Code Blue (Protected)

Key Points

  • The clinical procedures for Protected Code Blue are similar to those for Emergency Intubation during COVID 19 pandemic.
  • Cardiopulmonary resuscitation (CPR) is considered an aerosol generating procedure. Medical personnel involved in CPR of patients with COVID positive / unknown status must wear FULL aerosol generating procedure PPE.
  • Medical personnel involved in resuscitation must don FULL PPE (airborne transmission) quickly but meticulously prior to initiation of resuscitation.
  • Do not rush into the resuscitation room without proper donning. This is a paradigm shift for many health care providers.
  • Minimize the number of personnel in the room during resuscitation.
  • Recommend administering a full dose of muscle relaxant for paralysis prior to intubation even when vital signs are absent.
  • Stop chest compression at the time of endotracheal intubation to prevent the risk of viral aerosolization.



  • Preferably resuscitation is performed in an isolation room with negative pressure ventilation; if not possible, ensure all doors are all closed.
  • Minimize the number of door opening and people entry during resuscitation


  • Prefer to use disposable equipment over reusable equipment whenever possible.
  • Use a dedicated COVID resuscitation cart, cardiac monitor, intubation and drug cart containing only essential supplies.  Many protocols recommend discarding all unused disposable items in the room after resuscitation thus bring in only essential items into the room.
  • Drape to cover resuscitation cart, monitors and other airway equipment where appropriate.

Drugs & Equipment INSIDE the Room

  • A dedicated COVID cardiac arrest cart with monitor and defibrillator.
  • Confirm room oxygen supply, nipple, and suction before entry into room.
  • Ventilation & oxygenation equipment
    1. Ambu / Laerdal bag & mask
    2. inline suction system
    3. airway extension (tube catheter mount)
    4. breathing HEPA viral filter
    5. CO2 detector
      assemble equipment before entering the patient’s room


  • Airway and intubation equipment:
    1. video laryngoscope + blades (e.g, C Mac with #3 and D blades)
    2. oral airways
    3. ETT tubes (consider evac ETT for prolonged ICU intubation)
    4. malleable stylet
    5. syringe to inflate cuff
    6. ETT securing device / tape
    7. Yankauer suction
  • Assemble all equipment and place in a box prior to room entry


  • Cardiovascular drugs - basic resuscitation drugs per local hospital protocol e.g.,  1) epinephrine; 2) atropine; 3) amiodarone
  •  Anesthesia drugs:
    1. rocuronium 10 mg/mL x 10 mL
    2. ketamine / propofol / midazolam / fentanyl (as needed)
    3. phenylephrine
  • Consider preparing a COVID code blue box containing an ACLS COVID card, disposable stethoscope, role sticker, pen, stop watch, plastic cover for arrest record, checklist for transportation and other essential items.

Drugs and Equipment OUTSIDE the Room

  • Main cardiac arrest cart with other cardiac drugs e.g., lidocaine, dopamine; vasopressin; adenosine, sodium bicarbonate dextrose, magnesium, and nitroglycerin
  • Other airway, oxygen and ventilation equipment e.g., Bougie, second generation LMA (size 3, 4, and 5), gel pack to lubricate ETT / LMA if necessary (dry secretion) and difficult intubation cart including fiberoptic bronchoscopy and surgical airway kit.



  • The patient may be in one of the following situations:

            1) scenario # 1 true Code Blue, i.e., absent vital signs;

            2) scenario # 2 Code Blue called due to respiratory failure or airway obstruction;

            3) scenario # 3 Code Blue called due to a non cardio-respiratory event e.g., seizure.

  • If the patient has an oxygen mask on, leave it on until intubation to minimize droplet and airborne spread.

Medical Team

  • Conduct an expedited review of pertinent patient history, cardio-respiratory