How to run a code

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lifetime

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Hi guys,

Second year resident. Ran a few codes so far. I just want to get an idea of how you guys lead codes, especially when first arriving to the scene. I came up with this. I tried putting it in order of most importance.

1. Assess quality of compressions and airway. At our institution the crna is paged too and the patient always gets intubated. Usually nurses are compressing until we arrive.
2. Establish IV access (peripheral or central)
3. Assign roles (usually interns compress, which nurse admins meds, scribe, etc)
4. Determine when patient was last seen
5. Rhythm prior to cardiac arrest
6. Go through patient's chart, ask nurse about any complaint's pt was having prior to arrest. Think
of H's and T's. Any meds that were given.
7. Follow ACLS protocol during above process.

Please add what you think is important that was likely left out or if you think the order needs to be changed.
Also, how do you guys deal with co residents or third years who try giving their input when you are clearly running the code.
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lifetime said:
Hi guys,

Second year resident. Ran a few codes so far. I just want to get an idea of how you guys lead codes, especially when first arriving to the scene. I came up with this. I tried putting it in order of most importance.

1. Assess quality of compressions and airway. At our institution the crna is paged too and the patient always gets intubated. Usually nurses are compressing until we arrive.
2. Establish IV access (peripheral or central)
3. Assign roles (usually interns compress, which nurse admins meds, scribe, etc)
4. Determine when patient was last seen
5. Rhythm prior to cardiac arrest
6. Go through patient's chart, ask nurse about any complaint's pt was having prior to arrest. Think
of H's and T's. Any meds that were given.
7. Follow ACLS protocol during above process.

Please add what you think is important that was likely left out or if you think the order needs to be changed.
Also, how do you guys deal with co residents or third years who try giving their input when you are clearly running the code.
Click to expand...

The most important thing is setting the correct tone. Codes actually are extremely simple. It is following a very simple flowsheet. However, people tend to freak out for some reason. When I run a code, I ask everyone to quiet down and tell me what happened. Then you assign roles and go from there.

The key is that people relax and just perform the functions they are assigned. The patient is already dead, you can't hurt them. Just relax and perform your job, you almost are never the 'cause' of why the patient is dead.

I'd debate you almost 'never' need central access. Peripheral or IO is sufficient. Intubation is fine but it is not going to interrupt compression during my codes.

If other people/residents want to contribute ideas that is great, but there is only one leader and one person making decisions.
 
I think the most important thing during the algorithm is to keep appropriate track of time. Most of the time there's a nurse assigned as timekeeper, but having to keep asking how long it's been when the nurses try to give epi too often or whatever else is always very frustrating. I learned pretty early on the best thing to do for me is to pull out my phone at the beginning of every code and open a stopwatch/timer app so I can keep my own clock wrt when to give medications and such.
 
Step 1: Are compressions being done?
Step 2: Is pads on patient?
Step 2.1: If no, put pads on patients.
Step 2.2: Are pads positioned correctly?
Step 2.3: If no, reposition pads.
Step 2.4: Is the monitor on?
Step 2.5: If no, turn on, turn monitor to pads.
Step 3: Check rhythm, if appropriate, bring patient to Electric Avenue.

Step 4: Run code.

On one hand, the amount of times I've had to do those steps myself despite not being the first person to the code is scary. On the other hand, it's quicker to set the monitor up myself then try to get someone else to do it... correctly (and no, nurse manager, it doesn't matter if the pads are switched in terms of the picture... and yes.. I've had that fight during a code).
 
The steps you've outlined above are okay. How you ultimately arrange them is going to be dependent on the nursing staff's skills in codes. I'm a peds intensivist and in the unit, nurses, pharmacy and RT fall in to place without any prompting. The floor in a children's hospital though is not used to having patients code, even in a high acuity place like the Heme/onc floor. So in the unit, I can typically skip assigning roles (other than to ask who is my timer so I know who to listen for), while on the floor, that step takes on greater importance.

The absolute most important thing in running a code though is to be LOUD. Everyone needs to be able to hear you clearly. In mock code debriefs that's usually the most praised thing for code leaders, and team members typically like when code leaders think out loud and recap periodically.

Peripheral access is always sufficient in a code. If they have a central access, great, but it's not going to change the situation one way or the other, and it's hard to get access in the middle of compressions (although probably not as hard in adults as it is in kids as there's more room on that adult body)

An airway is useful, but the situation needs to be appraised and the reason why the patient coded should figure into that decision before you delay compressions. In kids, our arrests are more typically respiratory in origin, so it is a more important consideration. In an adult, depending on the situation, it's probably not as pressing. In all patients, if you are managing to get decent saturations with bagging, then it is less urgent. At my prior institution, there was a slight trend towards throwing in an LMA in reasonable patients as a bridge towards intubation. The AirQ brands you can actually pass an endotracheal tube through and slide the LMA over.

I always tell residents that a code is easy, you don't have to think, just follow the algorithm. Don't ever be afraid to pull out your ACLS card. This is not about your ego or showing off your knowledge, but it is about doing what is right for the patient.

I disagree with the idea from another poster that there is only one decision maker. It should be clear who is the code leader, but everyone, even those late arriving should be able to offer up useful thoughts or information.

You should constantly be appraising the quality of compressions. It's evidence based and a simple fix.

The last thing is don't be afraid to be traffic cop and ask people to leave the room. The ideal code is a quiet code. If you feel like there are too many people around (which at an academic medical center happens often because of all the layers and extra students in all fields floating around), either ask people to leave or have one of the nurses clear the room.

So for you steps, here's how I would list them:

1. Assess quality of compressions and airway.
2. Assign roles
ACLS
3. Place pads and turn on monitor
4. Is the backboard in place?
5. Access - either PIV or IO
ACLS
6. Assess quality of compressions.
7. Collect info on the history
ACLS
8. Airway?
9. Assess quality of compressions
ACLS
 
BigRedBeta said:
I disagree with the idea from another poster that there is only one decision maker. It should be clear who is the code leader, but everyone, even those late arriving should be able to offer up useful thoughts or information.
Click to expand...

I think it's a little more nuanced. There needs to be one person making decisions. Period. A code is not the time to have a committee meeting about what to do next.

That said, the person running the code needs to be able to solicit feedback and advice from everyone involved to make sure that there isn't something being missed and be willing to listen to the other team members. The pilot is still the pilot, but the pilot ignores the first officer at the plane's peril.
 
Not totally on topic, but I always love sharing this:

acls.png
 
I would add how crucial closed loop communication is

When I ask someone to do something, I always say to them, "can you confirm by repeating back to me" and also "are you comfortable doing that/in that role" and then say "and let me know when that task is completed"

helps SOOOOOOO much so you don't have redundancy or someting not happening "cuz I thought someone else got that" or someone trying to so somthing they don't really know how to do

it only takes seconds to do that kind of communication and stitch in time saves nine
 
Thanks for the advice guys. Interns do compressions because that's how it is at our hospital although other staff members do help out.
 
Doctor4Life1769 said:
Why are the interns doing compressions?
Aren't there enough nursing/PCTs in your hospital floors for them to do the compressions while the interns can learn how to properly RUN a code?
Click to expand...
Only 1 person can run the code. Often interns have never been part of a code and getting in there, doing compressions makes it real, and tangible.

Sent from my VS986 using Tapatalk
 
shoal said:
Only 1 person can run the code. Often interns have never been part of a code and getting in there, doing compressions makes it real, and tangible.

Sent from my VS986 using Tapatalk
Click to expand...

So, instead of getting familiar with the environment, they're doing chest compressions which anyone can do. They should be taking it in and eventually be taking command.
 
Rhythm: shockable?
Airway/Breathing: bag valve mask, anesthesia for intubation, surgery for surgical airway
Circulation: compressions, access, meds

As you're assessing these, you have to be assigning roles

You have to try to figure out what happened, because there are several rapidly reversible causes of an arrest. Tension pneumothorax, cardiac tamponade, etc.

Then you have to be thinking about what else you can do. Balloon pump? ECMO?

Doctor4Life1769 said:
The most important thing is to know the code STATUS.
Click to expand...

Does ECMO count...?
 
Which H's and T's have you guys had experience with and reversing it? Hypoxia, either from volume overload or aspiration, leading to cardiac arrest has been quickly reversed with intubation for me. Nothing else that I could catch. Do you guys rule out all the H's and T's prior to calling it? Like getting a bedside US for tamponade/PTX.
 
lifetime said:
Which H's and T's have you guys had experience with and reversing it? Hypoxia, either from volume overload or aspiration, leading to cardiac arrest has been quickly reversed with intubation for me. Nothing else that I could catch. Do you guys rule out all the H's and T's prior to calling it? Like getting a bedside US for tamponade/PTX.
Click to expand...


Accucheck. Always make sure there is an accucheck.

Nothing worse then realizing 10 minutes in the blood sugar is 14.....
 
lifetime said:
Also, how do you guys deal with co residents or third years who try giving their input when you are clearly running the code.
Click to expand...
Mercifully, I don't have to deal with this anymore, but when I did...
"Alright b***h, here's the ball, you run with it. I'll be in the cafeteria if you need me."

Obviously, if the attending showed up and did this, or I was drowning (or f***ing up), I'd accept their help graciously (which is what usually happened). But the few times somebody came to the code just to show that they knew more than I did, I dropped the mic and walked away.
 
Last edited:
I think one of the most important things is to be the calm one.

Codes in the ICU and ER are generally run well, because everyone knows their role and they happen so often.

Codes on the floor are always chaos.

Others will take there lead from you, so you need to be ICE COLD calm.
 
gutonc said:
Mercifully, I don't have to deal with this anymore, but when I did...
"Alright b***h, here's the ball, you run with it. I'll be in the cafeteria if you need me."

Obviously, if the attending showed up and did this, or I was drowning (or f***ing up), I'd accept their help graciously (which is what usually happened). But the few times somebody came to the code just to show that they knew more than I did, I dropped the mic and walked away.
Click to expand...

No one likes those people.

At our hospital, the "supervised code leader" is usually the intern getting their toes wet. I had a senior pull me up and make me run the code as an intern, and I was glad he did.

If the code leader is a resident (2 or above), then anyone showing up simply asks if they need any help, airway, something along those lines. If the leader says No, I'm good, and there is tons of people in line for compressions (there usually is), then I usually just roll out. No need to clog the room.
 
HooliganSnail said:
No one likes those people.
Click to expand...

Ok, I'm guilty of this.

When there's a code on the floor I'll go and hover because eventually (if they survive) the person is coming to me in the ICU. At my institution, the ICU does not generally respond to codes on the floor.

For the most part I try to stand at the back of the room. Occasionally if the code turns into a goat rodeo I'll go stand at the shoulder of the resident running the code and try to offer suggestions. But when I do that, I still want the resident to give the order to the room; that way there isn't confusion from the staff (should they listen to me, to the resident, etc etc etc).
 
BigRedBeta said:
The last thing is don't be afraid to be traffic cop and ask people to leave the room. The ideal code is a quiet code. If you feel like there are too many people around (which at an academic medical center happens often because of all the layers and extra students in all fields floating around), either ask people to leave or have one of the nurses clear the room.
Click to expand...

Yes, yes, yes.

I've been in some codes that were almost eerily quiet, and in some where the room was louder than the trading floor of the New York Stock Exchange. I much prefer the quiet codes, which make it a lot easier to think and communicate with the people around you. Loud codes just amplify the sense of chaos and make the process much more confusing and stressful than it actually is.

I've also seen rapid responses when so many medical students etc crowd into the room that you can't even get an EKG machine to the bedside...when this happens, I have no problem with loudly telling people to get out.

gutonc said:
Obviously, if the attending showed up and did this, or I was drowning (or f***ing up), I'd accept their help graciously (which is what usually happened). But the few times somebody came to the code just to show that they knew more than I did, I dropped the mic and walked away.
Click to expand...

I am super irritated when people do this. It's another example of the constant medical penis measuring contest that I refuse to participate in anymore. Mic drop + exit stage left seems like about the best way of dealing with it...otherwise occasionally you'll get some really persistent person that can't resist barking out orders/thoughts/whatever while you're trying to run the code, and everyone will end up confused as hell.
 
dozitgetchahi said:
Yes, yes, yes.

I've been in some codes that were almost eerily quiet, and in some where the room was louder than the trading floor of the New York Stock Exchange. I much prefer the quiet codes, which make it a lot easier to think and communicate with the people around you. Loud codes just amplify the sense of chaos and make the process much more confusing and stressful than it actually is.

I've also seen rapid responses when so many medical students etc crowd into the room that you can't even get an EKG machine to the bedside...when this happens, I have no problem with loudly telling people to get out.



I am super irritated when people do this. It's another example of the constant medical penis measuring contest that I refuse to participate in anymore. Mic drop + exit stage left seems like about the best way of dealing with it...otherwise occasionally you'll get some really persistent person that can't resist barking out orders/thoughts/whatever while you're trying to run the code, and everyone will end up confused as hell.
Click to expand...

There was a nurse/AOD who came in and started questioning things, and barking orders. I looked at him and asked him if he knew this patient at all and if so, would he like to take over. He stopped talking and walked away and the nurses and I taking care of the patient resumed with the code. Of course, compressions continued.
 
Doctor4Life1769 said:
There was a nurse/AOD who came in and started questioning things, and barking orders. I looked at him and asked him if he knew this patient at all and if so, would he like to take over. He stopped talking and walked away and the nurses and I taking care of the patient resumed with the code. Of course, compressions continued.
Click to expand...

It's a bit different when it's another resident (which is what I've experienced at my program several times). Some of these people show up and simply won't butt out (they think they're doing what's best for the patient!), and having a long argument with someone during a code is unwise to say the least.

Nurses? I tell them to get out of they're getting in the way, and they do.
 
dozitgetchahi said:
It's a bit different when it's another resident (which is what I've experienced at my program several times). Some of these people show up and simply won't butt out (they think they're doing what's best for the patient!), and having a long argument with someone during a code is unwise to say the least.

Nurses? I tell them to get out of they're getting in the way, and they do.
Click to expand...

I'm not sure why other residents are butting in, unless it is your senior. I usually will allow the intern to run it unless they are totally overwhelmed, then I take over.

We run the codes. If a Pulm Crit attending is there, they usually turn it over to us when we arrive. Honestly, it'd be awesome if they just continued, but it is appreciated that we have that level of respect and autonomy.
 
As a leader your stress level is usually added on top of the existing stress level of everyone else in the room. I work very hard on seeming like the calmest person in the room besides the patient. For floor codes, I am looking for 3 pieces of information. What is currently being done for the patient, a (brief) summary of reason for admission and events surrounding code, and my physical assessment of the patient. For some reason, the primary nurse usually teleports out of the room so piece #2 is usually the last bit of info I have.

Others have done a good job of describing assessing the adequacy of CPR. For my physical assessment, I'm looking for clues as to the cause of the code. Most of the H's and T's are either ruled out based on history or can be assessed by looking for things like thoracic lines or dialysis catheters. Dialysis catheters get calcium gluconate for presumed hyperK, evidence of recent thoracic manipulation (primarily central lines) increases suspicion for pneumo, etc. Unrecognized tamponade from a fixable source is pretty rare in floor patients but is something to think about if they've had recent CT surgery. And glucose for everyone.

Once you've finished the cognitive/procedural portion of the code, it basically turns into a waiting game of compressions and epi. That's the time to be on the look-out for new information (code status, STAT labs) that may help drive the code in a certain direction. Finally, while I'm the code leader I will solicit input when I'm ready to call the code so that no one feels like we gave up on a salvageable patient. That typically doesn't create any further interventions although about 20% of the time somebody will request a dose of sodium bicarb.
 
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