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Nov 7, 2015

What I do in the in the first 90 seconds of a code…

We want to avoid simultaneous action paralysis: the feeling that multiple things need to happen at once and then nothing gets done. In a code, it seems like everything has to HAPPEN RIGHT THIS SECOND. While it can feel that way, it’s not the case.

My sequence of events in an emergency department cardiac arrest

When the medics roll in, I am listening for five pieces of information. 

  • What happened, preferably in one sentence
  • What was the initial rhythm
  • What have they done (actions, meds, etc)
  • What was the last rhythm
  • How long has the patient been down, unconscious, and presumably in cardiac arrest.

While that report is coming, I keep my eye on the patient's chest to make sure CPR is not stopping. Continuous quality CPR in the first 90 seconds is important because there is so much potential to pause it: transfer to the stretcher, putting on leads, or “Can you stop it for a second for this or that.” Ideally, I’ll have the LUCAS set up so I can take the cognitive load of thinking about CPR out of the picture. 
We’re  about 30 seconds in, and I’ve got general a look at the patient: what's the airway situation, what’s the vascular access. Now is the first decision point. Do I check the rhythm, secure an ET tube, get vascular access? Well, what makes a difference? Electricity is the first thing that comes to mind. So I have the CPR continue while the patient is settled on our stretcher, keeping the EMS chest pads on, keeping the patient attached to their monitor. At this stage, changing over to our monitor (if they’re already on a perfectly good one) makes no sense. Once we’re ready, stop CPR and check the rhythm while simultaneously using the ultrasound for subxiphoid view of the heart. 

Now I’ve got the rhythm and direct visualization of any cardiac activity.  Whatever the rhythm, I know what I'm going to do. 

We're 90 seconds in and I’m moving to intubate/get ETCO2. I that’s already done, I just keep a finger on the femoral pulse while the CPR is happening. Why do I do this? I want to have my hands on the patient but not do be a primary operator of CPR, bag valve mask squeezing, vascular access - just watching and thinking. The room is quiet, there are no raised voices - tone and volume are conversational and calm.

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