How To Run A code in a Hospital

By: Maged Taman


1- See if patient unresponsive.
2- Activate code, in hospitals call operator for code blue.
3- Usually this is the first step for the code runner to start to run the code. Scan the place in few seconds to get idea what you are for, as identify patient, how he looks, team around you to help it should only take few seconds.
4- Confirm no pulse and no breathing or either.
5- Ensure quick start of the chest compressions if not started yet (about 100/minute and at least 2 inches deep).
6- Confirm the delivery of Oxygen by Ambu bag and monitor O2 saturation.
7- Confirm AED in place and pads on the right position of patient chest wall.
8- Confirm Code status full code or DNR, note the time spent in this may take 1-2 minutes which in this situation may mean survival, many of hospitals have the DNR bracelets in patients wrist.
8- Confirm there is an IV line in place, consider add another line in the future if needed.
9- After 2 minutes from chest compressions, stop chest compressions check the AED monitor for the rhythm, let AED take over it will tell you if it is a shockable rhythm and it will tell you to shock or it will deliver a shock. It will also tell you if it is not a shockable rhythm. Be sure every one stay away from patient including stop ambu bag as the AED tell you do (all Clear) before shock delivery.
10- If the rhythm is shockable (Ventricular tachycardia/fibrillation, V tach/fib) give one shock and resume chest compressions immediately for about 2 minutes before check rhythm again (can resume the sequence for about 2 times more). If patient has normal rhythm or a rhythm that can give him a pulse check for pulse, if there is a pulse check for blood pressure. If no pulse and patient in v tach or v fib consider epinephrine 1 mg amp IV, repeat chest compressions again and the 2 minutes stop for rhythm analysis. Epinephrine can be repeated every 3-5 minutes. One dose of vasopressin 40 units IV can be also considered. Other choices for V tach/fib is Amiodarone one dose push of 300 mg can be followed by one dose of 150 mg push in 3-5 minutes. Amiodarone is also another choice 1-1.5 mg/Kg IV psuh followed by 0.5-1.75 mg/Kg IV push.
10- If the rhythm is nonshockable (asystole or pulseless electrical activity PEA) give epinephrine 1 mg IV every 3-5 minutes. Continue chest compression for 2 minutes and then rhythm analysis as above. Atropine was used in this category but stopped in the new 2010 recommendations.
11- Understand that patient can take any direction can start in asytole and go in V tach/fibrillation or the opposite. Thus both protocols can be used in the same patient. Many times it is the choice between shock or adrenaline.
12- Endotracheal intubation can be considered, however it comes next in after chest compression, ambu bag and shock if indicated in the first few minutes. Should particularly considered if aspiration, hempotysis, angioedema or lodged foreign body in the airway after good suction. Do not confuse that with respiratory arrest which commonly happen before cardiac arrest in Adults and patient in respiratory distress or hypoventilation. Those people in large part may be maintain early a reasonable blood pressure and have a pulse. Intubation is done after sedation is ensured. With no adequate sedation injury to airway could happen and intubation can be difficult. Delay in intubation can result in secondary cardiac arrest.



Thus the most important in CPR is early and semi-vigorous chest compressions as above with ambu bag and AED with delivering shock early after about 2 minutes of chest compressions when indicated. Everything else comes distantly next. Epinephrine is the drug to remember most since it is the only drug for Asystole/PEA and the most effective in V tach/fib. Remember the cycle of 2 minutes chest compression followed by rhythm analysis. Think about shock or IV medications after the rhythm analysis. In most hospitals AED will tell you if need to shock.

Note above is cardiac arrest code which is part of the ACLS or advanced life support which include other acute cadiovascular emergencies.

ACLS Drugs


Adenosine: in PSVT: 6 mg iv rapid push with saline flush, if no response a second dose of 12 mg can be given in 1-2 minutes, if no response another dose of 12 mg can be given in 1-2 minutes.


Amiodarone:
Non-cardiac arrest in recurrect life threatening ventricular arrhythmias.
load 15 mg/min over 10 min (150 mg) may repeat every 10 minutes as needed
then 1 mg/min x 6 hrs (360 mg total)
then 0.5 mg/min x 18 hrs (540 mg total)
Total amidarone is 2.2 gram per 24 hours.
Cardiac arrest
300 mg iv push (diluted in 20 cc D5W)
can consider repeat 150 mg iv x 1 in 3-5 minutes
Max dose: 2.2 gm in 24hrs

Aspirin:
160-325 mg chewing (non-entric coated)
300 mg supp

Atropine:
Asystole/PEA was used as 1 mg IV push q 3-5 minutes maximum of 3 doses, howevere not used now.
Bradycardia: 0.5 mg every 3-5 minutes not to exceed 3 mg

epinephrine:
1 mg q 3-5 min, higher doses can be used in betablocker or calcium channel blocker overdose.
Continous infusion: 1-10 microgram/min start by 1 and titrate up to efect.

iv diltiazem:
load 0.25mg/kg iv over 2 min about 15-20 mg , may repeat another dose after 15 minutes, maintainance: 5-15 mg per hour.

Digoxin:
loading dose of 10-15 ug/kg of lean body mass.

Dopamine:
Second lind drug for symptomatic bradycardia (after atropine) or hypotension systolic 70-100 with symptoms and signs of shock 2-20 ug/min

Dobutamine:
Congestive heart failure and pulmonary edema with sytolic blood pressure 70-100 Hg with no signs of shock 2-20 ug/min titrate so heart rate does not increase by > 10% of baseline.

Flumazenil:
in benzo overdose: 02 mg IV over 15 seconds, if no response 0.3 mg IV over 30 seconds, if no response: 0.5 mg IV over 30 seconds. If no response repeat once every miute until adequate response or total of 3 mg is given.

Glucagon:
in overdose of betablocker and calcium channel blocker: 3 mg bolus then 3mg/hour

ibutilde:
>60 kg 1 mg over 10 minutes, may repeat a second dose

Isoproterenol:
Fro symptomatic bradycardia or refractory torsades infuse at 2-10 microgram/min

Labetolol:
in hypertensive crisis: 10 mg IV push over 1-2 minutes, may repeat or double dose every 10 minutes to a maximum of 150 mg, can start infusion early after the first bolus at 2-8 mg/min

Lidocaine:
1 to 1.5 mg/kg bolus
additional 0.5 - 0.75 mg/kg up to total 3 mg/kg.
Then infuse 1-4 mg/min

Magnesium sulfate:
1-2g over 5-60 min: in cardiac arrest due to hypomagnesmia and torsades 5- 20 minutes less acute over 5 -60 minutes. May follow with 05-1 gram/ hour infusion to control torsades.

Mannitol:
For increased intracranial pressure: 0.5 - 1 g/kg over 5-10 minutes can be given every 4-6 hours as needed.

Metoprolol:
in Acute MI or hypertensive crisis: 5 mg slow IV every 5 minutes for a total of 15 mg.

Morphine sulfate:
In chest pain unresponsive to nitroglycerin or acute cardiogenic pulmonary edema: 2-4 mg Iv over 1-5 minutes repeat dose according to effect and patient tolerance

Naloxone:
in opiate intoxication: 0.4 - 2 mg titrated until adequate ventilation, repeat to effect and response.

Nitroglycerin:
For angina: IV bolus if no SL nitro or spray 12.5-25 microgram/ min then infusion at 10 microgram /minute increase by 5-10 microgram/min every 5-10 minutes until pain controlled avoid hypotension.

Nitroprusside:
For hypertensive crisis: start 0.1 microgram/kg/min titrate by 5-10 microgram/minute every 3-5 minutes for desired effect.

Norepinephrine:
in hypotension systolic <70>100 mmhg maximum 30 microgram/min

Oxygen:
nasal cannula 1-6 L/min o2: 21-44%
venturi mask 4-12 L/min o2: 24-50%
partial rebreather mask: 6-10 L/min o2 : 35-60%
nonrebreather: 6-15 L/min o2 : 60-100%
Bag mask with nonrebreather tail 15 L/min o2: 95-100%

Procainamide:
load 20 mg/min up to 17 mg/kg in urgent situation 50 mg/min for total of 17 mg/kg
then infuse 1-4 mg/min

vasopressin:
40 IU x 1 dose only (for pulseless VT/VF)

Sodium bicrabonate:
in hyperkalemia, some causes of metabolic acidosis: 1 mEq/kg

Verapamil:
in supraventricular tachycardia: 5 mg bolus every 15 minutes for a total of 30 mg if blood pressure allow.