Please walk me through a code blue

EDValerieRN, ASN, RN · Sep 8, 2005

Is there any way you could get into an ACLS class? It helps with the process, so you'll know what to expect (when to give what meds, what the doc is thinking, etc.)

I work in the ER, so usually we can see a code coming and get ready for it. Call for help, yank the call light out of the wall to get the emergency light on... and after the code team comes in, it depends a lot on hospital policy.

Put a backboard under the patient if they are in a bed!!! This is so important, and I've never heard it taught! There is usually one on the bed somewhere, or on your crash cart.

One person will do compressions (deep compressions, it suprised me at how far I had to push down) While one person will bag the pt. to breathe.

When the code leader (doc usually) gets ready to tube the patient, you'll halt compressions right before he goes in. Once the tube gets in, compressions never halt for breathing, you just keep on keepin' on, with an occasional pause to check for a pulse.

A lot of it depends on the doc. I have one doc who will think aloud, and he says everything he is considering, so you have to make eye contact with him and repeat the order back before doing it, because he could be saying it but not really wanting it done. Other docs are smooth with it, and very calm. Some docs freak out and are really jumpy/loud.

You may be giving medications during the code. Most meds in the crash cart (epi, lido, amio, etc.) are pre-drawn up, and just need to be screwed in and pushed. Always flush them down after pushing them. If you take ACLS you will learn the doses.... it is convenient that the standard dose (in adults) is one box. Makes it easier. Also the boxes are color coded.

Go through your crash cart, learn where every single thing is. Play with the defibrillator and see which switches do what (most have a learning mode). Watch the first few codes, and gradually join in as you feel like you can. Usually more people than you would ever need show up to a code. Remember the guy is already dead, you're just trying to bring him back. Most codes aren't successful. That doesn't make it any easier, but it helps to know that.

The biggest problem I've ran into in codes is staff not knowing where things are. That will probably fall to you, because the code team most likely does not work on your floor, so they don't know where to find things they may need (drugs, cart, extra IV supplies, central line kits, etc).

Read your hospital's policy on codes and the code team. You will never feel prepared when you walk in and find someone down... because you aren't prepared. Nurses just don't expect to find their patients dead. If you do feel like someone is gonna crash and you can't ship 'em to the unit, pull the code cart up outside their door. Put them on a monitor, and gather supplies. Set up wall suction and oxygen. This is all JUST IN CASE!

I hope this helps! Let me know if you have any specific questions- I'm new myself, but I've already been through 14 codes during school and as a new grad. They were different every time, and I still feel a wave of panic when one is called. I've found that during the code I'm in a zen mode, not really thinking, just doing what I was trained to do. It's afterward that I freak out.

jmgrn65, RN · Sep 8, 2005

help should come, a code team, and they usually will take over, you become tired quickly while performing cpr. They will need to know info on your patient if you don't know get the chart. Don't leave the room stay and at least chart everything that happens, this will get you used to seeing and being around codes. Remember airway is most important, so check for breathing first. well after yelling for help. :)

Editorial Team / Admin · Sep 8, 2005

Okay, I am a new RN working on a hectic med/surg floor. I have never seen a code in school or since I've been working. I've seen tapes in school about the process and the mayhem that goes on. I am terrified (having nightmares actually) that I will walk in the room, my full code pt. is not breathing, and I don't have a clue what to do.
(As you can tell, my orientation left a little for the imagination)
If my understanding is correct- (please correct me)
First I would yell at or try to arouse the pt, maybe shaking them
If no response, (check for breathing and pulse)I would yell for help while lying bed flat and getting pt positioned for CPR
Then initiate CPR
By this time, someone has called the code since I yelled for help a few steps before-
When the code team comes in, do I just keep on doing CPR, or does someone move me out of the way and intubate?
What is my role after that?
What if I just came on shift and only know a small amount about the pt?
As you can tell, I want to save this person- I don't want to mess up. Can you tell I'm panicked?
BTW, I've never done real CPR either.
Please help
bfbuff

Hello, bfbuff,

First of all, calm down.......

Have you taken ACLS? If not, sign up for this. I am sure you have BLS.

Now..........when you see someone that you suspect has "coded".....first verify responsiveness or lack there of......."Are you o.k.?" Gently shake them at the same time. You were right on that!!

If no response, call for help......

Now, think A - B - C........A=airway. Create an airway by doing a jaw thrust. B=breathing. Look, listen and feel for air exchange. Do you see the chest rise and fall? Do you feel the air on your cheek when you lean down? Do you hear them breathing? If not, give two breaths.

C=circulation. Now, check for a pulse at the carotid. No pulse? Begin chest compressions and alternate with ventilations.

Help is here as you said. You will continue CPR until otherwise instructed. You may continue chest compressions or ventilations. You may be asked to record. You may be asked to administer drugs. Many different things.

As for not knowing anything about the patient, well, that happens. You may know NOTHING about him/her. It does not change the basics.

But, you have the basic idea.........You need ACLS, however. It helps.

Good luck. You will do just fine. I promise.

UM Review RN, ASN, RN · Sep 9, 2005

I had the same "Code Fear" as you express.

Our docs are very calm, very smooth in a Code and that helped me learn to be calm.

I went to every single Code. Sometimes I'd be able to help get gloves or run and get supplies while I picked up a little more information each time, until I felt comfortable calling a Code and initiating care.

At this point, I just step in wherever I'm needed.

I also took ACLS so that I could understand what was happening better and be able to anticipate how to assist.

There's truly nothing more gratifying than being part of a successful Code.

bellehill, RN · Sep 9, 2005

The first few codes I saw I was the recorder, that is an enormous help to learn what happens and when. I have been in maybe 5 codes, they don't really get any easier. The main thing to remember is stay calm, help is coming. Remember the ABC's and you will be fine. Someone mentioned chest compressions and how hard you have to press, very true and you will get tired very quickly.

There will be alot of people who respond especially if it is a teaching hospital. Sometimes it is too many people and you will need to elbow your way through the crowd, don't be afraid to elbow, these residents are doing the same thing you are...learning. I can't emphasize enough,.....stay calm. You will be fine.

My patient coded last week and ended up going for an emergent trach, I still don't agree with that coorifice of action but that is for another thread. The main thing is that I spoke up and questioned what was going on, I was there with the chart to give info and I coordinated what was going on. The hard part was for the docs who couldn't intubate the patient. there were probably 5 people (residents) standing around the bed watching, I was the one who was doing. Trust yourself.

chadash · Sep 9, 2005

question: when do you attach a monitor? How do you determine when to shock, and when is schronized shock needed?

hrtprncss · Sep 9, 2005

question: when do you attach a monitor? How do you determine when to shock, and when is schronized shock needed?

During Primary Survey.....You determine to shock if the rhythm is shockable and the patient is pulseless, synchronized is done when a patient is unstable and medications are not working, an R wave is needed as a determinant for a synchronized shock which is not present on Vfib.

hrtprncss · Sep 9, 2005

I guess I should be more specific in regards to when you place the monitor. The answer is as soon as you can when it is available. When a patient develops sudden cardiac death, most likely culprit is vfib. And it's definitive treatment is to shock the patient. There's no way to know wether a patient is on vfib unless the patient is put on a monitor. CPR though an admirable and very usefull tool during a code would not convert that patient back into NSR therefore putting a monitor ASAP is a must.

chadash · Sep 9, 2005

During Primary Survey.....You determine to shock if the rhythm is shockable and the patient is pulseless, synchronized is done when a patient is unstable and medications are not working, an R wave is needed as a determinant for a synchronized shock which is not present on Vfib.

How about pulseless VT? would that be considered to have a R wave? or would that be treated with an unsynchronized shock?

With Vfib, do you start shocking before meds?(again, unsynchronized)

chadash · Sep 9, 2005

Oh, and by the way, thanks sooo much for your answers!

hrtprncss · Sep 9, 2005

Pulses Vtach needs to be shocked asynchronously just like Vfib and follows the same algo as Vfib, and yes you shock first before any meds are given. I teach ACLS and this has been phased out but when I was first a nurse, this was the mantra and it helped me out....

Shock Shock Shock, Everybody Shock, Little Shock, Big Shock, Mama Shock, Papa Shock, Everybody Shock...though with the advent of Amiodarone that's been lost since ACLS is now geared to be more basic...I guess we could have put "Auntie Shock" j/k