JenHRN

So this is the exact dilemma I'm referring to. Are you checking a pulse during these episodes? Because if it's longer than 10 seconds without a pulse, aren't we doing our patient a disservice by not initiating compressions? But I get it, in those situations where we suspect vasovagal syncope, it seems counter-intuitive to start compressions so quickly. There's a part of me that wants to give them a chance to recover.. and 10 seconds is not very much time to recover. That said, the conclusion I'm coming to based on my experiences and the responses in this post is that I will never question it again. To elaborate on the episodes I've witnessed... the first woman was young and recovering after a car accident. She had multiple rib fractures, but was otherwise stable. She was on our telemetry unit. The surgeon wanted her up out of bed. The primary nurse (not me) asked for myself and one other nurse to assist with getting the patient up for the first time. She was pre-medicated with dilaudid, but still in significant pain. She lost consciousness as soon as moved her from laying flat to sitting on the side of the bed. Sounds like vasovagal, right? But this is the woman that needed 1-2 minutes of CPR. And I agree with a previous post that 2 minutes is more than a syncopal episode. So if we had waited it out (which we didn't), the outcome could have been bad. Who knows? But the surgeon was PISSED that I did compressions. His exact words were "you mashed on that chest?!" My response was "three nurses could not find a pulse, what was I supposed to do?" The second episode was an elderly woman in with frequent falls and a hairline hip fracture. I was ambulating her from the bathroom to bed when she collapsed in my arms. She did have a cardiac history and also a history of multiple falls (without a clear cause), but the situation of losing consciousness with ambulation/toileting is often syncope, right? For her, more time elapsed that with my first lady, but that was situation more than anything. I yelled for help, got her to the floor, felt for a pulse for 10 sec, no pulse, I was next to the code button so I hopped up to call for a code, returned to the pt, placed my hands on her chest, and my coworker (a tele tech) says "I think I found a pulse." So I didn't start compressions, and instead started looking for a pulse again. In hindsight, I don't believe my coworker found her pulse, because she was half-way up the patient's forearm.. but it was enough to make me hesitate. Another few seconds and I did finally feel a faint pulse. In this case I feel like compressions should have been started given the pt's history, and yet, she did recover on her own. The lesson I'm taking is that my assumptions can be wrong, and that I need to keep it simple. 10 seconds without a pulse = compressions. Simple. If the docs or senior nurses have issues with my choice, that's on them. Also, with the first episode, I did talk to my unit director. She was very supportive of my actions and upset with the physician. I just let the physician get in my head.

Again, these responses are very helpful. Thanks! You all are confirming everything I've been thinking.

Both were witnessed. The second patient literally collapsed in my arms. But there was a small delay getting her safely to the ground. Good thing she was small!

Ok thanks. This feedback is helpful. I think the primary reason I'm asking this is because in both situations, the general response I got from more experienced staff was that the code was unnecessary.. But there's no way in those initial seconds to determine who is going to recover on their own and who needs CPR. No pulse is no pulse. 10 seconds is 10 seconds. Anything else is speculation. It's frustrating to feel belittled for doing what's best for my patient. And to be fair, it's not everyone who reacted this way. A few of my fellow nurses were very supportive. And of course, all nurses present in these situations were in agreement!

On two occasions I've had my patient lose pulse during a syncopal episode. With the first patient, three nurses could not find a pulse for 10ish seconds and compressions were initiated. The pt recovered after 1-2 minutes of CPR. The doctor felt confident that it was syncope and she likely would have recovered without compressions. With the second patient, myself and another nurse were unable to find a pulse for 10-20 seconds. Just as I was about to start compressions, my fellow nurse found a faint pulse and shortly after the pt began breathing and became responsive. She did not receive any compressions. So here's my question... ACLS tells us to spend no more than 10 seconds checking for a pulse.. but in these severe vasovagal episodes, the patient may be pulseless or with a non-palpable HR for longer than 10 seconds... And yet they will likely recover on their own. How do you handle these situations? Always initiate compressions/ACLS protocol? In the case of my first patient, she had a flail chest prior to compressions and received several new fractures from CPR. The second was elderly and would not have done well with compressions. And yet, following ACLS, don't we have to start compressions? Is this a common experience? Thanks!

The doc on call that night ended up ordering Kayexalate. It had not been ordered prior.

This shift we happened to not have a charge nurse scheduled. We're a small hospital in a rural part of the state, so that happens occasionally. My only supervisor on premise was the house supervisor. I asked him face-to-face probably a half dozen times. I debated calling my director, but it was a Sunday evening. I ended up calling her at the end of my shift and I wrote up a variance. The only thing I could have done was call my director sooner. But she made me feel that I may have overreacted, hence the post here :/

What sort of ICU will you be working in? That makes a huge difference on what you will be frequently dealing with. I work in a small hospital on weekends only... so the main diagnoses I see are COPD exacerbation, DKA, overdose, sepsis, and various cardiology issues like symptomatic a fib.

Acute renal failure, not a dialysis patient. I asked my director if I was permitted to crack the crash cart in this situation, and she said "It's probably best that you didn't." They figured out the sodium bicarb and why I couldn't pull it out of the pyxis (it was programmed incorrectly), so that one is fixed. And I got the okay to mix the calcium gluconate myself using a vial adapter, so next time I know what to do. The problem was that our policy was unclear. I was under the impression I was in no way to mix the medication myself. I guess I'm just wondering if hyperkalemia is as emergent as I'm thinking.. or if it really wasn't a big deal that the patient waited so long for treatment.

I work in a 10 bed ICU in a rural hospital, and we currently take 2-3 patients. Three is definitely exhausting and can be very unsafe depending on acuity. Our director just had it approved to drop our max ratio down to 2:1. There were too many mistakes being made and too many nurses leaving.

I would also be concerned that rapid afib would mask the signs of a post-op bleed. How are you going to know if the pt is bleeding internally when they are already tachy and hypotensive :/ The cardiologists I work with would have definitely addressed it with something IV push or a drip.

I have been a critical care nurse for less than a year, so I am looking for advice from nurses who have more experience with this situation. I admitted a patient with a potassium of 6.4, BP 200/100, EKG with peaked T waves and occasional PVCs, and c/o weakness. Despite spending over 5 hours in ER, the only treatment she had received was an amp of D50 and 10 units of insulin. It was a Sunday afternoon and I work in a small hospital. Our pharmacy had left for the day, which meant the house supervisor was responsible for any medication problems. I had both calcium gluconate and sodium bicarb ordered, but due to issues with our pyxis and hospital policies, I was unable to give either without help from the supervisor. I repeatedly asked the supervisor for help, but he was so overwhelmed with various emergencies that I didn't receive either medication by the end of my shift. By the time the night supervisor came on and addressed the medications, 2 1/2 hours had elapsed since the patient was admitted to the floor. My question is - during this time of waiting I was VERY upset. In my experience, patients with a critical high potassium and EKG changes should be treated as a ticking time bomb. At the end of my shift I ended up calling my director. Was I overreacting? Is the risk of sudden cardiac arrest or wide complex tachycardia not as high as I imagine? Any opinions or advice would be appreciated :)