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Resuscitating a Code Blue patient is a high-stress, high-stakes event in any healthcare setting. But responding to cardiac and respiratory arrests in the Emergency Department (ED) presents special challenges that require special consideration. 

Keep reading to learn about the key differences between inpatient in-hospital cardiac arrest (IHCA) response and Code Blue in the ED — as well as three tips that could prove invaluable for saving lives in this unique setting.

Key Differences Between Inpatient IHCA and Code Blue in the ED

An Integrated Chain of Care

Unlike cardiac arrests that occur within more controlled environments throughout the hospital, many patients arrive at the ED with resuscitation already in progress. Or they may arrive at the ED in stable condition, only to code while they are being treated for some other illness or injury.

So ED staff need to be prepared to start resuscitation efforts at any time, under a wide variety of situations, and often with limited information about the patient’s medical history or the events that caused the arrest.

In fact, The Global Resuscitation Alliance has called for the Emergency Department to be considered part of a larger chain of survival for cardiac arrest. This means the ED doesn’t operate as an independent unit, but as part of an integrated system of care that includes emergency response in the field, transport to a hospital, and initial hospital care.1


COVID Complications

The pandemic has made things even more complicated when it comes to resuscitation in the Emergency Department. That’s because ED staff are among the frontline workers at highest risk of COVID-19 infection, so they must take additional precautions during Code Blue events, including using special protocols and PPE. 


Training Considerations

With so many variables to consider, it’s even more important for ED staff to participate in regular, specialized training for resuscitation events. These trainings should focus on improving communication, optimizing the role of each responder, and clarifying the process of handing off patients who arrive in active cardiac arrest.2

3 Clinical Considerations for Code Blue in the ED

In addition to environmental and logistical considerations, there are often important clinical differences in resuscitations that take place in the ED as well. Learning how to recognize and address these opportunities for improved care can make the difference between life and death for Code Blue patients.


Use TEE for Definitive Diagnosis

When a patient arrives in the ED in a state of cardiac arrest, it’s important to quickly diagnose the cause of arrest in order to determine whether defibrillation will be effective. Transesophageal echocardiography (TEE) may be used to diagnose Hs and Ts to determine which protocol should be followed for resuscitation. It can also provide a definitive diagnosis of fine ventricular fibrillation, a condition which is often mistaken for asystole, but which requires a different treatment protocol.3


ECMO Can Help Stabilize Patients and Provide a Bridge to Treatment

In conjunction with CPR, Extracorporeal Membrane Oxygenation (ECMO) can support patients with life-threatening conditions, such as circulatory arrest or shock, severe trauma, near drowning, and hypothermia. Both Venovenous (VV) ECMO, which is used to support lung function, and Venoarterial (VA) ECMO, which supports both heart and lung function, can help maintain fluid circulation to the patient’s organs while responders stabilize an acute injury.4

Also known as Extracorporeal Life Support (ECLS) or Extracorporeal Cardiopulmonary Resuscitation (ECPR), ECMO requires specialized training and also more staffing resources than other forms of resuscitation or life support. But its costs are far outweighed by its value as a lifesaving bridge to treatment for patients in cardiac and/or respiratory arrest.5


Give Special Consideration to Hypotensive Patients

Patients presenting with low blood pressure are at higher risk of going into cardiac arrest during intubation. Therefore, staff should carefully consider using pressors and fluids to maintain normal blood pressure in patients who aren’t breathing when they arrive at the ED.6

The Bottom Line? Be Prepared.

Responding to cardiac arrest in the Emergency Department requires unique considerations. Staff must be prepared to respond to a wide variety of patients and cases in a fluid environment.

And while EDs will always be inherently more unpredictable than other hospital settings, understanding these logistical and clinical differences can help EDs improve their resuscitation response, and, ultimately, save more lives.


How Can We Help?

With solutions from Nuvara, response teams in your Emergency Department can more easily and effectively capture the Code Blue care process — and adhere to best practices thanks to in-the-moment guardrails that align with ACLS algorithms.


  1. Nadarajan, G., Tiah, L., Ho, A., Azazh, A., Castren, M., Chong, S., El Sayed, M., Hara, T., Leong, B., Lippert, F., Ma, M., Ng, Y., Ohn, H., Overton, J., Pek, P., Perret, S., Wallis, L., Wong, K., & Ong, M. (2018). Global resuscitation alliance utstein recommendations for developing emergency care systems to improve cardiac arrest survival. Resuscitation, 132, 85–89.
  2. Losert, H. (2006). Quality of cardiopulmonary resuscitation among highly trained staff in an emergency department setting. Archives of Internal Medicine, 166(21), 2375.
  3. Teran, F., Dean, A. J., Centeno, C., Panebianco, N. L., Zeidan, A. J., Chan, W., & Abella, B. S. (2019). Evaluation of out-of-hospital cardiac arrest using transesophageal echocardiography in the emergency department. Resuscitation, 137, 140–147.
  4. Panchal, A. R., Berg, K. M., Hirsch, K. G., Kudenchuk, P. J., Del Rios, M., Cabañas, J. G., Link, M. S., Kurz, M. C., Chan, P. S., Morley, P. T., Hazinski, M., & Donnino, M. W. (2019). 2019 american heart association focused update on advanced cardiovascular life support: Use of advanced airways, vasopressors, and extracorporeal cardiopulmonary resuscitation during cardiac arrest: An update to the american heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 140(24).
  5. Swol, J., Belohlávek, J., Brodie, D., Bellezzo, J., Weingart, S. D., Shinar, Z., Schober, A., Bachetta, M., Haft, J. W., Ichiba, S., Sakamoto, T., Peek, G. J., Lorusso, R., & Conrad, S. A. (2018). Extracorporeal life support in the emergency department: A narrative review for the emergency physician. Resuscitation, 133, 108–117.
  6. Yang, T.-H., Chen, K.-F., Gao, S.-Y., & Lin, C.-C. (2022). Risk factors associated with peri-intubation cardiac arrest in the emergency department. The American Journal of Emergency Medicine, 58, 229–234.
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