HYMR1

Wednesday, August 30, 2017

What I Bring When Attending A Code

Pharmacists have been shown to improve adherence to advanced cardiovascular life support (ACLS) guidelines (1,2), and pharmacist involvement adds instant drug expertise during intense situations. Not to mention, the multidisciplinary team wants us there at the bedside. Nurses and providers surveyed have overwhelmingly (97%) believed that having a pharmacist present during a medical resuscitation enhances their ability to deliver safe, quality care to patients.(3) The large amount of code cart drugs suffering from national shortages has added an additional spotlight to pharmacists attending codes.

First things first, you should know your code cart inside and out. Inside and out being very much figurative and literal. Take the time to go through each drawer, medication, piece of supply, and refresh your memory on how to use the defibrillator.

Knowing your code cart like the back of your hand allows the code to run smoother and other team members to focus on emergent procedures, compressions, IV/IO placement, recording, etc. This includes knowing where supplies is located and what each one is used for (e.g. Bougie, blade differences, endotracheal tube sizes, 3-way stopcock, defibrillator pads, pressure-bag). Since I know which drugs and equipment are unavailable in the code cart, bringing supplies is imperative to my emergency medicine (EM) game.

Syringes, Needles, Flushes

While all are in our code cart (except an appropriate 20 mL syringe for some odd reason), restocking a code cart is a pain for the emergency department (ED), sterile processing, materials management, and pharmacy staff. Most would prefer not to “crack” the code cart open if it can be prevented and this is generally good news for the patient. By having these available ahead of time, if it is determined we need “x” drug STAT, such as rapid sequence intubation (RSI) medications or push dose pressors, we are ready to go. I will usually bring a 3 mL, 6 mL, 10-12 mL (x2), and a 20 mL syringe.

When the time comes for medication infusion a smart pump should be available (a pole as well if your patient bed does not have a built-in or if the area is overcrowded). This is a great opportunity to ask somebody outside the room for retrieval while you focus on other pressing issues if these are not readily accessible. Personally, I often use the volunteer onlookers or a curious looky loo for this purpose.

*Our code carts are stocked with 3-way stopcocks [20 mL syringe is handy for SVT] and transfer devices; if yours is not, consider bringing these devices, as they will especially be useful for pediatric codes.

RSI Kit 

Often the patient is being bagged by EMS and/or has a laryngeal mask airway (LMA) placed and will still require proper intubation. Standing there with your syringes and needles, along with your institutional RSI kit, you are ahead of the game and ready to go. This will prevent having to rush to the Pyxis/Omnicell/random-box-in-the-corner to retrieve the medication.

Alteplase 50 mg Vial

Having this stocked in your ED, you can prevent a wasted 50 mg from the 100 mg vial ($3900 saved!). Give a blast of alteplase if the cause of cardiac arrest is thought to be secondary to pulmonary embolism or ST-elevated myocardial infarction with no access to the catheterization lab or for some reason the catheterization lab cannot be ready in an appropriate amount of time.(4) We prefer the 50 mg bolus dose during a code situation, which can be followed by another 50 mg if necessary 30 minutes later. A lot can happen in 30 minutes during a code. Here’s a 2013 ALiEM post on the tPA code dosing.


Esmolol 

EMPharmD has previously discussed the utility of esmolol after ACLS measures have failed in refractory ventricular fibrillation and pulseless ventricular tachycardia. As a reminder, since you should be doing the defibrillations (you are ACLS-certified after all, right?), after 2 shocks have been given (don’t forget EMS defibrillations), consider using esmolol and how you plan to dose and prepare after a third shock. You will likely be the only one in the room that knows how to dose and prepare and esmolol infusion for this indication.

Lazer-Focus 


When walking into a room for a resuscitation be ready to anticipate the team and patient needs, listen to everything, prepare epinephrine/norepinephrine infusions, and cycle in your head the appropriate ACLS algorithm and H’s & T’s (Hypovolemia, Hypoxia, Hydrogen ion, Hyper-/hypokalemia, Hypothermia, Toxins, Tamponade,Tension pneumothorax, Thrombosis) and how to treat. Since every patient is different, often with limited information, numerous challenges are faced during cardiac arrest. Having a pharmacist who is prepared and can anticipate the needs of the team serves the patient well and puts the pharmacy profession in a positive light.

Short-Term Amnesia 

Bring this to a limited extent, as you should review what could have been done differently and what can be learned from the code, but the stark reality is that you were bedside with a human being just pronounced dead. This can be a heavy burden and have found that short-term amnesia helps to continue moving forward for the next patient. Remember, this patient was going to die without your help, but with it, they had a better shot. 

It should be mentioned that formal debriefing implementation after a code has been found to increase the feeling of support among peers and leaders, pay homage to the patient that has passed, and give a brief pause to reflect prior to resuming normal activities within the ED (5).

If your facility does not have a formalized process, the debriefing or lack thereof, will be provider-dependent. As a pharmacist training students and residents, if the provider does not offer a debriefing, I believe it is in our due diligence to offer our trainees one such session. If you are on your own, consider speaking with fellow team members, and more often than not, they will debrief with you.

Leave the Ego 

There will be times when the team does not know you (responding to a code on an unfamiliar floor or new to the department). The crystal-baller approach can work wonders in these scenarios. In addition, you already brought additional supplies you may need to the code. It is not unreasonable that the team has never had a pharmacist attend a code before and members may be unsure of what role you can play. Introduce yourself to the team and state that you are available. Sometimes you may be late to the party, but in this case, I would recommend introducing yourself to the person at the code cart and offer to help. At this point, if you are pushed away, consider making infusions and on-the-ready for anything called out that is unavailable in the code cart. During the debriefing (if applicable), introduce yourself again to the team and what role you could play in the future. After a few saves and anticipatory wins, you will likely have gained the team’s trust; try not to lose it.

Being forceful and arrogant in situations already intensified with stress and high-stakes often leads to defensive nurses and providers. When the team may be annoyed by your presence, even if you are the best pharmacist in the world, the patient care you can contribute will be significantly diminished. Consider this impact and be highly cautious of the 'guns a’ blazin’' approach with a new team.

Conclusion 

Undoubtedly, the first codes an inexperienced pharmacist attends will be scary, uncomfortable, and likely involve the “deer-in-the-headlights” look. However, with appropriate preparation and a repertoire of experience, the pharmacist becomes an integral and highly appreciated code team member. Make the profession proud!

Mark Culver, PharmD, BCPS (@EMdruggist)
Emergency Medicine Pharmacist
Banner University Medical Center
Phoenix, Arizona

Peer reviewed by Craig Cocchio, PharmD, BCPS (@iEMPharmD) and Nadia Awad, PharmD, BCPS (@Nadia_EMPharmD)

Sample of our institution’s medication tray in the Adult Code Cart - WITHOUT SHORTAGES

6
Epinephrine 1mg/10ml SYR
4
Atropine 1mg/10ml SYR
2
Calcium Chloride 10% 1gm/10ml SYR
2
Lidocaine 100mg/5ml SYR
1
Etomidate 40mg/20ml SYR
1
Sodium Bicarbonate 8.4% 50ml SYR
1
Dextrose 50% 50ml SYR
1
Flumazenil 1mg/10ml
1
Vecuronium 10 mg
5
Adenosine 6mg/2ml
2
Vasopressin 20units/ml
2
Naloxone 0.4mg/ml
1
Epinephrine 30mg/30ml MDV
4
Magnesium Sulfate 1gm/2ml
4
Norepinephrine 4mg/4ml
4
Amiodarone 150mg/3ml
1
Lidocaine 2% 5ml Jelly
1
Epinephrine 1mg/ml SubQ Administration Kit
1
Dopamine 400mg/250ml

References:

1. Draper HM, Eppert JA. Association of pharmacist presence on compliance with advanced cardiac life support guidelines during in-hospital cardiac arrest. Ann Pharmacother. 2008;42(4):469–74.
2. Hashemipour Z, Delgado G, Jr, Dehoorne-Smith M, Edwin SB. Pharmacist integration into cardiac arrest response teams. Am J Health Syst Pharm. 2013;70(8):662, 664, 666–7. 
3. Fairbanks RJ, Hildebrand JM, Kolstee KE, et al. Medical and nursing staff highly value clinical pharmacists in the emergency department. Emerg Med J. 2007;24(10):716–9.
4. Böttiger B, Bode C, Kern S, et al. Efficacy and safety of thrombolytic therapy after initially unsuccessful cardiopulmonary resuscitation: a prospective clinical trial. Lancet. 2001;357(9268):1583-1585.
5. Copeland D, Liska H. Implementation of a Post-Code Pause: Extending Post-Event Debriefing to Include Silence. J Trauma Nurs. 2016;23(2):58-64.

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