Chemical code???

[Cadet133]

So what exactly do you do when you walk in to a room on a patient who went pulse less and is chemical code and does not want CPR. You just keep pushing epi? Can't wrap my mind on how it would work if heart not pumping for drug to even get there

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[deleted547339]

So what exactly do you do when you walk in to a room on a patient who went pulse less and is chemical code and does not want CPR. You just keep pushing epi? Can't wrap my mind on how it would work if heart not pumping for drug to even get there

There is no such thing as a chemical code. That means they have a bad doctor.

 

[SurfingDoctor]

It’s not a menu at a restaurant where you get to pick items a la carte. You either get the 4 course meal... or you get nothing.

 

[EM Junkie]

So what exactly do you do when you walk in to a room on a patient who went pulse less and is chemical code and does not want CPR. You just keep pushing epi? Can't wrap my mind on how it would work if heart not pumping for drug to even get there

You slap their doctor/nurse that allowed that to happen.


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[NITRAS]

You check your facebook while the RNs push epi into a dead body for 15 minutes and call it and bill for a code. Or spend 35minutes and bill for critical care.

I guess you give the least experienced MS a chance to intubate. In all seriousness, I tell the resident that admitted them to grow a brain.

 

[chocomorsel]

O

So what exactly do you do when you walk in to a room on a patient who went pulse less and is chemical code and does not want CPR. You just keep pushing epi? Can't wrap my mind on how it would work if heart not pumping for drug to even get there

Nothing. No code should be called. You call a time of death. All chemical code or Full support DNR means is you titrate up continuous vassopressors/CV drugs till they stop working. Not IV pushes.

 

[Siggy]

So what exactly do you do when you walk in to a room on a patient who went pulse less and is chemical code and does not want CPR. You just keep pushing epi? Can't wrap my mind on how it would work if heart not pumping for drug to even get there

I ran what I consiedered a chemical code last night. End stage heart failure. Patient was slowly going more and more hypotensive despite adding 3 pressors, rechecking labs, and adding steroids. The family agreed for no compressions, so once the a-line went flat/PEA, I informed them that the patient had passed and offered emotional support. If the patient had gone into V-tach/V-fib, I would have defibrillated.

 

[SurfingDoctor]

No escalation of care (putting limits on treatment) and a chemical code (giving drugs to person who is dead) are not the same thing, though both are a sign of futility.

What is being referred to is actually a "slow code", the further additional of treatments despite the knowledge they will offer nothing in a person who near or at arrest (ie, the third or fourth vasopressor whose pulse waveform is becoming flat with bradycardia). Many people view that treatment as unethical, though like most ethics... that ends up being a matter of opinion. But it is futile and borders on dishonesty with the family.

I put them all into the "meh, whatever" category, same as "show codes", except chemical codes, those are just silly. Either you do a code according to ACLS/PALS or you don't.

 

[chessknt]

No escalation of care (putting limits on treatment) and a chemical code (giving drugs to person who is dead) are not the same thing, though both are a sign of futility.

What is being referred to is actually a "slow code", the further additional of treatments despite the knowledge they will offer nothing in a person who near or at arrest (ie, the third or fourth vasopressor whose pulse waveform is becoming flat with bradycardia). Many people view that treatment as unethical, though like most ethics... that ends up being a matter of opinion. But it is futile and borders on dishonesty with the family.

I put them all into the "meh, whatever" category, same as "show codes", except chemical codes, those are just silly. Either you do a code according to ACLS/PALS or you don't.

Slow code is pushing stuff like half dose epi and bicarb in hypotensive patients with pulses. While futile sometimes it is appropriate to buy time for someone nearby to make it to the hospital. Pushing a drug in to a pulseless person without cpr is literally pointless with no effect of any kind and I have never seen this done.

 

[deleted547339]

Slow code is pushing stuff like half dose epi and bicarb in hypotensive patients with pulses. While futile sometimes it is appropriate to buy time for someone nearby to make it to the hospital. Pushing a drug in to a pulseless person without cpr is literally pointless with no effect of any kind and I have never seen this done.

That’s not correct. Slow code is a term used to refer to the practice of intentionally performing slow and/or weak chest compressions in a patient that is nonrecoverable (usually elderly and infirmed) because you feel you must because they don’t have an advanced directive or have family stating that they are full code.

 

[chessknt]

That’s not correct. Slow code is a term used to refer to the practice of intentionally performing slow and/or weak chest compressions in a patient that is nonrecoverable (usually elderly and infirmed) because you feel you must because they don’t have an advanced directive or have family stating that they are full code.

Interesting I didn't know this had a formal definition.

 

[deleted547339]

Interesting I didn't know this had a formal definition.

Yea. It’s widely accepted. It’s not super ethical, but the counter argument is that it’s not ethical to code some of these folks. I, personally, don’t do it. I tend to just call codes early in these settings or plainly tell the family I won’t do it.

 

[engineeredout]

Code without CPR is not an option that I allow to be selected.

Similarly, code without intubation is not an option I allow to be selected. I see this one far more commonly, and tend to lose my **** when I do. I also tell the provider who allowed this as an option that if we get them back, they are going to stand at the head of the bed and bag the patient indefinitely.

 

[deleted547339]

Code without CPR is not an option that I allow to be selected.

Similarly, code without intubation is not an option I allow to be selected. I see this one far more commonly, and tend to lose my **** when I do. I also tell the provider who allowed this as an option that if we get them back, they are going to stand at the head of the bed and bag the patient indefinitely.

I think we would get along in real life.

 

[BigRedBeta]

. I also tell the provider who allowed this as an option that if we get them back, they are going to stand at the head of the bed and bag the patient indefinitely.

That's what the bipap machine is for.../snark

 

[FutureInternist]

The issue with patients picking & choosing which they want is that you end up doing futile care a lot of times
I've had pts want CPR for only 5 minutes, but no epi??
Or do chest compressions ONLY but no defib or intubation

We don't let pts tell us which antibx to use in a particular case so when they do ask for something that I feel is not beneficial, I tell them

I usually explain that "pumping the heart only won't help since the blood has to go to lungs to pick up oxygen & if there is no tube there to help then the blood has nothing to pick up" or something like that

The goal is definitely not to get more DNRs but something has to be said for avoiding doing things TO patients (rather than for them) just because one couldn't/didn't want to explain the ramifications of a particular choice.

 

[Siggy]

I've had pts want CPR for only 5 minutes, but no epi??

To be fair, the evidence for epi in codes is pretty limited and the original delivery method (direct cardiac injection) isn't how we actually provide it.

 

[turkeyjerky]

While I generally despise the fast food menu type of advanced directive, I do fantasize that my personal desire would be to have only enough CPR to get me to a single defibrillation attempt

 

[Hamhock]

Who cares what dead people get? Are we really worried about epi pushes in the pulseless?

I understand being concerned about your staff or the patient's family. However, I think we are hiding our own uncertainties and insecurities when we waste time discussing "chemical codes" (whatever that means; we should never be in this discussion) in disparaging terms.

HH