Resources for Running a Code

[MNCASC]

What are some good resources for learning how to run a code? Are there good youtube videos? I'm basically looking for different scenarios during a code and how to deal with them.

---

Members don't see this ad.

 

[wamcp]

What are some good resources for learning how to run a code? Are there good youtube videos? I'm basically looking for different scenarios during a code and how to deal with them.

I follow a mental checklist.

1. pull out my iphone and start the stopwatch once i hear a code is called. I always personally track the time intervals during the code.

once you arrive to the room, announce yourself to lead the team.

and turn on the effing lights. As a nocturnist, 90% of the time the room is still dim and dark whenever i get to the code

2. Verify a backboard is in place, proper compressions are done, and that the bed height is lowered or step stool provided for the compressor as needed

3. Verify iv access. Order your team to place IO or central line as needed

4. ensure someone is bagging the patient; pause for 2 breaths every 30 compressions (if no adv airway)

5. Order 1 mg epi to be given, i give it every 3 minutes

6. order someone to obtain fingerstick glucose check

7. order someone to call anesthesia, intensivist or whoever is responsible for airway during a code at your hospital, if they haven’t arrived

8. order someone to double verify code status in chart and to call family asap

9. optional: order someone to get an Ultrasound to later image the heart for thrombus/tamponade and get pulse doppler if available

10. Order for defib pads placed, as it should be near time for pulse and rhythm check by now. During this first check, order the bed be pulled out from against the wall to give the intubator space when they arrive

11. if a shockable rhythm, order compressions resumed and charge to 200J, when charged clear everyone and deliver shock, then immediately resume compressions

12. If it was shockable rhythm, give 300 mg amiodarone and IV Mag. Give 150 mg amio if refractory vf/vt on the next check. I give 100 mg lido if still refractory. Try to avoid epi within the next 2 min of known vt/vf.

12. Whether the rhythm check was or was not shockable, keep going: epi q3min and pulse/rhythm checks q2 min. 1 breath q6-8 seconds plus continuous compressions when intubated.

as the second round of compressions begins, obtain info from the nurse on what happened, if pt was on tele then what was the last rhythm identified, was narcotics given earlier today, what were the last set of labs especially potassium, think your Hs/Ts

13. by the third or fourth round of compressions without rosc, i often give amp of sodium bicarb and Calcium empirically

If rosc is obtained, always keep someone checking the pulse. Check blood pressure and o2 sats immediately. Get Ekg look for stemi. Monitor the etco2. Check neuro response

For specific arrest situations, this link is pretty comprehensive:

https://www.ahajournals.org/doi/full/10.1161/circulationaha.110.971069

I’ve thankfully never ran a code on a pregnant pt but have seen one back in pgy1. Gotta remember to push the gravid uterus aside and get the L+D team stat

 

[HemeOncHopeful19]

In residency I kept those small fold-out cardboard cards that came with the ACLS book in my white coat pocket. I won’t say it ever made me stellar at running codes but it did help me feel more comfortable having them with me 24/7.

 

[InternistDO]

wamcp has a good checklist. I like to give epi every 2nd pulse check (q4 mins) because it's easier for me to keep track of. I've also never done 30:2 CPR in my life (and I've worked 100s of codes). I do continuous compressions and people bag around them. This has also been the case at the hospitals I've been at. There's no real evidence that bagging (or early intubation) is terribly helpful anyway, and you can easily overinflate the chest and stomach and worsen the patient's already terrible preload. This also means there's less to keep track of during the code--the compressor just needs to go until the pulse check and the person managing the airway can bag q8 seconds as best as possible.

I have no interest in checking the glucose because D50 during codes is associated with worse neurological outcomes, but you should check and treat post arrest.

Most important step is to stay cool and calm. You can't make the patient any deader so there's really no reason to get worked up about a code, and if you're in the ICU or the ED the nurses know what they're doing and can run most of the steps of the code without you anyway. A panicked code leader means a terribly run arrest and likely a bad outcome, even if you have a good team.

 

[DrMetal]

A Bible. Unless they're relatively young, healthy and have an obviously reversible cause, most will die.

 

[ShuperNewbie]

The AHA has an app called "Full Code Pro" that you might want to look into getting. It has a built in timer and a metronome for chest compressions, and helps you run the algorithm in real time. Great little tool, especially during an active code

 

[wamcp]

wamcp has a good checklist. I like to give epi every 2nd pulse check (q4 mins) because it's easier for me to keep track of. I've also never done 30:2 CPR in my life (and I've worked 100s of codes). I do continuous compressions and people bag around them. This has also been the case at the hospitals I've been at. There's no real evidence that bagging (or early intubation) is terribly helpful anyway, and you can easily overinflate the chest and stomach and worsen the patient's already terrible preload. This also means there's less to keep track of during the code--the compressor just needs to go until the pulse check and the person managing the airway can bag q8 seconds as best as possible.

I have no interest in checking the glucose because D50 during codes is associated with worse neurological outcomes, but you should check and treat post arrest.

Most important step is to stay cool and calm. You can't make the patient any deader so there's really no reason to get worked up about a code, and if you're in the ICU or the ED the nurses know what they're doing and can run most of the steps of the code without you anyway. A panicked code leader means a terribly run arrest and likely a bad outcome, even if you have a good team.

I disagree, hypoglycemia itself can cause cardiac arrests. Especially when you get to a code you know nothing about the pt, checking glucose and treating hypoglycemia makes perfect sense to me

Hypoglycemia as an independent cause of cardiac arrest: A case report - CCEM Journal

Hypoglycemia is a very common side effect of insulin therapy and oral hypoglycemic agents. Occurrence of cardiac arrest as a result of severe hypoglycaemia has not been documented much in literature. We describe a interesting case of a type 2 diabetic patient admitted in intensive care unit...

ccemjournal.com

 

[InternistDO]

I disagree, hypoglycemia itself can cause cardiac arrests. Especially when you get to a code you know nothing about the pt, checking glucose and treating hypoglycemia makes perfect sense to me

Hypoglycemia as an independent cause of cardiac arrest: A case report - CCEM Journal

Hypoglycemia is a very common side effect of insulin therapy and oral hypoglycemic agents. Occurrence of cardiac arrest as a result of severe hypoglycaemia has not been documented much in literature. We describe a interesting case of a type 2 diabetic patient admitted in intensive care unit...

ccemjournal.com

My concern is primarily that capillary BGL measurement is very inaccurate in poor perfusion states and therefore there's likely a lot of extra D50 administered, which is associated with worse outcomes. I don't think we should ignore your case report, but I imagine the amount of people who have a true hypoglycemic arrest with any salvageable brain tissue left is incredibly small next to the amount of people who will have a borderline low POC glucose during a code and get treated with IV glucose.

That being said, this is cardiac arrest and the evidence base for and against a lot of these treatments is so flimsy that I don't think I can make a tremendously strong argument against someone who wants to do treat hypoglycemia. But personally I routinely do not.

 

[Kaustikos]

I follow a mental checklist.

1. pull out my iphone and start the stopwatch once i hear a code is called. I always personally track the time intervals during the code.

once you arrive to the room, announce yourself to lead the team.

and turn on the effing lights. As a nocturnist, 90% of the time the room is still dim and dark whenever i get to the code

2. Verify a backboard is in place, proper compressions are done, and that the bed height is lowered or step stool provided for the compressor as needed

3. Verify iv access. Order your team to place IO or central line as needed

4. ensure someone is bagging the patient; pause for 2 breaths every 30 compressions (if no adv airway)

5. Order 1 mg epi to be given, i give it every 3 minutes

6. order someone to obtain fingerstick glucose check

7. order someone to call anesthesia, intensivist or whoever is responsible for airway during a code at your hospital, if they haven’t arrived

8. order someone to double verify code status in chart and to call family asap

9. optional: order someone to get an Ultrasound to later image the heart for thrombus/tamponade and get pulse doppler if available

10. Order for defib pads placed, as it should be near time for pulse and rhythm check by now. During this first check, order the bed be pulled out from against the wall to give the intubator space when they arrive

11. if a shockable rhythm, order compressions resumed and charge to 200J, when charged clear everyone and deliver shock, then immediately resume compressions

12. If it was shockable rhythm, give 300 mg amiodarone and IV Mag. Give 150 mg amio if refractory vf/vt on the next check. I give 100 mg lido if still refractory. Try to avoid epi within the next 2 min of known vt/vf.

12. Whether the rhythm check was or was not shockable, keep going: epi q3min and pulse/rhythm checks q2 min. 1 breath q6-8 seconds plus continuous compressions when intubated.

as the second round of compressions begins, obtain info from the nurse on what happened, if pt was on tele then what was the last rhythm identified, was narcotics given earlier today, what were the last set of labs especially potassium, think your Hs/Ts

13. by the third or fourth round of compressions without rosc, i often give amp of sodium bicarb and Calcium empirically

If rosc is obtained, always keep someone checking the pulse. Check blood pressure and o2 sats immediately. Get Ekg look for stemi. Monitor the etco2. Check neuro response

For specific arrest situations, this link is pretty comprehensive:

https://www.ahajournals.org/doi/full/10.1161/circulationaha.110.971069

I’ve thankfully never ran a code on a pregnant pt but have seen one back in pgy1. Gotta remember to push the gravid uterus aside and get the L+D team stat

The first parts are definitely important: ALWAYS announce and make sure everyone knows you're running the code.
And don't let people do things without your approval. Too many times people think they know what to do and it's not appropriate.

Also, I also ask non essential people to leave the room

Tell primary team to call nok for code status reassessment
I also request a doppler for pulse check - these patients tend to be morbidly obese with short necks and pulse checks can be tricky.

Intubations: I'm not one to intubate or call anesthesia unless I hace rosc confirmed. I'm jaded/cynical, but I'm not asking for intubation unless I know hypoxia was the cause or I've got rosc. Team can always bag mask until they arrive.

I'll just add one important thing: confirm that there is no pulse. There have been too many an occasion a code is called when there is a pulse.

Regarding amio/lidocaine: I hate giving it because it has to be drawn and there's always a delay in getting it ready.

Lastly, definitely recommend using an app if you're not comfortable doing it. It's okay to have help then pretend you know.

 

[Kaustikos]

A Bible. Unless they're relatively young, healthy and have an obviously reversible cause, most will die.

Technically they already did