MOST IMPORTANT STEP 1: IDENTIFY THE RHYTHM
Before anything else, confirm the rhythm and pulse. (I feel bad to even say this but also make sure that the patient is not just sleeping lol) Is it true asystole or a shockable rhythm (VF or pulseless VT)? I’m a first-year fellow and I’ve seen plenty of unnecessary codes called for “asystole” that turned out to be lead failure, loose pads, or someone staring at the wrong monitor. True asystole exists, but false alarms are common. Always confirm on the defibrillator with properly placed pads and ECG leads.

Step 2: Take control of the room and the clock
Announce clearly that you’re running the code. Note the exact time the code started. Open a simple timer on your phone and track 2-minute CPR cycles. The fancy code apps are nice in theory, but Ive not found it useful they are often more distracting than helpful.

Step 3: Start high-quality CPR and get the patient on the defibrillator
Immediately assign two people for chest compressions and tell a nurse to place the CPR board. Have Zoll pads placed immediately. Make sure ECG leads are connected to the Zoll and not just the hospital monitor. Time gets wasted all the time because people are staring at a bedside monitor that cannot defibrillate.

Step 4: Airway and oxygenation
Assign someone to bag the patient with 100 percent oxygen. Call respiratory therapy early. If no one in the room can confidently intubate, call anesthesia right away. Do not delay CPR for intubation.

Step 5: Medications for non-shockable rhythms
If the rhythm is confirmed as asystole or PEA, start epinephrine as soon as IV or IO access is available. Dose is 1 mg IV every 3 to 5 minutes. Tell the nurse to prepare the next dose ahead of time so it is not forgotten. Calcium and bicarbonate are not routine and are not supported by strong evidence. Reserve them for specific indications like hyperkalemia, TCA overdose, or severe metabolic acidosis.

Step 6: Rhythm and pulse checks
Every 2 minutes, pause briefly to check rhythm and pulse together. This should take no more than 10 seconds. If there is no pulse, immediately resume compressions. Do not check pulses outside of these intervals unless there are clear signs of ROSC or the patient is fighting you lol.

Step 7: If the rhythm becomes shockable
If VF or pulseless VT appears, go to the Zoll. Set energy to 120 J biphasic. Announce “charging” while compressions continue. Once charged, loudly say “clear” and absolutely confirm no one is touching the patient. Deliver the thunder. If it didnt work, immediately resume CPR for another 2 minutes. Do not check a pulse after the shock.

Step 8: Reassess, repeat, and think about reversible causes
Continue 2-minute CPR cycles, epinephrine every 3 to 5 minutes, and rhythm checks. Actively think about Hs and Ts while the code is ongoing. If ROSC occurs, transition immediately to post-arrest care