Running a code

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HoosierdaddyO

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10+ Year Member
I'm almost done with my 1st year of residency and while having run quite a bit of codes in the ED as well as on the floor during my off service months, was wondering if any of the vets here have any pearls or tricks or advice for running codes... do you push bicarbonate based on pH alone? How long do you find yourself running a code before calling it quits? Etc etc etc?, tricks to get better at organizing tasks, when to do this when not to do that...any tips or tricks or advice is as always appreciated 🙂?!
 
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I don't push bicarbonate during a code. If there's a clear indication once I have ROSC, then yes. At my hospital, nurses on the floor and medicine residents are obsessed with bicarb during codes and are always screaming for it. I'm tired of explaining why it isn't going to help.

As far as tips:
- If you're going to be running the code, assert yourself as the code leader by calmly but loudly announcing "I'm running this code." I hate codes when no one knows who is in charge. It's ok to not be in charge, but everyone needs to know who is.
- Give everyone a job to do. Get the nursing/medic students in line for compressions. Get someone ready with an ultrasound for pulse checks. Do this early, it will help with organization.
- DELEGATE. You should be overseeing things, not concentrating on placing a line, messing with the ultrasound, etc. Of course this can go out the window if you're in a small critical access hospital with limited resources.
- Involve the family. Explain what is going on and what you are doing.
- If it's a young person, get used to running the code longer. Even when I know it's futile, I can't yet bring myself to call it early.
- Constantly run through things in your mind; airway, are compressions effective, are we missing any H's and T's, etc.
- End tital CO2 is your friend, get it hooked up ASAP.
- Remember that ACLS is a guideline.

I'm not a veteran by any means, but these are some things that popped into my mind as a senior resident.


Sent from my iPhone using SDN mobile
 
alpinism said:
-VSE drug cocktail (Vasopressin, steroids, epinephrine)
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Round 1:
Epinephrine 1 mg
Vasopressin 20 IU (or 40 IU?)
Salumedrol 40 mg IV

Are you guys only doing this during Round 1? Or Epi and Vaso for 5 cycles?

And then a dose of Hydrocortisone 100 mg IV upon ROSC?
 
I'm a strong skeptic of that VSE cocktail. Both vasopressin and epinephrine have been found to have no difference in neurologically intact survival to hospital discharge. That leaves solumedrol as essentially the sole contributor to these improved outcomes with an amazing NNT of 7 or 8. We can't even demonstrate that steroids have a mortality benefit in septic shock. If someone can explain how steroids provide survival benefit in a cardiac arrest, I'm all ears. I wish someone outside of the group out of Greece would attempt to replicate this study. I still give VSE intermittently, I just don't expect it to actually help.

As for running codes, yeah, bicarb is probably worthless. How long I code someone is based on a multitude of things. 90 year old coming from a nursing home who the family thought was going to live forever? I might do a single round and then call it. 60 year old with multiple co-morbidities with a witnessed arrest and a shockable rhythm upon initial eval, maybe 20 minutes or more depending on whether there were any shockable rhythms when he got to the hospital. 25 year old, no co-morbidities, witnessed arrest w/ a shockable rhythm, I might work on that individual indefinitely if I'm getting intermittent ROSC. No ROSC? I might code them for 40 minutes before calling it quits.

I think the most important part of the code is communication. I tell each person exactly when the pulse check is going to be, I tell them to feel for a pulse 10 seconds before compressions stop. I have the ultrasound in place before chest compressions stop to assess the heart. I tell the person managing the defibrillator to charge it up 10 seconds before pulse check. I tell the techs exactly when I want them to switch out beforehand. When I am about to call it, I tell them the exact timing I am planning to call it and ask for any other suggestions.
 
Here are some good tips for running an efficient code on the floors, from what I have witnessed:

1) First step: It is important to fully acquaint yourself with the chart. Make it a habit to ask for the chart the moment you enter the room, and then read it over a couple times to make sure you know the full past medical and surgical history, allergies, and social history of the patient. Query the nurses for information about the patient. Floor nurses always have relevant information to give.

2) Remember: It is rude to declare yourself the code leader. Instead, it is better to allow for a more communal approach to treatment, allowing nurses, techs, and patient family to give their input on treatment options. This way you know that you are getting the best ideas.

3) Don't be rude, so make sure to speak softly. And, if you must give a command, then don't pick on one person. Instead, say your order out loud, and someone will volunteer to do it. This way each person is doing a task that best fits their capabilities. Additionally, sometimes more than one person can do the same task for double efficiency.

4) The more people, the better: Codes are team efforts, so you really want to maximize your manpower. The more bodies, the more people to do tasks. Try to maximize any empty space in the room to fit another vital team member. Additionally, the more packed the room and the louder the noise, the more family will feel confident that everything is being done for their loved one.

5) Frequent rhythm checks: It is a good idea to do frequent rhythm checks to make sure you are not missing ROSC. It is a good idea to interrupt chest compressions to do frequent rhythm checks.

6) Bicarb: No code is complete without giving bicarb. In fact, bicarb is the last intervention needed in order to call a code.

7) The progress note: This is the most important procedure of all. All of the above steps will allow you to write the best possible note.
 
Any tips for the code that you get intermittent ROSC in a fairly chronically ill person maybe in the 60-70 age range? I get this patient often, and due to (likely excellent HQCPR) compressions they achieve ROSC only to basically peter out in 2-3 minutes again despite epi, NE, vasopressin drips currently running through the central line. Clinically I know it's futile, but it's hard to call a code when you do have some organized cardiac activity on ultrasound but it's clearly not compatible with life or a perfusing rhythm despite being on a multitude of pressors and when there's no other apparent cause that needs to be addressed.

Usually by this point I've brought family into the room, and they sometimes start to see the futility, but even they can recognize that the heart is moving on ultrasound and that there is electrical activity on the monitor which gives them some, in my opinion, false hope.

Thanks for any thoughts or suggestions!
 
Angry Birds said:
Here are some good tips for running an efficient code on the floors, from what I have witnessed:

Instead, it is better to allow for a more communal approach to treatment, allowing nurses, techs, and patient family to give their input on treatment options. This way you know that you are getting the best ideas.
Click to expand...

:laugh:🤣😆 to the entire post!

But specifically addressing the part I quoted: I will say towards the end of a code I will ask the team if there are any other options or treatments that should be considered before we call it. This seems to be received well by the team and the family if they are in the room.
 
exsanguination said:
Any tips for the code that you get intermittent ROSC in a fairly chronically ill person maybe in the 60-70 age range? I get this patient often, and due to (likely excellent HQCPR) compressions they achieve ROSC only to basically peter out in 2-3 minutes again despite epi, NE, vasopressin drips currently running through the central line. Clinically I know it's futile, but it's hard to call a code when you do have some organized cardiac activity on ultrasound but it's clearly not compatible with life or a perfusing rhythm despite being on a multitude of pressors and when there's no other apparent cause that needs to be addressed.

Usually by this point I've brought family into the room, and they sometimes start to see the futility, but even they can recognize that the heart is moving on ultrasound and that there is electrical activity on the monitor which gives them some, in my opinion, false hope.

Thanks for any thoughts or suggestions!
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I stop coding them after 2-3 time returning to arrest. Usually if they are maxed out on pressors, there is no chance they will have recovery and you are just wasting your time.
 
Keeping the discussion going about code tips and tricks.

I’m a huge fan of epinephrine for unstable bradycardia and bradycardic periarrest (re: the bradycardia death spiral).

IMO epinephrine is far superior to atropine based off the underlying pharmacology and from my own personal experience.

Josh Farkas did a good write up on the subject back in February: PulmCrit- Epinephrine vs. atropine for bradycardic periarrest
 
Ok you have ACLS....which is great, but you are a doctor. Try to actually figure out why they code and if it quickly reversible (hypoxia, PTX, massive PE, etc.).

The ACLS part can be run by the nurses or janitor or whoever can read the english language on the card. The acls part of the code is really a technician type task.
 
I'm not in a critical access hospital, but it is uncommon for me to have more docs in the room with me during a code. Some hours of the day, I might have a PA with me.

Which means running it, airway, advanced access, echo... all of those are mine.

Which is one reason why I love to give the time-keeper / code-sheet-note-taker nurse the job of leading. I will make the big decisions, but we can agree up front that said RN will call out the time every minute, ask for a pulse/rhythm check and Chest Compression personnel q2 minutes, and ask for epi to be pushed say q3min x a few times. That gives me something like 9-12 minutes to intubate the patient, do an echo during a pulse check, get a fem line if i'm not happy with the I/O and walk off to my office to make an espresso.

Sure if its some type of recurrent polymorphic Vtach--> Vfib mega code of doom, perhaps I'll be more involved in the nuts-and-bolts. But the majority of codes are rapidly into the PEA or asystole phase, and the freedom of cognitively unloading the pulse checks and epi-dosing will let you focus on the H&T and any key procedure you must perform.

Now this is in the ED where I have a team I know very well and who I've done a bunch of codes with. We could probably do them without speaking.

Up on the floor I do take control, firmly, of all the minutiae. That is a different environment and I don't know the talent I'm working with...
 
WildcatS11 said:
2015 ACLS Guidelines: What happened to VSE?

Here's a good review on "VSE." I think the data is better than I thought it was. I've never given steroids for arrests, nor have I ever seen it given. I'm not sure entirely why. The data isn't robust, but it's definitely eye-catching.
Click to expand...

I don't even think it would be available in our crash cart. I'd have to ask a nurse to fetch it from the Pixis, which would be annoying in a code situation.
 
GeneralVeers said:
I stop coding them after 2-3 time returning to arrest. Usually if they are maxed out on pressors, there is no chance they will have recovery and you are just wasting your time.
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What do you do then when they still have a rhythm (PEA)? Do you just stop compressions and wait and then call it when the patient becomes asystolic? Or do you call it when they are in PEA?

I realized I didn't know what to do in this situation. It seems awkward/"wrong" to call time of death when a patient still has a rhythm, but waiting for asystole might take a long time. Thoughts ?
 
Angry Birds said:
What do you do then when they still have a rhythm (PEA)? Do you just stop compressions and wait and then call it when the patient becomes asystolic? Or do you call it when they are in PEA?

I realized I didn't know what to do in this situation. It seems awkward/"wrong" to call time of death when a patient still has a rhythm, but waiting for asystole might take a long time. Thoughts ?
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I have called it with pt. still in VF. But, it was not a primary VF arrest, it was 40+ minutes in to the resuscitation. I have no problem calling it with PEA, especially an agonal one. To me, it depends on the duration of the resuscitation, comorbidities, age, downtime prior to resuscitation.
 
Angry Birds said:
What do you do then when they still have a rhythm (PEA)? Do you just stop compressions and wait and then call it when the patient becomes asystolic? Or do you call it when they are in PEA?

I realized I didn't know what to do in this situation. It seems awkward/"wrong" to call time of death when a patient still has a rhythm, but waiting for asystole might take a long time. Thoughts ?
Click to expand...

They're dead when you say they're dead.
 
The culture of running a code will depend slightly upon where you are.

I am intrigued by some of the advice here as it is quite different from my experience (underscores the value of the conversation).

As for reading a chart and knowing a full history etc, its never been part of my process. I operate under the impression that time is exceptionally valuable and that reading chart (at least in my current shop) is very time consuming. I outsource it to someone I trust who will look for relevant recent history, surgeries, causes of bleeding, kidney problems, heart problems, medications, electrolyte problems etc.

I don't announce myself as a code leader but I am an attending who has been in practice in my ED for a while now, so there really isn't any need. Yet, when I was in environments where I may not be known to be the leader (in the field until EMS arrives, in a hallway of the hospital, in a new hospital, or as a resident) I would say that I will be leading the resuscitation and ask that conversations be directed to me rather than occur in a more distracting fashion.

Also, to remind myself not to get deeply involved in a procedure etc, I don wear gloves or other PPE. This keeps me from losing sight of my role as leader.

Do I think having a leader stifles teamwork? No. Look at any great sports team...there is a leader, but there is also teamwork. One of my responsibilities as the leader is to facilitate communication of relevant or potentially relevant information and coordinate the appropriate actions.

Once I enter, I take a deep breath and remind myself that I need to remain composed no matter what happens.
- I designate a person to do compressions and two backups if possible. I instruct them to let me know 1 minute before they need to switch out from fatigue so I have time to coordinate.
- i designate one person to keep time and to alert me every 2 1/2 minutes, and every 3 minutes. This thirty seconds lets me prep the team like this: "great work gang, we are approaching another rhythm check, please charge the defibrillator just in case, have a round of epi ready, John, you are in charge of feeling a pulse, Jane you will check the rhythm...."
- I designate two people to work on access, one person to enter orders and review the EMR
- Social services and or a nurse stays with family in the resuscitation room
- A chaplain is brought to the room just in case

In terms of evaluations, I lean heavily on likelihoods. Potassium derangement, PE, and bleeding are far too common in my shop to not think of them. I use point of care testing: blood gas, lactate, ultrasound, X-ray, as much as possible.

I verbalize the sequence of things to happen and during the minutes when we are doing compressions and there is mostly silence, I ask for other observations and thoughts on what is going right and what else can be done.

In young people without obvious trauma, I consider intralipid, I do use bicarb sometimes for profound acidemia as it can help drugs and other factors to be more effective but it doesn't replace fluids and other interventions. I also engage ECMO team early, as they take a few minutes to mobilize.

After pronouncing, I feel as though we must take care to attend to the families and our own team's well being. I usually say this when the family is gathered around the deceased: "I'm very sorry that we did not get to meet your loved one when they were well to enjoy who they were as a person. Can you share with me what made them very special to you? What you will miss the most or remember the most about them?"

The conversations that flow from this simple set of questions is impressive and truly one of the most rewarding parts of my career as a physician. I also have heard from and witnessed the positive impact it has upon our team when they hear this. Many times, laughter, smiles, and tears are mixed and its a very powerful moment.

I immediately go to my calendar (outlook at my shop) after leaving the room and right a reminder note for 1 month and 1 year from that moment and i type as many details from the stories as I can remember into the note of the calendar item. When that time rolls around at 1 month and 1 year I use the time to write a letter to the family reminding them of our sympathies and of the great things about their loved one. I express our sadness that we did not get to experience the joys of their deceased loved one and wish them the very best prayers and well wishes.

I briefly presented this idea on 60 second soapbox:
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I don't want people to die, but from start through the last moments of writing those letters, I take great pride in running a code.
 
Angry Birds said:
What do you do then when they still have a rhythm (PEA)? Do you just stop compressions and wait and then call it when the patient becomes asystolic? Or do you call it when they are in PEA?

I realized I didn't know what to do in this situation. It seems awkward/"wrong" to call time of death when a patient still has a rhythm, but waiting for asystole might take a long time. Thoughts ?
Click to expand...

Don't cease until:
1. There's nothing left to do, and...
2. The heart is ultrasonographically still.

Then, you can say to family that you didn't stop until you could see that the heart wasn't beating, even after you had tried everything you could think to do.
 
TimesNewRoman said:
They're dead when you say they're dead.
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Along those lines it is time for old man story time.

It used to be (probably still is) that a military family would receive the most benefits if a service member died within 30 days or so of retirement. As a result, if a military member was received in a military ER (as the term was then) and was essentially dead, the official declaration would be delayed until the member could be medically retired. This process could be done in an hour or so in an emergency. Once this was accomplished the military member would be officially declared dead, and the family gets more benefits.

The problem of course was if the military member ended up at a non-military hospital. Those physicians would not know about that loophole, they probably wouldn't feel comfortable with it if they did, and it was almost impossible to do the rapid retirement in that situation anyway. So the DoD in the 80's proposed to Congress that legislation be passed to ensure that a military member would not be officially dead until declared dead by a military physician.

Congress basically replied, "Look, we know what you are doing. It is taking advantage of a loophole, but under the circumstances we don't really have a problem with it. But there is no way we can enshrine that in legislation."

They are dead when you say they are dead.

(So for those with more recent service, does the ultra-quick medical retirement still exist, or has it been eliminated in the attempt "to bring the war in under budget?")
 
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It still existed in Uncle Sams Confused Group 10 years ago when I retired. We called it "Death Imminent" which was all you had to tell the commcen watchstander who then patched you through to the nearest flag officer who could summarily discharge the patient. I believe we were the only service to still do that, but I could be wrong. We may not do it anymore.
 
RustedFox said:
Don't cease until:
1. There's nothing left to do, and...
2. The heart is ultrasonographically still.

Then, you can say to family that you didn't stop until you could see that the heart wasn't beating, even after you had tried everything you could think to do.
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With enough epi you can keep the heart beating long after there's any chance of neurologic recovery. I agree with the statement that you should do what you need to do in order to face the family without undue guilt. The common code brought to the EDs in my region have down times in the hour range, were unwitnessed, and have received 15-20 amps of epi prior to arrival. I don't really care what the heart is doing, the patient has no chance of leaving the hospital alive. I'm not spending two nurses and two techs coding them for another hour before I let family say goodbye.
 
The vast majority of "codes" I run in the ED are >65 y/o patients w/ > 30 min downtime, who present with an initial rhythm of asystole vs PEA and are neurologically devastated prior to ED arrival.

Most of the rest are younger pts w/ heroin/opiate overdoses, also usually in asystole, and the very occasional actual person who you might be able to bring back.

There's a lot of good information in this thread, but imo it should only be applied to the patient who actually has a chance. Flogging an 80 y/o in asystole for 30 minutes in the ED after 45 min of EMS ACLS is just cruel to the patient, nurses, techs, and everyone else.

I have no problem calling it when there is still a quiver of cardiac activity on BS U/S after a reasonable attempt at resuscitation. If the patient's clinical scenario indicates no reasonable chance of neurologic recovery and the quiver you see is non-perfusing and likely iatrogenic, the patient is dead.
 
You run codes as interns? our interns are airway and then US/central line/a-line while the 2nd or 3rd year supervises and runs.
 
Jlaw said:
You run codes as interns? our interns are airway and then US/central line/a-line while the 2nd or 3rd year supervises and runs.
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Our shop is kinda similiar (except we never put A lines in a code), the intern kinda gets the tube or the central line if they are proactive (most of our codes don't get a central line, but if someone wants to do it, we don't scoff) but anyone can be the code leader if they step up to it. The problem is that many interns are skiddish to step into that code leader role, so they just move to the airway because it feels comfortable to them.

Our attendings have this thing with the seniors that they should be able to get the airway and run the code at the same time, which is frankly hard. If you get the tube easy, no problem, but often you can get distracted by the airway and things get sloppy......I hate sloppy codes. Their logic is that a lot of shops are single coverage or low on staff, so being able to do those tasks simultaneously, while not what ACLS recommends, is just a fact of life. You gotta be prepared for everything as an attending, so best to practice the skill in residency.

It is definitely a learned skill. I have learned to "set up the code", make sure tasks are assigned, CP are solid, get the report from EMS re:last epi, rhythm that stuff, and then fuss with the airway. The last 5 or so I have run doing everything have gone very well as long as you don't get too focused on intubating, which really is NOT that important.
 
HooliganSnail said:
Our attendings have this thing with the seniors that they should be able to get the airway and run the code at the same time, which is frankly hard. If you get the tube easy, no problem, but often you can get distracted by the airway and things get sloppy......I hate sloppy codes. Their logic is that a lot of shops are single coverage or low on staff, so being able to do those tasks simultaneously, while not what ACLS recommends, is just a fact of life. You gotta be prepared for everything as an attending, so best to practice the skill in residency.
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So this doesn't happen in the ED for me right now, but when I'm covering the inpatient side, I frequently end up being the person who is not only the code leader but the only person who has any airway training. When I am in that situation, I throw in an LMA rapidly and go back to running the code. Definitive airway can come later if we even make it to that point.
 
HooliganSnail said:
Our shop is kinda similiar (except we never put A lines in a code), the intern kinda gets the tube or the central line if they are proactive (most of our codes don't get a central line, but if someone wants to do it, we don't scoff) but anyone can be the code leader if they step up to it. The problem is that many interns are skiddish to step into that code leader role, so they just move to the airway because it feels comfortable to them.

Our attendings have this thing with the seniors that they should be able to get the airway and run the code at the same time, which is frankly hard. If you get the tube easy, no problem, but often you can get distracted by the airway and things get sloppy......I hate sloppy codes. Their logic is that a lot of shops are single coverage or low on staff, so being able to do those tasks simultaneously, while not what ACLS recommends, is just a fact of life. You gotta be prepared for everything as an attending, so best to practice the skill in residency.

It is definitely a learned skill. I have learned to "set up the code", make sure tasks are assigned, CP are solid, get the report from EMS re:last epi, rhythm that stuff, and then fuss with the airway. The last 5 or so I have run doing everything have gone very well as long as you don't get too focused on intubating, which really is NOT that important.
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The code A line can very occasionally be useful, so I wouldn't say never. I've done it maybe 5 times in a code situation, and it affected management at least a couple times.
 
TooMuchResearch said:
The code A line can very occasionally be useful, so I wouldn't say never. I've done it maybe 5 times in a code situation, and it affected management at least a couple times.
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I'm interested to know in what meaningful way it has affected management. What percentage of your codes would you say it changed management? How did it change management (examples)? Were there improved outcomes, in your opinion, or were you just keeping the heart of a dead body pumping? In your opinion, would a bedside echo have been just as beneficial in determining whether a patient might be salvageable?

Not trying to be confrontational, just truly curious as I am of the opinion that an a-line has almost no utility in the majority of critical ER patients.
 
Zebra Hunter said:
Not trying to be confrontational, just truly curious as I am of the opinion that an a-line has almost no utility in the majority of critical ER patients.
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Good, because I never really learned how to put one in, so I support all research that says this.
 
The only purpose placing an a-line serves for a patient in active cardiac arrest is distracting the team from delivering high-quality CPR and appropriate respiratory support.

You can say the same for central lines, labs, ekg, and essentially all ACLS drugs.

No medication has been proven to improve neurologic outcomes in patients with cardiac arrest.

Unless the patient has a treatable condition (which is relatively rare) such as hyperK, tension ptx, or tamponade *combined* with immediate medical care, the only thing that could help them is artificially delivering oxygenated blood to vital organs via respiratory support and high quality CPR, and immediate defibrillation if they demonstrate vfib/vtach.
 
Zebra Hunter said:
I'm interested to know in what meaningful way it has affected management. What percentage of your codes would you say it changed management? How did it change management (examples)? Were there improved outcomes, in your opinion, or were you just keeping the heart of a dead body pumping? In your opinion, would a bedside echo have been just as beneficial in determining whether a patient might be salvageable?

Not trying to be confrontational, just truly curious as I am of the opinion that an a-line has almost no utility in the majority of critical ER patients.
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IMO a-lines have no place during codes.

However I do commonly place them in critical ER patients for 2 main reasons:

1. If the patient is getting BP meds I want real-time monitoring of the BP so that I can appropriately titrate meds. I'm not waiting for the BP cuff to cycle before learning that the patient's BP dropped into the 60s and corrective actions need to be taken. For stable patients it doesn't matter but for unstable patients it can make a huge difference.
2. BP cuffs are notoriously inaccurate in a large subset of patients. Go up to the ICU and compare the readings from the BP cuff and the a-line. Its very common to see readings differ by as much as 20-30mmHg in some patients. Again for stable patients it doesn't matter but for unstable patients it can make a huge difference.
 
alpinism said:
IMO a-lines have no place during codes.

However I do commonly place them in critical ER patients for 2 main reasons:

1. If the patient is getting BP meds I want real-time monitoring of the BP so that I can appropriately titrate meds. I'm not waiting for the BP cuff to cycle before learning that the patient's BP dropped into the 60s and corrective actions need to be taken. For stable patients it doesn't matter but for unstable patients it can make a huge difference.
2. BP cuffs are notoriously inaccurate in a large subset of patients. Go up to the ICU and compare the readings from the BP cuff and the a-line. Its very common to see readings differ by as much as 20-30mmHg in some patients. Again for stable patients it doesn't matter but for unstable patients it can make a huge difference.
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I just disagree with their utility, even in the ICU I have issues with their utility outside of very specific scenarios. Are you really going to be sitting there watching the a-line BP every second? No, of course not. An automatic BP cuff running q3-5 minutes, close nursing monitoring, frequent re-evaluations of the clearly sick patient is going to work just as well for what you are talking about.

I have a lot of experience with a-lines during my ICU months, and my point is that even though there are the occasional individuals where the a-line reading might differ 20-30 mmHg, it rarely, if ever, significantly changes the management of the patient. Most of my ICU attendings I have worked with have stopped placing them routinely in the unstable patient due to limited utility. Hypotensive patients with evidence of end organ hypoperfusion are going to end up on pressors if the evidence hypoperfusion persists, regardless of whether the patient has a MAP >65mmHg. Not only that, it introduces another source of potential infection. The patients I have found a-lines to be beneficial in are the individuals who are hypotensive and also 700 lbs, burn patients with involvement of their upper extremities, patients that require frequent blood work, and a few select others.

Also, there was a retrospective study in JAMA in 2014 that compared patients that received an a-line vs those who did not with 13,000+ propensity matched pairs that demonstrated no difference in mortality whether they had an a-line or not.

Arterial Catheter Use and Hospital Mortality
 
Zebra Hunter said:
I'm interested to know in what meaningful way it has affected management. What percentage of your codes would you say it changed management? How did it change management (examples)? Were there improved outcomes, in your opinion, or were you just keeping the heart of a dead body pumping? In your opinion, would a bedside echo have been just as beneficial in determining whether a patient might be salvageable?

Not trying to be confrontational, just truly curious as I am of the opinion that an a-line has almost no utility in the majority of critical ER patients.
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I agree it's rarely useful in the ED. Keep in mind I'm still a resident (for 2 more weeks).

Percentage of codes where it mattered? Roughly half of the ones where I've placed an A line in the code. I have only very rarely placed them, again probably 5ish times.

Very obese guy, narrow complex PEA, couldn't get a BP on him while doing ACLS stuff including after a couple liters of fluid, seemed to have reasonable squeeze on ultrasound, couldn't palpate pulses. Radial aline shows 90/50...we are now doing post arrest care and wondering if he was ever actually dead (medics brought him in).

Only other case I can think of was again a very obese patient who we weren't sure was actually dead.

Could we have just stopped CPR with good squeeze on US? Maybe, but tough to do without palpable pulses, no readable BP, and no improvement with fluids.

Again, I don't typically place them.
Zebra Hunter said:
I'm interested to know in what meaningful way it has affected management. What percentage of your codes would you say it changed management? How did it change management (examples)? Were there improved outcomes, in your opinion, or were you just keeping the heart of a dead body pumping? In your opinion, would a bedside echo have been just as beneficial in determining whether a patient might be salvageable?

Not trying to be confrontational, just truly curious as I am of the opinion that an a-line has almost no utility in the majority of critical ER patients.
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Might see A lines become more useful in codes in the future, as we move away from q3-5min MEGAEPI DOSE to more hemodynamically directed use of epi (IE targeting a specific diastolic so we ensure coronary artery filling). That being said, too cumbersome to use in codes right now.

A-lines for critically sick patients are money. Hemorrhagic stroke patient on cardene? They deserve not to have their BP riding out of control between cuff readings, in either direction. Septic shock guy? Should he get stuck at a pressure so low his kidneys get boxed until someone figures it out?

BP cuffs are inaccurate at extremes of blood pressure, body habitus, and vascular issues. Know any patients with these problems? Hint: it's just about every patient who ends up in situations like this.
 
engineeredout said:
So this doesn't happen in the ED for me right now, but when I'm covering the inpatient side, I frequently end up being the person who is not only the code leader but the only person who has any airway training. When I am in that situation, I throw in an LMA rapidly and go back to running the code. Definitive airway can come later if we even make it to that point.
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This is a reasonable approach on a floor patient, but many of our ER "codes" are kinda just checking boxes. In our shop, we don't call a CPR without a definitive airway, so we pull the Combitube that EMS put it. Admittedly this is a thing we do because we are a training center, and residents need practice intubating. We intubate quickly so we can "get on with it", no point in doing CPR endlessly if we don't need to.....

When I moonlight at more rural places, I never pull the Combitube unless I have a ventilation problem, and I have no problem calling TOD with a combitube as an airway and not an ET tube.
 
HooliganSnail said:
This is a reasonable approach on a floor patient, but many of our ER "codes" are kinda just checking boxes. In our shop, we don't call a CPR without a definitive airway, so we pull the Combitube that EMS put it. Admittedly this is a thing we do because we are a training center, and residents need practice intubating. We intubate quickly so we can "get on with it", no point in doing CPR endlessly if we don't need to.....

When I moonlight at more rural places, I never pull the Combitube unless I have a ventilation problem, and I have no problem calling TOD with a combitube as an airway and not an ET tube.
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Plus, tubing is fun.
 
Angry Birds said:
Plus, tubing is fun.
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The beer plus river version is. When you're responsible for the entirety of the code, it's hard to bask in the satisfaction of putting plastic in trachea when family is screaming after you tell them the patient is dead.
 
Arcan57 said:
The beer plus river version is. When you're responsible for the entirety of the code, it's hard to bask in the satisfaction of putting plastic in trachea when family is screaming after you tell them the patient is dead.
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Remember the arcade game "TOOBIN'"?

It was ported to the NES, which made the graphics lackluster... still fun.
 
Zebra Hunter said:
I'm a strong skeptic of that VSE cocktail. Both vasopressin and epinephrine have been found to have no difference in neurologically intact survival to hospital discharge. That leaves solumedrol as essentially the sole contributor to these improved outcomes with an amazing NNT of 7 or 8. We can't even demonstrate that steroids have a mortality benefit in septic shock. If someone can explain how steroids provide survival benefit in a cardiac arrest, I'm all ears. I wish someone outside of the group out of Greece would attempt to replicate this study. I still give VSE intermittently, I just don't expect it to actually help.

As for running codes, yeah, bicarb is probably worthless. How long I code someone is based on a multitude of things. 90 year old coming from a nursing home who the family thought was going to live forever? I might do a single round and then call it. 60 year old with multiple co-morbidities with a witnessed arrest and a shockable rhythm upon initial eval, maybe 20 minutes or more depending on whether there were any shockable rhythms when he got to the hospital. 25 year old, no co-morbidities, witnessed arrest w/ a shockable rhythm, I might work on that individual indefinitely if I'm getting intermittent ROSC. No ROSC? I might code them for 40 minutes before calling it quits.

I think the most important part of the code is communication. I tell each person exactly when the pulse check is going to be, I tell them to feel for a pulse 10 seconds before compressions stop. I have the ultrasound in place before chest compressions stop to assess the heart. I tell the person managing the defibrillator to charge it up 10 seconds before pulse check. I tell the techs exactly when I want them to switch out beforehand. When I am about to call it, I tell them the exact timing I am planning to call it and ask for any other suggestions.
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I appreciate a well orchestrated code. I plan to use some of these when I run a code.
 
HoosierdaddyO said:
I'm almost done with my 1st year of residency and while having run quite a bit of codes in the ED as well as on the floor during my off service months, was wondering if any of the vets here have any pearls or tricks or advice for running codes... do you push bicarbonate based on pH alone? How long do you find yourself running a code before calling it quits? Etc etc etc?, tricks to get better at organizing tasks, when to do this when not to do that...any tips or tricks or advice is as always appreciated 🙂?!
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Bicarb is like spraying water on a house that's already burned down.


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Birdstrike said:
Bicarb is like spraying water on a house that's already burned down.


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I did get a hyperK back recently with bicarb and calcium. Sadly EMS had been trying to ventilate her through an uncuffed trach for ~1 hr with EtCO2 in the 100s and a sat in the 40s during their brief periods of pre-hospital ROSC so I don't think it's going to end up as a win long term.
 
Birdstrike said:
Good one. Useful in that case

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On the plus side for curbing unnecessary bicarb use, there's apparently a national back order of basically everything that's in a code box. We had 3 codes in an hour last night and the pharmacist (yes, we have on in the ED) was going around with a bottle of epi and premaking 1mg syringes since we didn't have any of the premade injectors. We are out or have limited supply of calcium (gluconate and chloride), atropine, dopamine, etomidate, rocuronium, any injectable sodium except chloride, and just because it's not hard enough both zosyn and cefepime.
 
Arcan57 said:
On the plus side for curbing unnecessary bicarb use, there's apparently a national back order of basically everything that's in a code box. We had 3 codes in an hour last night and the pharmacist (yes, we have on in the ED) was going around with a bottle of epi and premaking 1mg syringes since we didn't have any of the premade injectors. We are out or have limited supply of calcium (gluconate and chloride), atropine, dopamine, etomidate, rocuronium, any injectable sodium except chloride, and just because it's not hard enough both zosyn and cefepime.
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There's some imperfections in our medical system, isn't there?


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I just do everything for about 15 minutes. If they're alive at that point, then I worry about evidence based medicine. If they're not alive, who cares. Saving the system an amp of bicarb or calcium or atropine isn't going to make a difference.

Who cares if you shock asystole that the medics have been working for 30 minutes already without a response? Who cares if you gave bicarb or calcium or amiodarone or whatever to a dead guy? Make sure the compressions are good and don't do anything crazy.

An A-line? What is this, dog lab? Sure, I guess if there's a bunch of residents around who need procedures then sure, have one of them work on their A-lines. Just make sure they don't get in the way of the person doing compressions.

You know what the best thing I started doing as a young attending? I told everyone what we were going to do long before we did it. It works great in traumas too.

"We're going to give this epinephrine, calcium and bicarb, then we're going to circulate it for 2 minutes, then we're going to do a rhythm and pulse check while we change compressors."

"We're going to get another IV and draw labs while we intubate, then we'll place an NGT, then we're going to shoot a chest and pelvis and then go to CT."

I can only dream that I was at a place where there was some sort of confusion about who's in charge of the code. I used to wonder if I was in charge when I showed up in the ICU or L&D or wherever. The only code I've ever showed up to in my community hospital where I wasn't in charge was in the OR and I was no kidding like the 40th person there (and the surgeon and anesthesiologist were doing a bang up job already.)

The hard ones to call are the young ones where you're getting some sort of a minimal response to your efforts. But at a certain point, you can't spend all day coding someone, so if it has been an hour and we've been doing compressions for most of that, it's probably time for that heart to s*** or get off the pot.
 
Janders said:
Up on the floor I do take control, firmly, of all the minutiae. That is a different environment and I don't know the talent I'm working with...
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Take the talent with you. Seriously. I basically don't need anything from the med-surg nurses. Got my own glidescope, my own RSI drugs, the code carts are all standardized, I've got two nurses and a tech with me.

It's like when you call the nursery folks down to help with the precipitous delivery. They know you don't do this very often and might not even know where the tools are so they show up with several people and all their fancy tools, and you're grateful for it. Be like them when you show up to a code.
 
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