when a code goes down (part 1).
By impactEDnurse • Jan 22nd, 2009 • Category: clinical skills
You were just helping Mr Doobles adjust his breakfast tray when without so much as a thankyou he makes a funny guffing sound and stares off intently at something mysterious above his eyebrows.
That annoying holy-crap gland perched atop your kidneys starts excreting its Gellato of distracting juices, and you brain flicks through a Hindu shuffle, frantically looking for the Basic Life Support card.
Luckily, you have the Ace of Hearts up your sleeve.
DR ABCD.
DANGER: Turn on your situational awareness. Make sure your patient does not remain in a dangerous environment, and (more importantly) make sure you are not at risk yourself.
And keep in mind that if the current situation begins to unfold as an issue involving airway, breathing or circulation interventions, you will need to don some gloves and eye protection as soon as possible.
RESPONSE: Is Mr Doobles in trouble, or has he just fallen asleep amongst your scintillating conversations?
Time to inflict a little noxious stimuli to find out. You can tap and talk: tap him fairly briskly and in a loud voice ask him if he is still with you. Or you can give his sternum a bit of a rub with your knuckles and ask him what he thinks about that.
If he does not respond… then you must.
Call for help: hit the emergency buzzer or call out in a loud voice for help. And when help arrives the first thing to do is make sure someone is activating your hospitals code protocol.
Note the time. Take a deep breath down into your tummy and a microsecond or two to un-fluster yourself.
Dont rush things.
It is important that you deliver quality BLS with good technique and calm teamwork. Flusterization will spread like a pox through the team. Conversely, a calm focused response will anchor the resuscitation effort and give Mr Doobles his best chance of survival.
Move to his airway.
AIRWAY: Lay the patient supine and open his airway. Use a chin lift and head tilt or a jaw thrust. Inspect his mouth for any foreign bodies or secretions and either suction or briefly roll the patient onto their side to facilitate drainage.
BREATHING: Maintaining a good airway alignment, bring your cheek just above the patients mouth and LOOK, LISTEN, FEEL.
Look for a rise in the chest wall. Listen for breath sounds and feel for any movement of air across your cheek.
If the patient is not spontaneously breathing you will need to deliver 2 effective breaths with a bag valve mask.
I think one of the hardest parts of Basic Life Support is to maintain an effective seal when delivering ventilation with a bag valve mask (BVM). Connect the bag valve mask to oxygen running at 15 lpm.
Make a letter ‘C’ out the thumb and forefinger of your dominant hand. This will go around the mask. The other 3 fingers will then be used to grip under the angle of the jaw and provide a jaw thrust.
Your other hand will squeeze the bag delivering just enough oxygen to get a visible rise in the chest wall.
No rise? Reposition your mask and try again. OK.
Give 2 breaths.
What if I don’t have a bag valve mask available? Mouth to mouth? Well that’s a call for you to make, but from personal experience (a story for another time1), I would strongly advise against it. Some ward areas have pocket masks with a one way valve which would be OK.
Skip mouth to mouth and move on.
CIRCULATION: Feel for a carotid (or femoral) pulse and look for any signs of life. Signs of life would include spontaneous movement or verbalizations. Don’t take too long trying to figure out if you can feel a pulse or not. If you cannot feel one or you are unsure… begin CPR2.
Interlock fingers, heel of the hand in the center of the chest. Lock elbows out straight. Get your shoulders directly over your hands3.
Deliver the compressions by bending from the hips and letting your body weight do the work.
Compressions should be 1/3 the depth of the anterior/posterior diameter of the chest (or around 4-5 cm). You should be compressing at 100 beats per minute. Its important not to compress too fast4.
For a good metronome to pace your rate, silently sing a little song.
After 30 compressions you need to deliver 2 effective ventilations. Continue at a compression to ventilation ratio of 30:2. After 2 minutes, stop and quickly reassess your patients circulation.
In most hospitals you should be getting a little help and equipment long before the first 2 minutes have transpired.
Once others arrive, one person should perform the compressions whilst the second ventilates at a ratio of 30:2. Make sure that somebody has in fact activated a the code alarm.
Other important tasks to perform as reinforcements arrive:
- Clear away all the unnecessary crap that is getting in the way and blocking access to the scene.
- You will get much better ventilation if 2 operators use the BVM, one using 2 hands to maintain a good seal and airway positioning, whilst the second bags5.
- Collect the patients relevant notes, pathology results etc.
- If possible, screen the scenario from any other patients in the room.
- And do not neglect any relatives that were present when the code went down.
- Someone should be posted at the ward entrance to direct the inbound code team.
DEFIBRILLATION: These days, many wards have automated external defibrillators (AED’s) close at hand. These are user friendly devises that, once attached to the patients chest via a set of pads, will analyze the rhythm, and talk you through delivering a shock if it is needed.
If you have access to one, it is very important to utilize these devises as soon as possible once CPR has been commenced6.
In Part 2 of When A Code Goes Down, we will look at what to do when the resuscitation or code team arrives on the scene. Stay and play? Or run away.
- I ended up with a patient projectile vomiting into my mouth, down my oesophagus, into my eyes and up my Eustachian tubes [↩]
- you are not going to kill someone by starting CPR if they have an output [↩]
- If you are short you will need to lower the bed, or get a stool, or get up on the bed on your knees [↩]
- a rapid compression rate does not allow the ventricles enough time to fill therefore decreasing cardiac output [↩]
- you should also consider inserting an airway adjunct such as an oropharyngeal or nasopharyngeal airway at this point [↩]
- if your hospital does use AED’s it is vital that you familiarize yourself with where they are located and how they work. Really, they are dead simple to use [↩]
impactEDnurse is also known as Ian Miller, a nurse with over 26 years experience working in a busy emergency department in, Australia. This site in no way reflects the opinions of that hospital.
All stories (although based on actual experiences) have been changed to protect patient confidentiality.
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Ian, what will I do without your insight about ED nursing? I have 24 years’ experience too, and vacillate between giddy excitement about my job to raging burnout. I’ll still tune in, though.
just to correct you sir,it is nolonger recommended to waste time feeling for pulse,the best way to do it is asses for signs of life and if there is none proceed with BLS…..ta
In relation to 4…at recent training we were told that the rate should be similar to the song ‘another one bites the dust’. I wouldn’t recommend singing out loud, no matter how helpful/true!
Joe, regardless of recommendations I would much rather someone check for a pulse than start chest compressions unnecessarily and risk the potential complications associted with same, eg: fractured ribs.
It’s current ARC guidlines to not check for a pulse and continue straight on to compressions.
Regardless of ARC guidelines, clinical judgement comes first. I would always check for pulse, as experience has thought me that it’s best to do so. Each to their own!