Rising Senior Topic

Run the code from the foot.

Leading a code or rapid response: stepping back, assigning roles, closed-loop talk, calling for help, pauses and stopping, family presence (Jabre 2013), and the TALK debrief — aligned with the 2025 AHA guidelines.

Reviewed October 2026 · verify against current guidelines

Codes · 1 of 6

Step back to lead.

Your hands are the wrong tool

The team leader's job is to think, not to do. Stand at the foot of the bed where you can see the patient, the monitor and the whole team. The moment you start compressions or grab the airway, no one is watching the clock or the causes.

First 30 seconds

  • Say it: “I'm Dr. ___, I'm running this code.”
  • Confirm compressions are going and the pads are on.
  • Assign every role by name, out loud.
  • Ask: “Who knows this patient? What happened? What's the code status?”
  • Start the clock and name a recorder.

Roles to fill

LeaderDirects, decides, keeps time and the differential. Hands off.
CompressorsTwo or more, rotating. The 2025 AHA guidelines call it reasonable to switch about every 2 minutes.
AirwayBag-mask first; advanced airway when the right person is ready.
Monitor / defibPads, rhythm checks, charging during compressions, shocks.
Access / medsIV or IO access, draws and pushes drugs on the leader's order.
RecorderTimes, rhythms, shocks, drugs. Calls out the 2-minute mark.
SupportGets the chart, labs and the primary team. Supports the family.
If your hands are on the patient, nobody is leading. Hand off the task, step back, and say so.
Codes · 2 of 6

Talk in closed loops.

What the 2025 guidelines say

The 2025 AHA guidelines (published October 22, 2025, in Circulation) recommend that life-support training for health care professionals include a specific emphasis on teamwork competencies (Class 1). The chapter names communication, leadership, decision-making and workload management. In-hospital code teams should be ALS-trained (Class 1), and dedicated code teams with clearly defined roles are reasonable (Class 2a). The guidelines also say it may be reasonable for professionals to use cognitive aids during resuscitation.

Habits that make it work

Closed loopName, then order, then read-back, then “done.” “Sam, 1 mg epinephrine IV now.” “1 mg epi in.” Unclaimed orders do not happen.
Shared mental modelSay what you think is going on and what comes next: “PEA, probably hypoxic. Next: airway, then reversible causes.”
Summarize aloudEvery 2-minute cycle: time down, rhythm, shocks, last epi, what you've ruled out.
Invite input“What am I missing?” Then actually wait three seconds.
Control the noiseOne voice gives orders. Everyone else reports to it.
Two-minute summary script — “We're 8 minutes in. PEA throughout, no shocks, epi times two, last at minute 6. Glucose and potassium sent. Next: rhythm check at 10, then look at the echo. Anyone have anything?”
AHA American Heart AssociationIV / IO intravenous / intraosseousALS advanced life supportPEA pulseless electrical activity
Codes · 3 of 6

Call for help early.

Rapid response is code prevention

The 2025 AHA Systems of Care guidelines rate rapid response or medical emergency teams as reasonable for reducing cardiac arrest (Class 2a). At a rapid response, you lead the same way. The goal is different: stop the arrest from happening, and decide where the patient goes next.

Call your attending or the intensive care unit now when

  • The airway looks difficult.
  • The patient is pregnant. Activate the maternal code (OB and neonatal teams) now, start manual left uterine displacement, secure the airway early, and prepare for resuscitative delivery. The 2025 AHA special-circumstances chapter names early airway management and left uterine displacement as resuscitation priorities in pregnancy.
  • The rhythm is refractory or keeps recurring.
  • You are also covering the floor and cannot stay.
  • Code status is unclear and the family is not reachable.
  • Your gut says this is beyond your team. That is enough.

Rapid response checklist

Code statusConfirm it first. It shapes everything after.
What changedAsk the nurse for the timeline and the last normal set of vitals.
ABCDEWork through airway, breathing, circulation, disability and exposure. See the ABCDE topic.
Decide the bedStay, step-down or intensive care. Say it out loud before the team leaves.
Set the next check“Recheck vitals in 30 minutes. Call me directly if systolic pressure is under 90.”
Doses and algorithms — use the adult cardiac arrest guide and the adult code companion (2025 AHA), the pediatric and newborn guides, and your hospital's code-cart cards. Don't work from memory.
Codes · 4 of 6

Pause, then decide.

Short pauses, real thinking

Rhythm checks are planned pauses, not breaks. The 2025 guidelines keep pulse checks to no more than 10 seconds, with pre- and post-shock pauses as short as possible (Class 1). Do your thinking during compressions. Use the pause to act on it.

Time-out during compressions

  • Re-read the reversible causes (Hs and Ts) out loud. Cross off what you've addressed.
  • Ask the recorder for the timeline.
  • Check that compressions are deep enough and that the compressors are rotating.
  • Ask the room whether anyone has a concern.

Stopping: what the 2025 guidelines say

No validated in-hospital ruleThe adult ALS chapter says termination rules are inappropriate for populations they were not validated in, including in-hospital arrest.
ETCO2Should not be used alone to end resuscitation. In intubated adults, an ETCO2 of 10 mm Hg or less after 20 minutes of ALS may be considered (Class 2b), as one part of a multimodal decision. In patients who are not intubated, do not use a specific ETCO2 cutoff to stop (Class 3: Harm). See Capnography.
UltrasoundUsing point-of-care echo to predict outcome during arrest is not well established (Class 2b).
How to stop — loop in the attending. Then: “We've done [for example, 30] minutes of high-quality CPR and treated every reversible cause we found, with no ROSC despite that. I'm proposing we stop. Does anyone have a concern or something we haven't tried?” Wait. Then call the time aloud. The AHA sets no fixed in-hospital duration; the decision is clinical.
ETCO2 end-tidal carbon dioxideHs and Ts the reversible causes of arrestCPR cardiopulmonary resuscitationROSC return of spontaneous circulationACLS advanced cardiovascular life supportABCDE airway, breathing, circulation, disability, exposure
Codes · 5 of 6

Let the family in.

The evidence

In the trial by Jabre and colleagues (NEJM 2013), 15 prehospital EMS units in France were randomized either to offer relatives the chance to watch CPR or to follow usual practice. Among 570 relatives, PTSD-related symptoms at 90 days were more common in the usual-practice group (adjusted OR 1.7). Family presence did not change how resuscitation went, patient survival or team stress, and led to no medicolegal claims. The benefit persisted at 1 year (Jabre, Intensive Care Med 2014).

Read it fairly — this was resuscitation at home, not in the hospital. A 2023 Cochrane review rated the evidence very low certainty. The 2025 AHA Ethics chapter still calls allowing family presence the recommended approach in most situations, and notes that interference is uncommon.

How to do it well

  • Assign one person to the family. The AHA suggests a dedicated team member such as a social worker or chaplain.
  • Before they enter, tell them what they'll see and where to stand.
  • As leader, acknowledge them once, by name, and keep running the code.
  • If someone interferes with care or safety, the support person walks them out. That's not a punishment.
EMS emergency medical servicesPTSD post-traumatic stress disorderOR odds ratio
Codes · 6 of 6

Debrief every time.

Debriefing is a guideline, not a nicety

The 2025 AHA Systems of Care guidelines support performance-focused debriefing after cardiac arrest (Class 2a), reviewing objective CPR data (Class 2a), and using both immediate and delayed debriefs (Class 2a). In one hospital, internal medicine residents who debriefed weekly using defibrillator CPR data improved compression depth and ventilation rate compared with a historical cohort, and return of spontaneous circulation (ROSC) rose from 44.6% to 59.4%. Survival to discharge did not change (Edelson, 2008).

TALK: a hot debrief in under 10 minutes

TargetPick one focus. “What should we discuss to improve care?”
Analysis“This went well. How do we repeat it?” or “This was hard. How do we do it better?”
Learning“What do we take away from this?”
Key actions“What will we do, who will do it, and how will we know it's done?”

Make it safe

  • Anyone can call a TALK debrief, nurses and techs included. Invite everyone who was there.
  • Talk about systems and actions, not blame.
  • Check on people. The AHA Ethics chapter notes that CPR is among the most stressful events in health care and that clinicians are at risk of post-traumatic stress.
  • After an emotionally heavy event, set up a separate session with a trained facilitator. The TALK authors recommend this.
Opener — “Can we take five minutes? One thing that went well, one thing we'd change, and who owns the fix.”

Educational reference only — not medical advice. Verify against current AHA guidelines and local protocol.

Sources

Verify against current guidelines and local protocol before acting.

  1. Del Rios M, Bartos JA, Panchal AR, et al. Part 1: Executive Summary: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2025;152(16 Suppl 2):S284-S312. Published October 22, 2025. doi:10.1161/CIR.0000000000001372.
  2. Elmer J, Atkins DL, Daya MR, et al. Part 3: Ethics: 2025 AHA Guidelines for CPR and ECC. Circulation 2025;152(16 Suppl 2):S323-S352. doi:10.1161/CIR.0000000000001371.
  3. Dezfulian C, Cabañas JG, Buckley JR, et al. Part 4: Systems of Care: 2025 AHA Guidelines for CPR and ECC. Circulation 2025;152(16 Suppl 2):S353-S384. doi:10.1161/CIR.0000000000001378.
  4. Kleinman ME, Buick JE, Huber N, et al. Part 7: Adult Basic Life Support: 2025 AHA Guidelines for CPR and ECC. Circulation 2025;152(16 Suppl 2):S448-S478. doi:10.1161/CIR.0000000000001369.
  5. Wigginton JG, Agarwal S, Bartos JA, et al. Part 9: Adult Advanced Life Support: 2025 AHA Guidelines for CPR and ECC. Circulation 2025;152(16 Suppl 2):S538-S577. doi:10.1161/CIR.0000000000001376.
  6. Cao D, Arens AM, Chow SL, et al. Part 10: Adult and Pediatric Special Circumstances of Resuscitation: 2025 AHA Guidelines for CPR and ECC. Circulation 2025;152(16 Suppl 2):S578-S672. doi:10.1161/CIR.0000000000001380 (take-home message 9: pregnancy).
  7. Donoghue AJ, Auerbach M, Banerjee A, et al. Part 12: Resuscitation Education Science: 2025 AHA Guidelines for CPR and ECC. Circulation 2025;152(16 Suppl 2):S719-S750. doi:10.1161/CIR.0000000000001374.
  8. Jabre P, Belpomme V, Azoulay E, et al. Family presence during cardiopulmonary resuscitation. N Engl J Med 2013;368(11):1008-1018. doi:10.1056/NEJMoa1203366.
  9. Jabre P, Tazarourte K, Azoulay E, et al. Offering the opportunity for family to be present during cardiopulmonary resuscitation: 1-year assessment. Intensive Care Med 2014;40(7):981-987. doi:10.1007/s00134-014-3337-1.
  10. Afzali Rubin M, Svensson TL, Herling SF, Jabre P, Møller AM. Family presence during resuscitation. Cochrane Database Syst Rev 2023;5:CD013619. doi:10.1002/14651858.CD013619.pub2.
  11. Diaz-Navarro C, León Castelao E, Hadfield A, Pierce S, Szyld D. Clinical debriefing: TALK© to learn and improve together in healthcare environments. Trends in Anaesthesia and Critical Care 2021;40:4-8. doi:10.1016/j.tacc.2021.07.004.
  12. Edelson DP, Litzinger B, Arora V, et al. Improving in-hospital cardiac arrest process and outcomes with performance debriefing. Arch Intern Med 2008;168(10):1063-1069. doi:10.1001/archinte.168.10.1063.
  13. Drug doses and algorithms: use the current AHA ACLS algorithms and your hospital's code-cart references.