Who goes to the code

• Interns, senior residents, AIs, and 3rd year

medical students on Long Call on wards and in
MICU
• DACR/VACR/NACR
• Anesthesia team
• Respiratory Therapists
• Critical care nurses (from MICU/CICU)
• Critical care pharmacist (sometimes)
 Who runs the code?
• First resident on the scene, or
DACR/VACR/NACR
• The leader of the code assigns roles and
responsibilities to the other residents and
interns available
 Roles during the code
• Stabilizing/managing airway
• Line for chest compressions
• Recording timing of events
• Managing code cart/ Medication administration
• Checking labs and past medical history, telemetry
• Obtaining emergency access
• Thinking through Hs and Ts
• Calling the patient’s family
 Code Blue
You are the Naff intern on call, working on notes
in the Naff team room. Code Blue is called for
a patient on Lakeside 20. Your senior is MIA.
You run down the hall and are the first on the
scene. What do you do?
 Scenario 1
• You feel a thready femoral pulse, the patient
feels tachycardic
• Automatic blood pressure cuff is not reading
• Patient is agonal breathing, not responding to
verbal or painful stimuli
• The nurses look to you and say “Doctor, what
do we do?”
• On arrival, you do a quick initial assessment while
assessing his responsiveness and vital signs and
immediately instruct someone to begin
compressions.
• While compressions are occurring you ask the
nurse to apply pads and electrodes to the patient
to analyze the rhythm.
• In addition, you ask that oxygen be applied to the
patient
• You ask about any complaints the patient may
have had and find that minutes ago he was
complaining of chest pain, palpitations, and
dizziness.
• Being a very keen intern, you recognize this may
be Acute Coronary Syndrome causing arrest.
Cardiac Arrest, 4 rhythms
• As you pause during compressions you analyze the
rhythm… the patient is in Ventricular Fibrillation
• The DACR runs into the room, you notify him/her of
the patient’s rhythm and
• ANALYZE.. CLEAR…SHOCK DELIVERED
• Resume CPR! Wait to reanalyze the rhythm after the
next round of CPR
• The patient receives a dose of Epinephrine in addition
to another shock and has conversion to sinus rhythm.
He has ROSC. His vitals begin to improve and he is
rushed to the Cardiac Catherization Lab.
• Nice Work!
 High quality CPR is key
• Rate approx 100/min
• Compression depth >2
inches (5cm) in adults
• Allow complete chest
recoil after each
compression
• Minimize interruptions
• Rotate every 2 minutes
 Scenario 2
• One of your many pagers on Intern Nightfloat
goes off.
• “There’s a Code White on your patient in
Lakeside 55 her heart rate is a little low and
she’s feeling dizzy”
• You ask the nurse to get a full set of vitals as
you head towards the patient’s room.
• As you’re headed over you hear the overhead
announcement “CODE BLUE, CODE BLUE,
CODE BLUE..LAKESIDE 55”
• You arrive at the patient’s room and the nurse
informs you that the patient’s HR was 60-70’s
during the day but suddenly decreased from 48
to 35bpm.
• Current vitals: HR 35bpm, SBP 70/DBP is
undetectable RR 16/min, and O2 saturation 93%.
• The patient was initially complaining of
lightheadedness but now is more lethargic.
• You take a look at the EKG that was obtained.
• You request oxygen be applied to the patient and
the pads for transcutaneous pacing be applied.
• Just as you are doing so, additional help arrives
and your Nightfloat senior assists you.
• Atropine is obtained from the crashcart and the
patient is bolused 0.5mg.
• The patient’s HR slightly improves to 49bpm but
he remains somewhat confused and lethargic.
• Transcutaneous pacing is started with a target HR
of 60bpm. She begins to wake up and her BP
improves to 110/57.
• EP is consulted and the patient receives a
transvenous and ultimately an implanted
pacemaker.
 Last Scenario
• You are on Hellerstein waiting to sign out at
630 pm on a Sunday when you’re paged about
a patient with past hx of SVT here for CP now
has a HR of 160.
• BP 125/80, narrow complex tachycardia as
below
• After attempting vagal maneuvers
(unsuccessful) you give adenosine 6mg IV
push, and then 12 mg IV push
• Now the patient develops severe chest pain,
He 220, BP not obtainable, pulse weak. The
patient begins losing consciousness. What do
you do next?
• Synchronized cardioversion is unsuccessful.
Patient now is pulseless and unconscious.

What next? Time to shock! (unsynchronized

120-200 J)
 Synchronized vs unsynchronized
cardioversion
Synchronized Unsynchronized
Low energy shock High energy shock
delivers shock w/ peak delivers as soon as
of QRS shock button is pushed
Indications: unstable A Indications: pulseless
fib, A flutter, SVT VT/VF

If shock occurs on t-wave,

high likelihood of VF
• After 5 cycles of CPR, the rhythm check
suggests a second shock. Now with 200 J.
Which medications should you be giving?

• Epinephrine 1mg IV q3min and/or vasopressin

40 U IV to replace first or second epi dose
• Amiodarone after 3rd shock in pulseless VT
(300 mg IV x1, then consider 150 mg IV x1
• SROC! The patient was intubated by
anesthesia at the scene, and is not responding
to verbal commands. Patient transported to
CICU. What post cardiac arrest intervention
would this patient benefit from?
 What Is ACLS?
• ACLS guidelines first published 1974 by AHA, most
recent update 2010
• A series of interventions for urgent treatment of
cardiac arrest, stroke, and life threatening medical
emergencies
• Several algorithms for VF/Pulseless VT, Bradycardia,
Suspected Stroke
• An essential part of using the algorithm correctly is to
search for and correct potentially reversible causes of
arrest
• Performing high quality CPR, identifying arrhythmias
and understanding the pharmacology behind key drugs
are central to ACLS.
 H’s and T’s
Treatable causes of cardiac arrest
• Hypoxia • Thrombosis
• Hypovolemia (pulmonary)
• Hydrogen ion (acidosis) • Thrombosis (coronary)
• Hypokalemia • Tamponade
• Hyperkalemia • Tension pneumothorax
• Hypothermia • Toxins
 Things to discuss with patients
• All patients admitted to the hospital should be
asked about their code status
• It’s important to discuss the morbidity
associated with ACLS
• Statistics regarding survival after arrest
• Adverse outcomes of CPR and Advanced
Airway Support