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Running Codes

Jacqueline Visina

Arrival to a Code

  • Questions to ask when you arrive: Is someone running the code? What is the pt’s code status? Who is doing compressions? Pads on the pt? IV access?
  • Take charge: establish if anyone is actively running the code. If someone is running the code, introduce yourself and ask how you may be helpful. If someone is NOT, have someone begin chest compressions IMMEDIATELY and assume responsibility for the running the code
  • IV access: IV access preferred, if no immediate IV access, place IO
  • Obtain a brief medical history and events surrounding the code and the pt’s code status
  • Have someone find the nearest crash cart and get pads on the pt as soon as possible

Running the Code

  • Assess the rhythm
    • If Vfib/VT, immediately shock
    • For polymorphic VT, this is ischemia until proven otherwise unless the pt is on a large amount of QTc prolonging medications.
    • If PEA/Asystole- resume compressions, give Epi 1mg ASAP
  • Strong ACLS
    • Q2min- pulse check, rhythm check, shock?
    • Remember the two interventions with proven mortality benefit are high quality chest compressions and early defibrillation. Do not interrupt these actions for other things
    • Monitor the quality of chest compressions
    • Warn resuscitators when shock is being delivered
  • Consider Advanced Airway
    • Remember chest compressions save lives. Not intubation. Do not stop compressions for intubation
  • Stay Calm
    • Closed Loop communication- continue giving instructions, use names, minimize interruptions
    • Do not move from foot of bed if you are running the code
    • Ensure delivery of adequate compressions. Avoid excessive ventilation
    • If you are running the code, it is helpful to maintain a constant verbal running summary of interventions that have been tried and the course of the code
    • Have a member of the team locate an ultrasound for line placement and diagnostics
    • **Allow family to be present - If family present, ensure that some healthcare provider (nurse, APP, resident, attending) is with the family (to answer questions, explain what is going on)
  • H’s and T’s: Treat Reversible Factors
  • Some of the fellows here will empirically give 2 grams of magnesium, 1 amp of D50, 1 amp of bicarb, and 1g calcium chloride at the onset of the code irrespective of presenting rhythm
  • Can send Labs – ask for a “loaded gas.” This will usually be a VBG/ABG with lactate, K, Ca, and Hgb. Often information does not result quick enough to change immediate management. Have someone look up most recent labs in Epic (looking for recent hyperK, acidosis)

Terminating a Code

  • Consider initial rhythm, pt comorbidities, cardiac vs non-cardiac arrest, bedside echo findings. ROSC or rhythm changes during code?
  • Persistent ETCO2 < 10 mmHg after 20min CPR has minimal survival
  • Ask your team if they have any other therapies that they feel would be indicated
  • Ask if anyone remains in favor of continuing CPR
  • When unanimous, terminate the code and announce time of death. Thank your team. Take a moment of silence for the deceased pt

Post-Arrest Care

  • Immediately following ROSC is the most dangerous point of ACLS
  • Airway: Secure airway if not done during code, ensure RT avoids hypoxia or hyperoxia
  • BP: MAPs>65, IVF and/or pressors if needed
  • If on floor, prioritize moving pt to a unit for ongoing care once hemodynamically stable enough for transfer. Would not delay for other diagnostics/interventions (lines, CXR, etc)
  • Cardiac: obtain EKG. Assess if urgent cardiac intervention is required for STEMI vs unstable cardiogenic shock vs VT storm or Vfib
  • Neuro: if not following commands, consider TTM. TTM is still performed at VUMC with a strict protocol and inclusion criteria. If there is any question about TTM eligibility, page the CCU fellow
  • Send rainbow labs (CBC, CMP, Mg, coags, trop, lactate, VBG/ABG). Treat rapidly reversible causes
  • CXR
  • Propofol/fentanyl infusion if the pt is intubated. Pressor of choice post ROSC is usually levophed
  • If not done during the code, usually central access will be obtained and an arterial line will be placed

*Intern role during codes: maintain hand on femoral pulse, place IO if needed, or have access to the pt’s chart to answer questions that arise during the code. If family is not available, looking up primary contact information is invaluable. In the MICU, your role is to grab the yellow IO kit prior to leaving for the code

**Family presence during CPR: studies show that it reduces the frequency of PTSD-related symptoms and does not interfere with medical efforts

Treatable Causes of Cardiac Arrest: The H’s and T’s
H's T’s
Hypoxia Toxins
Hypovolemia Tamponade
H+ Tension Pneumothorax
Hypo/Hyper K Thrombosis: Pulmonary
Hypothermia Thrombosis: Coronary