Code Blue (Protected)

Resuscitation UKKey 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

pcb_prearrest pcb_roleofmonitorsup pcb_cardiacarrest pcb_allunits
  • Conduct an expedited review of pertinent patient history, cardio-respiratory     status, oxygenation status, COVID status, and appropriateness of resuscitation outside the room. Confirm DNR status.
  • Clearly delineate roles, use closed loop communication and articulate clear plan for resuscitation and airway management.
  • Hospital protocol varies regarding the number of medical personnel in the resuscitation room.  The overall goal is to limit the number of people in the room.
  • At a minimum, the team inside the room will consist of:
    1.  one member acting as both the code blue team leader and the experienced airway operator - staff anesthesiologist or ER / ICU physician       
    2. airway assistant - respiratory therapist (RT)
    3. RN to monitor vital signs and administer drugs and
    4. one member to do CPR.
      Outside the room: 1-2 door runners - RN and unit attendant to respond to equipment / drug needs.
  • For a bigger team concept, the team inside the room will comprise:
    1. code blue team leader (per local hospital policy)
    2. an experienced airway operator - staff anesthesiologist or ER / ICU physician
    3. airway assistant - respiratory therapist (RT)
    4. RN to monitor vital signs and administer drugs
    5. in room runner - registered nurse (RN) for documentation and time keeping
    6. one team member to perform cardiac compression
    7. a second member to do CPR. 
      Outside the room: 1-2 door runners - RN and unit attendant to respond to equipment / drug needs.
  • All resuscitation team members don FULL personal protective equipment (PPE) properly before entering room.  CPR is an aerosol generating procedure.  Do not rush. (See PPE section)
  • Donning doffing PCB - VIDEO
  • Donning and Doffing Full Precautions (UHN) - VIDEO
  • Assign a clean safety officer (spotter) to supervise donning and doffing PPE.
  • Leave all non-essential personal items outside the room.
  • Full PPE consists of:
    1. a disposable Association for the Advancement of Medical Instrumentation (AAMI) level III fluid resistant long sleeve gown
    2. long cuffed gloves (double)
    3. eye protection (goggles or full face shield
    4. fit tested N95 respirator
    5. neck bib protector
    6. hair cover / hood.
      Follow local hospital infection prevention and control protocol.

  • Some protocols recommended Level 3 PPE protection procedure as follows: hand disinfection → head cap → protective mask N95 → surgical masks → isolation gown → disposable latex gloves → goggles → protective clothing → disposable latex gloves → shoe covers → disposable gown → disposable latex   gloves → full head hood (Mengqiang Luo MQ et al. Precautions for Intubating Patients with COVID-19. Anesthesiology, 2020). 
  • VIDEO - Humber River Hospital Protected Code Blue Strategy
  • The reason for a second layer of disposable gown and glove is the option of removing the outer layer once intubation is completed.  This will minimize the risk of contamination to any equipment or furniture in resuscitation room.
  • Wash hand with disinfectant-containing alcohol whenever possible after a contaminated task.
  • Record names of all participating staff members in case of contact tracing.
  • Simulation training is strongly recommended for preparation ahead of Protected Code Blue surge.




  • Outside the resuscitation room, assemble the  Ambu / Laerdal bag & mask in the following manner: face mask, inline suction, airway extension, filter, CO2 detector, ventilation bag and oxygen supply tube (see picture).  Tighten all connections.

Use a high efficiency hydrophobic heat and moisture exchanging (HME) filter with 99.99% bacterial/viral efficiency.

  • Once entered room, place drugs and airway equipment on a table, and position video laryngoscope stand and cardiac monitor in appropriate locations around the bed.
  • Check oxygen supply and suction system.
  • Apply defibrillator to check cardiac rhythm, assess patient’s level of consciousness, vital signs and sign of respiratory effort. Defibrillate if indicated.
  • Turn off the oxygen flow before removing patient’s procedural mask and oxygen mask to minimize viral aerosolization.


For scenario # 1 - True Code Blue - Absent Vital Signs

  • If patient has no vital signs and no respiration, proceed to intubation immediately. Hold chest compression if already in progress.
  • Flush iv line to check for patency.
  • Perform rapid sequence intubation. Suggest use rocuronium >1.5 mg/kg and then intubate.
  • Recommend the most experienced airway operator to intubate assisted by an experienced RT / RN.
  • Prefer to use video laryngoscopy as a first line approach to visualize and confirm airway intubation. Recommend using disposable plastic blades e.g., for C-MAC and McGrath laryngoscope or a single use disposable video laryngoscope.
  • Pay attention to the intubation posture.  Suggest the airway operator to stand upright and step back to maximize the distance between the airway operator’s face and the patient during intubation.
  • Place video laryngoscope and all airway equipment into a dirty bin in one move; seal for decontamination.
  • Once intubation is completed, inflate endotracheal tube (ETT) cuff fully and reconnect ETT to Ambu / Laerdal bag and filter immediately.  Check for cuff leak before starting positive pressure ventilation.
  • Confirm positive CO2 detection.
  • Avoid manual IPPV using face mask before intubation; if necessary for rescue oxygenation, use minimal tidal volume and low ventilation pressure using 2 person vice grip technique with an oral airway.
PCB grip
  • One may consider covering the area around the patient’s mouth and nose with a wet gauze to help prevent virus spreading during assisted bag mask positive ventilation ((Mengqiang Luo MQ et al. Precautions for Intubating Patients with COVID-19. Anesthesiology, 2020).
  • After successful intubation, suggest remove outside contaminated gloves if double gloving and remove contaminated gown if no PPE shortage.
  • Confirming the depth of the ETT is difficult using auscultation while wearing PPE. Suggest use point of care ultrasound to confirm bilateral lung movement and a CXR later to confirm ETT tip location.
  •  Fogging of eye goggles and poor visibility can be a serious problem during RSI intubation. A possible solution is to apply a layer of anti-fogging agent, such as transparent hand sanitizer to the inside of the goggles.
  • May insert a NG tube (per local resuscitation protocol) to minimize the need for another close contact with the airway.

Scenario # 2 - Respiratory Arrest

Scenario # 3 - Non Cardio-respiratory Event

Failed Intubation

If failed intubation despite video laryngoscopy and bougie intubation, suggest


  • Insert oral airway.
  • Reapply mask using a 2 hand vice grip technique to maintain a good mask seal.
  • Use minimal tidal volume and low ventilation pressure to ventilate manually.
  • Alternatively, insert immediately a supraglottic airway device e.g., Intubating LMA or air-Q to further decrease air leak and as a conduit to facilitate intubation.
  • Note the reliability of seal is greatest with tracheal tube > supraglottic airway > face mask.
  • Last resort for a can’t intubate can’t oxygenate (CICO) situation, use emergency front of neck access (eFONA) technique.

Manual Ventilation After Intubation

  • Ventilate per clinical requirement.
  • Avoid any unnecessary circuit disconnection.
  • When the circuit disconnection is necessary e.g., changing from manual to mechanical ventilation, stop manual ventilation, clamp ETT (e.g., with Kelly forceps); always leave the HME filter attached to the ETT before disconnection to prevent viral aerosolization.
  • Always make a clear loud announcement to alert team members in the room when disconnect ETT from resuscitation bag.


  • For successful resuscitation, transfer the patient to ICU ventilated manually or using a transport ventilator.
  • Ideally there will be 2 teams, team 1 (the resuscitation team) to prepare the patient for transport and team 2 will receive the patient outside the room to minimize the risk of contamination. Both teams will wear PPE per hospital policy.
  • If there is only 1 team, the resuscitation team members must change to clean PPE before transfer.
  • Always clamp the ETT when switching from one method of ventilation to another and remove the clamp when ready to ventilate again.
  • Always keep HME filter connected to ETT whenever disconnect circuit.
  • Maintain muscle paralysis to avoid coughing during transfer.
  • Maintain some level of sedation where appropriate with small aliquots of midazolam or ketamine.
  • Remove contaminated gown and gloves and change to clean PPE before leaving the resuscitation room.
  • Assign a dedicated person who will NOT contact the patient to open doors and operate elevators etc.  Other transport team members do not touch any doors or other hospital equipment during transport.
  • On arrival to the ICU, repeat same disconnection procedure (stop ventilation, clamp ETT, disconnect from Ambu / Laerdal bag and connect to ICU ventilator; declamp ETT and start ventilation.
  • Do not leave any contaminated items on patient’s bed


  • Remove PPE per local hospital protocol before leaving the resuscitation room and ICU. Doffing is preferably done in an anteroom if available. If not available, remove gloves and gown in the resuscitation room and remove face shield and mask outside the room.
  • Doffing with utmost care; use buddy system and use a checklist.
PCB Video      VIDEO
  • Wash hands after each step of doffing.
  • Remember to remove the N95 mask last when doffing.
  • Some protocols suggest changing scrub and taking a shower after having been involved in a COVID case.
  • All surfaces of non disposable equipment and supply must be wiped down after resuscitation per hospital policy.
  • Discard all contaminated disposable equipment per hospital protocol.
  • Team debriefing
  • Staff to complete personal log book of clinical exposures



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