When to call a code

[JenHRN]

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!

[Pangea Reunited, ASN, RN]

Always initiate compressions/ACLS protocol?

Yes. If the patient desires otherwise, they can specify that in an advance directive. Some desire an attempt at chemical resuscitation, but no CPR.

[kskarzin91]

Yes always initiate compressions. Would kinda suck if you thought oh well she'll come back and she doesn't and you delayed care because of that thought. The doctor was doing nothing more than speculating

[Stella_Blue]

Rather than feeling a pulse you could always listen for an apical HR. Sometimes more reliable than a pulse.

[TiffyRN, BSN, PhD]

You need to start compressions in the absence orders limiting resuscitation. Could you defend that the reason your patient lost their pulse was truly a Vaso-Vagal episode? If your patient is elderly and would suffer from compressions that needs to be addressed before hand. I know, I know, easier said than done but what if that person doesn't recover their pulse after 10 seconds, 20? How will you feel if you've delayed?

I also know the strong desire to deny that this is happening. I've been there, it's very surreal.

[blondy2061h, MSN, RN]

If you had to do 2 minutes of CPR it was more than a syncope episode.

[GE90]

dont give a ****, i'd do cpr, breaking ribs or causing pain is better than dying

[JenHRN]

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!

[nynursey_]

At my hospital, a Code Blue is initiated when a patient is unresponsive: with or without a pulse, or has an absence of spontaneous respirations. These interventions typically necessitate ACLS protocol initiation.

I don't care what any physician says. They don't decide whether I utilize nursing judgement to call a Rapid Response, Code Blue, or initiate chest compressions on a pulseless patient.

[TiffyRN, BSN, PhD]

Sorry you were getting a hard time. Everyone's a Monday morning quarterback right? If the patient recovers their pulse and you are compressing they are likely to start protesting. I think it's legitimate to reassess the pulse if the patient tries to smack you for hurting their ribs!

[calivianya, BSN, RN]

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.

Exactly! Don't speculate - just do compressions.

Even if that's true that the compressions would do more harm than good - that isn't something to take into consideration when someone's pulseless and a full code. You've got to fulfill your legal obligations at that point. The moral obligations are going to have to take a back seat.

[Nurse Leigh]

OP, you made the call you felt was warranted (and I would have likely done the same) so, as difficult as it may be, try to remember you did the best you could with the assessment you had. ((hugs))