What are the immediate steps to take in the event of a code blue (cardiac arrest)?

Code Blue: Immediate Management of Cardiac Arrest

Begin high-quality chest compressions immediately at 100-120 compressions per minute with a depth of at least 2 inches (5-6 cm) in adults, while simultaneously activating the emergency response system and retrieving an automated external defibrillator (AED). 1, 2

Immediate Recognition and Scene Safety

• Verify scene safety before approaching to avoid becoming a second victim 1
• Any collapsed, unresponsive person should be treated as cardiac arrest until proven otherwise—do not waste time trying to differentiate from seizures, syncope, or other conditions 3, 1
• Check responsiveness by shouting and tapping the victim 1
• Simultaneously assess breathing and pulse within 10 seconds maximum—look for absent or only gasping respirations while palpating for a pulse 1, 2
• If uncertain about pulse presence after 10 seconds, immediately start CPR rather than continuing to check 1

Critical Pitfall to Avoid

Agonal gasping occurs in over 50% of cardiac arrests and is commonly mistaken for normal breathing—any gasping or irregular breathing pattern in an unresponsive person indicates cardiac arrest 3, 1

High-Quality CPR Technique

Chest compressions are the single most critical intervention and must never be delayed or interrupted unnecessarily. 1, 2

Compression Parameters

• Rate: 100-120 compressions per minute (not faster, not slower) 1, 2
• Depth: At least 2 inches (5-6 cm) in adults—inadequate depth is a common fatal error 1, 2
• Allow complete chest recoil between compressions—leaning on the chest prevents cardiac refilling and dramatically reduces effectiveness 1, 2
• Minimize all interruptions—every pause in compressions decreases survival 1, 2
• Change compressors every 2 minutes (or sooner if fatigued) to maintain quality 2

Ventilation Strategy

• Use 30:2 compression-to-ventilation ratio (30 compressions, then 2 breaths) if no advanced airway is in place 1, 2
• Each breath should take 1 second and produce visible chest rise 3
• For untrained bystanders, compression-only CPR is acceptable and preferred over no CPR 3, 1
• Once an advanced airway is placed, provide continuous compressions without pauses and give 1 breath every 6 seconds (10 breaths/minute) asynchronously 2

Early Defibrillation

Time to defibrillation is the single greatest determinant of survival—survival decreases 10% per minute without defibrillation (or 3-4% per minute with CPR). 3

AED Application

• Apply the AED immediately when it arrives—do not delay CPR to retrieve it, but apply it the instant it becomes available 1, 2
• Pause compressions briefly (less than 10 seconds) to analyze rhythm 2
• For shockable rhythms (VF/pulseless VT): deliver one shock immediately (biphasic 120-200J or monophasic 360J) 2
• Resume CPR immediately after shock delivery without pausing to recheck pulse—continue for 2 minutes before next rhythm check 1, 2
• For non-shockable rhythms (PEA/asystole): continue CPR and reassess rhythm every 2 minutes 2

Medication Administration

Vascular Access

• Establish IV or intraosseous (IO) access while CPR is ongoing—do not interrupt compressions 2

Epinephrine Protocol

• Administer epinephrine 1 mg IV/IO every 3-5 minutes for all cardiac arrest rhythms (shockable and non-shockable) 2

Antiarrhythmic Therapy

• For persistent or recurrent VF/pulseless VT after initial shock: administer amiodarone 300 mg IV/IO or lidocaine 1-1.5 mg/kg IV/IO 2

Advanced Airway Management

• Consider endotracheal intubation or supraglottic airway placement, but never interrupt chest compressions for more than 10 seconds during placement attempts 2
• Confirm placement with continuous waveform capnography—this is mandatory, not optional 2
• Monitor capnography values: ETCO2 <10 mmHg indicates inadequate CPR quality and predicts poor outcomes 2

Reversible Causes: The H's and T's

Systematically consider and treat reversible causes while CPR continues: 2

The H's

• Hypovolemia: administer IV fluids
• Hypoxia: ensure adequate oxygenation and ventilation
• Hydrogen ion (acidosis): consider sodium bicarbonate if prolonged arrest
• Hypo/hyperkalemia: check point-of-care potassium, treat accordingly
• Hypothermia: rewarm if suspected

The T's

• Tension pneumothorax: needle decompression if suspected
• Tamponade (cardiac): bedside ultrasound, pericardiocentesis if confirmed
• Toxins: consider naloxone for suspected opioid overdose 1
• Thrombosis (pulmonary): consider thrombolytics if high suspicion
• Thrombosis (coronary): prepare for emergent cardiac catheterization

Special Population Considerations

Pediatric Modifications

• Compression-to-ventilation ratio: 30:2 for single rescuer, 15:2 for two or more rescuers 1
• Compression depth: at least one-third of anterior-posterior chest diameter 1

Pregnancy (≥20 weeks gestation)

• Provide manual left uterine displacement to relieve aortic compression 3
• Prepare for perimortem cesarean delivery if no ROSC within 4 minutes of resuscitation efforts 3
• Use 100% oxygen at ≥15 L/min—maternal oxygen reserves are critically reduced in pregnancy 3

Drowning Victims

• Modify the sequence to A-B-C (airway-breathing-compressions) rather than C-A-B because drowning is a hypoxic arrest 3
• Provide 5 cycles (approximately 2 minutes) of CPR before leaving to activate EMS if alone 3
• Do not attempt abdominal thrusts or Heimlich maneuver—water is rapidly absorbed and these maneuvers cause harm and delay 3

Hypothermia

• Continue resuscitation efforts until the patient is evaluated by advanced care providers—"no one is dead until they are warm and dead" 3
• Do not delay CPR to check temperature or wait for rewarming 3

Team Dynamics and Code Blue Activation

• Activate the code blue team immediately—use a single "bundled" emergency call (e.g., "Code Blue, Room 302") to alert all necessary responders simultaneously 3
• Assign specific roles: compressor, airway manager, medication administrator, recorder, team leader 2
• Use closed-loop communication to confirm all orders 2
• Consider assigning a "cognitive aid reader" to read resuscitation algorithms aloud—this has been shown to improve completion of critical steps during rare events 4

Monitoring Return of Spontaneous Circulation (ROSC)

• Check for ROSC every 2 minutes during rhythm checks 2
• Signs of ROSC: palpable pulse, sudden increase in ETCO2 (typically >40 mmHg), spontaneous arterial pressure waveform 2
• Once ROSC is achieved, initiate post-cardiac arrest care including targeted temperature management for patients who remain comatose 2

Critical Errors That Kill Patients

• Inadequate compression depth or rate—compressions must be hard and fast 1
• Excessive ventilation—hyperventilation decreases survival by increasing intrathoracic pressure and reducing venous return 3
• Prolonged pulse checks—if uncertain after 10 seconds, start CPR 1
• Leaning on the chest between compressions—prevents adequate cardiac refilling 1
• Excessive interruptions in compressions—every pause decreases coronary perfusion pressure and survival 1, 2
• Delayed defibrillation—survival decreases 10% per minute without shock delivery 3