Critical Moments Case Study Review Episode 1: Mucous Plug Turned Code Blue

There are moments in nursing you never forget - the ones that shape and stay with you, long after your shift ends. For me, one of those moments was my first code blue.

I was a brand new baby ER nurse, in my first solo week off orientation. I got report from night shift and started seeing my assigned patients. I noticed my first patient was sleeping and vitally stable to I moved onto my trached patient.

Pt Information: 76yo F, trached after motorcycle accident 25years ago. Presented to the ER with dyspnea on exertion and dizziness. Hx of hypertension and high cholesterol. Takes Lisinopril and Simvastatin. Pt's Son is the primary caregiver.

I obtained my start of shift vital signs and assessments - nothing was abnormal. HR 95/min, BP 145/75, T98.1F, RR 24/min, and O2 was 98% on Room Air. Trach was in place, breath sounds were clear and equal bilaterally. I had just walked my trached patient to the bathroom and sat her up in the chair for breakfast. The patient had no complaints, in fact, we were laughing and talking about our weekend plans. After she was comfortable in the chair, I walked back to the nursing station to chart when I heard the patient's son yell down the hall "I need help, my Mom isn't breathing".

I ran back into the room to find the patient slumped over in the chair. Lips turning blue, not breathing, still had a pulse. I immediately grabbed the suction equipment and attempted to suction her trach - nothing suctioned out on either of my two attempts. Another nurse ran in behind me and we were able to get her back into bed. As I started bagging her with a BVM, the 2nd nurse (Matt) called a code blue.

We cycled the vital signs and I remember looking up at the 5-Lead EKG and I watched her go from NSR to Sinus Brady to Asystole on the monitor. Pulse ox dropped from 92% to the 70s% despite my bagging. I remember it was difficult to ventilate her. Matt immediately started CPR. The room was filled within seconds - nurses, doctors, RT, pharmacy. As more people came into the room, we gave a quick patient SBAR and rushed her over to one of our trauma bays (the room she was in was very small - slightly bigger than a coat closet).

As we rolled into the trauma bay, RT took over my bagging and I stepped back to start getting code medications together. Matt continued CPR and the charge nurse came into the room to assign rolls. Someone started another IV and drew a new set of labs, someone placed the defib pads, someone jumped on the computer, another person started getting the airway equipment together. The techs made a CPR line so no one person would tire doing compressions (the pt was too small for the Lucas machine). Honestly, it was kind of a blur. It was like I was watching everything happen in slow motion - I didn't feel present. I just kept thinking about what happened, how it happened, why it happened.

At some point the doctor yelled "Everyone Pause" (except the CPR person!) and I snapped back into reality. He did a quick recap of the case and explained his plan to everyone. We all got into position and the code ran smoothly. The doc was calm and collected, we utilized closed loop communication to ensure everyone understood and confirmed our messages.

As labs started returning, We worked through other possible reversible causes of her cardiac arrest:

CBC: Mildly elevated WBC at 14, otherwise unremarkable.

CMP: Slightly low potassium at 3.2 and sodium at 130, otherwise WNL.

ABG: pH: 7.20, PaO2: 50 mmHg, PaCO2: 60 mmHg, HCO3-: 18 mEq/L, Lactate: 6 mmol/L.

Due to insufficient oxygenation and continued difficulty with ventilation, the doctor made the decision to remove the trach and attempt endotracheal intubation. With one attempt, we had secured an airway and the pt's oxygen had returned to the high 90s. RT hooked the pt up the vent and we continued resuscitation. We continued CPR, following ACLS protocols and after a few rounds of epinephrine, we were able to provide a shock for Vfib. The doctor asked us to review our Hs&Ts (from ACLS) - understanding that hypoxia was the most likely cause of her cardiac arrest.

It was only a total of 12min from the start of the code blue until I saw her end tidal spike >20. The patient was noted to have a successful return of spontaneous circulation (ROSC) and her heart rate normalized. Chest compressions were discontinued and we obtained a blood pressure of 190/89. Post cardiac arrest procedures were initiated. The patient survived and left the hospital a few days later. I saw her many times during my 8yr career at that hospital. I still think about her often and wonder how she's doing.

THINKING ABOUT THE CASE:

1. What were your initial thoughts?. Was there anything in her history or physical that could have led to her cardiac arrest?

2. Reviewing her labs, what was abnormal? Why is this concerning?

3. What did you think of our care? Why?

4. Review ACLS Protocol: What Hs & Ts could have contributed to her arrest?

5. What would you do differently next time? Why?

POST CASE REFLECTIONS:

1. I still remember her face and her voice. We were just talking and less than 2 min later, we were doing CPR. This is ONE of the BIGGEST reasons I struggled with her cardiac arrest. I've cared for many patients in cardiac arrest, most people come in "dead" and you work them. You're detached in a sense. This patient was different. We connected and were laughing together - she was a "real person" and in a flash she was fighting for her life.

2. The code was actually really smooth- one of the best codes I've ever been a part of. Everyone had their roles, communication was clear, tasks were completed - dare I say it was pretty textbook. No hiccups.

3. It was clear from the situation and the ABGs the patient was hypoxic but in the moment I didn't know why. Again, we were just talking and she collapsed. It wasn't until the MD removed the trach to intubate endotracheally that he saw the mucus plug on the end of the trach tube. That was why I didn't get anything out when I tried to suction - a HUGE AH AH Moment for me.

4. The son admitted that he had recently been out of town for work and a home health nurse had come to the house, however, she wasn't familiar with trachs and so he believed her standard trach care hadn't been completed in a few days.

5. Following this case, we debriefed as a department and made a few changes to our standard of care (we actually didn't have a policy in place in our ER for trached pts):

   1. All trach patients were to have trach care completed Q8hrs.

   2. All trach patients were to be on humidified oxygen to help thin secretions.

   3. All trach patients were required to have a trach box (it was a tackle box that we created) on the counter of their room which included: trach supplies, ties/dressings, sterile gloves, PPE, suction supplies, gauze, sterile water, and the RN was responsible for keeping the pt's trach size and one size smaller in the box.

   4. RT consults were required on every trached ER patient - RT would come down and assess each patient and provide a plan of care to the ER RN.

I thought about this patient and this case for a long time. I still think about this patient and share this store with my nursing students when I teach about trachs. My 1.25hr long drive home that night proved to be just enough time for my mind to spiral out of control thinking about all of the things I could have done differently. I wish I knew more about trachs in that moment - as confident as I felt to be "out on my own", in that moment I realized I had so much more to learn. You better believe I signed up for CEUs about advanced airways and connected with RT to learn more about how to care for patients with artificial airways.

It took me a long time to realize I didn't do anything wrong. However, I wish I would have done things differently. This is the power of a case study. It's not about blame, it's about learning, it's about personal growth and mastering your craft so you take better care of the next patient.

*Names and some personal information changed to protect the privacy of the patient and my colleagues.