Code blue · adult ALS

Approach to Basic Resuscitation

A bedside flow for the first ten minutes of an in-hospital cardiac arrest.

recognize → ABC + CPR → rhythm → airway → drugs → reversibles → post-ROSC

Step 1

Recognition & call for help

Confirm unresponsiveness and no breathing / only gasping
Activate the code team immediately
Bring crash cart, cardiac monitor, defibrillator, airway equipment, and IV/IO access

Step 2

Airway: open the airway and provide oxygen (bag-mask ventilation)
Breathing: 2 breaths every 30 compressions if no advanced airway; once advanced airway is in place → 1 breath every 6 sec (10/min)
Circulation: start high-quality CPR
- Rate: 100–120/min
- Depth: 5–6 cm, allow full recoil
- Minimize interruptions < 10 sec
- Switch compressors every 2 min

Step 3

Every 2 min of CPR → check rhythm
Shockable (VF / pulseless VT) shock
- Immediate defibrillation 200 J biphasic (or per device)
- Resume CPR immediately after
- Epinephrine after the 2nd shock; amiodarone after the 3rd shock
Non-shockable (PEA / asystole)
- Continue CPR
- Administer epinephrine 1 mg IV/IO every 3–5 minutes as early as possible

Step 4

Initial: bag-mask ventilation
Once anesthesia is available, consider supraglottic airway or endotracheal intubation
Do not interrupt compressions for >10 sec

Step 5

Establish IV or IO access early
Epinephrine 1 mg IV/IO q3–5 min
- Non-shockable: give ASAP
- Shockable: after 2nd shock
Amiodarone 300 mg IV bolus (or lidocaine) for refractory VF / pulseless VT
Calcium, sodium bicarbonate, magnesium, steroids → not for routine use except specific indications (e.g. hyperkalemia, TCA toxicity)

Step 6

The Hs

The Ts

Step 7

Reference

Last reviewed · May 2026