What are the steps to manage a code blue (cardiac arrest)?

How to Run a Code Blue

Immediately begin high-quality chest compressions at 100-120 per minute with a depth of 2-2.4 inches, establish clear team roles with a designated leader, and follow a systematic ACLS algorithm approach while minimizing interruptions to compressions. 1, 2

Initial Response and Team Activation

Verify scene safety before approaching the patient to avoid becoming a second victim. 2 Check for responsiveness by shouting and tapping the victim, then simultaneously assess breathing and pulse within 10 seconds—look for no breathing or only gasping while checking for a pulse. 3, 2

Activate the emergency response system immediately by calling a "code blue" to mobilize all necessary responders simultaneously, which saves time and prevents confusion. 3 In the current era of mobile devices, both the call to activate the emergency response and initiation of CPR should occur simultaneously. 3

Immediate CPR Initiation

Start chest compressions immediately without removing the patient's clothing first. 3 A lone healthcare provider should commence with chest compressions rather than ventilation to minimize time to first compression. 3

Compression Technique

• Push hard and fast: Compress at least 2 inches (5-6 cm) in adults at a rate of 100-120 compressions per minute 1, 2
• Allow complete chest recoil between compressions—incomplete recoil prevents full cardiac refilling and is a critical error 1, 2
• Minimize interruptions in chest compressions, maintaining a chest compression fraction >80% 1
• Use a 30:2 compression-to-ventilation ratio until an advanced airway is placed 3, 1

Team Role Assignment

Assign specific roles immediately to prevent too many people attending without assigned tasks, which hinders team performance: 1, 4

• Designated team leader (identifiable leadership is critical) 4
• Compressor (rotate every 2 minutes to prevent fatigue) 1
• Airway manager (respiratory therapist positioned at head of bed) 1
• Medication administrator 1
• Defibrillator operator 1
• Recorder/documentation 1

Airway Management Algorithm

Start with two-handed bag-mask ventilation using 100% oxygen at ≥15 L/min as first-line airway management, which is more effective than single-handed technique. 3, 1 For first responders with minimal airway experience, bag-mask ventilation is the most rapid noninvasive strategy. 3

Stepwise Airway Approach

Limit each technique to 2 attempts maximum to minimize compression interruptions: 3, 1

1. First intubation attempt (use 6.0-7.0 mm inner diameter endotracheal tube) 3
2. Second intubation attempt (if first fails) 3
3. First supraglottic airway attempt (if intubation fails) 3
4. Second supraglottic airway attempt (if first fails) 3
5. Return to mask ventilation (if supraglottic fails) 3
6. Cricothyrotomy (if mask ventilation inadequate) 3

Do not attempt intubation for >30 seconds as prolonged attempts interrupt compressions and decrease survival. 1

Post-Intubation Management

Once an advanced airway is placed:

• Ventilate at 8-10 breaths per minute with continuous compressions (no pauses for ventilation) 3, 1
• Immediately confirm tube placement with continuous capnography 3, 1
• Monitor end-tidal CO2 to confirm adequate tube placement and perfusion 1
• Avoid hyperventilation (>10 breaths/min), which decreases survival by reducing venous return and cardiac output 3, 1

Rhythm Analysis and Defibrillation

Charge the defibrillator during compressions to minimize hands-off time, then deliver shock immediately after a brief pause. 1 Use the AED/defibrillator as soon as it becomes available. 3, 2, 5

• Check rhythm every 2 minutes during CPR 2
• Announce rhythm checks and shock delivery clearly to the team 1
• Resume compressions immediately after shock delivery without performing a pulse check 1, 5
• Deliver one shock for shockable rhythms (ventricular fibrillation or pulseless ventricular tachycardia), then immediately resume CPR for 2 minutes 2, 5

Medication Administration

Administer epinephrine every 3-5 minutes throughout resuscitation for all cardiac arrest rhythms. 1, 2 Consider amiodarone or lidocaine for refractory ventricular fibrillation or pulseless ventricular tachycardia. 2

Critical Pitfalls to Avoid

• Never hyperventilate—this is the most common error reducing survival 1
• Never perform prolonged intubation attempts (>30 seconds) that interrupt compressions 1
• Never lean on the chest between compressions—this prevents adequate cardiac refilling 2
• Never delay CPR to obtain a detailed history or remove clothing 3, 2
• Never perform prolonged pulse checks—if uncertain after 10 seconds, start CPR 2
• Never allow too many people to attend without assigned roles, as this hinders team performance 4

Quality Metrics to Monitor

• Compression depth: 2-2.4 inches 1
• Compression rate: 100-120 per minute 1, 2
• Chest compression fraction: >80% 1
• Ventilation rate post-intubation: 8-10 breaths/min 1
• Use real-time feedback devices during training to ensure quality 1

Post-Resuscitation Care

• Continuously monitor end-tidal CO2 to confirm tube placement and adequate perfusion 1
• Assess chest rise with each ventilation 1
• Secure endotracheal tube and verify position repeatedly, as movement and secretions cause dislodgement 1
• Regularly aspirate airways using sterile technique starting immediately after intubation 1
• Monitor oxygen saturation trends, airway pressures, and tube security continuously 1

Training and Preparedness

Conduct unannounced mock code blues in actual clinical locations to identify system gaps and improve team performance. 1, 6, 7 Use CPR feedback devices during training that provide directive feedback on compression rate, depth, release, and hand position, which significantly improves objective CPR quality metrics, particularly for novice providers. 1 Training has been shown to significantly reduce arrival time, improve recovery time, increase ICU transfers, and decrease mortality. 7