documenting-resuscitation-events

# Documenting Resuscitation Events

Creates structured, time-stamped code documentation that captures every intervention, rhythm change, medication administration, and team action during cardiac arrest resuscitation per AHA/ACLS standards.

## Why This Skill Exists

Resuscitation documentation is among the most legally scrutinized records in emergency medicine. In wrongful death litigation, plaintiff attorneys dissect every timestamp, every drug dose, and every gap between interventions. Incomplete code sheets are cited in over 40% of cardiac arrest malpractice cases as evidence of substandard care—even when the clinical care itself was appropriate. Beyond legal risk, accurate code documentation drives quality improvement: Utstein-style data collection enables meaningful survival-to-discharge analysis and CPR quality benchmarking.

AHA 2020 guidelines emphasize that high-quality CPR metrics (compression rate 100-120/min, depth 5-6 cm, full recoil, minimal interruptions) should be documented in real time. Facilities that rigorously track these metrics show 15-25% improvement in ROSC rates over two years.

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## Checkpoint A: Pre-Draft Intake (Mandatory)

Before constructing the resuscitation record, confirm:

1. What was the exact time the code was called (or arrest discovered)?
2. Was the arrest witnessed or unwitnessed? If witnessed, by whom?
3. What was the initial rhythm on the monitor (VF, pVT, PEA, asystole)?
4. Were there any advance directives, POLST, or DNR orders in the chart?
5. What was the patient's pre-arrest status (alert, intubated, on vasopressors, post-operative)?
6. Who was designated as the code team leader?
7. Was the event in-hospital or was the patient brought in during active CPR (OHCA)?
8. For out-of-hospital cardiac arrest: What was the EMS-reported downtime, bystander CPR status, and number of pre-hospital shocks delivered?

### Documents to Request

- Pre-arrest medical record and medication administration record
- Advance directive or POLST form if available
- EMS run sheet (for out-of-hospital arrests)
- Defibrillator download data (biphasic waveform, shock energy, CPR metrics)
- Code sheet or code narrator log
- Nursing flow sheet from the code period
- Pharmacy verification of medications drawn and administered
- Post-ROSC or termination-of-efforts order
- Family notification documentation

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## Step 1: Pre-Arrest Baseline Documentation

Record the patient's status immediately before the arrest:

| Element | Required Data |
|---|---|
| Location | Unit, room number, in-transport, procedural area |
| Pre-arrest rhythm | Normal sinus, atrial fibrillation, monitored/unmonitored |
| Pre-arrest vitals | Last recorded BP, HR, RR, SpO2, temperature |
| Pre-arrest mental status | GCS score or alert/verbal/pain/unresponsive |
| Active medications | Vasopressors, antiarrhythmics, sedation infusions |
| IV access | Existing lines, gauge, location |
| Airway status | Room air, nasal cannula, BiPAP, intubated |
| Code status | Full code, DNR-A, DNR-B, comfort measures |

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## Step 2: Arrest Recognition and Initial Response Timeline

Document with times accurate to the minute:

1. **Time zero (T+0)**: Arrest recognized—who discovered, how (witnessed collapse, monitor alarm, routine check)
2. **T+0 to T+1 min**: CPR initiated—by whom, on what surface (backboard placed?)
3. **T+1 to T+2 min**: Code called—overhead page, code button, rapid response escalation
4. **T+2 min**: Defibrillator/monitor attached—initial rhythm identified and documented
5. **First shock** (if VF/pVT): Time, energy level (biphasic 120-200J per device), response

For each CPR cycle (2-minute intervals), document:
- Compressor identity and rotation times
- Any pauses >10 seconds with reason (rhythm check, intubation attempt, pulse check)
- End-tidal CO2 reading if capnography in use (target >10 mmHg for effective CPR; >40 mmHg may indicate ROSC)

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## Step 3: Medication Administration Log

Record every medication with six-rights verification:

| Medication | Standard Dose | Route | Timing per ACLS |
|---|---|---|---|
| Epinephrine | 1 mg (1:10,000) | IV/IO | Every 3-5 minutes |
| Amiodarone | 300 mg first dose, 150 mg second | IV/IO | After 3rd shock for refractory VF/pVT |
| Lidocaine | 1-1.5 mg/kg first, 0.5-0.75 mg/kg subsequent | IV/IO | Alternative to amiodarone |
| Sodium bicarbonate | 1 mEq/kg | IV/IO | For known hyperkalemia or TCA overdose |
| Calcium chloride | 1-2 g (10% solution) | IV central preferred | For hyperkalemia, calcium channel blocker OD |
| Magnesium sulfate | 1-2 g | IV/IO | For torsades de pointes |
| Lipid emulsion 20% | 1.5 mL/kg bolus | IV | For local anesthetic systemic toxicity |

For each dose: exact time given, who drew and who administered, route (peripheral IV, IO, central line), and any complications (extravasation, line malfunction).

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## Step 4: Rhythm Analysis and Defibrillation Record

Document each rhythm check at 2-minute intervals:

1. Time of rhythm check
2. Rhythm identified (VF, pVT, PEA, asystole, organized rhythm with pulse)
3. Action taken (shock delivered, resume CPR, pulse check)
4. If shock: energy delivered, device manufacturer/model, pad placement (anterolateral vs. anteroposterior)
5. Post-shock rhythm at next check
6. Total number of shocks delivered

**Key documentation for quality**: Note if defibrillator data download was performed post-event—this provides objective CPR quality metrics (compression rate, depth, fraction) that supplement the written record.

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## Step 5: Airway Management Documentation

| Airway Action | Time | Provider | Method | Confirmation |
|---|---|---|---|---|
| BVM ventilation initiated | | | OPA/NPA size, 2-hand technique | Chest rise observed |
| Supraglottic airway placed | | | Device type and size (iGel, King LT) | ETCO2 waveform confirmed |
| Endotracheal intubation | | | Blade type/size, tube size, depth at teeth | ETCO2 waveform + bilateral breath sounds |
| Surgical airway | | | Cricothyrotomy vs. tracheostomy | ETCO2 confirmed |

Document number of attempts per provider (ACLS recommends limiting laryngoscopy to <10 seconds to minimize CPR interruption). Record any use of video laryngoscopy versus direct.

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## Step 6: ROSC or Termination Documentation

**If ROSC achieved:**
1. Time of ROSC (first sustained organized rhythm with palpable pulse >30 seconds)
2. Post-ROSC vitals: BP, HR, rhythm, SpO2, ETCO2
3. Post-ROSC interventions: targeted temperature management (TTM) at 32-36 degrees C, vasopressor titration, 12-lead ECG for STEMI evaluation, arterial blood gas
4. Post-ROSC neurologic status: GCS, pupillary response, presence of spontaneous movement
5. Disposition: ICU admission, cardiac catheterization lab, continued ED management

**If efforts terminated:**
1. Time of death pronounced
2. Total resuscitation duration
3. Physician who made the termination decision
4. Clinical rationale (e.g., refractory asystole >20 minutes, no ETCO2 >10 despite quality CPR, known terminal condition)
5. Family notification: by whom, time, persons present
6. Medical examiner notification if required by jurisdiction
7. Organ/tissue donation referral per protocol

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## Checkpoint B: Post-Draft Alignment (Mandatory)

Before finalizing the resuscitation record, verify:

1. Are all timestamps internally consistent (no interventions documented before the code was called)?
2. Does the medication log show ACLS-compliant dosing intervals (epinephrine every 3-5 min)?
3. Is CPR quality documented (compression rate, depth if monitor data available, interruptions)?
4. Does the record identify the code team leader and each team member's role?
5. Is the outcome clearly documented (ROSC with disposition or death with time and notification)?

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## Quality Audit

| # | Criterion | Pass/Fail |
|---|---|---|
| 1 | Exact time of arrest recognition documented | |
| 2 | Initial rhythm clearly identified and recorded | |
| 3 | CPR start time within 1 minute of recognition for in-hospital | |
| 4 | First defibrillation within 3 minutes for shockable rhythms | |
| 5 | Epinephrine timing documented with 3-5 minute intervals | |
| 6 | All medications include dose, route, time, and administrator | |
| 7 | Rhythm documented at each 2-minute CPR cycle | |
| 8 | Airway management attempts numbered with times and providers | |
| 9 | H's and T's (reversible causes) evaluated and documented | |
| 10 | ETCO2 values recorded if capnography used | |
| 11 | Post-ROSC 12-lead ECG obtained within 15 minutes | |
| 12 | Post-ROSC TTM consideration documented | |
| 13 | Family notification time and method recorded | |
| 14 | Defibrillator download requested/obtained | |

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## Guidelines

1. **Use Utstein-style reporting** elements for all cardiac arrest documentation to enable benchmarking and registry participation (CARES, Get With The Guidelines)
2. **Designate a code recorder** at the start of every resuscitation—this person does not perform clinical tasks but captures real-time data
3. **Document H's and T's assessment**: Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo/Hyperkalemia, Hypothermia, Tension pneumothorax, Tamponade, Toxins, Thrombosis (pulmonary), Thrombosis (coronary)
4. **CPR fraction target >80%**: Document any interruption >10 seconds with explicit reason
5. **Do not alter timestamps retroactively**—if a time is uncertain, record as approximate with a notation
6. **Pediatric arrests** require weight-based dosing documentation: use Broselow tape color or actual weight, document which reference was used
7. **For medical-legal protection**, the code sheet is a contemporaneous medical record—ensure it matches the defibrillator data download and nursing notes exactly
8. **Post-event debriefing** should be documented separately, noting any system issues (equipment failures, delayed response) for quality improvement without creating discoverable self-critical analysis