What are the medications and administration rates used in a code blue situation?

Code Blue Medications and Administration Rates

Administer epinephrine 1 mg IV/IO every 3-5 minutes during cardiac arrest, starting after the first defibrillation attempt for shockable rhythms or immediately for non-shockable rhythms, and consider amiodarone 300 mg IV/IO bolus for refractory ventricular fibrillation/pulseless ventricular tachycardia after the third shock. 1

Primary Medications During Cardiac Arrest

Epinephrine (First-Line Vasopressor)

Adult Dosing:

• Standard dose: 1 mg IV/IO every 3-5 minutes throughout the resuscitation 1, 2
• Concentration: 1:10,000 dilution (0.1 mg/mL) for IV/IO administration 1
• Timing for shockable rhythms (VF/pVT): After the first or second failed defibrillation attempt 1, 2
• Timing for non-shockable rhythms (PEA/asystole): As soon as IV/IO access is established 1, 2
• Endotracheal route (if no IV/IO access): 2-2.5 mg diluted in 10 mL normal saline 1

Pediatric Dosing:

• Standard dose: 0.01 mg/kg (0.1 mL/kg of 1:10,000 concentration) IV/IO every 3-5 minutes 1
• Maximum single dose: 1 mg 1
• Endotracheal dose: 0.1 mg/kg (0.1 mL/kg of 1:1,000 concentration) 1

Critical Points:

• Epinephrine increases return of spontaneous circulation (ROSC) through alpha-adrenergic vasoconstriction, improving coronary and cerebral perfusion pressure 2, 3
• Earlier administration is associated with higher ROSC rates, particularly in non-shockable rhythms 2
• Important caveat: While epinephrine improves short-term survival, it does not improve long-term neurologically favorable outcomes 2, 3
• High-dose epinephrine (>1 mg) provides no additional benefit and is not recommended 2

Amiodarone (Antiarrhythmic for Refractory VF/pVT)

Adult Dosing:

• First dose: 300 mg IV/IO rapid bolus 1, 2, 4
• Second dose: 150 mg IV/IO bolus if VF/pVT persists 1, 2
• Administration: Can be given as rapid bolus during cardiac arrest 1, 4
• Timing: After the third failed defibrillation attempt 1, 2

Pediatric Dosing:

• Dose: 5 mg/kg IV/IO bolus 1
• Maximum: May repeat up to 3 total doses for refractory VF/pulseless VT 1

Critical Points:

• Amiodarone improves ROSC and hospital admission rates but does not improve long-term survival or neurological outcomes 2
• Should only be used after defibrillation and epinephrine have been initiated 1, 2
• Contraindicated in severe sinus node dysfunction, marked sinus bradycardia, and second/third-degree AV block without a pacemaker 1, 4
• May cause hypotension, bradycardia, and QT prolongation 1, 4

Lidocaine (Alternative Antiarrhythmic)

Adult Dosing:

• First dose: 1-1.5 mg/kg IV/IO 1, 2
• Second dose: 0.5-0.75 mg/kg IV/IO 1
• Use: Alternative to amiodarone for refractory VF/pVT 1, 2

Pediatric Dosing:

• Initial loading dose: 1 mg/kg IV/IO 1
• Maintenance infusion: 20-50 mcg/kg/min 1

Defibrillation Energy Levels

Adult:

• Biphasic (preferred): 120-200 J for initial shock; use manufacturer recommendation or maximum available if unknown 1, 5
• Monophasic: 360 J for all shocks 1, 5
• Subsequent shocks: Use at least the same energy, consider escalating 1, 5

Pediatric:

• Initial dose: 2 J/kg 1
• Subsequent doses: 4 J/kg, may increase to maximum of 10 J/kg or adult dose 1

Critical timing: Minimize interval between stopping compressions and delivering shock; resume CPR immediately after shock without pulse check 1, 5

Secondary Medications (Specific Situations)

Atropine (Bradycardia/Asystole)

Adult:

• Dose: 1 mg IV/IO every 3-5 minutes 1
• Use: May be considered for asystole or pulseless electrical activity, though no longer emphasized in current guidelines 1

Pediatric:

• Dose: 0.02 mg/kg IV/IO 1
• Minimum single dose: 0.1 mg 1
• Maximum single dose: 0.5 mg (child), 1.0 mg (adolescent) 1
• May repeat every 5 minutes to maximum total of 1 mg (child) or 2 mg (adolescent) 1

Sodium Bicarbonate

Indications (limited):

• Prolonged cardiac arrest 1
• Known pre-existing hyperkalemia 1
• Tricyclic antidepressant overdose 1

Dosing:

• Adult: 1 mEq/kg IV/IO 1
• Pediatric: 1 mEq/kg IV/IO 1

Calcium Chloride

Indications (specific):

• Documented or suspected hypocalcemia 1
• Hyperkalemia 1
• Calcium channel blocker overdose 1

Dosing:

• Adult: 500-1000 mg (5-10 mL of 10% solution) IV/IO 1
• Pediatric: 20 mg/kg (0.2 mL/kg of 10% solution) IV/IO 1

Special Situation: Anaphylaxis-Induced Cardiac Arrest

High-dose epinephrine protocol:

• Initial: 1-3 mg (1:10,000 dilution) IV slowly over 3 minutes 1
• Second dose: 3-5 mg IV over 3 minutes 1
• Infusion: 4-10 mg/min continuous infusion 1
• Pediatric resuscitation: 0.01 mg/kg (0.1 mL/kg of 1:10,000) repeated every 3-5 minutes; higher doses (0.1-0.2 mg/kg of 1:1,000) may be considered for unresponsive asystole 1

Additional considerations:

• Prolonged resuscitation efforts are more likely to be successful in anaphylaxis 1
• Consider glucagon 1-5 mg IV over 5 minutes if patient is on beta-blockers 1

Critical Procedural Points

Route of Administration Priority

1. IV access preferred but IO access is equally acceptable 1, 2
2. Never delay CPR or defibrillation to establish vascular access 2
3. Endotracheal administration is least preferred and requires 2-2.5 times the IV dose 1

CPR Quality During Medication Administration

• Compression depth: At least 2 inches (5 cm) in adults; at least one-third anteroposterior diameter in children 1
• Compression rate: 100-120/min 1
• Minimize interruptions: Medication administration should not interrupt compressions 1, 2
• Change compressors every 2 minutes or sooner if fatigued 1

Ventilation After Advanced Airway

• Rate: 1 breath every 6 seconds (10 breaths/min) with continuous compressions 1
• Pediatric: 1 breath every 2-3 seconds (20-30 breaths/min) with continuous compressions 1

Common Pitfalls to Avoid

1. Do not delay defibrillation to administer medications in shockable rhythms 1, 5, 2
2. Do not check pulse immediately after shock—resume compressions first 1, 5
3. Do not use high-dose epinephrine (>1 mg in adults)—no benefit demonstrated 2
4. Do not give stacked shocks without intervening CPR 5
5. Do not use vasopressin—offers no advantage over epinephrine 2
6. Do not combine amiodarone with procainamide or other QT-prolonging drugs without expert consultation 1
7. Do not confuse amiodarone with amrinone—potentially fatal if interchanged 1