CODE BLUE FLOW SHEET

FORM#: HFBH-59-1223MR-0808 WHITE: CHART YELLOW: ICU MANAGER

Date____________ Time Event Recognized_____________ Location______________ Witnessed: � Yes � No

Age __________ Weight__________ Height__________ Hospital-wide resuscitation response activated? � Yes � No

Condition when need for chest compression/defibrillation was identified? � Pulseless � Pulse (poor perfusion)

Was patient conscious at onset? � Yes � No Monitoring at onset: � ECG � Pulse Oximeter � Apnea Monitor

Airway/Ventilation

Breathing at Onset: � Spontaneous �Apneic �Agonal �AssistedTime of First Assisted Ventilation:_______________________

Ventilation: � Bag-Valve-Mask � Endotracheal Tube

�Tracheostomy � Other:________________Intubation: Time:_________ Size: ___________ By:_________

Confirmation: �Auscultation � Exhaled CO2 � Other

Circulation

First Documented PULSELESS Rhythm: ____________

Compressions: � None � Manual � Device:__________Time chest commpressions started :_________________

AED applied: � Yes � No � Time applied:_________

Defibrillator type(s):______________________________

Pacemaker On: � Yes � No

IV Site:________ Guage_______at_______ � In progress

Bolus – Dose / Route Infusions – Dose / ml per hour

Time

Breathing Pulse

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r IO Comments:

i.e.: Peripheral/Central Line

Placement, IO, Chest Tube,

Response to Interventions

Time Resuscitation Event Ended: __________________________________ Status: � Alive � DeadReason Resuscitation Ended: � Return of Circulation (ROC)>20 min � Efforts Terminated (No Sustained ROC)

� Medical Futility � Advance Directives � Restrictions by Family

Recorder Signature________________________________ Team Leader Printed Name_________________________ ID#___________

ICU/Team Nurse Signature_____________________________ Team Leader Signature________________________________________

Page ____of____

Members Present:

_____________________________ ____________________________ ____________________________ __________________________

_____________________________ ____________________________ ____________________________ __________________________

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