Code Blue Nursing Guide 2026: CPR, ACLS & Nurse Roles
Part of the ICU Emergencies Hub — browse every related guide in one place.
This article was created with AI assistance.
Code blue = cardiac/respiratory arrest. Call the code immediately. Do NOT delay CPR to call the physician first. Time to first compression is the single biggest determinant of survival.
Recognizing Cardiac Arrest
- No response to verbal or sternal rub stimulation
- No normal breathing (absent or gasping/agonal only)
- No pulse (check carotid 5–10 seconds; do NOT delay CPR if unsure)
Immediate Actions (First 30 Seconds)
- Call for help — activate code blue (use call light, shout, or crash button)
- Start chest compressions immediately
- Attach AED/defibrillator as soon as available
- Designate a team leader when help arrives
Code Blue Team Roles
| Role | Responsibility | Key Actions |
|---|
| Team Leader (MD/ACLS provider) | Directs resuscitation; makes decisions | Calls rhythm interpretations; orders drugs; decides to defibrillate; assigns roles |
| Compressor (Nurse 1) | Chest compressions | Hard, fast, full recoil; switch every 2 min to prevent fatigue |
| Airway (Nurse 2 or RT) | Manages airway | BVM ventilation; assists intubation; confirms tube placement |
| IV/Medication Nurse | Draws and gives medications | Announces: "Epinephrine 1 mg IVP given at 10:32"; confirms orders |
| Recorder (Nurse) | Documents timeline | Times compressions, shocks, drugs; tracks 2-min cycles; reads back orders |
| Family Liaison | Communicates with family | Remove family from room if needed; keep informed; pastoral care |
Closed-loop communication: Leader orders → nurse repeats back to confirm → leader acknowledges. This prevents medication errors and confusion during high-stress codes.
High-Quality CPR Standards (2020 AHA Guidelines)
| Element | Standard |
|---|
| Compression rate | 100–120 per minute |
| Compression depth | At least 2 inches (5 cm); no more than 2.4 inches (6 cm) |
| Hand position | Lower half of sternum; heel of hand; 2-hand technique |
| Full chest recoil | Allow complete recoil between compressions; do NOT lean on chest |
| Interruptions | Minimize; <10 seconds for any pause (rhythm check, defibrillation) |
| Compression fraction | ≥60% of resuscitation time spent doing compressions |
| Ventilation rate | 1 breath every 6 seconds (10/min) during continuous compressions with advanced airway |
| Ratio (no airway) | 30:2 (30 compressions: 2 breaths) |
| Compressor switch | Every 2 minutes to prevent fatigue-related degradation |
Cardiac Arrest Algorithm (Simplified)
Shockable Rhythms: VF / Pulseless VT
- Start CPR; attach defibrillator
- Shock (biphasic 120–200J or per device recommendation)
- Resume CPR immediately x 2 min
- Epinephrine 1 mg IV every 3–5 min
- Rhythm check q2 min; shock if shockable
- After 2nd shock: Amiodarone 300 mg IV (then 150 mg for 2nd dose) OR Lidocaine 1–1.5 mg/kg IV
- Treat reversible causes (H's and T's)
Non-Shockable Rhythms: Asystole / PEA
- Start CPR immediately
- Epinephrine 1 mg IV as soon as IV/IO access obtained; repeat every 3–5 min
- NO defibrillation (no shockable rhythm)
- Search for and treat reversible causes (H's and T's)
- Rhythm check q2 min
H's and T's (Reversible Causes)
| H's | T's |
|---|
| Hypovolemia | Tension pneumothorax |
| Hypoxia | Tamponade (cardiac) |
| Hydrogen ion (acidosis) | Toxins (drug OD) |
| Hypo/Hyperkalemia | Thrombosis (pulmonary — PE) |
| Hypothermia | Thrombosis (coronary — MI) |
Defibrillation
CLEAR! Before every shock, verbally announce "I'm going to shock — everyone clear!" and visually confirm no one is touching the patient or bed. Shocks to staff = serious injury.
- Biphasic defibrillation: 120–200J (per device); if unknown, use maximum setting
- Pad placement: right clavicle (sternum) + left lower rib (lateral)
- Synchronized cardioversion: for hemodynamically unstable A-fib/flutter, SVT, unstable VT with pulse. Start 100–200J biphasic for A-fib; 50–100J for SVT/flutter
- Resume CPR immediately after shock — do NOT pause to check rhythm
ACLS Medications
| Drug | Dose | Indication | Notes |
|---|
| Epinephrine | 1 mg IV q3–5 min | All cardiac arrest rhythms | Follow with 20 mL NS flush; elevate arm |
| Amiodarone | 300 mg IV x1, then 150 mg | Shock-refractory VF/pVT | Give after 2nd shock |
| Lidocaine | 1–1.5 mg/kg IV | VF/pVT (alternative to amiodarone) | May repeat 0.5–0.75 mg/kg q5–10 min |
| Magnesium Sulfate | 2 g IV push | Torsades de Pointes | For hypomagnesemia-related VF/VT |
| Sodium Bicarb | 1 mEq/kg IV | Hyperkalemia, TCA OD, severe acidosis | NOT routine; specific indications only |
| Calcium Chloride | 1 g (10 mL of 10%) IV | Hyperkalemia, calcium channel blocker OD | Flush line before and after; caustic to veins |
| Atropine | 1 mg IV (max 3 mg) | Symptomatic bradycardia (NOT asystole) | No longer recommended for asystole in 2020 AHA guidelines |
Post-Resuscitation Care (ROSC)
ROSC = Return of Spontaneous Circulation. Care after ROSC:
- Airway: Confirm tube placement; target SpO2 94–98%; avoid hyperoxia; titrate FiO2 down
- Breathing: Target PaCO2 35–45 mmHg; normocapnia; avoid hyperventilation
- Circulation: Target SBP ≥90 mmHg; MAP ≥65 mmHg; vasopressors as needed; 12-lead EKG ASAP; emergent cath lab if STEMI
- Temperature: Targeted Temperature Management (TTM): maintain 32–36°C for 24 hours in comatose patients; prevent fever
- Glucose: Target 140–180 mg/dL; avoid hypoglycemia
- Neuro: Avoid stimulation; neuro assessment q1h; CT head if any focal deficits
- Family: Immediate update; prognosis conversations are MD's role
Code debrief: AHA recommends a structured debrief within 24 hours of every code. Helps identify system issues and support team wellbeing.
NCLEX High-Yield Points
- VF and pulseless VT = SHOCK first; asystole and PEA = CPR + epinephrine (no shock)
- Epinephrine 1 mg IV every 3–5 min is the only ACLS vasopressor
- Compression rate: 100–120/min; depth: at least 2 inches
- Atropine is NOT recommended for asystole (2020 AHA guidelines)
- After ROSC: target SpO2 94–98% (not 100%); TTM 32–36°C for 24 hours in comatose
- Synchronized cardioversion = QRS present; defibrillation = no QRS (pulseless)
- Resume compressions IMMEDIATELY after every shock — do NOT pause for pulse check first
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