Logo HCS CARDIAC CARE CENTER SOP ID -CNSOP001

Version No: 01

Approved by CODE BLUE MANAGEMENT Date of Approval

CODE BLUE MANAGEMENT

1. Introduction:
Code Blue is a rapid response system for emergency resuscitation and stabilization of
medical emergency situations that happen within the hospital area. These medical
emergencies require immediate attention. It should be initiated immediately whenever
a person is found in cardiac or respiratory arrest (unresponsive, pulse less, or not
breathing), the patient needs cardiopulmonary resuscitation (CPR).

The Response System is in 2 phases.

 The initial response (first responder) should always be from the hospital personnel who
are at the vicinity; where Basic Life Support (BLS) service should be provided.
 The second response (second responder) will be from a specialized and well trained
team from a department identified by hospital authorities.

Objective:

 To provide rapid (almost immediate) resuscitation and stabilization for victims of

medical emergencies or cardio-respiratory arrest within the hospital grounds.
 To establish well-trained and equipped medical emergency (code blue) teams that can
be deployed rapidly from pre-determined departments to the medical emergency site.
 To initiate training in BLS skills and use of Automated External Defibrillators (AEDs) for
all hospital staff whether clinical or non clinical based.
 To initiate placement of BLS equipment in various strategic locations within the hospital
grounds to facilitate a rapid response for medical emergencies.
 To make the hospital safe for emergency.
 WORK FLOW CHART
Person in cardiopulmonary arrest discovered

Hospital staff calls for help Activates Local Alert for Primary Code Blue team

Personnel/bystander who activates Code Blue initiates BLS/CPR if adequately skilled BYSTANDER
Continues BLS/CPR until Code Blue team arrives
If not skilled in BLS, wait for help and crowd control Simultaneously call the Hospital Code Blue number 5555 to activate the Hospital Alert.

PRIMARY CODE BLUE TEAM

Upon getting code blue activation, Primary Code blue team in charge of incident site rushes to location with crash cart (resuscitation kit).
Start or continue the BLS/CPR while waiting the Secondary/ETD Code Blue team.

• Upon arrival of Secondary or ETD Code blue

team: will take over resuscitation.
• Continue the BLS and apply AED
• Record pertinent data on code blue record
clerking sheet

ransfer the victim to ETD as soon as stable for further management

f resuscitation is unsuccessful or victim dies at location, victim still will be transported to ETD for further treatment or confirmation of death respectively.

Phases of Code Blue Rapid Response System:

Alert system
There should be a smooth and coordinated system in place in order to activate the
occurrence of a medical emergency within the hospital areas to the Code Blue team
 members.
The current telephone system will be used.
If a medical emergency occurs, any hospital personnel anywhere within DDH-Cardiac
Care Center can trigger the Code Blue response by call for help and activates:

 Call the ICCU alert number, display the Code Blue Number in the Wards
 Once the Code Blue case occurs, the Primary Team should leave her/his job and take
the code blue bag and rushing to the location and start the CPR/BLS.
 To activate the Primary Code Blue Team (lead by Clinical Coordinator)

Pre-determined members of the Primary Code Blue Response Team in charge of the
vicinity where the medical emergency has occurred will respond to the Code Blue
situation as soon as possible.

The team members will mobilize their resuscitation equipment kit and rush to the site of
the medical emergency.

The service standard for the duration of time taken between receiving the ‘Code Blue’
message (Code Blue activation) and arrival of the Code Blue team at the incident site is 5
to 10 minutes.

This service standard will be timed & subject to performance reviews and quality
assurance checks in order to determine pitfalls in the alert system and maintain an
efficient and rapid deployment of the ‘Code Blue’ team.

Responsibility of MECC toward Code Blue line.

 Assume every call through the Code Blue line is a real Code Blue cases (until proven
otherwise)
 Code blue call should be answer as soon as possible (< 3 ringing)
 Minimal conversation/question and focus towards activation of code blue team as soon as
possible.
 Vital information are
 Name and particular either public/hospital staff/ paramedic/ Doctor
 Exact Location
 Trauma or medical case
 Adult or pediatric
 Announcement to Primary Code Blue Team- CODE BLUE 3 x in the respective area.
 The Code Blue Staff should leave his or her job and run with carry the crash cart to code
blue scene if within the zone coverage by foot
 Record and document in the Code Blue Census
i) Immediate Intervention at the Incident Site
Staff at the site where a medical emergency (patient is unconscious or in cardio respiratory
arrest) has occurred have a responsibility to call for further help, initiate resuscitation using
Basic Life Support (BLS) guidelines and use advanced life support skills and equipment if
adequately trained and equipped.

a) The Hospital Code Blue team number will be placed in wards, departments, divisions,
units, offices, lift lobbies, corridors, canteens, gardens, parking lots, walkways etc and
other locations within the hospital grounds.

b) The hospital personnel who found the victim should activate the Local Alert for Primary
Code Blue team or instruct someone to do it for them; they should also call for further
help from nearby staff if available.

c) At the same time, activation of the Hospital Alert should be carried out by dialing the
Hospital Code Blue number.

d) Parties responsible or in charge of a particular area (for example, Medical Officer on call
or in charge of a ward) must also be informed to come to the site immediately.

e) While awaiting the arrival of the primary responding Code Blue team, if BLS- trained
staff are available, they should start BLS (airway positioning, rescue breathing, chest
compression etc).
f) If there are no BLS-trained staffs who can attend to the victim, the attending staff
should wait for experienced help and keep the site clear from crowding (crowd and
traffic control) if possible.

g) If cardiac monitors, manual defibrillators or Automated External Defibrillators (AEDs)

are available, these equipment should be attached to the patient to determine the need
for defibrillation; this phase is done by experienced staff or staff trained in Advance
Cardiac Life Support (ACLS).

h) Each department, division, ward or unit should strive to ensure that their staffs are
trained in at least BLS skills and their resuscitation kits or trolleys are well equipped with
at least basic resuscitation equipment and placed in strategic locations.

i) Staff at each department will be responsible for the maintenance of their resuscitation
kits.

j) If the victim is successfully resuscitated while awaiting the arrival of the Code Blue
response team, the attending staff should place the patient in the recovery position and
monitor the vital signs.
 k) All code blue case should be sending to the ER for further evaluation and management
regardless the outcome.
ii) Code Blue team arrival

a) Once the Code Blue team members receive the Code Blue activation, they have to stop
their current tasks, collect their resuscitation kits (equipment bag) and rush to the site
of the medical emergency on foot.

b) They have to deploy themselves rapidly and smoothly and use the shortest route
available.

c) The response time (service standard) from time of Code Blue call/activation to arrival of
Code Blue team at the scene will be recorded.

d) If the victim is still in cardio respiratory arrest when the Code Blue response team
arrives at the scene, the team will take over the resuscitation task; the staff at the scene
should stay around to provide additional assistance if required.
e) Every case of code blue will be send to Primary Code Blue Team regardless the patient
condition either sustain return of spontaneous circulation or not. In the ER, patient
disposition will be decided after integration post cardiac arrest care.

iii) Definitive Care

a) Medical emergencies that occur in any area either clinical or non-clinical and either
involve in-patient or out-patient (public) will be attended to by the Code Blue response
teams; these patients will be transported to the ER for further resuscitation and
definitive care as these places usually do not have adequate infrastructure and
equipment for advanced care.

b) If resuscitation is unsuccessful (the victim dies at the scene), the victim still need to be
transferred to the ER for further documentation or confirmation of death.

c) Every code blue case will received definitive care after integration post cardiac arrest
care and discussion in ER.

iv)Equipment used in Codes Crash Cart

All adult crash carts in the hospital contain the same basic emergency equipment and
medications. To open the crash cart, turn the red plastic lock located on the bottom
drawer until it breaks. Flip up the bottom panel of the crash cart and push it back firmly
 until it stops to be able to open the remaining drawers on the cart.

Summary of Crash Cart Contents/Location

 1st drawer: 1st line drugs
 2nd drawer: 2nd line drugs
 3rd drawer: equipment, central line trays
 Bottom drawer: equipment, ambu bag & intubation box

What is not in the crash cart?

 No Narcotics
 No Sedatives
 No Paralytics

Location Medication/Equipment Quantity

Top of Cart Monitor/Defibrillato 1

r Quik combo redi- 1
pak Electrodes 1 Pouch
Equipment Suction Machine/ Canister 1
Clip board with Dr. Blue sheets and gray charge slips 1

Back of Cart Cardiac Back Board 1

Extension cord 1
* Oxygen tank is located on the side of the cart

Drawer 1  Lidocaine 2% 100mg/5ml 2

 Atropine 1mg (0.1mg/ml) 3
1st line resuscitation drugs
 Epinephrine 1:10,000 syringe 12
1mg/10ml (0.1mg/ml)
 Procainamide 1 gm 1
 Vasopressin 20 units/1 ml 2
 Dopamine 800mg/250ml D5W 1
 Adenosine (Adenocard) 6mg/2ml (3mg/ml) 5
 Amiodarone 150mg/3ml (50mg/ml) 3
 D5W 250ml 1
 NaCl 0.9% Flush Syringes 10ml 20
 Labels I.V. 2
  Calcium Chloride 10% 10ml 2
Drawer 2  NaCl0.9% 20 ml 20
 Furosemide (Lasix) 40mg/4ml 2
 Norepinephrine (Levophed) 4mg/4ml (in plastic 2
2nd line emergency drugs bag with D5W 250ml to mix)
 Verapamil (Calan) 5mg/2ml 4
 Hydrocortisone (Solu-Cortef) 250mg/2ml 1
 Romazicon 0.5mg/5ml 1
 Narcan 0.4mg/ml 2
 Epinephrine 1:1,000 (1mg/ml) 1
 Benadryl 50mg/ml 1
 Regitine 5mg 1
 50% Dextrose 25 grams 2
 8.4% Sodium Carbonate 50meq 1
 Dilantin 250mg/5ml 4
 Mag SO4 50% 2ml 4

Drawer 3 Needles: 19 gauge 1 ½ inch 6

20 gauge 1 ½ inch 8
Syringes: 60cc 2
Vascular Access 60cc Cath Tip 1
Equipment; pacemaker 20cc 4
wire, multilumen catheter 10cc 6
5cc 4
3cc 8
Salem sump #18 1
Alcohol sponges 8
Topper sponges 4
Tapes: Non-allergenic 1 inch 2
Dermaclear 1 inch 1

IV equipment:
Tourniquets 1 inch 2
Jelco 14 gauge 2
16 gauge 2
18 gauge 2
20 gauge 4
22 gauge 2
Scalp vein set 19 gauge 1
21 gauge 1
PRN adaptor 6
Exam gloves 6
Face mask with shield 3
Disposable eye protector 1
 #11 Scalpel with handle 3
Temporary pacing kit 5 Fr. 1
Multilumen Cath 1
Pacemaker Kit includes: 1
 Disposable pacing kit 6 Fr.
 8.5 Introducer
2
cath Stop cock 9
EKG monitor electrodes 1 each
Vacutainer tubes (yellow, blue, gray, purple, red)
Lower shelf Sterile gloves (6 1/2, 7, 7 1/2, 8) 2 each
IV tubing (primary, secondary, extension) 3 each
IV Fluids (0.9 N.S. 500cc & 1000cc) 2 each
IV fluids & tubing/other Lidocaine 2 Gms.500cc D5W 1
equipment Needle box 1
Suction trays 14 Fr. 2
Ambu respiratory bag: RED box 1
Intubation tray: GRAY box 1

3. Code Blue team composition:

The Code Blue team is available all the time.

1. Primary Code Blue response team members trained in at least Basic Life Support
(BLS).
The Code Blue team consists of 4 to 5 members:
1 Critical Care Doctor / Anesthetist (Clinical Coordinator)
2 Critical Care / Cardiac Nurses
1 Medical Attender
1 Operations Staff

The Coordinator is responsible to submit the roster of local/primary Code Blue

team to the MECC monthly.

2. ER Code Blue response team. It is compulsory for each member trained in BLS.
The Code Blue team consists of 3 to 4 members:
1 Critical Care Doctor / Anesthetist / Medical Officer (Clinical Coordinator)
2 ER-Nurses
1 Medical Attendant

Each code blue team member will have a designated responsibility such as the team
leader, airway manager, chest compression, intravenous line, drug preparation and
defibrillation. Each designated team member will carry a hand phone
 Responders
Director of the Code: All house staff that is near the site of the Code Blue shall respond. Physician staff may be
dismissed from the Code Blue scene after the “physician in charge” is determined. The physician in charge
must be clearly identified as being in charge. Responsibilities include:
 Direct all activities of the resuscitation effort
 Delegate or directly participate in airway management, vascular
access, medication orders, and maintaining Advanced Cardiac Life
Support (ACLS) interventions

Recording Nurse: The nurse assigned to the patient should be the person that documents all the
events of the code for reasons of continuity in documentation and ability to provide information
regarding the patients hospitalization, current treatments, medications and the events that
occurred immediately before the code. The recording nurse is responsible for:
 Ensuring the patient chart is brought to the room when the code is called
 Utilizing the Resuscitation Record to document events of the
resuscitation effort, and assists with utilization of the Crash Cart
including medication and IV preparation
 Place the completed Resuscitation Record in the chart. Progress notes
should indicate patient condition prior to resuscitation “code call”. If
necessary a “late entry” describing patient condition prior to the
resuscitation event should be recorded. A notation must be made in
the progress notes referring to the Resuscitation Record for events of
the resuscitation
 Ensuring the family and physician has been contacted
 Transport patient to Critical Care Unit

Medication Nurse: This “hands on” nurse is responsible for:

 Initiating BLS-HCP measures according to American Heart Association (AHA)

standards
 Provide ACLS measures
 Initiate cardiac monitoring
 Locate/apply quick-comb redi-pak that can be utilized for defibrillation,
cardioversion, transcutaneous pacing, and viewing the cardiac rhythm.
 Assess for patent IV and/or assist with the initiation of IV route
 Prepare, label and administer medications per physician order
 Assemble equipment for intubation and suctioning

Critical Care Nurse: Three respiratory care staff is assigned each shift to respond to Code Blue.
Critical Care Doctor responsibilities include:
 Perform BLS-HCP according to AHA standards
 Maintain airway by suctioning and manual ventilation before intubation
 Assist physician with intubation and securing endotracheal tube (ETT)
 Obtaining blood sample for arterial blood gas analysis
 Set up oxygen and ventilation equipment
  Assist with transport to critical care unit
 Ensure proper paperwork is completed for the Respiratory Care Department

Anesthesiologist: If the physician is unable to intubate the patient, the operator may page an
anesthesiologist (call 3375 to confirm an anesthesiologist was contacted) to intubate the patient,
ensure an adequate airway and to facilitate ventilation.

Charge Nurse/Nursing Supervisor: The supervising nurse acts as a resource facilitator for the
code team. The resource facilitator is responsible for:

 Communicating with personnel regarding equipment and ancillary

service needs.
 Coordination of the initial resuscitation effort, assisting the
recording and medication nurse
 Checking on and removing any other patients or visitors in the
room as necessary
 Making space for the resuscitation effort
 Clearing unnecessary staff from the room
 Those who are not listed as team members and who are not actively participating in
the resuscitation effort.
 Coordinating the transfer effort by contacting Registrar and/or
ICU/CCU to facilitate transfer of the patient after resuscitation.
 Directing actions of the “runner”.
 Monitoring of the continued care of other patients
 Notifying the attending physician, and patient’s family.
 Assisting with evaluation of the resuscitation effort.

Nurse Assistant: One nurse assistant could be delegated to remain outside of the room to
assume the role of “runner”. The responsibilities may include:
 Running errands
 Obtaining supplies/equipment
 Transferring patients to another area.
The remaining nurse assistants will remain on their assigned unit. When the NA is utilized as a runner, provide specific
instructions regarding what is wanted, where it is located and how quickly you want it.

ACLS Medication Summary

Medications administered during a code depend on the cause of arrest, cardiac rhythm and patient’s response.
The goal of treatment with medications is to reestablish and maintain cardiac function, correct hypoxemia, and
suppress cardiac ectopics
 Most Frequently Used Code Drugs
Drug Indication Adult Dosage
Amiodarone Ventricular Fibrillation (VF)  Cardiac Arrest: 300mg IV
Pulseless Ventricular Tachycardia (VT) in 3-5 minutes (dilute to
Ventricular Tachycardia (VT) 20-30ml D5W). Consider
repeating 150mg IV in 3-
5 minutes. Max
cumulative dose: 2.2g
IV/24 hours.
 Wide Complex
Tachycardia (stable):
Amiodarone IVPB is obtained in Pharmacy  150mg
(diluted)rapid IV
over first 10 minutes
(15mg/min)
 May repeat rapid
150mg dose every
10 minutes as
needed
 Slow infusion: 360
mg IV over 6 hours
(1mg/min)
 Maintenance
infusion: 540mg IV
over 18 hours
(0.5mg/min)
Atropine Bradycardia  Asystole or PEA: 1mg IV.
Asystole Repeat every 3-5
Pulseless electrical activity (PEA) minutes. Max total dose:
3 doses (3mg)
 Bradycardia: 0.5 mg IV
every 3-5 minutes as
needed., max
0.04mg/kg
 ETT: 2-3mg diluted in
10ml normal saline
Epinephrine Ventricular Fibrillation (VF)  1mg (10ml of 1:10,000
Pulseless VT solution) IV every 3-5
Asystole minutes. Follow each
Pulseless Electrical Activity (PEA) dose with 20ml N.S. IV
 ETT: 2-3mg diluted in
10cc N.S.
 More Code Drugs
Drug Indication Adult Dosage
Adenosine Narrow Complex Paroxysmal Supraventricular With patient in reverse
Tachycardia (PSVT) Trendelenburg position:
 Initial bolus of 6mg rapidly over 1-3
seconds, followed by 20ml normal
saline, then elevate the extremity
 Repeat dose of 12mg in 1-2
minutes if needed
 A third dose of 12mg may be given
in 1-2 minutes if needed
Calcium Known or suspected hypercalcemia;  Hyperkalemia, calcium channel
Chloride hypocalcemia; antidote for calcium blocker overdose, or IV prophylaxis
channel blocker or B-adrenergic blocker before calcium channel blocker:
overdose; Prophylactically before IV Slow IV push of 500-1000 mg/kg
calcium channel blockers to prevent (5-10ml of a 10% solution).
hypotension

Dopamine Symptomatic Bradycardia (after atropine) See IV Drips section below

Hypotension(SBP<70-100 mmHg)with s/s shock
Levophed Hypotension SBP <70 with S/S shock
Lidocaine Ventricular Fibrillation (VF)
Pulseless electrical Activity (PEA)
Stable Ventricular Tachycardia (VT)
Magnesium For use in cardiac arrest only if Torsades De
Sulfate Pointes or suspected hypomagnesemia is
present
Nitroglycerin Suspected ischemic pain or MI
Oxygen Suspected ischemic chest pain
See IV Drips section below
 Cardiac Arrest from VF/VT: Initial
dose:1-1.5mg/kg IV. For refractory
VF may give additional 0.5-
0.75mg/kg IV, repeat in 5-10
minutes (max dose of 3mg/kg).
Single dose of 1.5mg/kg IV
 ETT: 2-4mg/kg (Also see IV Drips)
 Cardiac arrest for torsades de
pointes or hypomagnesemia: 1-2g
(2-4ml of 50% solution) diluted in
10ml of D5W IV over 5 – 20 min.
 Non-cardiac arrest with Torsade de
pointes:Loading dose of 1-2g mixed
in 50-100ml of D5W over 5-60
minutes. Follow with 0.5-1g/h IV
(titrate to control the torsades)
 IV infusion: 10-20mcg/min.
Increase by 5 – 10 mcg/min every
5
– 10 minutes until desired response.
Onset of actions 1-2 minutes
 Sublingual: 1 tablet (0.3-0.4mg) x3
at 5 minute intervals(Also see IV Drips)
4 lpm per nc for uncomplicated MI;
100% oxygen during resuscitation
 Drug Indication Adult Dosage
Procainamide VF, Pulseless VT, may use for treatment of PSVT  Recurrent VF/VT: 20mg/min IV
uncontrolled by adenosine/vagal maneuvers if infusion (max total dose: 17mg/kg).
BP is stable, stable wide complex tachycardia of Also see IV Drips section
unknown origin, atrial fibrillation with rapid
rate in WPW syndrome
Vasopressin VF, pulseless VT 40 units IV single dose. May be used as
an alternative pressor to epinephrine
for
the 1st or 2nd dose. Epinephrine may be
administer 10 minutes after
vasopressin
Verapamil Alternative drug (after adenosine) to IV infusion:
terminate Paroxysmal Supraventricular  Initial: 2.5-5mg IV bolus over 2
Tachycardia (PSVT) minutes
May control ventricular response in patients  Second dose: 5-10mg if needed in
with atrial fib, atrial flutter, and multipfocal 15-30 minutes. Max dose:20 mg
atrial tachycardia.

ACLS Medication IV Drips

Drug Concentration/Indication Adult Dosage

Dopamine Mix as: 800mg dopamine in 250cc D5W  2 – 20 mcg/kg/min and titrate
(Intropin) Concentration: 3200mcg/ml Indications: to patients response.
 Hypotension that occurs with
symptomatic bradycardia
 Hypotension that occurs after return
of spontaneous circulation
 Cardiogenic shock. May be used in
bradycardia to increase HR.

Lidocaine Mix as: 2 grams of Lidocaine in 500 cc D5W  Maintenance infusion: 1-

(Xylocaine) Concentration: 4mg/ml 4mg/min (20-50mcg/kg per
Indications: minute)
 Significant ventricular ectopy (runs of VT, R
on T, frequent or multiform PVc’s) seen in
the setting of AMI or ischemia Infusion rates:
 VT/VF that persists after defibrillation and 15cc/hr=60mg/hr=1mg/min
administration of epinephrine 30cc/hr=120mg/hr=2mg/mi
 VT with pulse n
 Wide complex tachycardia of 45cc/hr=180mg/hr=3mg/mi
uncertain origin n
60cc/hr=240mg/hr=4mg/mi
n
Norepinephrine Mix as: 8 mg Norepinephrine in 250cc D5W  IV Infusion only: 0.5-1mcg/min
(Levophed) Concentration: 32mcg/ml titrated to improve BP up to
 Indications: 30mcg/min
 Treatment of profound hypotension
unresponsive to volume loading &
dopamine
Procainamide Mix as: 1 gram Procainamide in 250cc D5W  Recurrent VF/VT: 20mg/min IV
Or infusion (max total dose of
2 grams Procainamide in 500 cc D5W 17mg/kg).
Concentration: 4mg/ml  Administer at 20mg/min until one
Indications: Treatment of ventricular of the following occurs:
arrythmias Arrhythmia suppression
Hypotension
QRS widens by >50%
Total dose of 17mg/kg is given
 Maintenance Infusion: 1-4mg/min
 Renal or cardiac dysfunction: Max
total dose: 12 mg/kg.

Infusion Rates:
15cc/hr=60mg/hr=1mg/mi
n

Tracheal Administration of Resuscitation Medications

Certain medications can be administered via the tracheal tube if unable to obtain
intravenous access. Tracheal doses of medications should be 2 to 4 times higher than
the intravenous route. Resuscitation medications that can be given via tracheal tube are
the “ALE” drugs.

Medication Tracheal Administration

Atropine 2 to 3 mg diluted in 10 ml normal saline

Lidocaine 2 to 4 mg/kg

Epinephrine 2 to 2.5 mg diluted in 10ml normal saline

Recommended Technique for Tracheal Drug Administration

 Prepare medication according to tracheal administration guidelines

 Stop chest compressions and inject the medication via the ETT
 Flush the ETT with 10 ml of normal saline when indicated
 Immediately attach the ventilation bag to the tracheal tube and ventilate
forcefully 3 to 4 times to circulate the drug
4. Education, Training and Quality Assurance:

BLS (compulsory) or ACLS certification for team members is required every three (3)
years.
Review of all policies and procedures.
Review of regulatory standards.
Response time (service standards)
measurement. An Audit
BLS, ACLS and MTLS/ATLS courses will also be provided to staff from various hospital
departments and units to improve the standard of care and outcome for the code blue
response as these staff will play a vital role as first responders for code blue situations.

Parties interested in attending these courses should contact the Emergency and Trauma
Department or CPR committee (Anesthesiology department).

5. Communication:

MECC
Specific dial/ext or hand phone number to activate the primary Code Blue team

6. Coordination with other departments/units:

Input will be acquired from other departments and units regarding the absence or
presence of their current medical emergency response. If there is no emergency
response plan in place, ER of DDH will get input regarding their requirements for
emergency medical care and coordinate with them on how to establish an emergency
medical response using the code blue system.