#9 Leading a Cardiac Arrest
"Running a code is a stressful proposition. The code team leader is responsible for conducting an orchestra in a most austere environment, with the goal of guiding the team towards success - defined hopefully by a successful resuscitation. The code team leader needs to have the presence of mind to lead, but also needs to know how to delegate responsibilities and quickly cultivate a shared mental-model between the various team members. Join Nick and Cyrus as they try to demystify some of the elements of leading a code by providing practical pearls and shedding light on potential pitfalls during this episode on Cardiac Arrest and Running a Code."
Quick Take Home Points
Codes are Stressful, high stakes events requiring a series of rapid coordinated actions by a tea. Physicians and Nurses can run codes. Title is less important, than leadership skills. Consider delegating if you need to perform procedures.
First 10 seconds - determine who is running the code, look for clues
First 60 seconds - ensure basics are being performed well (ABCDE)
Second 60 seconds - make sure roles are clear and that advanced steps are in process (ABCD-EMU)
The primary job of the code leader is to establish the rhythm of the code. Narrate the events and establish a shared mental model for what is going on.
After appropriate preparation, consider family presence during resuscitation.
Always debrief after a code
Infographic:
See this ICU OnePager infographic for a visual summary of caring for the critically ill person in the criminal justice system,
Show Notes:
What is a “Code”?
A code is typically defined as a cardiac arrest (a non-perfusing arrythmia), but a similar degree of resources can (& should) be mobilized for other life-threatening emergences: respiratory failure, massive hemorrhage, status epilepticus.
Nick’s Definition: “Stressful, high stakes events requiring a series of rapid coordinated actions by a team”
When in doubt, call the code to get help.
Physician vs RN led codes
Codes require the rapid coordinated actions of many people. Thus leadership and clear communication are essential.
The CANLEAD study found that in simulated codes, having an RN team leader resulted in more cognitive offloading for the physician as well as improved time to defibrillator application (23.5 s vs 59 s, p=0.004), better CPR quality, and shorter time to address reversible causes (107.1 s vs 209.5 s, p=0.002).
Depending on staff availability, having an RN code leader can free up physicians to perform procedures such as intubation, ultrasonography, central access, chest tubes, etc.
Whatever the title/training of the person leading the code, the key is to avoid task saturation; delegate responsibility, keep eyes on the big picture, and keep the team working together.
Essential actions for a code leader to take at a code:
First 10 seconds
Quickly look around the room for clues - dialysis machine, surgical drains full of blood, medications that are infusing, etc.
Who is involved and is there a code leader?
In the first 10 seconds, if you don’t know who’s running it: you are (probably) running it!
First 60 seconds
The first minute is all about establishing that the key basic interventions are being performed.
Nick’s ABCDE mnemonic for First minute actions:
A - ask “what Airway do we have?”
B - “are we able to Bag valve mask ventilate?”
C - “are adequate Compressions being performed? Is there a CPR board?”
D - “are the Defib pads on & what was the initial rhythm?”
E - “give Epinephrine!” (it’s the right drug in every ACLS algorithm)
Next 60 seconds
Now that the rhythm of resuscitation is being established, we need to make sure the key Roles have been assigned & the next set of tasks are being performed.
This time use the ABCD-EMU mnemonic:
Airway - say “who is holding the BVM or placing an advanced airway?”
Ideally we should have two rescuer technique for better ventilation.
Who is going to place a Supraglottic airway (e.g. LMA) vs endotracheal tube (ETT)
Breathing - “who is bagging, is there chest rise?”
In the meanwhile lets make sure there is a Oral Airway (OPA) + Bag Valve Mask (BVM)
Compressions - “Who is performing CPR and who is on deck?”
Assuming that we have sufficient people, we should change compressors every cycle (2 minutes);
Several observational studies show decline in CPR quality.
Note that the European Resuscitation Council actually recommends switching every 2 minutes
A small CPET study found that among rescuers who performed CPR for10 minutes most (7/9) people hit anaerobic threshold before 10 minutes.
Defib - who is running he defibrillators; consider charging during compressions so we only need to interrupt CPR once.
End-tidal CO2 - “can we connect an ETCO2 monitor?”
Meds - “who is drawing up & who is administering meds?”
Ultrasound - “let’s perform an ultrasound survey”
Ongoing Resuscitation (minutes 2 to 30+)
For the first 2 minutes our goal was to take control of the situation. In the following minutes our goal is to fix the underlying causes that may have led to a code.
There are several things the Code leader must do:
Ensure ABCs are followed - make sure high quality CPR is performed, airway obtained, meds administered, etc. Coaching the person performing CPR is extremely important (e.g. “good depth of compressions, try to go slightly faster, only 30 seconds more to go!”)
Provide Periodic updates & foster a shared mental model - think aloud (e.g. “we are 3 cycles into a PEA arrest. We have secured an airway, are performing high quality CPR, and have given epinephrine twice”)
Perform a Differential diagnosis - ensure that Blood glucose, ABG/VBG, labs, and POCUS are performed (see H’s & T’s section below).
Obtain necessary resources & plan ahead - for example determine if blood transfusions (activate MTP), procedures (pericardiocentesis, chest tubes) or ECMO cannulation will be necessary. Call for those resources
The temporal structure of a code consists of alternating differentials and narrative summaries. Charge the defibrillator prior to rhythm checks to minimize interruptions in CPR (ideally <5 seconds).
Vascular access during a code
In general, perfection is the enemy of the good, and the fastest access is best:
Accessing an existing HD line, port, etc - very good (high flow rates, quick access)
IO - good, generally the fastest access
PIV - great if you can get ‘em
Central lines
Placing lines during code? Good if you have the resources & inadequate access. Not necessary in most cases.
Cyrus: use a Double stick femoral (place a femoral central line and arterial line)
POCUS during a code
Goal: Identify Reversible conditions: PTX, tamponade, hemorrhage, etc
Differentiate pseudo-PEA from PEA
In 2010, Prosen et al reported on 16 patients in whom echocardiography was used in conjunction with end-tidal CO2 to identify P-PEA. CPR was ceased for 15 seconds and vasopressin administered. 15/16 patients had ROSC using this strategy. Obviously given the small n, this is not the most robust study in the history of academic medicine, but the physiology makes sense and it gives you some ammunition to deviate from the ACLS algorithm if findings at the bedside suggest you may be dealing with pseudo PEA.
Consider H&T’s using the framework of tests & interventions
Couple each etiology to a diagnosis and potential treatment. Prioritize blood draw and POCUS examination to gather the necessary data.
In extreme cases, consider treating electrolyte derangements.
Remember hypoglycemia is a cause of sudden cardiac arrest, particularly in type 1 diabetics.
Needle decompression is often inadequate depending on body habitus. Consider finger thoracostomy to treat pneumothorax leading to cardiac arrest.
Point of care blood gas and chemistry analysis greatly facilitates differentiate diagnosis.
POCUS provides enormous value to rule in/out several etiologies of PEA. Consider using a protocolized assessment during cardiac arrest (e.g. CAUSE exam).
Consider the following:
| Diagnosis | Treatment | |
|---|---|---|
| Hypoglycemia | Blood glucose | D50W |
| Hyperkalemia | Chemistry | Calcium, Insulin/D50W, etc |
| Hypokalemia | Chemistry | Potassium (if K < 2 mEq/L) |
| H+ (acidosis) | ABG/VBG | Hyperventilation / HCO3 |
| Hypoxemia | ABG/VBG | Intubation, increase PEEP |
| Hypothermia | Core temp | Active rewarming |
| Hypovolemia | POCUS | MTP, IVF |
| Tension PTX | POCUS | Needle decompression, finger thoracostomy/chest tube |
| Tamponade | POCUS | Pericardiocentesis |
| Thrombosis (PE/MI) | POCUS | Thrombolytics |
| Toxins | Med List | Consider antidotes (naloxone, calcium, NaHCO3, digibind, etc) |
| Trauma | Exam, POCUS | MTP, procedures |
Family presence during resuscitation
In general, inviting families to be present during resuscitation is associated with better psychosocial outcomes & no differences in resuscitation outcomes.
A RCT of family presence during CPR by Jabre et al in NEJM 2013 found that when offered about 75% of family members chose to be present. The family members who witnessed CPR had lower rates of PTSD as well as fewer symptoms of anxiety and depression.
A meta-analysis found that there was no effect on the quality of resuscitation. Mortality was unaffected. The duration of resuscitation was also unaffected.
Nick & Cyrus’ approach:
Move family/loved ones out of the room if they are present at the beginning of the code.
Assign someone who can stay with them, providing support, through out the resuscitation.
Invite them to return and witness rescuscitation efforts if they are willing.
Make sure that they are supported after the code, regardless of outcome.
Return of Spontaneous Circulation
Detecting ROSC:
Change in ECG
Palpable pulse
Change in pulse oximetry plethysmograph waveform
Return of pulse on Arterial line (best)
Once ROSC has been obtained, continue to treat reversible causes. Consider gradually dismissing the code team.
Beware that re-arrest can occur frequently in the peri-arrest setting.
“The greatest danger comes at the moment of victory” - Napoleon Bonaparte
Determining futility
Evidence of futility (duration, persistently low ETCO2, severe acidosis/hyperkalemia, lack of cardiac motion on TTE)
Duration >30 minutes without some attenuating factor (cold, stuttering arrest)
pH < 6.8 and K > 10 are poor prognostic factors; though mostly as markers or progressive worsening acidosis
(complete) lack of motion on POCUS (adjunctive)
Post Code Debriefing
Take 3 minutes and debrief the code. Every time.
Debrief quickly → everyone will disperse and get busy; no time like the present
Get water → have the team hydrate. Everyone needs it.
Start with a moment of silence; honor the patient as person.
“Let’s talk about what went well and what we can do even better next time”
Always discuss CPR quality (time on chest, quality of compressions, short interruptions, etc).
Always emphasize at least one point that went well.
Listen. For many people this may have been their first time seeing/performing CPR. Give them space to share.
Audio
Video
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Advanced Challenges in Resuscitation: Life-Threatening Electrolyte Abnormalities, Circulation 2000
Tan et al, Clinical evaluation of intravenous alone versus intravenous or intraosseous access for treatment of out-of-hospital cardiac arrest, Resuscitation 2021
Pallas et al, Cardiac Arrest Nurse Leadership (CANLEAD) trial: a simulation-based randomised controlled trial implementation of a new cardiac arrest role to facilitate cognitive offload for medical team leaders, Emerg Med Journal 2021
Rabjohns et al, Pseudo-pulseless electrical activity in the emergency department, an evidence based approach, Am J Emerg Med 2020
Prosen et al, Impact of modified treatment in echocardiographically confirmed pseudo-pulseless electrical activity in out-of-hospital cardiac arrest patients with constant end-tidal carbon dioxide pressure during compression pauses, J Int Med Res 2010
Jabre et al, Family Presence during Cardiopulmonary Resuscitation, NEJM 2013
Oczkowski et al, The offering of family presence during resuscitation: a systematic review and meta-analysis. J Intensive Care. 2015
Levine et al, End-Tidal Carbon Dioxide and Outcome of Out-of-Hospital Cardiac Arrest, NEJM 1997
Lee et al, Effect of Placement of a Supraglottic Airway Device vs Endotracheal Intubation on Return of Spontaneous Circulation in Adults With Out-of-Hospital Cardiac Arrest in Taipei, Taiwan, JAMA 2022
Meaney et al, Cardiopulmonary Resuscitation Quality: Improving Cardiac Resuscitation Outcomes Both Inside and Outside the Hospital, Circulation 2013
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Family Presence During CPR, NEJM 2013
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