Code Blue Procedures
Updated Mar 2006: D. Tucker, RPh, BCPS
with K. Wahby, PharmD and R. Simpson, PharmD
Objectives
To acquaint the pharmacist with the activities
of a code blue emergency
To identify the procedures followed during a
code blue emergency by the pharmacist
To elucidate the appropriate conduct to
follow during a code blue emergency by the
pharmacist
Why Pharmacist Participation
Use of medications is an inherent part of
most code blue emergencies
Preparation of intravenous medications
comes under the purview of pharmacists
It is a dynamic and interactive process of
pharmaceutical care
Crash Cart Locations
Determine location of crash cart on any
unit(s) covering
Replacement medication trays are kept in the
central pharmacy manufacturing area
Replaced to ICU Pyxis machines
Replaced to CPD post-code when cart is cleaned
and medications and instruments replaced
HUH/HWH Crash Cart
Components
Drawer 1:
Medications Drawer 3:
Syringes
Needles
Drawer 6:
Drawer 5: Gloves
IV Fluids Face masks
Angiocaths
RIM Crash Cart Components
Drawer 3:
IV Fluids
Drawer 4:
Medications
Drawer 5:
Gloves Drawer 6
Syringes Gloves
Needles Stethoscope
Attending a Code Blue
Notification
Overhead PA system
Code blue pager
Reach site of code
Take stairs when possible
Enter room/area and identify yourself to staff
already in attendance
Pharmacist Procedures
If the medication tray is still in the cart,
remove it at an opportune time when the
other drawers are not in use
If medication tray is already being attended
by a physician or nurse, offer to work with
them or to handle the medications
Remove the Medication Tray
RIM Crash Cart
Medication
Tray
HUH/HWH Crash Cart
Place Tray on Solid Surface
Medication Tray
Remove the
plastic from
the tray
Pharmacist Procedures
Identify the physician calling the code
Identify the nurse recording the events
Stand by the medication tray in sight of the
physician running the code
If possible, be in view of the ECG monitor
Pharmacist Procedures
Identify yourself to the recording nurse
If events allow, identify yourself to the
physician calling the code
Locate the nurse or physician administering
the medications
Syringe Preparation
At the start of the code open and assemble an
epinephrine and an atropine syringe
Replace each assembled syringed in its box to make
quick identification easier
Draw up 2-3 syringes with 20ml NS for flushing
between doses of medications
To Assemble a Syringe
Open the syringe box
from the side indicated
To Assemble a Syringe
So that the two parts
fall out into your hand,
then
To Assemble a Syringe
Flip off the plastic end-
caps and
To Assemble a Syringe
Attach the medication
half to the plunger half
with a push
To Assemble a Syringe
And a twist until
resistance is met
Pharmacist Procedures
Obtain IV solutions, syringes, and needles
from the cart as necessary for requested
medications
Determine if IV medications will be
administered by needle or blunt tip system;
may need to exchange needles on syringes
Stay focused on physician calling the code
Dispensing Medications
Select correct medication requested by the
physician calling the code
Assemble the syringe (if not done in earlier
step) or draw up medication requested;
change to blunt tip system if required
Step to bedside and loudly read name of
medication and dose from syringe or vial as
you hand it to the administering MD or RN
Dispensing Medications
Reading name of dose of medication from
syringe or vial
Ensures that the correct medication is being
dispensed
Is a double check that the correct medication is
handed to the administering physician or nurse
Dispensing Medications
Return to stand by the medication tray
Check with recording nurse that the correct
time and medication were recorded
Try and use overhead clock in room to write
administration times so everyone can follow the
medication timing
Draw up another syringe/vial/ampule of
medication just used
Dispensing Medications
Helpful hints
Back of the medication list found in the
medication tray contains dosing basics
Keep track of empty boxes/vials/ampules as
physician calling the code often asks how much
of various medications were already used
z Line up empty containers next to the medication tray
as used
z Keep track of timing between doses of epinephrine
z The recording nurse can corroborate counts and timing
Dispensing Medications
More helpful hints
Wearing gloves is not mandatory
Be aware that other code blue attendees may
encounter blood then hand you a syringe to
dispose of in the needle box,
Therefore, know where to find gloves and try to
keep some nearby in case they are needed
Preparing Medications
Helpful hints
If possible, check patient’s chart for allergies,
age, height, and weight
Correct patient demographics make for more
accurate calculation of doses or infusion rates if
needed
Preparing Medications
Amiodarone
Initial dose: 300 mg IVP qs to 20
ml with NS or D5W; may repeat
with 150 mg qs to 20 ml prn
Infuse each dose over 10 minutes
Infusion dose: 150 mg in 150 ml
D5W; stable for 2 hours only
Infuse at 1 mg/minute = 60 ml/hour
Kit with drug, label, and IV fluid
in medication tray
Preparing Medications
Norepinephrine
Dilute 4 mg in 250 ml D5W or
D5NS (16 mcg/min)
Avoid dilution with plain NS
Infuse at 0.5-1 mcg/min and
titrate up to 30 mcg/min to
improve blood pressure
Avoid giving in same line as
alkaline solutions
Preparing Medications
Isoproterenol
Dilute 1 mg in 250 ml D5W, LR,
or NS (4 mcg/ml)
Infuse at 2-10 mcg/min titrated
to an adequate heart rate
Preparing Medications
Epinephrine
For cardiac arrest, dilute 30
mg epinephrine (30 ml of
1:1000 solution) in 250 ml
NS or D5W to infuse at 100
ml/hr and titrate to response
For bradycardia, dilute 1 mg
of 1:1000 epinephrine in 500
ml NS and infuse at 1-5
ml/min (2-10 mcg/min)
Preparing Medications
Procainamide
Dilute 1 grams in 250 ml D5W
or NS (4 mg/ml)
Maximum concentration 20
mg/ml
Recurrent VF/VT: 20 mg/min
up to 50 mg/min with maximum
dose of 17 mg/kg
Maintenance: 1-4 mg/min
Professional Conduct
Always remain focused on the physician
calling the code
Watch and be aware of events going on
around you
Never leave a code that is underway without
arranging for someone to handle medications
and, if possible, letting the physician calling
the code know
Professional Conduct
Sometimes additional medications are
needed; options to obtain them include:
Calling from room to have tubed or delivered to
nursing unit, i.e., phenytoin IVPB; send RN,
MD, or other pharmacist to pick up from tube
Having RN, MD, or other pharmacist go to front
desk and call pharmacy
Having RN or other pharmacist obtain
medication from Pyxis, i.e., flumazenil
Professional Conduct
End of Code
Always ask permission to leave even though the
code has ended as further drips and their
calculated rates may be needed
Clean up your area and dispose of syringes and
waste paper in the appropriate containers
Conclusion
Always remain calm and in control
Note that each code you attend will be a
different scenario; be alert and pay attention
Remember that participation in code blue
emergencies becomes easier with each time
you do it
