Inpatient / Cardiology

ALCS - Leading a Code

Last Updated 5/4/2023

First Things First
-- If at any point, there is no pulse within 10 seconds, start chest compressions
-- Ensure that the patient is full code before further escalation

Initial Steps and Delegating
-- Call Code - Ensure code is called overhead - will bring anesthesia, pharmacy, and other bodies for assistance
-- Compressions - Ask for backboard and for nursing staff and learners in the room to line up for compressions
-- Rhythm/Pulse Check - get doppler, and pads and get them connected for rhythm check ASAP
-- Access - adequate access - if not, ask RN or colleague to place IV, then IO if unsuccessful
-- Data - ask for an ultrasound for POCUS, and draw labs (ABG - pH, PaO2, K, Hgb; CBC, BMP, LFTs, lactate, T+S, coags, fibrinogen, trop)
-- Info Gathering - Ask a colleague to be your second brain and "code whisperer"  (one-liner, day events, access, recent labs, etc)
-- Family - Ask a colleague to call the patient's family or primary contact when more information is gathered

Intake and Summary
-- Reason in the hospital
-- Relevant comorbidities
-- Day events - recent meds or procedures
-- Current Access
-- Code Status and Decision-makers
-- ECMO candidate? (reverisble cause of arrest with ECMO as bridge to definitive treatment) - ideal to involve team within 10 mins of code starting

-- Compressions immediately and consistently (except when rhythm check)
-- Rhythm check ASAP (below) every 2 minutes (with pulse check)
-- Pulse checks every 2 minutes (both carotid and femoral - use dopplers)
-- POCUS - heart (tamponade, RV function, LV function), Lungs (PTX, edema), IVC
-- Intubate when able

-- shock (120-200J) immediately and every 2 minutes if still VT/VFib
-- epi 1mg q3-5mins (every other round)
-- lidocaine 1-1.5mg/kg first dose, then 0.5-0.75mg/kg ; amiodarone 300mg first dose, then 150mg
-- magnesium sulfate 1-2g over 15 mins if c/f torsades

- epi 1mg q3-5mins (every other round)

Adjuvants for Either
-- Volume - give 500-1000cc of LR, start epi drip 0.1-0.5mcg/kg/min
-- HyperK - calcium gluconate 1-2 IV
-- Hypoglycemia - D50W amp push
-- Acidosis - Bicarb 1-2 amp push
-- PE - tPA - 50-100mg IV bolus over 2 minutes - need to continue CPR for at least 15-20 minutes after giving (time to bust clot)
-- Intubate when anesthesia team arrives

Differential for Reverisble Causes of Arrest - H's and T's

-- Hypovolemia
- give fluid empirically
-- Hemorrhage
- give fluid and blood - massive transfusion
-- Hypoxia
- pulse ox and ABG - oxygenate and intubate
-- H+ Ion (
Acidosis) - pH on gas - bicarb, intubate and blow off CO2, fluid and pressor for sepsis
Hyperkalemia- on ABG/ABG - give calcium gluconate 1-2g IV, insulin 10u with D5W 1-2 amp
-- Hypothermia -
warm em up

-- Thrombosis (
ACS) - elevated trop - achieve ROSC and get to cath lab
-- Thrombosis (
Pulmonary Embolism) - RV function on POCUS - push tPA
Tension Pneumothorax - lung sliding on POCUS - needle decompression
-- Tamponade -
effusion on POCUS - achieve ROSC, pericardiocentesis
-- Toxins (drugs, overdose )
- check MAR, push naloxone 2 mg IV, glucagon for BB

Achieved ROSC -
Post Cardiac Arrest Care
-- Continue to address the most likely etiology (hypoxia, hypovolemia, acidosis, ACS, etc)
-- Keep pressor infusion going (epi 0.1-0.5 mcg/kg/min, norepi 0.1-0.5 mcg/kg/min) and consider giving more fluid
-- Maintain SpO2 92-98% and ETCO2 35-40
-- If patient wakes and following commands and c/f ACS --> EKG and consider cath lab
-- Targeted Temperature Management and CT Head if not following commands

If You Remember Nothing Else

Stay calm, get to the head of the bed, and begin delegating. Chest compressions and getting the pads on the patient ASAP for rhythm check and shocks if indicated are the most important first steps. Determining the etiology comes next. Follow the ACLS algorithm and treat with adjuvants if it will be helpful. It's not over when you achieve ROSC - make sure you address the likely etiology of arrest and prevent them from arresting again!

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