In-hospital cardiac arrest situations, “code blues,” can be sudden and disorienting for the care providers involved. Typical code blue events last only a few minutes, but the actions taken by the providers during that time play an essential role in patient outcomes.

Preparing for a quick, high-stress situation can be difficult.

Learning the code protocol at your facility and familiarizing yourself with the code blue documentation sheet can save valuable time during the event.

Nurse Nacole Riccaboni, an ICU nurse and influential nursing blogger, recounted the events of her first code blue:

“It was 2011, and I was doing an initial head to toe assessment, and I experienced my first code blue. He said his chest was hurting and that he couldn’t breathe. Before I could even get the phone up to my ear to call The Rapid Response Team, he yelled, “I’m dying” and just stopped moving. He went limp, his eyes rolled back, and he just stopped moving! It wasn’t like on television. There was no dramatic music or signals. He just was talking one minute and not the next. I wasn’t mentally prepared for that. I checked for a pulse, hit the code blue button, and immediately started cardiopulmonary resuscitation (CPR). Dozens of people soon ran into the room to help me. And by “helping me,” I mean running the code because I froze. I felt like it was my fault and I must have missed something for this to happen. I couldn’t get out of my own head.

I was just doing CPR, not counting or following the algorithm. It took the charge nurse yelling, “Nacole! Look at me and do this right!” for me to get it together and hear the support team’s instructions. When you’re learning basic life support or even advanced cardiac life support, you don’t learn about the human element of the process. Doing CPR on a mannequin is very different than doing it on a person. When you press down on a person, you feel the bones and their organs resistance. Often orifices leak and ooze, and it can be a very traumatic process. The human element can distract you, and you may forget the algorithms and tasks needed at specific times frames. That’s why code leaders and recorders are so crucial. One person can’t do it all. It takes a team to save a life.

The most significant action during a code blue is quality CPR. As nurses, we are often the first person at the bedside and the first person to initiate CPR. We must provide high-quality chest compressions in order to give our patients a chance at survival. There are five critical components of high-quality CPR:

  • minimize interruptions in chest compressions,
  • provide compressions of adequate rate and depth,
  • avoid leaning between compressions, and
  • avoid excessive ventilation.

High-quality CPR is often undervalued due to bedside monitors and gadgets, but it’s the single most important function during a code situation. If I could give any advice to nurses during code blues, it would be to know how to properly deliver high-quality chest compressions. I wrote a paper on CPR during my undergraduate program, and I remember this excerpt,

“External chest compressions provide approximately 20-25% of baseline cardiac output, with 10-20% of normal cerebral perfusion. This degree of vital organ perfusion can provide reasonable salvage for 15 minutes.”

(Trauma, 7e – Kenneth L. Mattox, Ernest E. Moore, David V. Feliciano)

I keep that in mind during each code. If high-quality CPR can only provide 20-25%, image how low the cardiac output suboptimal CPR provides, if any.

When you are in a code blue situation, understand that the return of spontaneous circulation with unimpaired neurologic function unimpaired is the primary goal. Strive towards achieving this objective with utilizing proper cardiac arrest algorithms and by knowing the H’s and T’s. The H’s and T’s of advanced cardiac life support (ACLS) is a mnemonic used to help recall the major contributing factors related to:

  • asystole,
  • pulseless arrest including (PEA),
  • ventricular fibrillation (VF), and
  • pulseless ventricular tachycardia (VT).

Often during a code, the team reviews these causes an in attempt to improve the patient’s outcome. When a person goes into cardiopulmonary arrest, there often isn’t an apparent cause. As nurses, we obviously review a patient’s history, along with laboratory and diagnostic findings. But the cause often eludes us, and that’s where the H’s and T’s come into play. The code team works as a unit making sure each Hs/Ts is evaluated, and the appropriate intervention is implemented.

Last but not least, know the patient (if your patient has the cardiopulmonary arrest, of course). If you’re just there to help, assist in any way you can. Common questions during a code are:

  • Was the event witnessed?
  • Was the patient found down?
  • What was the initial rhythm displayed?
  • What time did the code start?
  • Vital signs pre-event?
  • Most recent laboratory and diagnostics?

These details are what providers and the team will need. Yes, the patient doesn’t have a pulse, that’s of the utmost importance but what lead up to the event is just as important. Does the patient have a cardiac history? Who is the next of kin? All these questions play a role during the code blue process. And only the nurse assigned to the patient has these answers. So, be available and be ready. Use the team but remember, you are the point of contact during this event. You are the only one with this knowledge.

A code blue event is a singular episode packed with many moving components. This is why a team is crucial to a patient’s survival. Often nothing could have been done to avoid the cardiopulmonary arrest development. So instead of folding inward and collapsing in on yourself, focus on saving the patient. Know the background, the cardiac arrest algorithms, how to perform high-quality CPR, each team member’s role and your H’s and T’s. Being prepared is all we can do and when the time comes, implement that awesomeness to the best of your ability.”

Nurse Nacole recalls the angst that many new nurses feel during their first several code blues. Study, preparation, and simulated training are key to effectively responding to in a code blue event. Sufficient training and preparation tools such as these inexpensive mini-cardiovascular cards help to build familiarity with essential cardiac elements. These cards cover: beta blockers, calcium channel blockers (CCBs), angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin II receptor blockers (ARBs), and antianginal medications.

Recognizing the key factors can certainly help in preparation for a code blue. Understanding what questions are going to be asked, preparing for the quick pace, studying H’s and T’s, and practicing high-quality CPR are excellent activities for care providers.

Notes make for excellent preparation. It’s a good idea to ensure that your notes are small and portable for those quick, break room reviews. Continuous study will build confidence and ensure you feel well prepared.

If you have some code blue prep ideas or would like to share your first code blue experience, we encourage you to comment below!

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