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End of Code
The patient should be transferred to the critical care unit as soon as possible for post resuscitation care, which includes airway management, blood pressure maintenance, oxygenation, and control of dysrhythmias. Once the patient is transferred with cardiac monitoring, ensure documentation is thorough and complete.
End of code responsibilities also include:
Ensure family is contacted. If the family is present during the code, assign a support person to inform them of the events during and after the code
Ensure patient’s physicians are contacted
Clear room of equipment.
Use caution with blood and body fluids.
Sharps precautions.
Take crash cart with all equipment (O2 tank, suction machine, red box, gray box, intubation supplies and clipboard) to sterile processing with a gray charge slip indicating the patients name and medical record number. A new crash cart will be issued.
Support staff and have a debriefing session.
Post Resuscitation Care
In the event the patient is unable to be immediately transferred to the ICU, it is critical that the patient be monitored during the post resuscitation period. Some patients may respond after a code by becoming awake and alert while others may be unconscious. Remain with the patient while providing an ongoing physical assessment and monitoring the vital signs, pulse oximetry, and EKG rhythm. Continue to use the ABCD’s (airway, breathing, circulation, defibrillation/drugs) to organize care with a goal of ensuring oxygenation and perfusion.
Criteria for monitoring the patient during the immediate post resuscitation period:
Establish a nonhostile environment to restore cerebral function to optimize oxygenation and perfusion by:
maintaining normothermia; hyperthermia increases oxygen requirements o controlling seizures; increases oxygen requirements
elevating HOB >30 degrees to increase cerebral venous drainage and decrease intracranial pressure
Treat hypotension per physicians orders: may impair recovery of cerebral function o Fluids
o Inotropics
Vasopressors
Post resuscitation VF/Pulseless VT; administer medications/treatment per physician orders
Beta-adrenoreceptor blocking agents
o Antiarrhythmics
o Magnesium sulfate
o Defibrillation
Post resuscitation Tachycardia; continue to monitor the patient and follow physicians orders
Post resuscitation Bradycardia; evaluate ABCD’s and follow physicians orders
Atropine
Cardiac pacing
Post resuscitation Premature Ventricular Contractions (PVC’s); evaluate ABCD’s & electrolytes
Troubleshooting the Code
Problem Intervention
Unsure “who” is in charge State, “Will the physician in charge please state and spell their last name”
Unsure “what” is happening Ask clearly (i.e. please clarify drug dose)
Too loud Request that only the physician in charge speak
Too many people Request for anyone not directly involved in the code to leave
Confusing Make sure one physician is in charge an giving orders
Patient not resuscitating Think: optimal oxygenation & circulation
Pulse with compressions?
ABG results
Unsure of “where” patient should go next Ask physician if an ICU bed is needed
References
ACLS Review made Incredibly Easy (2007). Lippincott Williams & Wilkins.
American Heart Association Advanced Cardiac Life Support Guidelines (2006).
American Heart Association ACLS Guidelines (2003).
Dulak, S. (2004). Hands-on help Temporary Pacemakers. RN Vol.67 (6)
Medtronic Lifepak 20 Defibrillator/Monitor with ADAPTIV Biphasic Technology Operating Instructions Manual (2002 – 2004).
Nursing 2007 Drug Handbook. Lippincott & Wilkins.
Sole, Lamborn, Hartshorn, 2001. Code Management. Introduction to Critical Care Nursing, 3rd edition. W.B. Sanders
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