Code blue procedures are described, including activating the code blue team for cardiac or respiratory arrest, the roles of physicians, nurses, and other staff who perform resuscitation, and guidelines for basic life support activities like establishing unresponsiveness, calling for help, providing chest compressions

1. CODE BLUE
PROCEDURES
Luis Enriquez RN, BS.
Los Angeles County USC Medical Center
Department of Emergency Medicine

2. CODE BLUE TEAM
 Trained patient care providers who perform
resuscitation on any person who sustains
Cardiopulmonary arrest
Respiratory arrest
Airway problem
 Train providers:
Doctor
Nurse
Support Personnel

3. 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

4. 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
 Nursing Supervisor Los Angeles County + USC
Medical Center
Code Blue Protocol

5. 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

6. 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

7. ROLE OF THE TEAM MEMBERS
PRIMARY NURSE
 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

8. CODE BLUE
NURSING SKILLS
 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

9. 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

10. BASIC LIFE SUPPORT
SURVEY
1- Establish Unresponsiveness
2- Activate Emergency Response System
3- Circulation
4- Defibrillation

11. Simplified adult BLS algorithm.
Berg R A et al. Circulation 2010;122:S685-S705
Copyright © American Heart Association

12. ESTABLISH
UNRESPONSIVENESS
 Tap and Shout “are you all right”
 Check for absent/abnormal breathing
by scanning the chest for movement

13. ACTIVATE THE EMERGENCY
RESPONSE SYSTEM
 Call for help or send someone for help
Yell for help
Code Blue protocol
 Get the Automatic External Defibrillator

14. CIRCULATION
 Check corotid pulse for 5-10 seconds
 If no pulse Begin Cardio Pulmonary Resuscitation
 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

15. DEFIBRILLATION
 If no pulse check for shockable
rhythm as soon as AED arrives
 Provide shocks as indicated
 Follow each shock immediately with
CPR compressions

16. Advance Cardiac
Life Support Survey
 Airway
 Breathing
 Circulation
 Differential Diagnosis

17. 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
Secure Device to prevent dislodgement
Monitor airway placement with continuous
quantitative waveform Capnography

18. BREATHING
 Supplemental O2 when indicated
Titrate O2 to oxygen sat ≥ 94% non arrest Pt’s
100% O2 for Pt’s in cardiac arrest
 Monitor adequacy of ventilation and
oxygenation
Clinical criteria: chest rise and cyanosis
Quantitative waveform capnography
Oxygen saturation
 Avoid excessive ventilation

19. 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

20. DIFFERENTIAL DIAGNOSIS
search for and treat reversible causes
H’s AND
 Hypoxia
 Hypovolemia
 Hydrogen ion (acidosis)
 Hypo/hyper kalemia
 Hypothermia
T’s
 Tension pneumothorax
 Tamponade cardiac
 Toxins
 Thrombosis Pulmonary
 Thrombosis Coronary

21. ACLS
Cardiac
Arrest
Algorithm.
Copyright © American Heart Association

22. ACLS Cardiac Arrest Circular Algorithm.
Neumar R W et al. Circulation 2010;122:S729-S767
Copyright © American Heart Association

23. Bradycardia Algorithm.
Neumar R W et al. Circulation 2010;122:S729-S767
Copyright © American Heart Association

24. Tachycardia Algorithm.
Neumar R W et al. Circulation 2010;122:S729-S767
Copyright © American Heart Association

25. 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.