Running a Code

The first sixty seconds

Most of what decides the outcome happens before the room fills up. The first minute is four things, in order.

1. Confirm the arrest. Shout, shake, feel for a carotid while you watch the chest. Ten seconds. Agonal gasping is not breathing, and if you are not sure there is a pulse, there is no pulse.
2. Call for help. Say "call a code" out loud and hit the button on the wall.
3. Start compressions. Now, on the bed, over clothes. Do not wait for the board, the pads or the cart.
4. Board and pads. Backboard on the next compressor change. Pads on the bare chest while compressions continue.

Also flatten the bed, pull the headboard off, and pull the bed off the wall so someone can stand at the head. If they are in a recliner or on the toilet, get them on the floor.

High quality CPR is the entire game

Everything else is a modifier on the compressions. Drugs, airways and rhythm interpretation matter less than whether somebody is pushing hard, fast and continuously.

Do not over-ventilate. Before an advanced airway, 30 compressions to 2 breaths. After it, compressions run continuously and the airway person gives one breath every 6 seconds. Excess ventilation drops venous return and kills people quietly.

Who does what, and where they stand

A code with seven defined roles runs well. One with fifteen undefined people does not. If there is no structure, create it by assigning people by name.

The leader stands at the foot because it is the only place you can see the monitor, the chest, the airway and the drug pusher at once. If you are leading and find a laryngoscope in your hand, you have stopped leading.

Shockable versus non-shockable

VF and pulseless VT. Shock, now. Do not push a drug first and do not finish the cycle. Defibrillate at your device's recommended energy. Resume compressions immediately without checking a pulse and go a full 2 minutes. Administer an antiarrhythmic right away: amiodarone 300 mg IV push, or lidocaine 1 to 1.5 mg/kg, which in practice is usually about a 100 or 200 mg push.

PEA and asystole. No shock, ever. There is no rhythm for a shock to reorganize. Epinephrine 1 mg IV or IO as early as you can get it in, then every 3 to 5 minutes, with continuous compressions. The rest of your attention goes to the cause, because the prognosis is worse than VF and finding out why is the only thing that changes it.

Why did they arrest

The Hs and Ts get recited in courses as a list. In a real room they are a search, and most are answerable while compressions continue. Assign somebody to run it. Findable at the bedside, in this code:

• Hypoxia. Is the tube where you think it is, are there breath sounds both sides. The commonest reversible cause on a medical floor.
• Hypovolemia. Bleeding, vomiting, dialysis. Fluids wide open, and activate massive transfusion before you need it.
• Hypo and hyperkalemia, and hydrogen ion. Send a gas with electrolytes at first access. In a dialysis patient treat empirically: calcium gluconate 1 g, insulin with dextrose. Bicarbonate is not routine, but is reasonable in known severe acidosis or hyperkalemia.
• Tension pneumothorax. Central line, thoracentesis, ventilated asthmatic. Absent breath sounds one side. Needle, then a tube. Do not wait for a film.
• Tamponade. Malignancy, uremia, recent cardiac procedure. The fastest ultrasound finding, and treatable in the room.
• Toxins. Read the medication administration record. Opiate, beta blocker, calcium channel blocker, insulin. The nurse usually knows.
• Hypothermia. Get a real core temperature. Nobody is dead until they are warm and dead.

The two that need imaging or a commitment are the thromboses. Pulmonary embolism looks like sudden arrest in an immobile or postoperative patient, often PEA with a dilated right ventricle, and thrombolysis during CPR is a real option that commits you to prolonged compressions afterwards. Coronary thrombosis is suggested by preceding chest pain or an ischemic rhythm, and if you get ROSC it means an EKG and the cath lab.

Ultrasound and end tidal CO2

A subxiphoid or parasternal view during the pulse check answers three questions fast: is the heart moving at all, is there an effusion, is the right ventricle enormous. Cardiac standstill after a prolonged resuscitation is useful when you are deciding whether to stop.

With an advanced airway, use waveform capnography. It confirms the tube, since no waveform during good compressions means esophagus until proven otherwise. It grades the compressions, since a value persistently under 10 mm Hg means they are inadequate or the prognosis is poor, and the first answer to a low number is to push harder. And it announces ROSC, because an abrupt rise to 35 or 40 is often the first sign of return of circulation, before anyone finds a pulse.

What to say out loud

Codes fail on communication more often than on knowledge. Closed loop means every order goes to a named person, is repeated back, and is confirmed when done. It sounds stilted. Do it anyway.

The alternative is what usually happens. "Can somebody give some epi?" Two people reach for the drawer, nobody says when it went in, and four minutes later the leader asks whether it was given and gets three different answers.

Summarize out loud at every rhythm check: "Fourteen minutes down, sixth round, PEA at 30, epinephrine at 03:12, no cause found, ideas?" Then invite disagreement explicitly. The person who noticed the potassium of 7.9 is often the most junior one in the room and will not speak unless asked.

When to stop

No rule gives you a number of minutes. The decision runs on the initial rhythm, whether the arrest was witnessed, how fast CPR started, the end tidal CO2 trend, whether you found a cause, and what this patient's life looked like yesterday. A low end tidal CO2 throughout, asystole throughout, no cause found and cardiac standstill on ultrasound together make a reasonable case for stopping. Keep going longer for hypothermia, a toxin, thrombolysis already given, a recurrent shockable rhythm, or a young patient.

Then find the family yourself and sit down. Use the words died or dead, not "passed," because soft language leaves people believing there is still hope. Say what happened, say what you did, say they did not suffer if that is true, then be quiet and let them react. Do not fill the silence.

After ROSC

The code is over and the hard part is starting. All of this belongs in the first hour.

• Airway. Confirm the tube, chest film, gas. Ventilate to a normal CO2, not a low one.
• Avoid hyperoxia. Wean the FiO2 as soon as the saturation allows, targeting roughly 92 to 98 percent. Leaving a post-arrest patient at 100 percent because nobody looked is avoidable harm.
• Blood pressure. Expect hypotension and a vasopressor infusion. Re-arrest in the first hour is common.
• 12 lead EKG immediately. ST elevation means the cath lab now, not in the morning. Consider it without ST elevation if the story is ischemic.
• Targeted temperature management per your protocol for the patient who does not follow commands. Prevent fever regardless.
• Neuroprognostication is not a day one activity. Sedation, paralytics and temperature all confound the exam. Practice is to wait at least 72 hours after normothermia and sedation clearance, using more than one modality. Say that to the family, because they will ask and they deserve an honest "we cannot know yet."

Documenting the code

The recorder's code sheet is the primary record. Your note is the narrative that makes sense of it, and it will be read years later by people who were not there. Write it the same day, from the sheet. For the general principles, see medical-legal charting.

Times to the minute, named people, the length of the ultrasound pause, an impression instead of a shrug, and the family conversation. It does not editorialize, it does not blame, and it does not say "found down for an unknown period" when the last seen normal time is known.

Your job as the intern

You are not leading this code and you should not be trying to. Here is what actually helps.

• Get there and get on the chest. Good compressions from an intern beat a fellow standing in the doorway thinking.
• Know the patient. If it is yours, you are the most valuable person in the room, and it has nothing to do with your skills. Tell the leader without being asked: code status, admitting diagnosis, this morning's potassium, the dialysis schedule, the hydromorphone at 02:00.
• Announce yourself and take one assignment. "I am the intern for this patient, what do you want me to do?" Then do only that.
• Say the thing. Nobody has ever been fired for saying "his potassium was 6.8 this morning."
• Do not attempt a procedure you have never done, unsupervised, in a code. Five people in the room have done it.
• Afterwards, write the note and go with someone to see the family. That is how you learn what actually happened.

For the overnight calls that precede many of these arrests, see common night calls.