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CODE BLUE
PROCEDURES
Luis Enriquez RN, BS.
Los Angeles County USC Medical Center
Department of Emergency Medicine
CODE BLUE TEAM
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Trained patient care providers who perform
resuscitation on any person who sustains
 Cardiopulmonary
arrest
 Respiratory arrest
 Airway problem

Train providers:
 Doctor
 Nurse
 Support
Personnel
CODE BLUE ACTIVATION

All employees must be educated to activate
Code Blue response in the event of
 Cardiac
arrest
 Respiratory arrest

Activate Code Blue Response by
 Calling
Hospital Emergency Operator
 Provide Information: Patient location, Adult/Pediatric

Hospital Emergency Operator will activate
response when notified of Code Blue event
 Code
blue pager system
 Announce overhead the location of the code event
CODE BLUE MEMBERS
Physician: Emergency Department
 Pediatric attending or senior resident
 Physician: Internal Medicine
 Physician: general Surgery
 Intensive Care Unit/Emergency Nurse
 Respiratory Therapist
 EKG (Electrocardiogram) Technician
Los Angeles County + USC
 Nursing Supervisor
Medical Center

Code Blue Protocol
ROLE OF THE TEAM MEMBERS
EMERGENCY PHYSICIAN
Team Leader: direct overall patient care
 Manage the Code

 Medication
 Defibrillation
 Other

procedures: Intubation, compressions
Evaluate Code Blue procedures
 Effectiveness
of Chest Compression
 Effectiveness of assisted respirations
 Rhythm/pulse check

Document in the medical record
ROLE OF THE TEAM MEMBERS
EMERGENCY NURSE
Maintains airway/oxygenation/ventilation
 Applies monitor leads/defibrillator pads
 Starts Intravenous access
 Administer medications
 Administers Electrical Shock (ACLS trained)
 Assist with intubation procedures
 Completes CPR record
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ROLE OF THE TEAM MEMBERS
PRIMARY NURSE
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Activate code blue team
Bring Emergency Resuscitation Cart
Place backboard under patient
Initiate 2 man Cardio Pulmonary Resuscitation
Administer ventilations with 100% O2 with Bag/valve/mask
Attach Electro cardiogram leads
Attach “hands off” defibrillator pads
Ensure patient Intra Venous access
Prepare suction
Obtain supplies from CPR Cart/Ward Stock
Record events on CPR record
CODE BLUE
NURSING SKILLS
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Identify respiratory/cardiac arrest
Activate Code Blue
Oxygen administration: Nasal cannula, mask
Bag-Valve-Mask resuscitation with 100% O2
Cardiac Monitor/defibrillator pads Application
Intra Venous access
Medication Administration
Defibrillation (ACLS trained)
CPR documentation
ROLE OF THE TEAM MEMBERS
SUPPORT PERSONNEL

Respiratory Therapist
 Maintains
airway and oxygenation/ventilation
 Assist with intubation procedures
EKG Technician: Performs 12-lead EKG
 Pharmacist: Prepares medications

BASIC LIFE SUPPORT
SURVEY
1- Establish Unresponsiveness
2- Activate Emergency Response System
3- Circulation
4- Defibrillation
Simplified adult BLS algorithm.
Berg R A et al. Circulation 2010;122:S685-S705
Copyright © American Heart Association
ESTABLISH
UNRESPONSIVENESS
 Tap
and Shout “are you all right”
 Check for absent/abnormal breathing
by scanning the chest for movement
ACTIVATE THE EMERGENCY
RESPONSE SYSTEM

Call for help or send someone for help
 Yell
for help
 Code Blue protocol

Get the Automatic External Defibrillator
CIRCULATION
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Check corotid pulse for 5-10 seconds
If no pulse Begin Cardio Pulmonary Resuscitation
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Compress center of chest (lower ½ of sternum)
Ratio: 30:2 compressions to breaths
Depth: at least 2 inches
Rate: at least 100 compressions per minute
Allow complete chest recoil
Minimize interruptions
Switch providers every 2 minutes
Avoid excessive ventilation
If pulse present start rescue breathing

1breath every 5-6 seconds (10-12 breaths per min.)
 Check pulse every 2 minutes
DEFIBRILLATION
 If
no pulse check for shockable
rhythm as soon as AED arrives
 Provide shocks as indicated
 Follow each shock immediately with
CPR compressions
Advance Cardiac
Life Support Survey
 Airway
 Breathing
 Circulation
 Differential
Diagnosis
AIRWAY

Maintain patent airway in unconscious Pt’s
 Head
tilt chin lift
 Simple airway adjuncts:

Use advance airway if needed:
 Confirm
proper placement
Physical exam
 Quantitative waveform Capnography
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 Secure
Device to prevent dislodgement
 Monitor airway placement with continuous
quantitative waveform Capnography
BREATHING
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Supplemental O2 when indicated
O2 to oxygen sat ≥ 94% non arrest Pt’s
 100% O2 for Pt’s in cardiac arrest
 Titrate
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Monitor adequacy of ventilation and
oxygenation
 Clinical
criteria: chest rise and cyanosis
 Quantitative waveform capnography
 Oxygen saturation

Avoid excessive ventilation
CIRCULATION
Monitor CPR quality
 Attach monitor/Defibrillator
 Monitor for arrhythmias or arrest rhythms
 Provide defibrillation/Cardioversion
 Obtain IV/IO access
 Give appropriate drugs
 Give fluids if needed
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DIFFERENTIAL DIAGNOSIS
search for and treat reversible causes
H’s
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AND
Hypoxia
Hypovolemia
Hydrogen ion (acidosis)
Hypo/hyper kalemia
Hypothermia
T’s
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Tension pneumothorax
Tamponade cardiac
Toxins
Thrombosis Pulmonary
Thrombosis Coronary
ACLS
Cardiac
Arrest
Algorithm
.
Copyright © American Heart Association
ACLS Cardiac Arrest Circular Algorithm.
Neumar R W et al. Circulation 2010;122:S729-S767
Copyright © American Heart Association
Bradycardia Algorithm.
Neumar R W et al. Circulation 2010;122:S729-S767
Copyright © American Heart Association
Tachycardia Algorithm.
Neumar R W et al. Circulation 2010;122:S729-S767
Copyright © American Heart Association
NSR with Ectopy > VT>VF>NSR
• A 48 year old iron worker is brought to the
Emergency Department by co-workers following an
onset of sudden sever “pressure-type” chest pain
radiating to his neck, jaw and left arm.
• He is pale slightly diaphoretic, and very anxious.
Wide-complex tachycardia >VF>NSR
• A 63-Year-old woman alcoholic with a history of
CHF is brought to the hospital by her daughters
becouse of worsening symptoms of dyspnea, cough
and wheezing.
• She looks moderately ill but denies chest pain.