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 upon recognizing cardiac arrest—any unresponsive patient with no breathing or only gasping and no definite pulse within 10 seconds should receive CPR without delay. 1, 2

Immediate Recognition and Response

Verify scene safety first, then rapidly assess responsiveness by shouting and tapping the victim. 1 The most critical error is delayed recognition—any collapsed, unresponsive patient should be managed as cardiac arrest until proven otherwise. 3

Simultaneous Assessment (≤10 seconds):

• Check for breathing AND pulse simultaneously—do not perform sequential checks. 1, 2
• Look for absent breathing or only agonal gasping (present in >50% of cardiac arrests and often mistaken for normal breathing). 3
• If uncertain about pulse presence after 10 seconds, immediately start CPR. 1

Activate the emergency response system immediately and retrieve an AED/defibrillator. 1 If multiple rescuers are present, send someone for the AED while you begin compressions. 1

High-Quality CPR Technique

Deliver chest compressions at 100-120 per minute with depth of 5-6 cm (at least 2 inches) in adults. 1, 2

Critical Technical Points:

• Allow complete chest recoil between compressions—do not lean on the chest. 1, 2 Incomplete recoil prevents cardiac refilling and is a common fatal error. 1
• Minimize interruptions in compressions—continuous compressions are essential for survival. 1, 2
• Use 30:2 compression-to-ventilation ratio if no advanced airway is present. 1, 2
• Change compressors every 2 minutes to prevent fatigue and maintain quality. 2

For untrained bystanders, compression-only CPR is acceptable and should be encouraged over no CPR. 1

Early Defibrillation

Apply the AED immediately when available—do not delay CPR to retrieve it, but apply it the moment it arrives. 1, 2 Time to defibrillation is the single greatest factor affecting survival, with survival decreasing 10% per minute without CPR (3-4% with CPR). 3

Defibrillation Protocol:

• Pause briefly after 2 minutes of CPR to check rhythm. 2
• For shockable rhythms (VF/pVT): deliver one shock (120-200J biphasic or 360J monophasic) and immediately resume CPR for 2 minutes. 2
• For non-shockable rhythms (PEA/asystole): continue CPR without shock and reassess every 2 minutes. 2

Medication Administration

Establish IV/IO access during ongoing CPR—do not stop compressions to obtain access. 2

Medication Timing:

• Administer epinephrine 1 mg IV/IO every 3-5 minutes for all cardiac arrest rhythms. 1, 2
• For persistent/recurrent VF/pVT after initial shock: give amiodarone 300 mg IV/IO or lidocaine 1-1.5 mg/kg IV/IO. 2

Advanced Airway Management

Consider advanced airway (endotracheal tube or supraglottic airway) placement during ongoing CPR, but do not interrupt compressions for prolonged intubation attempts. 2 For initial management, bag-mask ventilation with 100% oxygen is rapid and effective. 3

Post-Airway Placement:

• Confirm placement with waveform capnography. 2
• Once advanced airway is secured: provide continuous compressions without pauses, delivering 1 breath every 6 seconds (10 breaths/min) asynchronously. 2
• Monitor CPR quality using quantitative waveform capnography if available. 2

Reversible Causes (H's and T's)

Systematically consider and treat reversible causes during resuscitation: 2

• Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo/hyperkalemia, Hypothermia
• Tension pneumothorax, Tamponade (cardiac), Toxins, Thrombosis (pulmonary), Thrombosis (coronary)

Special Population Considerations

Pediatric Patients:

• Use 30:2 compression ratio for single rescuer, 15:2 for two or more rescuers. 1
• Compress at least one-third of anterior-posterior chest diameter. 1

Suspected Opioid Overdose:

• Administer naloxone if available while continuing CPR. 1

Pregnancy:

• Provide manual left uterine displacement during CPR. 3
• Prepare for perimortem cesarean delivery if no ROSC by 4 minutes. 3

Critical Pitfalls to Avoid

• Do not delay CPR to obtain detailed history—immediate compressions are the priority. 1
• Do not perform prolonged pulse checks—if uncertain after 10 seconds, start CPR. 1
• Do not provide inadequate compression depth (<5 cm) or rate (<100/min)—compressions must be hard and fast. 1
• Do not mistake agonal gasping for normal breathing—this is a sign of cardiac arrest. 3
• Do not mistake seizure-like activity for a primary seizure—brief myoclonic movements occur in >50% of cardiac arrests. 3

Post-Resuscitation Care

Upon return of spontaneous circulation (ROSC), immediately begin post-cardiac arrest care including targeted temperature management for patients who do not follow commands. 2 Overall survival from in-hospital cardiac arrest is approximately 26%, with cardiac arrest-specific survival of 11%. 4 Among young adults with out-of-hospital cardiac arrest, only 9-16% survive to hospital discharge, though approximately 90% of survivors have good neurological outcomes. 5