Code Blue: What Should I Do?

There is nothing that gets your adrenaline going more than a cardiac or respiratory arrest during your shift, especially on a patient you were just going to do routine vital signs on...what do you do? Everyone has an initial fear, but it's how you work through that feeling, that can save lives. Nurses General Nursing Article


Code Blue: What Should I Do?

Code Blue (cardiac/respiratory arrest) events in-hospital can be really scary, especially if you work in the Medical-Surgical or procedural areas because they are so unexpected (most often, I should say.) I remember my first code quite clearly: a coworker and I were in a double room, helping to admit a relatively healthy (by transplant unit standards) patient, and as we were walking out to finish up the admission paperwork, we saw the patient in the first bed take his last breath. This man was not well, but we did not expect him to go into cardiac arrest!

So what did we do?

We both froze for probably 5 seconds, but it felt like forever, and another nurse walking by saw the scene, called out for help and ran to get the code cart, shouting at us to start compressions. She knew what to do and got us all doing what we needed to for the patient, and then we worked as a team. The code team showed up and took over leading the code within a few minutes and it was as if our hesitation didn't matter (it ultimately had no negative effects on the outcome of the patient), but it did matter to me. I have never felt so horrible about not knowing what to do like that very day, and I vowed that I would never let a patient down because of my own fears again, and I haven't. I have overcome my fear, I actually love responding to codes, and I now train others in how to respond to codes...and hopefully take the fear out of it for them too!

I know that fear of the coding patient, but I also know that while you don't have to be an adrenaline junky like me, you can train yourself to work through that fear you have the first few minutes because you can start to think of a code like changing a dressing over a wound: there are certain steps that need to be completed in order. Sounds to simple? I promise, it's not. And, if you have Advanced Cardiac Life Saving certification along with Basic Life Saving, that's great, but we all have that same adrenaline rush (or 'fear') for the first few minutes, no matter how many certifications we all have, we are still humans and responding to the unexpected life or death situation, right?

Breaking down codes into roles, and having situational awareness of it all will help you to feel confident in your skills during a code event. Based on the American Heart Association's guidelines, the roles of responders can be clear, concise, and very simple:

1st Responder (the person first on scene at an arrest):

  1. Call for help
  2. Drop the head of the bed so the patient is flat
  3. Check a carotid pulse (if you aren't sure if it's yours, theirs, or if there is one at all go to step 4)
  4. Start compressions (see above: if someone has a pulse and you just can't feel it, trust me, they will wake up and tell you to get off of their chest- compressions are NOT comfortable)

2nd Responder:

  1. Bring emergency equipment to the site of the emergency
  2. Help to get a backboard under the patient (if they are not on a hard surface)
  3. Manage the airway (using an Ambu bag or a pocket mask with a one-way valve)

*switch roles with the compressor every 2 minutes

3rd Responder:

  1. Turn on the AED/Defibrillator you have available and USE it (if the patient is pulseless)!

*It sounds silly, but a lot of people turn it on and feel that their job is does need some human interaction and critical thinking skills, like not defibrillating a patient with a pulse.

4th Responder:

  1. Assist in obtaining an IV and getting fluids ready, get emergency medications prepped and ready for the team (if you are comfortable), make sure emergency airway equipment is available, if needed.

5th Responder:

  1. Document the event (this is important for Quality Improvement and Medical/Legal reasons)

Anyone else?

Assist as runners to obtain items that may be needed outside of the room, make any phone calls that may be necessary/requested, and help the code team find the room!

For the first few minutes of a code, this is all you need. You are helping the patient to circulate blood, you are maintaining their airway, and trying to restore circulation through defibrillation (if necessary). When ACLS trained staff/the emergency response team arrives, medications may need to be given, so the patient's primary nurse should stay with the code team leader to give vital information about the patient so they can figure out why this happened and how best to treat it.

How to overcome your fear?

  • Practicing emergency events on your unit can help you immensely; the more you practice, the less you have to think about what you are doing as it becomes second nature (talk to your Manager/CNS/Educator about doing mock codes).
  • Get in the room, and take on a role, in every emergency that you can...if you can't practice with mock codes, the real thing is the best experience!
  • When you respond to an emergency, if you need a moment to take a breath before you get into action, take it, it will help you to use your adrenaline to focus on what needs to be done.
  • Debrief: talk to the other responders after real/mock code events and speak honestly about what you felt about the response, including what went really well, and what could be improved for next time. It will make you feel better and realize that everyone has fears and stresses about codes.

What should you try to avoid?

Running away: I understand the whole fight or flight response, but don't fly....please? You need to be there for your patient; fight through it!

Switching roles without communicating: If you need to switch roles for some reason, communicate with someone else in the room to make sure they are taking over your role (maybe you don't feel comfortable with the AED, or someone needs you to take over compressions, so communicate clearly that they need to cover your role).

Yelling: You can communicate best by speaking, and people respond best to clear and concise communication, as opposed to yelling.

When you walk into an emergency situation, think of the roles of responders, and as each action as a task that needs to be completed, just like any other routine care of a patient, and you will slowly but surely overcome your fears. You have the skills and you can put them into action, so be confident in your competence and keep saving lives!

Learn more in Part II of this topic!

Clinical Nurse Specialist, Emergency Cardiovascular Specialty: Surgery,Critical Care,Transplant,Neuro

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249 Posts

When in doubt. Epi out.


49 Posts

Want to look ,and feel like you are making a difference once a code has started ? No other , than the "Flush Man " . Yes, the "Flush Man " is in it to win it -other than the CPR guy. When the code is over -good or bad - you looked amazing during the code. Plus, no signing forms , not out of breath , etc. -you are free as a bird.

prmenrs, RN

4,565 Posts

Specializes in NICU, Infection Control.

Practice! Not the whole code, just the 'getting going' part. The more you do it, the easier you can just drop into action

The nurse whose assignment the patient belongs to will be quizzed numerous times--who is the patient, who's the doc, dx, meds, labs, what they ate for lunch, what color their scivvies are, and so forth. Yes, it's all in the chart, no, no one will take time to look @ it, so get ready. If you can bring a mobile computer in to access x-rays, labs, notes etc., that will help.

Specializes in Emergency/Cath Lab.

Communication is the big key through all of it. I like doing meds. Its my go to spot. I make sure to find the recorder and make sure to say what I gave and how much I gave each and overtime so they hear it. As a recorder, repeat it so I know you heard it. My next med is dependent on when I gave the last and if I ask you what time I gave the last at, I hope you know.


45 Posts

Specializes in Med/Surg crit care, coronary care, PACU,.

Our facility started doing Med-Surg code blue simulations on all 3 shifts, and the response has been tremendous. Overwhelmingly beneficial according to responding nurses, and support staff. As a code responder for many years, I appreciate staff initiating BLS, as opposed to past years where CPR has not even been initiated due to the shock of the situation. I can say that our patients who survive an event surely would appreciate the effort on their behalf. Also, a critical debriefing after an event is quite beneficial especially for new code responders, or an especially emotional event, I can't support this enough!!

Specializes in ICU.
Want to look ,and feel like you are making a difference once a code has started ? No other , than the "Flush Man " . Yes, the "Flush Man " is in it to win it -other than the CPR guy. When the code is over -good or bad - you looked amazing during the code. Plus, no signing forms , not out of breath , etc. -you are free as a bird.

This is so true. This is the role I usually end up taking if there are a ton and a half of people in the room already. There are never enough flushes ready to go. Having them at the ready for the person giving/drawing up meds just makes you look like you are really on top of things and you really know your stuff.


168 Posts

Specializes in ER, cardiac, addictions.

I just had to mention this: on the list of trending threads, this "Code Blue: What Should I Do?" topic was immediately followed by "Just need to vent for a few minutes." :laugh:

Specializes in ICU.
I just had to mention this: on the list of trending threads, this "Code Blue: What Should I Do?" topic was immediately followed by "Just need to vent for a few minutes." :laugh:


That was pretty slick.


8 Posts

Thank you for this great article! I'm a new nurse who is about to finish up my preceptorship on PCU and then I will be flying solo. I haven't had to deal with a code situation yet (twice we got the patient to ICU before they coded!) but I know it is inevitable and my biggest fear is that I will freeze and/or be incompetent even though I know I've been trained for it! This article put my mind at ease a little bit!

prmenrs, RN

4,565 Posts

Specializes in NICU, Infection Control.

Another big tip from when I was a superviser: if you have Med Students, put the biggest one on the chest--s/he can see all the action, and it frees up a nurse for someother task!

Pharmacy should show up, and take over the medication preparation and LABELING!s They can take possession of the Code Record Form. For some reason, they seem to be better at it. Nurses get distracted w/getting stuff.

I'm talking practicality, of course. This happens in the real world. Suction doesn't work, laryngoscope bulbs (that you JUST CHECKED!) is out. The codes I observed back then ran to 2 types: everything went totally horrible, the patient lived long enough to get to the ICU @ least; and everything went perfect, and the patient died anyway. Contrary to popular opinion, we don't have all that much control, we just do the very best we can!


944 Posts

Kind of a pain in the rear after you do a few you don't get the urge "For the big one." Working in EMS and Anesthesia as a responder and tech been around them. Basically patient on hard surface, compressions, crash cart, IV cart, ambulance bag, prime IV, prep endotracheal tubes, stabilize patient, draw blood, do EKGs, monitor, document, and huddle.

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