Ali Haedar

Clinical lecturer & Emergency Medicine Specialist

Department of Emergency Medicine

Faculty of Medicine – University of Brawijaya
Saiful Anwar General Hospital
Indonesia
Disclosure
Presenter is a:

 Professional Associate of
American Heart Association
& American Stroke
Association

 International Instructor for

the American Heart
Association’s for HeartSaver,
BLS, & ACLS

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 Code Blue Purpose

Standardize management of code blues Suggest plans for acute care cases

Practice leadership and teamwork skills Practice early CPR and defibrillation
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Code Blue Cases

Tension PTX | Pulseless VT

ACS | VF

Anaphylaxis | Asystole
Upper GI Bleed | PEA

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Early CPR,
Early Defibrillation

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Objective: to Improve the Outcomes

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From First Responder…

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Cardiac Arrest Chains of Survival

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BLS Sequences;
Different Level, Different Roles

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Roles; First Responder
 Providing BLS* If possible:
 Identify sudden  Bring Emergency Resuscitation
cardiac/respiratory arrest Cart
 Activate Code Blue team
 Place backboard under patient
 Initiate high quality Cardio
 Administer ventilations with
Pulmonary Resuscitation
100% O2 with Bag/valve/mask
 Perform shock with AED
 Attach Electro cardiogram leads
 Attach defibrillator pads
 Ensure patient Intra Venous
access
 Prepare suction

*Lay rescuer, trained lay rescuer, or healthcare provider

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Why first responder?

0 minutes No brain
damage at
Some Oxygen
this point…
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 Acceleration of the

LIFE

Event

Cardiac
Arrest
Brain
Death
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Cardiac Arrest to Brain Death

10-12 minutes Irreversible

Brain Damage
No Oxygen & Biological Death
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have very important role in saving lives!

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BLS by Lay Rescuer
 In adult victims of cardiac arrest, it is reasonable for rescuers
to perform chest compressions at a rate of 100 to 120/min.

 During manual CPR, rescuers should perform chest

compressions to a depth of at least 5 cm for an average adult,
while avoiding excessive chest compression depths (greater
than 6 cm).

 Untrained lay rescuers should provide compression-only

CPR, with or without dispatcher guidance, for adult victims of
cardiac arrest.

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BLS by Lay Rescuer

A special thanks to Prof Hideharu Tanaka & Mr Soji Fujii (Japan) for their kindliness in providing the mannequins and AED. 17
BLS by Trained Lay Rescuer (Heartsaver®)
 The rescuer should continue compression-only CPR until the
arrival of an AED or rescuers with additional training.

 If the trained lay rescuer is able to perform rescue breaths,

he or she should add rescue breaths in a ratio of 30
compressions to 2 breaths.

 The rescuer should continue CPR until an AED arrives and is

ready for use, EMS providers take over care of the victim, or
the victim starts to move.

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BLS by Healthcare Provider
 HCPs must call for nearby help upon finding the victim
unresponsive, but it would be practical for an HCP to
continue to assess the breathing and pulse simultaneously
before fully activating the emergency response system (or
calling for backup).

 It may be reasonable for the provider to deliver 1 breath

every 6 seconds (10 breaths per minute) while continuous
chest compressions are being performed (ie, during CPR
with an advanced airway).

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Lethal Arrhythmias

50-60%
of sudden deaths
are caused by
VF/pVT
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The victim of SCA needs CPR,
but…
CPR will only temporarily deliver some oxygen to
the brain. It Doesn’t Correct fibrillation.

needs
Defibrillation! 24
Electric Medicine

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Sudden Death Reversal Rates

AEDs are Highly Successful 26

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… to Advanced Team

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Code Blue Team
 Advanced team who perform resuscitation on any
person who sustains:
 Cardiopulmonary arrest
 Respiratory arrest

 Professions:
 Doctor
 Nurse

 Trained health care providers with BLS-ACLS

certification
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Code Blue Members
 Physicians
 Emergency Department
 Cardiology Department
 Internal Medicine Department
 General Surgery Department
 Intensive Care Unit Department

 Emergency Nurse

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Skills
 Identify respiratory/cardiac arrest
 Provide high quality CPR
 Administer Oxygen
 Perform Bag-Valve-Mask resuscitation with 100% O2
 Perform defibrillation
 Set intra venous/intra osseous access
 Administer medication
 Evaluate vital signs
 Consider causes
 CPR documentation
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Roles; Code Blue Team Members
 Maintains airway/oxygenation/ventilation
 Applies monitor leads/defibrillator pads
 Starts Intravenous access
 Administer medications
 Administers Electrical Shock
 Completes CPR & medical record

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Roles; Code Blue Team Leader
Direct overall patient care:
 Manage the Code
 Medication
 Defibrillation
 Other procedures: Intubation, compressions
 Evaluate Code Blue procedures
 Effectiveness of Chest Compression
 Effectiveness of assisted respirations
 Rhythm/pulse check

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Code Blue Effective Team Dynamics

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Code Blue Team Activation
 All employees must be educated to activate Code Blue
response in the event of
 Cardiac arrest
 Respiratory arrest
 Activate Code Blue Response by
 Calling Hospital Emergency Operator (exp. 1234)
 Provide Information: Patient location, Adult/Pediatric
 Hospital Emergency Operator will activate response when
notified of Code Blue event
 Code blue alarm system
 Announce overhead the location of the code event

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Basic Life Support Assessment*
1. Check responsiveness
2. Shout for nearby help/activate emergency response
system and get the AED/defibrillator
3. Check breathing and pulse
4. Defibrillation

*for unconscious patient

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BLS Assessment: Check responsiveness

 Tap and Shout, “Are you

OK?”

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BLS Assessment: Shout for nearby help

 Activate emergency
response system
 Code Blue (exp. 1234)

 Get the AED/defibrillator

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BLS Assessment: Check breathing and pulse
 Check for absent or
abnormal breathing
 Check for carotid pulse for
5-10 seconds
 If no pulse within 10 second,
start CPR, beginning with
chest compressions
 If there is a pulse, start
rescue breathing at 1 breath
every 5-6 seconds. Check
pulse every 2 minutes.

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BLS Assessment: Defibrillation
 If no pulse, check for a
shockable rhythm with
an AED/defibrillator as
soon as it arrives
 Provide shocks as
indicated
 Follow each shock
immediately with CPR,
beginning with
compressions

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Primary Assessment*
Primary Assessment Action
Assessment Examples Examples
Immediately Airway: patency, secretions, Maintain airway patency,
life-threatening obstruction advanced airway

Breathing: RR, O2 Sat, work of O2, BVM, avoid excessive

breathing, lung sounds, tracheal ventilation
deviation

Circulation: HR, BP, LOC, IV, monitor, fluids, waveform

bleeding, temperature capnograph

Disability AVPU, neurological function

Exposure Remove clothing, obvious signs

of trauma, bleeding, burn,
needle mark
*for unconscious patients in arrest (cardio or respiratory): conducted after completing BLS assessment
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Secondary Assessment*
Secondary Assessment Action
Assessment
Systematic survey History (SAMPLE) Investigations
Signs and symptoms
Allergies Differential diagnoses
Medications
PMHx Treatments
Last oral intake
Events prior

5H5T

Head-to-toe Exam

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H’s and T’s
 Hypoxia  Tension pneumothorax
 Hypovolemia  Tamponade cardiac
 Hydrogen ion (acidosis)  Toxins
 Hypo/hyper kalemia  Thrombosis Pulmonary
 Hypothermia  Thrombosis Coronary

*Consider to use the memory aid SAMPLE;

S – Signs/Symptoms (Symptoms are important but they are subjective.)
A – Allergies
M – Medications
P – Past Illnesses
L – Last Oral Intake (Sometimes also Last Menstrual Cycle.)
E – Events Leading Up To Present Illness / Injury

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Conclusions
 Code Blue skills are parts of BLS-ACLS
 Code Blue SOP should be derived from BLS-ACLS
algorithm
 Early CPR and defibrillation are the main important
steps; Time is myocardium
 Practice makes perfect; leadership and teamwork skills

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References
• Eroglu SE., et.al. Blue code : Is It A Real Emergency?
Word J Emerg Med 2014; 5(1): 20-23.
• Keys,VA.,et.al. Code Carnivals: Resuscitating Code
Blue Training With Accelerated Learning. J Contin
Educ Nurs 2009;40(12):560-564.
• Qureshi, SA., et.al. A Standardized Code Blue Team
Eliminates Variable Survival from In-Hospital Cardiac
Arrest. J Emerg Med 2012; 42(1): 74–78.

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haedaryahya@yahoo.com

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