Critical Care Pearls

Master Running Code Blues!

Most Important Factors

  • Team Leadership
  • Hemodynamic Directed Resuscitation
  • High Quality CPR
  • Early Defibrillation
  • Medications
  • Novel Therapies
  • Post Arrest Care

1. Team leadership

  • Deficits in leadership can cost lives
    • ex: poor performance of CPR, decreased ROSC, decreased survival
  • Benefits:
    • Good leadership –> establish ROSC faster
    • Proper planning (ex: role assignment) –> reduced hands-off time, less interruption, faster treatment completion
    • Improved communication –> accuracy of team leader communications linked to errors
  • Rolesof the team leader:
    • ensures delivery of adequate compressions
    • minimize interruptions
    • avoid excessive ventilation
  • What can you do? Take charge!
    • direct all components of resuscitation
    • assign tasks
    • communicate clearly
    • be decisive

2. Hemodynamic directed resuscitation

  • Survival dependent upon restoring myocardial blood flow
    • Keep coronary blood flow (CPP) >20mmHg, three ways to check
      • DBP – RAP(or CVP), caveat: need A-line and central line
      • DBP>25mmHg, just need A-line
      • ETCO2>20
    • May use these parameters to optimize CPR, guide vasopressor use, and detect ROSC

3. High quality CPR

  • Rate: 100-120/min
  • Depth: 5-6 cm(2-2.4 inches)
  • Allow full chest recoil
  • Avoid leaning
  • Chest compression fraction > 60% (minimize interruptions)
  • Eliminate pulse checks

4. Early defibrillation

  • Hands off for shock, charge while compressions are occurring
  • Limit perishock pause to <10s

5. Medication

  • Vasopressors
    • Increase aortic pressure
    • Improve CPP
    • Improve cerebral perfusion pressure
    • No definitive evidence that any vasopressor agent improves long-term survival
  • Epinephrine
    • Decreases microcirculatory cerebral flow
    • Increased myocardial O2 consumption
    • Increased post-defib ventricular arrhythmias
    • Increased post-ROSC myocardial dysfunction
    • Standard dose (1mg q3-5mins) MAY be reasonable
  • Vasopressin – not recommended

6. Novel therapies

  • ECPR not universally accepted
    • best outcomes: witnessed arrest, bystander CPR w/in mins, shockable rhythm, short EMS transport time, short time to ECMO, emergent hypothermia, and PCI

7. Post arrest goals

  • Optimize oxygenation and ventilation
    • Decrease FiO2 for O2sat>94%
    • Goal: PCO2 35-45; ETCO2 30-40
  • Optimize hemodynamics
  • Targeted temp management
    • Comatose adult patients with ROSC after cardiac arrest (32-36C for 24 hours)
    • No benefit of endovascular over surface cooling
  • Emergent PCI
    • STEMI, NSTEMI with hemodynamic instability or refractory VF/Vfib or ongoing ischemia

Algorithm for Risk stratification of Comatose
Cardiac Arrest Patients

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