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 Nurse Scientist-Research.
Check apical HR, if nothing, I initiate compressions.

I don't have supporting data on hand (and I'm on my phone right now), but there's a reason why you use a palpable pulse as a guideline. Like I wrote, this is from memory and years ago when I was still in adult care.

As I recall, a radial pulse requires SBP 80-90, femoral requires at least 60-70. One can have an audible apical pulse that is barely effective enough to move any blood.

I also know this from my own missteps. As a newish floor nurse I hesitated starting compressions because I had an audible heart tones and monitor rhythm. Thankfully the patient quickly got compressions and I was gently educated.

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Specializes in Emergency/Trauma/LDRP/Ortho ASC.

Sometimes it seems difficult to palpate a pulse if the pt is severely bradycardia from vasovagal syncope. I've seen this happen at countless RRs I've been to on the floor. Observe for respiratory effort as well.

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"Lose a pulse during a syncopal episode" is kind of a confusing or misleading picture to me? Why were these patients syncopal...and if you kind of sort of knew it was syncopal...well then I don't know if I would have called a code or started CPR. It all depends on the circumstances.

During a vaso-vagal episode the pulse will become very slow and weak. During a stressful event (as in oh my gosh is my patient coding) it is hard to find your own pulse let alone the patients and 10 seconds seems like 10 minutes!

If my patient was in for some cardiac issues and suddenly collapsed, stopped responding to me, I would call a code and start CAB.

If my patient had no cardiac issues, was in for a hernia repair, I'm starting an IV, or they've been lying flat for a while and it is their first time to stand up, and they collapse, stop responding to me. I would think it was vaso-vagal, lay them flat, put them on some O2, open up their IV (hopefully it was in), and let it pass.

  1. AT A CARDIAC ARREST, THE FIRST PROCEDURE IS TO TAKE YOUR OWN PULSE. The House of God

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Do you call a code if someone has slurred speech and lethargic? I heard 2 nurses laughing at another nurse for doing that and I thought that was wrong. I would think you'd call a code to be safe

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Specializes in Trauma Surgical ICU.
Do you call a code if someone has slurred speech and lethargic? I heard 2 nurses laughing at another nurse for doing that and I thought that was wrong. I would think you'd call a code to be safe

I wouldn't call a code for this but I would call a rapid response. I wouldn't laugh at the nurse either. That's just uncalled for

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I agree. I would call a code, regardless. However, I am a new graduate, and I would definitely be calling on my experienced nurses to help out :up:

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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!

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

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At the place I work at now, the population is such that we have a lot of vasovagal episodes (specialty post-surgical area, specific population). The staff here are very familiar with them and not many codes are called. These episodes tend to happen during particular events (ambulation, toileting) and usually quickly resolve once the patient is back in bed. However, that being said, if it was my patient and they didn't regain a carotid pulse after 10 seconds of being back in bed (and they are unresponsive, not breathing, etc.), I would start chest compressions and call a code. A code can always be cancelled. Chest compressions can be stopped. But if I incorrectly assume that I am dealing with a vasovagal episode and I am wrong, I have wasted invaluable time and delayed proper care. Time=brain!

Also keep in mind that everyone has a different comfort level. Some senior staff have seen it all. They know what to ask for, when to ask for it, and who to get it from. They know the right interventions and do them at the correct times. These nurses might have the experience and competence to manage certain acute situations while a newer nurse in a similar situation might call a rapid response. Neither nurse is necessarily wrong. The best advice I ever received as a new nurse was own my own practice and find my voice. Definitely use your experienced coworkers to help guide and shape your critical thinking but don't let them over-power your own judgment.

Lastly: do you have an educator or unit manager you could talk to about these incidents? They might be able to offer some insight!

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These episodes tend to happen during particular events (ambulation, toileting) and usually quickly resolve once the patient is back in bed.

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.

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Oh man!! It sounds like you did everything right. It sucks that this happened to a patient with recent rib fractures but it definitely seems like she needed CPR. I'm glad that your director supported you! Did the surgeon really just want you to wait around that whole time with a pulseless patient??

I had a similar episode with a patient and a similar reaction by one of the docs. It's definitely hard not to take it personally! (I think I may have even made a thread about my episode too?!) You're totally not alone in feeling this way but I don't think you need to feel like you did anything wrong.

To be honest, all of the vasovagal episodes I've encountered have involved patients losing consciousness in chairs (mostly commodes). In each instance, we moved them back into bed and all of them started regaining consciousness within a few seconds of being flat. I've heard of some severe vasovagal cases where the patient took longer to recover. But I don't think I would have the patience to wait and see in those types of cases. Even a few seconds feels like forever! Good thread!

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