Code Blue: Dos & Don'ts

Nurses and Code Blues

Code blues are one of the scariest situations to be in as a nurse. Every nurse should know the basics of code blue because they can happen at any time. Many times a nurse is the first one to witness a patient going into cardiac or respiratory arrest. There is a lot to know about how to run a good code blue.

Prevention

The best way to deal with a code blue is to prevent a code blue. As a nurse you need to try and round on your patients at appropriate times, even the more stable ones can turn on you. It is understandable that in certain situations hourly rounding is impossible but rounding should never be neglected on purpose. Labs are important and should be one of the first things to look into during your shift and throughout.

What to do during a code blue

It is very important to stay calm and professional during a code blue. The nurse in charge of the situation should delegate tasks accordingly. This includes making sure that when there are nurses available, they are doing what they can for their assigned patient while not forgetting about the other patients on the floor space as well.

During a code blue, nurses should first assess the situation. They need to check for signs of life, and then start CPR if needed. There are times when you can visually see that the patient is not breathing even by the way they look. If you enter the room and are not sure of what is going on with your patient always assess. Call their name, touch or shake them, and feel for a pulse. If there are no signs of life call a code!

According to ACLS guidelines, the adult cardiac arrest algorithm is:

For Shockable Rhythms

  1. Start CPR (100 compressions/min), attach to monitor and defibrillation pads, and give Oxygen.
  2. Check the rhythm: is it shockable? Ventricular Fibrillation and Pulseless Ventricular Tachycardia are shockable.
  3. Shock 120 – 360J
  4. Continue CPR for 2 min and establish IV access.
  5. Rhythm and pulse check, shockable? VF/pVT
  6. Shock 120 – 360J
  7. CPR: 2 min, Epinepherine every 3-5 min
  8. Rhythm and pulse check, shockable? VF/pVT
  9. Shock 120 – 360J
  10. CPR: 2 min, Amiodarone, lidocaine, treat reversible causes.
  11. Back to step 5

For Nonshockable Rhythms

  1. Start CPR (100 compressions/min), attach to monitor and defibrillation pads, and give Oxygen.
  2. Check the rhythm: is it shockable? Asystole and Pulseless Electrical Activity are not shockable.
  3. CPR every 2 min and IV access
  4. Epinephrine ASAP every 3-5 min
  5. Treat Reversible cause
  6. Back to step 3 until ROSC or termination

What are the nurses’ roles during a code blue?

There are a few nursing roles to play in a code blue situation and each has its own responsibility. The first thing to understand is that it is not your fault.

Lead Nurse

The first nurse role is the “lead” aka the nurse who is in charge of running the code. This nurse is responsible for dictating and delegating certain tasks. This should be the primary nurse or a charge nurse because the primary nurse is the one that knows the patient the best and the charge usually has a higher knowledge base and skill set. The primary nurse or a charge nurse are the best people to assess the situation because they have been managing the patient’s care and are our best hope in figuring out what happened. 

The lead can then change when a physician comes or another nurse takes over.

The dos and don’ts of a lead

  • Don’t take on other tasks or leave the room.
  • If you are the lead, you are running the show so know the cardiac arrest algorithm.
  • Speak loudly so everyone knows what is going on, make sure people know you are the one running the code.
  • If you are the primary hand this role over to the physical and critically think of what could have happened (harder than you think).

IV access and medication

This role can be filled by one or two nurses because getting IV access and maintaining IV access can be a tough job. It is better to have 2 nurses on this job until good IV access is maintained then one nurse can step away and take on another task. You will be administering medications per the cardiac arrest protocol but also some paralytics and sedatives like etomidate, propofol, versed, fentanyl, etc…

Dos and Don’ts

  • Don’t stop after the first attempt, keep trying.
  • If you are struggling ask for help and keep trying
  • Try not to forget the labs
  • If pushing med keep the vials so you don’t forget what you gave.
  • Push the correct medication.
  • Let people know what you’re pushing and when.

Recorder

the recorder’s role is exactly what its title is, you record. Many nurses don’t like this role because it usually requires you to chart after the code. As the recorder, you write down everything that is going on into time slots. A code blue sheet looks like a spreadsheet. It is your job to also manage time so everyone knows when it is time for a shock, pulse check, and medication.

Dos and Don’ts

  • Don’t think you will remember something, always write it down.
  • Maintain this role, don’t do other tasks
  • Keep your eyes on the clock.
  • Know the Cardiac arrest algorithm.
  • Speak loudly.

Compression master

This is usually when the boys come in. Every guy likes doing compressions but just like other things, not every guy is good at them. Always remember 100 – 120 compressions a minute is a way to go. This is also not a one-man job. There should be a person or two ready to hop on the chest. Compression gets tiring so try and switch every 2 min.

Dos and Don’ts

  • Don’t be a hero, ask for help, and switch!
  • Give good compressions, 2 inches, and push down hard and fast.
  • If no one is in line, delegate to someone that isn’t doing anything.

Runners

This role can be plated by a few people. Your job is to chase down and meds or equipment. You can also be the one putting in orders for labs, making phone calls to radiology, or getting ahold of anesthesia or a physician.

Dos and Don’ts

  • If there are a lot of you, then it is better to stay away
  • Try and recognize when the situation is under control and you might not be needed. Sometimes the more bodies the harder it is to run a code.
  • Check on the other patients.
  • Let people know what you are getting or where you’re going.
  • The better you get at this the more efficient you will be inputting in orders or grabbing meds.

Speaking with family

This is a very important role and will usually be the responsibility of the primary nurse. It is always hard letting the family know that their loved one is in cardiac arrest or has passed away. This is a skill that gets better with practice.

Dos and Don’ts

  • If you are not sure how to approach a family ask someone.
  • Be honest and don’t speak on things you aren’t sure of.
  • Ask the family to come in.
  • You can always defer some concepts to the physician and say the Doctor will better explain the situation once you arrive.
  • Don’t give false hope.

As the primary nurse, try to figure out the underlying causes of cardiac arrest. Look at lab values and prior issues. It’s easier said than done but try to stay calm. If this is not your patient make sure you have a role not just standing by and interfering. If it is your patient make sure to stay in or near the room because you will have to maintain the report. Remember to speak to the family and explain what has happened. Always try your best, brush up on your knowledge, and remember that it was not your fault.

https://cpr.heart.org/-/media/cpr-files/cpr-guidelines-files/algorithms/algorithmacls_ca_200612.pdf?la=en

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