Running Codes

Hannah Kieffer

Arrival to a Code

  • Questions to ask when you arrive: Who is running this code? Have we confirmed the pt’s code status?
  • Calmly 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, assume responsibility for running the code

1st Minute: Check in on ABCDE

A: Airway – Check that patient is receiving breaths; do they need an airway adjunct?

B: Breathing – Is someone bagging the patient effectively?

C: Compressions – Has someone started chest compressions? Have 2-3 people in line to take over during pulse checks

D: Defibrillation – Are there pads on the patient?

E: Epinephrine – Make sure first dose has been given

2nd Minute: Set up your room

  • You/the code leader stands at the foot of the bed. Do not move.
  • One person on chest compressions; 2-3 people in a line behind to take over during pulse checks
  • Airway manager at head of bed. Have second person to assist/hold the mask
  • Someone monitoring femoral pulse
  • Medication administrator
  • Timer/Recorder

Be clear and remove extra people out of the room

Now that your code is running

  • Access: IV access preferred, if no immediate IV access, place IO
  • Obtain a brief medical history and events surrounding the code

Interventions with proven mortality benefit

  • Strong ACLS
    • Check that high quality CPR with minimal interruptions (<10s)
    • Change compressors during pulse checks to decrease interruptions
    • Q2min - pulse check, rhythm check, shock?
    • Do NOT pause compressions for intubation
    • Restart CPR immediately after defibrillation - do not check pulse until after 1 additional round of CPR after defibrillation, even if possible perfusing rhythm returns
  • Early Defibrillation: 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
  • Epinephrine: Given every 3-5mins during CPR
  • Consider Advanced Airway
    • Intubation is not proven to increase survival over bag-mask ventilation
    • Remember chest compressions save lives, not intubation. Do NOT stop compressions for intubation
  • 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

Miscellaneous Advice

  • Closed Loop communication - continue giving instructions, minimize interruptions
  • It can be helpful to maintain a constant verbal running summary of the course of the code and interventions that have been tried
  • Have a member of the team locate an ultrasound for line placement and diagnostics
  • Once code is underway, you have more time to understand specifics of patient. Ask bedside nurse for more past medical and more immediate history. Have someone look up most recent labs in Epic (looking for recent hyperK, acidosis). Can send Labs – ask for a “loaded gas”
  • Allow family to be present if they want. Very Important: If family present, ensure that a healthcare provider (nurse, APP, resident, attending) is with the family (to answer questions, explain what is going on)

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 patient

Post-Arrest Care

  • Immediately following ROSC is the most dangerous point of ACLS
  • Airway: Secure airway if not done during code. Avoid hypoxia AND 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 Targeted Temperature Management. 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, obtain central access and an arterial line

Resident Roles

  • Intern: Grab yellow IO kit before leaving ICU for the code. Discuss learning opportunities with senior prior to codes; consider holding femoral pulse, placing IO if needed, chest compressions if no prior experience
  • Resident: Ask the fellow in advance if you can run the code with them standing next to you for support and assistance. This is a very important experience.
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