ACLS algorithms

WindwardOahuRN, RN · Dec 1, 2009

I am a new grad and landed my dream job in the SICU of a level 1 trauma hospital. It has been an incredible experience! However, I am freaked out. On Tuesday we will be running ACLS megacodes. Our nurse educator said we need to know all the algorithms without hesitation. YIKES! I have my ACLS card, but I basically just learned enough for the exam. Anyone have any suggestions for learning them AND remembering them? I googled, but all I find are learning aides for old versions of ACLS. I appreciate any help I can get! Thanks!

The truth of the matter is that you can kill yourself trying to memorize algorithms but it's only that---book learning by rote. The odds are all of what you have spent hours memorizing will blow out the window when the real thing happens.

Learn the meds and what they do. Learn WHEN you are supposed to use them and, just as important, when they are contraindicated. Learn your shockable rythyms.

IMHO your instructor is a bit of a bully and is being unrealistic and counterproductive.

Reminds me of when I took my first ACLS many moons ago, when dinosaurs roamed the earth and defibrillators were hooked up to lightning rods. The instructor was an EMT whose head was so big his ears scraped the sides of the doorway when he entered the room. He was more interested in showing us how much he knew and showing us how much we didn't know than he was in seeing us learn anything. He was an ass. And this was back in the days when you could actually fail ACLS so we were all pretty much terrorized. Yep, pay your money, fail, and walk out the door with nothing. I passed but a few did not.

You're not going to be running codes any time soon. As a member of the Code Blue team I can assure you that it will be a long time before you will be expected to be anything but a go-fer during a code. It depends on your facility, of course, but you might be expected to push meds if you are the patient's primary nurse. If you are the primary nurse please step up and offer information about the patient---why he's in the hospital, recent surgeries, co-morbidities, whether he's received narcotics, anything you think might be important.

Offer to be the recorder, note the clock, the numbers of amps of epi and atropine (especially atropine), the defibrillation joules, the gtts that are running.

The really messy codes usually involve difficult intubations, tracheotomies, chest tube insertions, TVPM insertions and of course traumas and surgical patients who are bleeding out while they're coding. The most awful, IMO, are the codes in L&D that require c-sections while the mom is coding. You won't be a major player or decision maker in these for quite a while.

Mega-codes are nice and neat and all the "patients" live. It's so much easier to yell out the next step in an algorithm when you're not slipping in a blood slick and the patient is not vomiting into the ETT. You always have really good venous access with the ACLS dummy, they never weigh 500 pounds, and they're always found neatly on their backs (never wedged between a toilet and a wall, lying in a pool of liquid stool). Ahh, just reminiscing here..

Advice? Learn what you can, learn WHY we give the meds when we do, why we shock when we shock and why we don't shock when we don't shock.

The algorithms are a natural progression once you understand the basic mechanisms of the arrhythmias, the actions of the code meds, and the purpose of defibrillation.

Good luck and don't beat yourself up over this.

yesdog, BSN, RN · Dec 1, 2009

IMHO your instructor is a bit of a bully and is being unrealistic and counterproductive

HA!!!! You hit the nail right on the head! Luckily he is not my only instructor. He is extremely knowledgeable though, and I know that his intentions are honorable.

I wasn't born yesterday This is my second career. So, I am really good at looking very calm and the other new grads look to me for support. I just want to perform well in front of my peers. I just took that pre-test and got a 90%, so I guess I'm ready. I will tell you all how it goes! Thank you all for your support!

yesdog, BSN, RN · Dec 2, 2009

Hey all!!!!!! I ROCKED THE MEGA CODE!!! I volunteered to go first as team leader. I totally ran the V Fib code. Yeah! I also only missed 2 on the written test! WooHooo!!!!

Thank you all for your words of encouragement!

:dancgrp::dancgrp::dancgrp:

detroitdano · Dec 2, 2009

See? I told you it would work out!

Speaking of codes, I had a ridiculous one last night. Two hours of chest compressions, about 20 rounds of epi/atropine and extra epi for PEA(we emptied two crash carts and the Pyxis and had pharmacy tubing us extras), 5 or 6 rounds of shocking for V-Fib, multiple intubation attempts since she had a stent and horribly bloody airway. We have amps of Bicarb, Amiodarone, Levo, it was insane.

Glad I studied up on my algorithms as I was the one telling people to back off so we could get some shocks in there.

She lived thankfully, albeit with nasty pneumo's from the trauma of keeping her alive. Hope she makes it, she was fine a few hours prior.

yesdog, BSN, RN · Dec 2, 2009

That's so great! So many times a code is such a feudal effort or it is performed on someone that should be allowed to die in the first place. I did my clinicals in the MICU and saw so many families thinking that we could make grandma all better if she was a full code. It was sad. My hope is to someday help with better education for families in order to understand end of life care.

WindwardOahuRN, RN · Dec 2, 2009

Hey all!!!!!! I ROCKED THE MEGA CODE!!! I volunteered to go first as team leader. I totally ran the V Fib code. Yeah! I also only missed 2 on the written test! WooHooo!!!!
Thank you all for your words of encouragement!
:dancgrp::dancgrp::dancgrp:

There ya go! Congratulations---now just keep swimming! :yeah:

nurse_mo1986 · Dec 5, 2009

The current emphasis in ACLS instruction is to teach people to use their tools. At my hospital, we keep the alogorithm cards on the code cart. We are expected to refer to them in an actual code. Trying to rely solely on memory is a recipe for error. I doubt you will feel confident in taking on this battle, but I think that if your nurse educator is actually expecting you memorizing the algorithms and run codes without the benefit of memory aides such as the AHA cards she is behind the times.

While I also think that the resources should be available in a code situation, I also think that yes, we should have the algorithms memorized completely. We see a lot of codes in my CCU, and I fully expect for myself and fellow staff members to be able run a code without having to stop and check a little booklet to "see if we're doing the right thing." You should know it inside and out before being expected to be an ACLS team leader.

WindwardOahuRN, RN · Dec 6, 2009

Pardon me but there is no way in Hell that any self-respecting nurse who is a member of the Code Blue response team would depend on ACLS cards to get her/him through a code.

There is also no way that you can function effectively in a code if you are still in the "oooh let me think oh I gotta look that up hold on a minute yeah I think I got it" phase.

THINK, babies. People's LIVES depend on us. SECONDS count in a code. This is not a dress rehearsal or a mock scenario Mega-Code with a dummy who cannot die. You do not have the luxury of time, second guesses, ruminatiions.

If it were your father/mother/spouse/child/loved one---how would you feel if you saw them crashing and burning and the people who were responsible for saving them were fumbling with cue cards while they were dying??

An ACLS course certificate does not equal Code Nurse material.

Laminated cue cards during a CODE??? Are you SERIOUS???? IMHO this is the height of idiocy and just so frightening. What's next, a copy of "CODES FOR DUMMIES" strapped to the code cart?

To think that this anyone believes this is acceptable and even admirable is just plain scary.

yesdog, BSN, RN · Dec 7, 2009

Are you my nurse educator? :hehe: I kid I kid!

I think you are right. A member of the code team should know the algorithms inside out. The fear that the nurse educator put into me made me study the algorithms until I got into the "rhythm of the code". It was really hard work, but I am so glad I did it. Although I will not be running a code any time soon, I now understand the concept of the algorithms. With experience, I hope to someday be able to have the knowledge and ability to be an integral member of the code team. I sure wouldn't want anyone looking at a card in order to run a code on one of my patients...or worse....one of my family members.

Thank you again for reminding me how important this issue is.

WindwardOahuRN, RN · Dec 8, 2009

Are you my nurse educator? :hehe: I kid I kid!
I think you are right. A member of the code team should know the algorithms inside out. The fear that the nurse educator put into me made me study the algorithms until I got into the "rhythm of the code". It was really hard work, but I am so glad I did it. Although I will not be running a code any time soon, I now understand the concept of the algorithms. With experience, I hope to someday be able to have the knowledge and ability to be an integral member of the code team. I sure wouldn't want anyone looking at a card in order to run a code on one of my patients...or worse....one of my family members.
Thank you again for reminding me how important this issue is.

The fact that you seem to grasp your limitations, as they are at this moment, is so refreshing. You're building a foundation here and I really think you get the concept.

A little humility, a little sense of one's smallness in the huge venue of critical care is nice to see.

I think if I see one more newbie declare that they are an "ICU NURSE---WOOOHOOO" after getting through orientation and preceptorship I will scream.

No, dear...you're not an "ICU NURSE." You're a nurse who works in ICU.

Big difference.

It takes time and more than one baptism by fire to earn the title.

Critical care is a very messy and often heartbreaking area of nursing. Requiring high-tech skills, quick reflexes (both mental and physical), and the ability to remember that, with all the high tech stuff, there is a real person in that bed. Juggling those high-tech tasks, high-risk meds, family needs, PIA docs, staff conflicts, no breaks,---it all adds up to such a very tough work environment.

Good luck to you as you go on with your ICU career. Doubting yourself is not a problem, IMHO. It's the ones who are so damn cocksure of themselves (and there seem to be so many these days) that scare the crap out of me.

And, BTW, I have been asked to be an educator more than once, LOL. I've politely declined, thank you. I'll gladly teach when the opportunities present themselves but frankly, I kinda like where I am right now and could live quite happily without the added aggravation. :specs:

yesdog, BSN, RN · Dec 8, 2009

Thank you again for your words of wisdom. In one week I will be on my own. As all of the great RNs that I work with tell me "on your own but never alone". I feel so fortunate to be in the place I am. Every day I learn so much. But also each day I am so humbled. There is so much to learn. Sometimes it is so overwhelming. What I fear the most are "the things I don't know I don't know". It is one thing to know that you need to ask someone, but what if there is something that I don't realize? I hope I can always look with a critical eye and know when I need help. As you said, I am not a critical care nurse yet. I am barely a nurse! I hope to grow and learn each day in order to someday be a critical care nurse. Thanks again!

PDX_RN · Dec 8, 2009

Pardon me but there is no way in Hell that any self-respecting nurse who is a member of the Code Blue response team would depend on ACLS cards to get her/him through a code.
There is also no way that you can function effectively in a code if you are still in the "oooh let me think oh I gotta look that up hold on a minute yeah I think I got it" phase.
THINK, babies. People's LIVES depend on us. SECONDS count in a code. This is not a dress rehearsal or a mock scenario Mega-Code with a dummy who cannot die. You do not have the luxury of time, second guesses, ruminatiions.
If it were your father/mother/spouse/child/loved one---how would you feel if you saw them crashing and burning and the people who were responsible for saving them were fumbling with cue cards while they were dying??
An ACLS course certificate does not equal Code Nurse material.
Laminated cue cards during a CODE??? Are you SERIOUS???? IMHO this is the height of idiocy and just so frightening. What's next, a copy of "CODES FOR DUMMIES" strapped to the code cart?
To think that this anyone believes this is acceptable and even admirable is just plain scary.

Ask yourself if you would be more frightened by having someone double check a drug dosage that they were not 150% sure of versus them relying solely on their memory in a stressful situation that for some of the readers of this forum is likely not an everyday, or even every month situation and likely giving your loved one the wrong medication? The fact is, people make mistakes in codes quite frequently. This is actually something that has been studied extensively and we know that patients get the wrong med, or the wrong dose, at the wrong time, around 10-30% of the time. Deviations from practice guidelines happen a lot. Many readers of this forum will read that and think they couldn't possibly be responsible for a med error, but it happens are patient outcomes not doubt suffer for it. I was not describing a situation where the code leader is clueless about what to do, and stares blindly at a algorithm, card like it was the first time they've seen one. But get serious, you got 2 minutes of compressions before the next action. Why not take a deep breath; look at your card; double check that dosage; make sure you aren't forgetting anything; ask your team members if they have any ideas? I don't think it adds anything to the discussion to scoff at someone who is humble enough to make use of an available tool, to ensure that they are adhering the best available scientific data as they attempt a resuscitation. Quick: what's the max dose of lidocaine you should give a 79 kg man in refractory v-fib? If you think you might have even a shadow of a doubt what the answer is in the heat of a code with the pressure cooker on high, why not make sure you know where your little flip book is? Because if you get it wrong, it will likely be by a factor of 10. That can't be good.