wonder what the opinion is on the "new" ACLS guidelines

[MassED]

I just took my recert today for ACLS and found it to be incredibly dumbed-down. I am shocked the primary focus is on compressions, mainly. It is a lot easier than it was two years ago, but is this better for us, as nurses?

[CritterLover, BSN, RN]

allow me to take issue with you? stats is a pretty neat concept and may help us understand things a little bit better. you seem to be calling solid cow waste on the claim of not having a successful code in six years?

lets go to gilarn's lab and do some mad scientist stuff?

i am going to define a successful code as somebody who can see wombies in green shorts. in our hospital we have a pretty good success with our codes. our success rate is 25%.

it is quite possible to go six years and not have a successful outcome. with the low rates of success (depending on how you define success), and some areas where ems can call in the field, it is possible that you may not even have a code in 6 years.

i'm not sure what you are getting at here. of course someone can define "successful code" however they want to.

my post was an attempt to clarify what she meas when she writes "successful code."

at first, it seemed as though she meant that she had never seen a code that survived through the initial resuscitation efforts. if that is the case, then i (and apparently several others who posted) find it very -- odd -- that she hasn't seen a single code survive that long, after working 6 yrs in an er.

but then she started quoting some of the literature, and i realized that she might be talking about longer survival rates, which would make more sense. i would still find it a little surprising if she hadn't seen a code from the er survive 24hrs, but not at all that surprising if she hadn't seen one survive 30 days.

so, here we have bubba bob thorton jr. the 4th twice removed frame shift mutation of the throne. bubba just started working in the er. bubba is a lucky dude and experiences a code a day. what are bubba's chances of having a successful code on day one? 25%. what about day two? 25%. what about every other day? yep, 25%. so, is it possible bubba could go six years and not have a successful code? yep, sure is.

while statistics can do a nice job of describing non-random events, but don't do such a great job of predicting non-random events. since code survival isn't random (we hope), you can't really say that bubba's chances of having a successful code each day is 25%.

[GilaRRT]

Yes, once we go out into the word with it's many variables, things become less concrete. I was simply thowing out a random definition of successful. Again, the percentage was random as well. i do not know how successful is defined in the context of this conversation yet.

Allow me to reword? If I have an average survival to discharge around say 8%, and survival to discharge is how I define success, then I can see how somebody could say they have never seen a successful code.

Actually, stats can apply. For example; a gang banger takes two rounds to the box and EMS drags him into the er in asystole. The average survival to discharge stats on these kind of patients are pretty reliable.

I am just playing devils advocate more than anything. It is quite interesting how this topic took a different turn however.

[MassED, BSN, RN]

another thought, massed.

i'm wondering what you are considering to be a "successful code."

i'm defining a "successful code" (in this instance) to be one where the patient is able to be resuscitated to the point where they are able to leave the er and make it to icu. they may die there (even shortly after they get there), they may be extremely critical, but they do leave the er with a pulse, bp, and respirations (even if those respirations are assisted with a vent and the bp is augmented with pressors).

i think you need to be careful when you look into the literature, because most of the literature out there deals with survival in terms of time -- 24 hrs, 72 hrs, 30 days, 1 year -- rather than er disposition. (i see quite a bit of literature surrounding the 24hr, 30 day, 90 day, and 1 yr points). usually hospital inpatient to d/c

so, if we are defining "successful code" in the same terms, and you are looking at er codes in general -- not just "came in dead/stayed that way," then i stand by what i wrote earlier: if you haven't seen any successful codes in your six years in the er, something is wrong.

(wow -- i realize that sounds kind of harsh, and i apologize for that, but i do stand behind it)

i am defining success as leaving the er with a pulse, bp, etc. that was my specific question. sorry, but i still believe it is not that common to survive a code (as the statistics suggest). when an individual comes in by ems with chest compressions in progress, the odds are against them. i realize the literature looks at success from admission to d/c, but i am specifically wondering regarding survivability within the er.

i disagree and do believe that "most" er nurses, or in fact very many, have not seen successful codes as i previously defined. i, in fact, question the validity of those many many successful codes within the er that some have noted. the odds are not stacked in their favor and the actual positive outcomes for cpr are quite slim. according to the aha, 70-80% of cardiac arrests happen at home and immediate intervention is what determines survival. so many variables are in place - what is the response time of ems, what was the cause of the arrest, early defibrillation, etc.....

i have posted this again regarding reliability of national statistics of cpr: "

there are no reliable national statistics on cpr because no single agency collects

information about how many people get cpr, how many don't get it who need it, how

many people are trained, etc." http://www.towson.edu/wellness/documents/cardiopulmonaryresuscitationstatistics.pdf

with perfect response time, witnessed arrest, rapid defibrillation, etc. there might be a successful code, but with patients coming in with cpr in progress, those factors are out of the er control. it's quite ridiculous for you to make a statement that something is wrong and i question how long you've worked in an er, what type of setting, and how many "successful" codes you have witnessed. it's called the statistics for a positive outcome, that's what's wrong. i haven't won the lottery and don't know anyone that has, so is something wrong there also? because chances are slim when a person arrives already with compressions occurring..... boy, this is getting redundant.

and i am not including defib for an arrythmia, rapid intervention to prevent a code situation....

[MassED, BSN, RN]

are you just talking about the "found down" people that come in with cpr in progress? in a sporadic 5 yrs in the er (most part-time/prn), i've seen at least a few of those survive (for a few days, anyway). one was particularly memorable -- what i think "saved" him was that his episode was caused by a brain bleed, rather than a cardiac event. it was the first (and only) time i've had to hang a cardene (i think) drip at the conclusion of a code.

so yeah -- unless you're in a rural/semirural area with long ems response times, i would probably question why you've never seen a prehospital code survive to make it to icu.

if you're including the people that get effective bystander response (cpr/aed), the people that code in the back of the ambulance, and people that code after being roomed in your er, then i really think someone needs to look in to the reason why you've never seen a code survive to the icu -- even if you are in a pretty rural area.

as for the "dumbing down" of acls, i was really surprised the emphasis that is placed on cpr right now. according to the little computer scenarios i did, the ambu bag is preferred over intubation so that cpr isn't interrupted, and that really surprised me.

but, the guidelines are based on the evidence that is out there. look at lidocaine -- how long did we use that first line for v-tach/v-fib, when there was very little evidence that it was effective?

the guidelines are bound to change as research evolves.

i think that part of the issue is the development of better drugs for ventricular arrythmias. it used to be epi, lidocaine, bertryllium (?) ... maybe some others that i never learned. now we have amiodarone -- one drug which actually works -- taking the place of at least two that don't really work all that well.

(i know that lidocaine is still on the algorithm, but it isn't on our crash cart anymore, and i can't remember the last time i used it)

cardene (nicardipine) must not be the drug of choice for chronic angina or htn. i've never seen it used.

--------------------------------------------------------------------------------

[MassED, BSN, RN]

The witnessed arrests were mostly those that came in barely alive and were actively crumping. Maybe our EMS service is a bit more proactive than shipping pre-deadended patients to us.

Although there was one guy that had a broken humerus which apparently disguised radiated shoulder pain associated with an MI and spontaneously went from A&O to pulseless on the ground in the span of mere seconds. That was lucky-- not the massive aMI he threw but the fact he decided to code right there.

I am not referring to those saves of those "near codes" - as we've all had those...

[MQ Edna]

I disagree and do believe that "most" ER nurses, or in fact very many, have not seen successful codes as I previously defined. I, in fact, question the validity of those many many successful codes within the ER that some have noted. The odds are not stacked in their favor and the actual positive outcomes for CPR are quite slim. According to the AHA, 70-80% of cardiac arrests happen at home and immediate intervention is what determines survival. So many variables are in place - what is the response time of EMS, what was the cause of the arrest, early defibrillation, etc.....

....

I've had the pleasure of working successful EDcodes as well.

I suppose you will have to take our word, MassED. As we have yours (that you've not had a successful code in the ED).

I've had the pleasure throughout my career, to see many successful ED codes. They leave our area, post-code, to the ICU/CCU, etc. As for the final outcome/morbidity/mortality, that is after they leave the ED.

Please do not question (my) validity about my situations.

[MassED, BSN, RN]

Allow me to take issue with you? Stats is a pretty neat concept and may help us understand things a little bit better. You seem to be calling solid cow waste on the claim of not having a successful code in six years?

Lets go to GilaRN's lab and do some mad scientist stuff?

I am going to define a successful code as somebody who can see wombies in green shorts. In our hospital we have a pretty good success with our codes. Our success rate is 25%.

So, here we have Bubba Bob Thorton Jr. the 4th twice removed frame shift mutation of the throne. Bubba just started working in the ER. Bubba is a lucky dude and experiences a code a day. What are Bubba's chances of having a successful code on day one? 25%. What about day two? 25%. What about every other day? Yep, 25%. So, is it possible Bubba could go six years and not have a successful code? Yep, sure is.

It is quite possible to go six years and not have a successful outcome. With the low rates of success (depending on how you define success), and some areas where EMS can call in the field, it is possible that you may not even have a code in 6 years.

thank you for understanding the unpredictable nature of CPR, codes, and all of those unpredictable variables. I believe our EMS response is fantastic and many are called en route or in the field, rather than being brought to the ER (unless it's for a specific reason, like SBI case). I think this speaks more to the EMS response for their ability to perform their job and not bring in those that are coding - or bring in those that are near coding and we fix and ship.

(Loved statistics!!)

[MassED, BSN, RN]

I've had the pleasure of working successful EDcodes as well.

I suppose you will have to take our word, MassED. As we have yours (that you've not had a successful code in the ED).

I've had the pleasure throughout my career, to see many successful ED codes. They leave our area, post-code, to the ICU/CCU, etc. As for the final outcome/morbidity/mortality, that is after they leave the ED.

Please do not question (my) validity about my situations.

I am merely questioning those that are questioning me. Seems fair to me.

[MassED, BSN, RN]

i'm not sure what you are getting at here. of course someone can define "successful code" however they want to.

my post was an attempt to clarify what she meas when she writes "successful code."

at first, it seemed as though she meant that she had never seen a code that survived through the initial resuscitation efforts. if that is the case, then i (and apparently several others who posted) find it very -- odd -- that she hasn't seen a single code survive that long, after working 6 yrs in an er.

but then she started quoting some of the literature, and i realized that she might be talking about longer survival rates, which would make more sense. i would still find it a little surprising if she hadn't seen a code from the er survive 24hrs, but not at all that surprising if she hadn't seen one survive 30 days.

while statistics can do a nice job of describing non-random events, but don't do such a great job of predicting non-random events. since code survival isn't random (we hope), you can't really say that bubba's chances of having a successful code each day is 25%.

i am referring to survival out of the er - i wouldn't know what goes on 30 days later, as i'm in the er. again, i stand on my point, cpr is not that successful for it to be so uncommon not to have had successful codes. :banghead::banghead:

[MassED, BSN, RN]

Yes, once we go out into the word with it's many variables, things become less concrete. I was simply thowing out a random definition of successful. Again, the percentage was random as well. i do not know how successful is defined in the context of this conversation yet.

Allow me to reword? If I have an average survival to discharge around say 8%, and survival to discharge is how I define success, then I can see how somebody could say they have never seen a successful code.

Actually, stats can apply. For example; a gang banger takes two rounds to the box and EMS drags him into the er in asystole. The average survival to discharge stats on these kind of patients are pretty reliable.

I am just playing devils advocate more than anything. It is quite interesting how this topic took a different turn however.

yes it did take a turn. Thanks for viewing this exactly as it is.

[CritterLover, BSN, RN]

with perfect response time, witnessed arrest, rapid defibrillation, etc. there might be a successful code, but with patients coming in with cpr in progress, those factors are out of the er control. it's quite ridiculous for you to make a statement that something is wrong and i question how long you've worked in an er, what type of setting, and how many "successful" codes you have witnessed. it's called the statistics for a positive outcome, that's what's wrong. i haven't won the lottery and don't know anyone that has, so is something wrong there also?

wow, i really seem to have hit a nerve with you. i don't think i've ever been quoted so much in a single thread. i certainly didn't mean to offend. again, when i wrote that i thought someone might need to look into why you haven't seen a successful er code in six years, i was responding to something you wrote:

i wasn't referring to codes in other units, as i'm in the er - i'm sure there are statistics out there for those that are inpatient codes versus those that come into the er coding, those inpatients would likely have a better shot at survival. i'm puzzled - how many of you have had successful codes in the er? how many? once an individual is in the position of being coded, it's not a good situation, so i'm surprised anyone is surprised that i haven't witnessed a successful code. i'm baffled that anyone has witnessed any - even one would be amazing. to experience more than one, well, maybe i need to question where i'm working and the docs running the codes!

i realize now that you were probably joking when you wrote that; however, at the time i responded, i was taking you seriously. mostly because i have noticed that the chances of a full arrest coming in by ambulance surviving depends in large part on which doctor is working, and which paramedic made the call. some try harder than others.

i am defining success as leaving the er with a pulse, bp, etc. that was my specific question. sorry, but i still believe it is not that common to survive a code (as the statistics suggest). when an individual comes in by ems with chest compressions in progress, the odds are against them. i realize the literature looks at success from admission to d/c, but i am specifically wondering regarding survivability within the er.

this helps clarify a bit more. if you are defining an er code as one that comes in with chest compressions in progress, then it is easier to understand why you haven't seen a successful code in 6 years.

however, i have still seen some successful (as in leaving the er with a pulse) codes in this situation. it seems as though it is most likely to happen when ems is unsuccessful in getting an iv in -- they intubate them, load and go. when we get them in the er and get a line in, that first round of drugs will sometimes be successful in restoring circulation.

in addition, our ems guys don't spend a whole lot of time messing around on the scene of a full arrest. i'm not sure what their exact protocols are, but it seems as though if a round of drugs doesn't do the trick, they load and go and do what they can in the truck. i'm in a very urban area, so response and transport times aren't that long. plus, in the area where i work, the paramedics are met by the pumper truck at the scene of any full arrest. that enables the paramedics to intubate/attempt lines, while bls efforts are done by the emt/firefighters. the extra firefighters will ride in the back of the ambulance with the paramedics, leaving one out to drive the pumper truck to the er to pick them all up at the end. these extra sets of hands may influence our outcomes.

i disagree and do believe that "most" er nurses, or in fact very many, have not seen successful codes as i previously defined. i, in fact, question the validity of those many many successful codes within the er that some have noted. the odds are not stacked in their favor and the actual positive outcomes for cpr are quite slim. according to the aha, 70-80% of cardiac arrests happen at home and immediate intervention is what determines survival. so many variables are in place - what is the response time of ems, what was the cause of the arrest, early defibrillation, etc.....

well, several er nurses (and techs) have posted here that we have, indeed, seen successful er codes; we really don't have any reason to lie or exaggerate.

i won't say that i've seen tons of patients that came in with cpr in progress make it to have that "alive" box checked on the resus record -- but i certainly have seen it. and, it has to be fairly often. when we get a full arrest coming in, there is an overhead page by the hospital operator. when our icu hears it, they start preparing a room for the patient. if the full arrests "never" made it, the experienced icu nurses would have stopped putting forth that effort long ago -- especially since it usually takes at least a couple of hours before the patient gets from the er to the icu.

(and to further drive home an earlier point, they put forth more effort in getting the room ready off that initial overhead page when some er docs are on rather than others.)

as far as you "[questioning] how long" i've worked in the er, and "in what type of setting,"

the er i've worked in is an inner-city, low-income area, medium-sized er. on a typical night when i was in triage, i would see between 40 and 60 patients in a 12 hour shift. i've worked there off and on for 4 years -- usually either part-time or per diem. i haven't worked there in almost a year. however, that doesn't change the number of "successful" codes i've seen. (and actually, i should have seen less than those of you who work er full-time)

by the way -- the rest of my nursing experience is mostly icu, and as an icu nurse, i've taken care of more than one patient that came in as a full-arrest and made it to become my patient in the unit.

[MassED, BSN, RN]

wow, i really seem to have hit a nerve with you. i don't think i've ever been quoted so much in a single thread. i certainly didn't mean to offend. again, when i wrote that i thought someone might need to look into why you haven't seen a successful er code in six years, i was responding to something you wrote:

i realize now that you were probably joking when you wrote that; however, at the time i responded, i was taking you seriously. mostly because i have noticed that the chances of a full arrest coming in by ambulance surviving depends in large part on which doctor is working, and which paramedic made the call. some try harder than others.

this helps clarify a bit more. if you are defining an er code as one that comes in with chest compressions in progress, then it is easier to understand why you haven't seen a successful code in 6 years.

however, i have still seen some successful (as in leaving the er with a pulse) codes in this situation. it seems as though it is most likely to happen when ems is unsuccessful in getting an iv in -- they intubate them, load and go. when we get them in the er and get a line in, that first round of drugs will sometimes be successful in restoring circulation.

in addition, our ems guys don't spend a whole lot of time messing around on the scene of a full arrest. i'm not sure what their exact protocols are, but it seems as though if a round of drugs doesn't do the trick, they load and go and do what they can in the truck. i'm in a very urban area, so response and transport times aren't that long. plus, in the area where i work, the paramedics are met by the pumper truck at the scene of any full arrest. that enables the paramedics to intubate/attempt lines, while bls efforts are done by the emt/firefighters. the extra firefighters will ride in the back of the ambulance with the paramedics, leaving one out to drive the pumper truck to the er to pick them all up at the end. these extra sets of hands may influence our outcomes.

well, several er nurses (and techs) have posted here that we have, indeed, seen successful er codes; we really don't have any reason to lie or exaggerate.

i won't say that i've seen tons of patients that came in with cpr in progress make it to have that "alive" box checked on the resus record -- but i certainly have seen it. and, it has to be fairly often. when we get a full arrest coming in, there is an overhead page by the hospital operator. when our icu hears it, they start preparing a room for the patient. if the full arrests "never" made it, the experienced icu nurses would have stopped putting forth that effort long ago -- especially since it usually takes at least a couple of hours before the patient gets from the er to the icu.

(and to further drive home an earlier point, they put forth more effort in getting the room ready off that initial overhead page when some er docs are on rather than others.)

as far as you "[questioning] how long" i've worked in the er, and "in what type of setting,"

the er i've worked in is an inner-city, low-income area, medium-sized er. on a typical night when i was in triage, i would see between 40 and 60 patients in a 12 hour shift. i've worked there off and on for 4 years -- usually either part-time or per diem. i haven't worked there in almost a year. however, that doesn't change the number of "successful" codes i've seen. (and actually, i should have seen less than those of you who work er full-time)

by the way -- the rest of my nursing experience is mostly icu, and as an icu nurse, i've taken care of more than one patient that came in as a full-arrest and made it to become my patient in the unit.

so the variable in question now could be what level are these ems responders. in n.c., it was common to have basics responding - very everything. and most were volunteer. forget about having paramedics around..... you never knew what you were going to get. as an example, rollover mvc with multiple patients ejected from the vehicle. dispatched basic emt's. give me a break. so much of what i had seen in that er might have a lot to do with the ability of those first responders. that area was low-income, high-drug, weapons.... needless to say high-volume er. add to that many diabetic, cardiac, dialysis patients that were seen. many codes were patients who were on h/d, implanted pacemakers and those unfortunate souls where the illness was beyond those first responders (active mi 40 minutes from the er with basics responding....) .... a sicker population on the whole than where i currently am residing and working.