Lessons I reinforced during my first intraoperative cardiac arrest

Regular visualization can keep you prepared for high-acuity, low-occurrence events

Before I was a physician, I worked as a paramedic and led countless cardiac arrests. However, when I started my anesthesia training, all the codes in the ICU were run by the fellows or attendings, and so my leadership skills atrophied.

Recently, I was maintaining general anesthesia for a routine case when the pulse oximeter suddenly decreased and the waveform deteriorated. My initial thought was that it might not be a true desaturation because the waveform was poor. Up to this point, the vitals had been stable—like train tracks. I checked the sensor and looked back at the monitor to see the end-tidal CO₂ abruptly dropping. That’s when I knew the pulse ox reading was real and the patient probably didn’t have a pulse.

By chance, a few months prior, I ran a code in the PACU. I walked away from that experience reflecting on how out of practice I was. So I made a short checklist for myself (see the end of the post for the checklist), and I started reviewing it regularly with a visualization exercise where I pictured myself executing each step. This brings us to my first lesson: regular mental rehearsal is paramount to high performance. A cardiac arrest in the operating room is a high-acuity, low-occurrence (HALO) event. If you want to be good at managing these types of situations, practice (ie, simulation) and mental rehearsal are necessary.

When I realized my patient was coding, I resorted to a simple “in case of emergency” checklist I keep in my head. Here is that checklist.

• Call for help

• Oxygen to 100%, max flow

• Cycle blood pressure cuff / verify transducers at correct height

• Change NIBP to cycle every 1 minute

• Notify surgeon

• Consider taking patient off ventilator

• Consider turning off anesthetic

• Consider turning off IV drips

My second lesson is to call for help first and to second-guess yourself second. There was a brief moment when I thought, “Is this data real?” While this is a reasonable thought, the most important thing to do is to get additional help. If it turns out to be a false alarm, no big deal. Conversely, time spent trying to confirm potentially suspect data is time wasted while the patient deteriorates. There is a saying in aviation, “Each subsequent bad decision reduces the remaining number of available good decisions.” Calling for help early preserves your pool of good decisions.

When I was a resident, I experienced multiple codes where the person in charge did not want an arterial line placed, despite having sufficient help to do so. I never understood this. Having an A-line gives real-time feedback about compression effectiveness, allows one to quickly and accurately perform pulse checks (simply look at the A-line during the briefest pause in compressions; no waveform = no pulse; and if systolic BP < 60 mmHg you should resume compressions), and allows easy blood sampling to guide treatment. My third lesson is to ALWAYS place an arterial line (using ultrasound) as soon as possible.

In this particular arrest, having point-of-care cardiac ultrasound was useful in confirming the diagnosis of a pulmonary embolism. I also strongly think that every cardiac arrest should have a central line placed, if sufficient help is available. One person could double-puncture the groin placing femoral central and arterial lines using just a central line kit; this can be a very efficient use of personnel and time.

This brings me to my last, and perhaps most important lesson: teamwork is everything. Anesthesia and surgery are team sports. Emergencies take that level of cooperation and coordination to the next level. My patient had a good outcome because many physicians, nurse anesthetists, nurses, scrub techs, and other healthcare providers were able to help out. Without this help, none of the other lessons I have outlined here would have been effective.

Hopefully, this sort of event rarely happens to you, but if it does, I hope this post and these checklists have helped you better prepare. If you’re looking to improve your code skills, I highly recommend checking out the various related episodes of Scott Weingart’s EMCrit podcast.

Here is my cardiac arrest checklist which I regularly review.

• Take charge

  • Verify patient is actually coding

  • If already on monitor, check for shockable rhythm

  • Ensure compressions adequate

  • Get crash cart

  • Assign rolls - recorder, compressors, monitor, drugs, airway

  • Drugs - epi, antiarrhythmics, etc.

  • Anterior-posterior (AP) pad placement is more effective than anterior lateral (AL) and should be used first even though it takes more time to place AP

  • Dual sequential defibrillation is more effective than single defib

  • Antiarrhythmics should be given right away, if indicated

• Maintain situational awareness

  • Gather patient history

  • Assess for reversible causes

• Further organize help

  • Get ultrasound

  • Intubate

  • A-line - perform ASAP

  • Check glucose

  • Labs - CBC, CMP, LFTs, coags, type & screen, troponin, BNP, ABG, lactate

  • Central line

  • POCUS (exclude tamponade, pneumothorax; RUSH exam for bleeding)

• Additional items

  • Consults (ICU, cardiology)

  • IV infusions (pharmacy)

  • Blood bank

If you have suggestions for improving these checklists, please leave them in the comments below.