What to do if a patient codes?

What to Do When a Patient Codes

Immediately begin high-quality chest compressions at a rate of 100-120 compressions per minute with a depth of 5-6 cm (at least 2 inches), ensuring complete chest recoil between compressions, while simultaneously activating the emergency response system and retrieving the defibrillator. 1, 2

Initial Response Sequence

Verify scene safety first before approaching the patient to avoid becoming a second victim. 2

Check for responsiveness by shouting and tapping the victim. 3, 1, 2

Activate the emergency response system immediately (call a code) and retrieve the AED/defibrillator, or send someone to do so if multiple rescuers are present. 3, 1, 2

Simultaneously assess breathing and pulse within 10 seconds—look for no breathing or only gasping while checking for a pulse. 3, 1, 2

• If no pulse is detected within 10 seconds, begin CPR immediately—do not delay. 1, 2
• If uncertain about pulse presence after 10 seconds, start CPR—the risk of providing CPR to someone not in cardiac arrest is far less than withholding it from someone who is. 3, 2

High-Quality CPR Technique

Chest compressions are the priority and should be started immediately by healthcare providers rather than beginning with ventilation. 3

Compression Parameters:

• Depth: 5-6 cm (at least 2 inches) in adults 1, 2
• Rate: 100-120 compressions per minute 1, 2
• Hand position: Center of chest on firm surface 3, 1
• Complete chest recoil: Allow full recoil between compressions—incomplete recoil prevents cardiac refilling and is a critical error 1, 2
• Minimize interruptions: Continuous compressions are essential for survival; keep pauses <10 seconds 1, 2

Compression-to-Ventilation Ratio:

• 30:2 ratio for single rescuer (30 compressions followed by 2 breaths) 3, 1, 2
• 30:2 ratio for two healthcare providers in adults 3, 1
• Deliver each breath over 1 second with sufficient tidal volume to produce visible chest rise 3
• Avoid excessive ventilation 3

Early Defibrillation

Use the AED/defibrillator as soon as it becomes available—do not delay CPR to retrieve it, but apply it immediately once present. 1, 2

Check rhythm to determine if shockable (ventricular fibrillation or pulseless ventricular tachycardia). 1, 2

• If shockable rhythm: Deliver one shock immediately and resume CPR for 2 minutes before reassessing rhythm 1, 2
• If non-shockable rhythm: Resume CPR immediately for 2 minutes 3, 1
• Check rhythm every 2 minutes during ongoing CPR 1, 2

Advanced Life Support Interventions

Establish IV/IO access as soon as feasible without interrupting compressions. 1

Administer epinephrine every 3-5 minutes for all cardiac arrest rhythms. 1, 2

Consider amiodarone or lidocaine for refractory ventricular fibrillation or pulseless ventricular tachycardia. 1, 2

Manage the airway appropriately:

• Administer 100% oxygen at 15 L/min 3
• Bag-mask ventilation is preferred initially 3
• Consider advanced airway placement without prolonged interruption of compressions 3

Special Populations

Pediatric Patients:

• Start CPR if heart rate <60/min with signs of poor perfusion 3, 4
• Use 30:2 ratio for single rescuer and 15:2 ratio for two or more rescuers 3, 4
• Compressions should be at least one-third of the anterior-posterior diameter of the chest 4

Pregnant Patients:

• Perform left uterine displacement during CPR 3
• Use a firm backboard with patient supine 3
• Activate the maternal cardiac arrest team immediately 3
• Consider perimortem cesarean delivery if no return of spontaneous circulation within 4 minutes 3

Suspected Opioid Overdose:

• Administer naloxone if available while continuing CPR 1, 2

Critical Pitfalls to Avoid

Do not delay CPR to obtain a detailed history—the priority is immediate chest compressions. 2

Do not perform prolonged pulse checks—if uncertain after 10 seconds, start CPR. 2

Do not provide inadequate compression depth or rate—compressions must be hard and fast (5-6 cm depth, 100-120/min) to be effective. 1, 2

Do not lean on the chest between compressions—this prevents adequate cardiac refilling and is a common error. 1, 2

Do not interrupt compressions for prolonged periods—every second without compressions decreases survival; keep pauses <10 seconds, especially during rhythm checks and defibrillation. 1, 2

Healthcare providers often take too long to check for a pulse—this leads to critical delays in starting compressions. 1

Continuation of Care

Continue CPR until:

• Advanced life support providers take over 3
• The patient shows signs of recovery (movement, normal breathing, pulse) 3
• You are physically unable to continue 3
• A physician determines resuscitation should be terminated 5

Early CPR by bystanders significantly improves survival from cardiac arrest, particularly when started within 4-6 minutes of collapse and followed by advanced life support within 10-12 minutes. 6