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

ACLS
‍-- 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
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VT/VFib
-- 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
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PEA/Asystole
- epi 1mg q3-5mins (every other round)
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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
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-- 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
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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

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