CODE BLUE DOCUMENTATION – EMERGENCY DEPARTMENT
Patient Information
Patient Name: ________________________
Age/Sex: _____________________________
MRN/ID: _____________________________
Date/Time of Event: __________________
Location: Emergency Department – ______
Code Blue Activation Time: ____________
Team Arrival Time: ____________________
Code Leader: _________________________
Recorder: ____________________________
Circumstances of Arrest
Initial Event: Patient found unresponsive in the Emergency Department.
Immediate Condition: No spontaneous breathing, no palpable pulse, unresponsive.
Witnessed/Unwitnessed: __________________
Time Last Seen Well: ____________________
Initial Rhythm: _________________________
Airway Status on Arrival: _______________
IV/IO Access: __________________________
Resuscitation Interventions
Airway & Breathing:
- Bag-valve-mask ventilation initiated.
- [Endotracheal tube / Supraglottic airway] placed at ________. Placement confirmed by:
• Bilateral chest rise
• End-tidal CO₂ ______
• Auscultation
- Oxygen delivered at 100%.
Circulation & Chest Compressions:
- High-quality CPR initiated at ________.
- Compression:ventilation ratio maintained 30:2 (prior to advanced airway) /
continuous after.
- Pulse checks every 2 minutes.
- IV/IO access secured at site: __________.
Defibrillation (if shockable rhythm):
- Initial Rhythm: __________________
- Shock #1: ______ J at ______
- Shock #2: ______ J at ______
- Shock #3: ______ J at ______
Medications Administered:
- Epinephrine 1 mg IV/IO at ________
- Amiodarone 300 mg IV at ________
- Additional medications: ___________________________
Other Interventions:
- Reversible causes considered (Hs & Ts): Hypoxia, Hypovolemia, Hypothermia,
Electrolytes, Toxins, Tamponade, Thrombosis, Tension pneumothorax.
- Fingerstick glucose: ______ mg/dL
- IV fluids/bolus administered: ____________
Rhythm & Pulse Checks
Initial Rhythm: ________________________
Subsequent rhythms: ____________________
ROSC achieved at: ______________________
Evidence of ROSC: Palpable pulse, BP ____, ETCO₂ ____, spontaneous respirations.
Post-ROSC Management
Vital Signs Post-ROSC:
- HR: ______ bpm
- BP: ______ mmHg
- SpO₂: ______ %
- RR: ______ /min
- Temp: ______ °C/°F
Airway: ________________________________
IV/IO lines: ___________________________
Fluids/Vasopressors: ___________________
12-lead ECG: __________________________
Labs Sent: ABG, CBC, CMP, Troponin, Lactate
CXR Ordered: Yes / No
Family Notified: Yes / No (time/person)
Transferred to: ICU / CCU / Cath Lab / Other
Outcome of Code
ROSC achieved at: ______________________
Patient condition: Critical / Guarded / Stable
Code concluded at: ______________________
Signatures
Code Leader (Physician): __________________
Recorder (Nurse): ________________________
Team Members: ___________________________