Last time I took ACLS I didn't work with hearts, but I don't remember anything specific?

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This is a very interesting thread. As someone who works in a cardio-thoracic surgical critical care setting, my colleagues and I have participated in ICU re-sternotomies or "cracking open a fresh chest" in the setting of strong suspicion of cardiac tamponade. However, more often than not, patients who do so poorly and have to be coded are ones who were really sick on arrival and already have an open chest which makes it easy to do direct cardiac massage. It is also fortunate for our unit, that we have 24-hour coverage from mid-level providers like myself who are trained in re-sternotomies.

But what does one do in settings where nobody trained in ICU re-sternotomy or open cardiac massage is immediately present during a code requiring chest compressions. I honestly couldn't find any literature or standard of care on the matter. However, Robert Bojar's Manual of Peri-operative Care in Cardiac Surgery covers the topic and states that external cardiac massage at a rate of 100/min should be initiated at a rate of 100/min if unable to defibrillate or establish pacing within 30 seconds of onset. It also adds that external massage can result in disruption of the sternal closure, injury to the bypass grafts, or damage to the ventricular myocardium from prosthetic valves. Well we all know that. So I guess this goes along with the concensus that current ACLS guidelines should still apply until someone trained to open the chest arrives.

One should also remember that opening the chest is only indicated when strong suspicion of a cardiac tamponade as the cause of the cardiac arrest is present.

Calcium and Bicarb and used often in our hearts, even without code situations.

this question is only concerning the first 24 hour period. do you deviate from ACLS protocols or do you give 1 mg epi q3-5 mins? anyone use calcium chloride ?

No compressions is strange, you might need to re eval that, but we have pretty much stuck with the standard acls round of drugs

The only thing I get take from your question. Is when I have my OHS I have to ask the hospital if they are going to do compressions on me if I need them. An arrest is an arrest is an arrest, ACLS no matter and that includes compressions. Please talk to your educator and have them do just a little bit of research, in order to change your policy.:bugeyes:

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