I recently went on vacation & was on an airplane. A person on the plane had a seizure & then went into full arrest. There was another RN on the plane with me. We are both ER nurses & ALCS certified. We used a BVM & an AED. We started an IV and gave epi. All supplies were from the plane. My license is in California. We Diverted to Nevada.
Looking back I wonder if I was covered under the good Samaritans law or did I practice outside my state & scope of practice. Technically, although we left California we landed in Nevada so I wasn't in my state. Also, there was no doctor on the flight who gave the epi order.
And if the patient is in rapid a-fib or SVT and you give epinephrine you have just killed the patient. The monitor is a tool to guide your assessment.
As already stated, these patients (afib rvr and svt) would have a pulse. Assess the PATIENT. If you have no apical, carotid or femoral pulses, they need epi.
That drug kit needs to be updated. There's no amiodarone. Lidocaine was removed from ACLS in 2010. They need to include the IO. This doesn't inspire a whole lot of faith in the FAA on call physician.
All bets are off at 30,000 feet. I would do what I could with limited equipment such as the oral airway and BVM with max 4 lpm 02, AED, high quality CPR, and the two doses of epi 1mg and the lido 1mg/kg (it's ok for refractory VT not responsive to amiodarone) provided until ROSC. If there was no terminal illness, dementia or coagulopathy, we will cool him while continuing to monitor.
How can Defibrillation be within scope of practice, and epi be outside scope of practice? There is nothing benign about defibrillation, and if done on the wrong patient, can be a heck of a lot worse than epi. We even revert to the amount of electricity as a "dose".
I was thinking of the AED's that analyze the rhythm, and if the machine determines V-Fib, the machine provides voice instructions to the user to press the button to deliver a shock (the dose of which is pre-set on the machine). What contraindications are you thinking of to defibrillating a patient in V-Fib, who is pulseless and unresponsive?
Specializes in Psych, Addictions, SOL (Student of Life).
Personally I would be the most worried that I gave epi without an order, even with ACLS training.
If they were carrying epi on a plane who would be the person trained in administering it?? I guess I don't understand how they would even be allowed to carry it if the flight attendants aren't trained in it- but I don't really know much about what training they get.
Just a thought that Lay people give epi all the time - I have had an epi pen for my allergic asthmatic son since he was two. Because he goes to a private school any number or teachers, coaches and Scout leaders have been trained - by me and authorized by me to give it when needed.
The current guidelines call for promptly beginning CPR, and AED as soon as it is available (assuming rhythm analysis reveals a shockable rhythm). Medications are secondary. Without an existing written medical protocol on board, or availability of a physician on the ground to give the order for epinephrine to a licensed nurse over the radio, I am inclined to believe that if the rescuers are nurses, even if the nurse/s are ACLS certified they would be acting outside of their scope of practice by administering epinephrine without a medical protocol or physician's orders. Compressions, yes; AED, yes, as soon as possible, to analyze the rhythm and deliver shocks if indicated; BVM if there are sufficient trained rescuers.
You are correct about medication being secondary, but you are 1000% incorrect about needing an order for ACLS medications - that is the entire point of ACLS certification and why people get it. If you are ACLS certified with those medications available (and no MD) you would be negligent for *not* giving them. I bring this up because lives could be lost because of this incorrect and flawed line of thinking.
You are correct about medication being secondary, but you are 1000% incorrect about needing an order for ACLS medications - that is the entire point of ACLS certification and why people get it. If you are ACLS certified with those medications available (and no MD) you would be negligent for *not* giving them. I bring this up because lives could be lost because of this incorrect and flawed line of thinking.
I checked the Board of Registered Nursing information on nursing practice for my state in regard to Good Samaritan laws, and I am still unclear.
In my posts I did not say that I believed an MD needed to be present; I said that I was inclined to believe that without a written on board medical protocol or physician's orders a nurse, even if ACLS trained, would be acting outside of their scope of practice by administering epinephrine in an on board emergency. I am quite willing to learn that this is not the case, but I have not yet satisfied myself that this is so.
I was thinking of the AED's that analyze the rhythm, and if the machine determines V-Fib, the machine provides voice instructions to the user to press the button to deliver a shock (the dose of which is pre-set on the machine). What contraindications are you thinking of to defibrillating a patient in V-Fib, who is pulseless and unresponsive?
There are no contraindications to either defibrillation or epi, and both should be given and both are within the scope of practice of the RN.
Just a thought that Lay people give epi all the time - I have had an epi pen for my allergic asthmatic son since he was two. Because he goes to a private school any number or teachers, coaches and Scout leaders have been trained - by me and authorized by me to give it when needed.
Actually, the exact same question could be given in the event of an out of hospital response to anaphylaxis.
It is, of course, common practice for lay people to give epi. And, more increasingly, Narcan.
But it is a reasonable question as to whether it is in the nursing scope of practice to give any med outside of an established medical framework and without an order.
The fact that it is prescribed to the pt does not make it an order for me to give.
I checked the Board of Registered Nursing information on nursing practice for my state in regard to Good Samaritan laws, and I am still unclear.
In my posts I did not say that I believed an MD needed to be present; I said that I was inclined to believe that without a written on board medical protocol or physician's orders a nurse, even if ACLS trained, would be acting outside of their scope of practice by administering epinephrine in an on board emergency. I am quite willing to learn that this is not the case, but I have not yet satisfied myself that this is so.
You can't compare the two. A flight falls under federal, not state guidelines regardless of what state the plane is flying over.
ACLS is essentially a medical protocol so I'm not sure it's completely true that an ACLS trained nurse who follows it is acting outside of medical direction.
As for the use of epinephrine and outcomes, there are studies that shows a correlation between the amount of epi given and poor neurologic and long term outcomes, but as far as I know there is anything that shows causation. More likely, a higher cumulative epi dosage just reflects a longer period of time without spontaneous circulation. Somebody who has return of circulation after only one minute of CPR is going to do better than someone who required CPR for 30 minutes and therefore received multiple epi doses, but that poorer prognosis is at least partly, if not completely due to the additional time in a hypo-perfusing state.
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https://allnurses.com/critical-care-nursing/acls-requires-a-661779-page2.html
Some interesting discussion from different perspectives.