Code Blue Note

Code Blue Overview (Not for Note Documentation)

** Your main job is to coordinate/run the room! You are not alone!**

Walk into the roomHi my name is _____ and I am the code leader. Does the patient have a pulse? Is he/she full code?
Quiet the room – ask directly for people to quiet down if needed and ask extra people to step out if too crowded
Stand at the foot of the bed, stay calm but make sure your voice is loud enough
Used close loop communication
Identify your team: announce rolesCode whisperer: ____________
Place back board/pads: Ask that someone places backboard and leads/pads if not already done
CPR: 100-120/min- beat of “Staying alive”. Make a line and get LUCAS if available.
Time-keeper: _____________  consider using Code Blue App
Airway: Identify anesthesia and intubate asap if needed. If trach patient, make sure pt hooked up to oxygen. Ask for end tidal CO2- ideally >20 if good compressions, if <10 then improve chest compressions or think about reasons for poor ventilation and V/Q mismatch (e.g. PE!).
Pharmacist: __________ Ask for 1mg epi right away, then see algorithm below. Ask for closed loop communication to confirm when meds are given.
Labs: Ask for rainbow to be sent (iSTAT; ABG with lytes/lactate, CBC, CMP, coags, type and cross, POC glucose, troponin). Ask to confirm when sent or let you know in two minutes if can’t get them. If at SFGH can run ABG with lytes faster in ED so another resident to run it down
Access: Get IV access. If no PIVs, get IO access. Occasionally get central line / Aline during code if long code, needed for access, etc but not an immediate priority.
Other tasks:Ask another resident to look up recent labs, review tele, etc
Ask primary team for basic info and that they call family asap
Ask another resident to grab an ultrasound- look for e/o tamponade, right heart strain
ACLS algorithm and MedicationsImmediately: 1mg epinephrine if PEA/asystole, 1L NS wide open (unless cardiogenic shock)
Then per ACLS algorithm epi every 3-5min (I do every 4min) and amio if shock! See next page
Next: Consider 1 gram calcium chloride, 1 gram mag sulfate, 2-3 amps bicarb, 1amp D50 I often give all of these within the first few rounds, but not part of ACLS. Caution with multiple rounds of bicarb if not intubated yet.
If you want TPA (PEA/asystole only), ask early! Takes 10-15min to make it, then after given it takes 20min to take effect so need to continue the code for at least 25 more minutes
Ask for levophed to be hung so ready when ROSC achieved
SUMMARIZE and TALK OUT LOUDReview pt one liner and where we are in the algorithm every few minutesExample “This is a 75M admitted with PNA who was hypoxic and then lost a pulse, we are in the PEA algorithm. This is our second round of check compressions, we have given 1mg epi and 1amp bicarb, he was just intubated and end tidal being set up, labs are being drawn, etc etc)”
Then go through the H’s and Ts out loudHs: 1. Hypovolemia 2. Hypoxia 3. Hydrogen (acidosis) 4. Hypo/hyperK 5. Hypothermia
Ts: 1. Tension pneumo 2. Tamponade 3. Toxins 4. Thrombosis (PE) 5. Thrombosis (ACS)
Invite thoughts from the room
End of codeIf you get ROSC, see post-ROSC instructions on page 2
20 minus with end tidal <10 = call code; 30 mins without clear etiology = call code
If the code has gone on >10 rounds, check with the ICU triage fellow/attending quietly first whether you should consider calling it then also ask the room. It is a group decision, you definitely don’t decide alone!
Once decided, continue the round of chest compressions and tell the room that we will continue chest compressions until the next rhythm check and if no pulse at that time we will call it – gives chance for everyone to anticipate ending mentally/emotionally and to make sure no final ideas
Can invite family into room during code or after- if during, ask primary team to stay with them
It’s just an algorithm! The harder part is the leadership/organization piece above… the meds are pretty easy once you’ve done it a few times. This is a brief summary, see Code Cards for complete version. I typically didn’t look at Code Cards during the code since distracting, but can hand them to the Code Whisperer or have them in your pocket in case.
ACLS Algorithms

PEA Arrest0 Min:Begin chest compressions. As soon as leads/pads set up, stop compressions to do a rhythm check (don’t wait for 2min the first time around!). No need to shock for PEA algorithm
Give 1mg epinephrine right off the bat
2 Min:Pulse/rhythm check.
4 Min:
Pulse/rhythm check.Give 1mg epinephrine (Give every 3-5minues)
Vfib/Vtach Arrest0 Min:Begin chest compressions. As soon as leads/pads set up, stop compressions to do a rhythm check (don’t wait for 2min the first time around!). If shockable rhythm (Vfib/Vtach), charge to 200J and shock. Then continue chest compressions right away after shocking and do the pulse/rhythm check at 2min (don’t do it right after you shock! Keep chest compressions going as much as possible!)
2 Min:Pulse/rhythm check. If shockable rhythm, charge to 200J and shock.
Give 1mg epinephrine at 2-4 mins (consider 1mg epi + vaso 20 + methylpred 40mg)
4 Min:Pulse/rhythm check. If shockable rhythm, charge to 200J and shock.
Give 300mg amiodarone (for refractory Vfib/Vtach)
6 Min:Pulse/rhythm check. If shockable rhythm, charge to 200J and shock.
Give 1mg epinephrine (consider + vaso 20mg)
8 Min:Pulse/rhythm check. If shockable rhythm, charge to 200J and shock.
Give 150mg amiodarone
ROSC: Post-Arrest CareMake sure pressors ready – ask for levophed to be hung during code if possible. Can consider asking for 1mg epi with you for transport.
Consider sedation if intubated, esp if paralytics used to intubate (often forgotten)
Where is patient is going? – ICU, cath lab, scanner etc. Ask charge when bed ready and you help transport
Make pt stable for a couple min, transport monitors ready, etc before transport
Get EKG, repeat labs, CXR, additional imaging, lines etc once pt arrives in ICU
Ask primary team to call neuro to get their recommendation about cooling - should be default to call them and they can recommend for or against cooling (unless pt wide awake after, just call them!)
Make sure that primary team calls family, notifies attending (remind/offer to help the early Foxes if medicine pts)
Always write code note (even if code is a false alarm!). “Significant Event Note” or “Code Documentation”
Post-code debrief- ask all parties to meet 20min after to debrief. If floor code, try to do this on the floor so floor RNs there
Ask for feedback – from ICU triage fellow, attending, co-residents, charge nurse, etc… ask specific questions!
Peri-Code Situations
These situations can sometimes be more challenging than codes, since less algorithmic. Ask for help! Ask somebody in the room to stat call cardiology or other relevant consultants if needed.

Bradycardia with a PulseAtropine 0.5mg IV bolus; repeat every 3-5min, max 3mg – but note won’t work if third degree block so ALSO work on setting up transcutaneous pacing at the same time.
Transcutaneous pacing- look for capture. Start 60 beats/min and go up
Dopamine infusion (2-20mcg/kg/min) or Epinephrine infusion (2-10 mcg/min)
Call cardiology!
DATE: Dopamine, Atropine, Transcutaneous pace, Epi
Tachycardia with a PulseNarrow regularAttempt vagal maneuvers
Give adenosine (only if regular!)- 6mg, then 12mg (but 3mg if via central line)
Call cardiology. Consider beta blocker, calcium channel blocker
If unstable, synchronized cardioversion. Start 50J, then 100J. If unstable, can ALWAYS cardiovert! Provide sedation if awake (50mcg fentanyl)
Narrow irregularAfib with RVR: Give metop 2.5 or 5mg IV if BPs can tolerate. Consider amio loading
If unstable, synchronized cardioversion. Start 120-200J biphasic or 200J monophasic.
Wide regularCall cardiology. Consider adenosine only if regular and monomorphic. Consider anti-arrythmic infusion – typically I reach for amio but check with cardiology
If unstable, synchronized cardioversion: 100J
Wide irregularCall cardiology – specifically EP if possible. Defibrillation dose (200J).
Other non-pulseless situationsAMS: Check glucose or empirically given 1amp D50. VBG to r/o hypercarbia. Review MAR- consider narcan. Consider stroke, seizure. Intubate if not protecting airway
Hypotension: Ask pharmacy to get levo or epi gtt ready; give smaller pushes of epi in meantime (eg 0.2mg epi). Ask for IVF wide open unless cardiogenic shock
Seizure: Give Ativan, call neuro
CVA: Check pupils, call code stroke
Dissection: Check bilateral cuff pressures and pulses. Get imaging if stable enough. Call vascular stat if concern
Anaphylaxis: Steroids, benadryl, famotidine, fluids, airway
Tamponade: Call cards stat. Avoid intubation if possible (drops preloadà HD collapse)
Chest tubes: If had air leak and now doesn’t, think about tension pneumo. Ask nurses to strip chest tubes. Call CT surgery stat for trouble shooting
Massive transfusion protocol: Ask co-resident to help count blood products – write on board or wall. Call GI/IR. Ask to get Belmont from the OR.
Trach issues: Cuff up/down? Call ENT stat for help. Get oral airway if issues and no contraindication
Torsades: Give magnesium
Massive transfusion protocol

Definition: 4U in 4 hours, 3U in 1 hour, anticipated ongoing bleeding

Setup:Identify point person to blood bank to activate MTP
Ask co-resident to help count blood products – write on board or wall.
Identify cause, FAST exam, start compression/tourniquet-- Call surgery/GI/IR.
Ask to get Belmont from the OR. Start active warming of patient
Access? 2 16-18g PIVs at least, consider upsizing with RIC.
Anticoagulation? Consider K-centra/vitK; TXA in trauma patients
Plyte/LR then Initial 1:1:1 pRBC/FFP/platelets damage control approach then guided by labs q30m
Labs: iSTAT, CBC, coags, fibrinogen, iCal, Type and cross, thromboelastography
GoalsMAP>65 (>85 if CNS)
Temperature           >35 °C
Acid-base status     pH >7.2, base excess <–6, lactate <4 mmol/L
Ionised calcium (Ca)           >1.1 mmol/L
Haemoglobin (Hb)  >10.
Platelet (Plt)            ≥ 50 (>100 if CNS)
PT/APTT    ≤ 1.5x of normal (FFP)
Fibrinogen ≥ 100 (cryo)
Complicationsvolume overload (careful monitoring of filling pressures, response to volume, diuresis etc)
over-transfusion (monitor Hb regularly, titrate according to needs)
hypothermia (monitor temp, use fluid warmers and other measures to reduce heat loss)
dilutional coagulopathy of clotting factors and platelets (regular and early monitoring of coagulation, involvement of haematology for replacement therapy )
Transfusion related acute lung injury (consider use of filters, leukodepletion)
excessive citrate causing metabolic alkalosis and hypocalcaemia (monitor pH and ionised calcium, replace calcium as necessary)
hyperkalaemia (use of younger blood, monitor regularly, may require specific therapy)
disease transmission (use of products only on a needed basis only, standard blood banking precautions etc)