Running Codes

Cairo De Souza

Resident Roles

  • Intern: Discuss learning opportunities with senior prior to codes. Grab yellow IO kit, hold femoral pulse, place IO if needed, coordinate getting ultrasound machine, help with chest compressions.
  • Senior: Ask fellow in advance to run code with supervision.

Arrival

  • Who is running this code? Have we confirmed the patient's code status? 
  • Establish if anyone is actively running the code. If someone is leading, ask how you may be helpful. If no one is leading, introduce yourself and assume control. Use closed-loop communication.

1st Minute: ABCDE

  • Airway – Breaths being delivered? Need an airway adjunct?
  • Breathing – Is someone bagging the patient effectively?
  • Compressions – Chest compression started? Queue 2-3 people to rotate during pulse checks.
  • Defibrillation – Pads on?
  • Epinephrine – Make sure first dose has been given.

2nd Minute: Organize

  • You/code leader: foot of the bed - do not move.
  • Compressor + 2-3 in line to rotate.
  • Femoral pulse monitor.
  • Airway manager at head of bed. Have second person to assist/hold the mask.
  • Medication administrator.
  • Timer/Recorder.
  • Clear extra people from room.

Now that your Code is Running

  • Access: IV preferred over IO.
  • Obtain a brief medical history and events surrounding the code.

Interventions with Proven Mortality Benefit

  • High quality CPR
    • Minimize interruptions (<10s).
    • Rotate compressors during pulse checks.
    • Q2min: pulse check → rhythm check → shock?
    • Resume CPR immediately after shock. Do not check pulse until after next 2min cycle.
    • Do NOT pause compressions for intubation.
  • Early Defibrillation
    • VF/VT: shock immediately; precharge during compressions to minimize pause.
      • Polymorphic VT: treat as ischemia unless suspicious of significant QTc prolongation.
    • PEA/Asystole: resume compressions, give epi early.
  • Epinephrine
    • 1 mg IV/IO q3-5 min (or every other CPR cycle).
  • Consider Advanced Airway
    • Intubation not proven to increase survival over bag-mask ventilation.
    • Do NOT stop compressions for intubation.
Treatable Causes of Cardiac Arrest
H's T's
Hypoxia Toxins
Hypovolemia Tamponade
H+ Tension Pneumothorax
Hypo/Hyper K Thrombosis: Pulmonary
Hypothermia Thrombosis: Coronary
  • Obtain loaded gas ("Adult Respiratory Lab Panel" on EPIC), POCUS.
  • Some fellows will empirically give 2g Mg, 1 amp of D50, 1 amp of bicarb, and 1g calcium chloride at the onset of the code irrespective of presenting rhythm.

Terminating a Code

  • Consider initial rhythm, pt comorbidities, cardiac vs non-cardiac arrest, POCUS. ROSC or rhythm changes during code?
  • ETCO2 < 10 mmHg after 20min CPR → minimal survival.
  • Ask your team if they have any other therapies/etiologies, confirm consensus to stop.
  • When unanimous, terminate the code and announce time of death. Thank your team. Take a moment of silence for the deceased patient.

Post-ROSC Care

  • Airway: Secure airway if not done. Avoid hypoxia AND hyperoxia.
  • BP: target MAPs > 65 mmHg, IVF +/- norepinephrine (usually pressor of choice).
  • Cardiac: Obtain EKG. Assess if urgent cardiac intervention is required for STEMI vs unstable cardiogenic shock vs VT storm or Vfib.
  • Neuro/Targeted Temperature Management
    • If not following commands, consider TTM.
    • Maintain T 32 - 37.5 C, prevent fever (>37.7 C) for >36h.
  • If any question about eligibility → page CCU fellow.
  • Send rainbow labs (CBC, CMP, Mg, coags, trop, lactate, VBG/ABG). Treat rapidly reversible causes.
  • CXR
  • Sedation: propofol/fentanyl infusion if intubated.
  • Dispo: if on floor, transfer to ICU once HDS, do not delay for CXR/lines.
  • If not done during the code, obtain central access and an arterial line.

AHA ACLS 2025 Guidelines

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.
  • 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).
  • 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).
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