When to call a code

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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!

Specializes in school nursing, ortho, trauma.

I would rather call a code and get a patient right back (or on the reverse side of the coin be called needlessly to a code) than explain why I waited.

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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!

I'm an ICU charge nurse, run STAT and code teams, etc... so I'd probably qualify as relatively experienced staff. And I say call the code.

Let's put it this way. If your patient's heart was not beating for 10 seconds, your patient was dead and needed CPR. I've seen many circumstances where a delay in CPR arguably contributed to patient demise, and no cases in which unnecessary CPR did the same. Likewise - even if your patient's heart was beating but the pulse was so weak that it could not be detected at the carotid artery... your patient needed CPR. He was not perfusing his brain and was, functionally, dead.

Senior staff who advise less experienced RNs not to call a code on a (full-code status) patient whose pulse cannot be felt quickly need remediation. This can, will, and does cause needless patient deaths.

What I will add, however, that you should make it a point to know exactly how to feel for a pulse in an emergency. Do not listen for an apical pulse - it takes too long, and is too unreliable with background noise and low quality stethoscopes (such as the isolation stethoscopes found in most hospitals). Do not feel for a radial pulse - it is unreliable, and might be absent in a patient who does have an adequate heart beat. Same goes with other peripheral pulses, and even to some extent the femoral pulse. Feel for the carotid pulse (one side at a time please), and make sure you know exactly where it is before an emergency arises.

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Specializes in Med-Surg, Emergency, CEN.

Agreed! Any time compressions happen, call the code. It could be any number of things that have nothing to do with vasovagal responses. Also, if you have to ask yourself "should we be doing CPR right now" the answer is always yes!

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Specializes in ICU, trauma.
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.

Does your hospital not have rapid response?

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Specializes in Med/Surg/ICU/Stepdown.
Does your hospital not have rapid response?

My hospital does have a rapid response team, however an unresponsive person can go from bad to worse very quickly, so it wastes less time to call a code.

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Specializes in ICU, trauma.
My hospital does have a rapid response team, however an unresponsive person can go from bad to worse very quickly, so it wastes less time to call a code.

This has kind of been a topic of debate at our hospital. However it was decided that we should call rapids on unresponsive pts because essentially most of the code team is already there. We are also currently working on transitioning our code doctor from the ER doc to the hospitalist. So for now, it is still the ER doc and i think the logic is to not call him unless absolutely needed. However, I do agree with you :)

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Specializes in Burn, ICU.

We called a code on a pt who had gone into V-Tach and didn't have a palpable pulse or a waveform on the pulse ox (or the A-line...I think the pt had an A-line). The nurse got to the bedside immediately after the rhythm change on the monitor and the pt was still 'awake' (barely, and definitely altered) and even started struggling weakly as compressions were started. *Still* required 2-3 rounds CPR and a shock, then lost the pulse again a couple minutes later and got more CPR and I think 4 more shocks (plus some amiodarone and standard ACLS drugs throughout the whole episode). Delaying calling the code would not have helped anything!

Also, you gotta figure that unless you were *with* the pt at the moment of (presumed) syncope, there will always be some amount of delay as the first person gets to the room, sees the pt unresponsive, yells 'Mrs. Jones!' a couple of times, gets the lights turned on, calls for help and puts the bed flat. So, if they have no pulse, they've already been not-perfusing for more than 10 seconds. Adding to this time won't improve their chances.

Our SWAT/RRT team is really good about saying they'd rather come to a false-alarm code than have someone wait to call for help.

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Specializes in Oncology.
My hospital does have a rapid response team, however an unresponsive person can go from bad to worse very quickly, so it wastes less time to call a code.

Someone can be unresponsive for a lot of reasons, some of which can last awhile, and some of which are associated with normal vitals.

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Trust your gut! [emoji106]

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Specializes in Family practice, emergency.

10 seconds is a really long time to be feeling for a pulse, so if you're not sure you feel it in that time, call the code and start compressions. I have worked on rapid response teams and code teams for many years and agree with my ICU colleague that I should not arrive and be the person to start compressions or realize this person is in arrest. That being said, I will also piggyback on highlighting WHERE you feel for a pulse. If the person has a low BP, you will not palpate a radial pulse. Get comfortable with carotid/femoral pulse checks. It is really easy to stand back on a person that was rapidly revived and roll your eyes, but finding someone unresponsive or seeing someone go unresponsive still elicits a sphincter response in even the most experienced of us.

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Specializes in Oncology, Medical Surgical, Tele, Hospic.

Hey,

If you cannot feel a pulse start cpr! As part of the rotation you reassess for pulse. I am always under the impression to do too much then nothing at all.

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Specializes in Hospice/Palliative, LTAC/SNF.

Check apical HR, if nothing, I initiate compressions.

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