What is the recommended algorithm for managing an adult code blue (cardiac arrest)?

Adult Code Blue Management Algorithm

Immediately begin high-quality chest compressions at 100-120/min with a depth of at least 2 inches (5 cm) as soon as cardiac arrest is recognized—this is the single most critical intervention for survival. 1

Initial Recognition and Activation

• Check responsiveness while simultaneously assessing breathing and pulse within 10 seconds maximum. 1
• Look for absent or only gasping respirations—agonal gasps are common and should NOT be mistaken for normal breathing. 1
• If pulse is not definitively palpated within 10 seconds, immediately start CPR, as pulse checks are unreliable even among trained providers. 1
• Activate the code blue team and obtain a defibrillator immediately. 2

High-Quality CPR Fundamentals

CPR quality is the foundation of all cardiac arrest management and must be optimized throughout the resuscitation. 2

• Push hard (at least 2 inches/5 cm) and fast (100-120/min) with complete chest recoil between compressions. 2, 1
• Use a 30:2 compression-to-ventilation ratio until an advanced airway is placed. 2, 1
• Minimize interruptions in compressions—any pause reduces perfusion pressure. 1
• Rotate the compressor every 2 minutes or sooner if fatigued to maintain quality. 2, 1
• Avoid excessive ventilation, which impairs venous return. 2

Rhythm Assessment and Management

For Shockable Rhythms (VF/Pulseless VT):

Defibrillation is the only rhythm-specific therapy proven to increase survival to hospital discharge. 2, 3

• Deliver one shock immediately using biphasic 120-200 J (or manufacturer recommendation) or monophasic 360 J. 2, 1, 3
• Resume CPR immediately after shock delivery WITHOUT a rhythm or pulse check, beginning with chest compressions. 2, 1, 3
• Continue CPR for 2 minutes, then perform brief rhythm check. 2
• If VF/pulseless VT persists, charge defibrillator while CPR continues, deliver second shock, and immediately resume CPR. 2
• Second and subsequent shocks should be equivalent or higher energy. 2

For Non-Shockable Rhythms (PEA/Asystole):

• Continue high-quality CPR and immediately search for reversible causes (H's and T's). 2
• Perform rhythm checks every 2 minutes with minimal interruption. 2

Medication Administration

• Establish IV or IO access as soon as feasible without interrupting compressions. 1
• Administer epinephrine 1 mg IV/IO every 3-5 minutes throughout resuscitation. 1
• For shockable rhythms, give epinephrine after the second shock. 2
• For non-shockable rhythms, give epinephrine as soon as access is obtained. 2

Advanced Airway Management

• Consider endotracheal intubation or supraglottic airway once advanced providers arrive, but do NOT interrupt compressions for placement. 1
• Use waveform capnography to confirm tube placement and monitor CPR quality. 2, 1
• After advanced airway placement, deliver 1 breath every 6 seconds (10 breaths/min) with continuous uninterrupted chest compressions. 2, 1

Monitoring CPR Quality

Use physiologic parameters to optimize CPR effectiveness: 2

• If PETCO₂ <10 mmHg, immediately attempt to improve CPR quality. 2
• If intra-arterial pressure monitoring available and diastolic pressure <20 mmHg, improve CPR quality. 2

Recognition of ROSC

Recognize ROSC by: 2, 1

• Palpable pulse and measurable blood pressure 2, 1
• Abrupt sustained increase in PETCO₂ to ≥40 mmHg 2, 1
• Spontaneous arterial pressure waves on invasive monitoring 2, 1

When ROSC is achieved, immediately transition to post-cardiac arrest care. 1

Reversible Causes (H's and T's)

Actively search for and treat reversible causes throughout the resuscitation: 2, 4

The 4 H's: 2

• Hypovolemia
• Hypoxia
• Hydrogen ion (acidosis)
• Hypo-/hyperkalemia and other electrolyte disorders

The 4 T's: 2

• Tension pneumothorax
• Tamponade (cardiac)
• Toxins
• Thrombosis (pulmonary or coronary)

Critical Pitfalls to Avoid

• Do NOT pause compressions to check rhythm or pulse except at designated 2-minute intervals. 2, 1
• Do NOT delay defibrillation to establish IV access or place an advanced airway. 2, 3
• Do NOT perform prolonged pulse checks—if pulse not definitively felt within 10 seconds, resume CPR. 1
• Do NOT hyperventilate—excessive ventilation impairs venous return and worsens outcomes. 2