Code blue simulation scenario: in-hospital cardiac arrest
A complete, ready-to-run scenario for the first five to ten minutes of an adult cardiac arrest on a medical-surgical unit, before and as the code team arrives. Use it as written, or change anything to fit your course, your equipment and your facility's policy.
Learning objectives
- Recognize cardiac arrest within 10 seconds and call for help by activating the emergency response (Recognize cues)
- Start high-quality chest compressions immediately and keep interruptions under 10 seconds (Take action)
- Apply the defibrillator pads, identify a shockable rhythm and deliver a shock safely (Analyze cues / Take action)
- Work in assigned roles using closed-loop communication, and give a structured handoff to the code team (Take action)
- Reassess after return of circulation and state the priorities for the next 10 minutes (Evaluate outcomes)
The patient
Robert Hayes, 67-year-old man, 82 kg, admitted yesterday with chest pain to rule out myocardial infarction.
- Coronary artery disease with a stent placed 4 years ago
- Hypertension
- Type 2 diabetes
- On a telemetry monitor
Prebrief
Mr. Hayes had two episodes of chest pressure overnight that eased with nitroglycerin. This morning's potassium and magnesium came back low and replacement has been ordered but not yet started. His wife is at the bedside.
Night nurse: "Robert Hayes, 67, here to rule out MI. Troponin is trending up, cardiology is seeing him this morning. He had chest pressure at 0200 and 0430, relieved with one nitroglycerin each time. Potassium is 3.2 and magnesium 1.6; the replacement orders just came through and nothing is hung yet. He's on telemetry, 2 liters by nasal cannula, full code. He said he felt 'a little off' about ten minutes ago."
- Primary nurse (first on scene): checks responsiveness, calls for help, starts compressions
- Second nurse: brings the code cart, applies pads, runs the defibrillator
- Airway: bag-valve mask with oxygen, 2 breaths after every 30 compressions
- Recorder: times every event, rhythm check, shock and medication
- Optional family member (played by faculty or a student)
- Manikin in bed, head of bed at 30 degrees, on a telemetry monitor showing sinus rhythm with frequent PVCs at the start
- Nasal cannula at 2 L/min, saline lock in the left forearm
- Code cart with a defibrillator trainer or AED trainer, backboard and bag-valve mask outside the room
- Call light and a way to "call a code" (phone or overhead button)
- A printed MAR, orders and lab sheet at the bedside
How the patient changes
1. Found unresponsive (0:00)
Rhythm: Ventricular fibrillation. Heart rate: No pulse. Blood pressure: Unobtainable. Respirations: Agonal gasps, then none. SpO2: No reading.
- Does not respond to voice or touch
- No carotid pulse within 10 seconds
- Skin pale and cool
- Monitor alarm sounding
- Check responsiveness; check breathing and pulse together for no more than 10 seconds
- Call for help and activate the code (state the room number)
- Lower the head of the bed and place the backboard
- Start chest compressions: 100 to 120 a minute, at least 2 inches deep, full recoil
If missed: If compressions have not started by 1 minute, the wife asks loudly, "Why isn't anyone doing anything?" Each minute without compressions makes return of circulation less likely; the facilitator may delay it.
2. First rhythm check and shock (About 1:00 to 3:00)
Rhythm: Ventricular fibrillation. Heart rate: No pulse. Blood pressure: Unobtainable. Respirations: Bag-valve mask, 30:2. SpO2: No reading.
- Second nurse arrives with the code cart
- Pads show ventricular fibrillation
- Chest rises with each breath when the mask seal is good
- Apply defibrillator pads without stopping compressions
- Give 2 breaths by bag-valve mask with oxygen after every 30 compressions
- Identify the rhythm as shockable; charge while compressions continue
- Say "clear" and look to confirm no one is touching the patient or bed; deliver the shock at the dose your defibrillator recommends
- Resume compressions immediately after the shock, without a pulse check
If missed: If the team pauses to check a pulse after the shock, more than 10 seconds pass without compressions. Note the length of the pause for the debrief.
3. Still in ventricular fibrillation: second shock and medications (About 3:00 to 8:00)
Rhythm: Ventricular fibrillation. Heart rate: No pulse. Blood pressure: Unobtainable. Respirations: Bag-valve mask, 30:2. SpO2: No reading.
- Rhythm check at 2 minutes still shows ventricular fibrillation
- Compressor is tiring; depth is getting shallow
- Code team arrives during this state
- Switch compressors every 2 minutes, in under 5 seconds
- Deliver the second shock and resume compressions immediately
- Confirm the IV is working; the code team gives epinephrine 1 mg IV and repeats it every 3 to 5 minutes
- After the third shock, the code team gives amiodarone 300 mg IV
- Give a structured handoff to the code team leader: who he is, what happened, what has been done and when
- Raise possible reversible causes: the low potassium and magnesium that were not yet replaced
If missed: If no one mentions the low potassium and magnesium, the code team leader asks, "Anything in his labs I should know?" If compressors do not switch, compression depth drops and EtCO2 falls below 10.
4. Return of circulation (After the third shock, about 8:00)
Rhythm: Sinus tachycardia. Heart rate: 112. Blood pressure: 92/58. Respirations: 10, assisted. SpO2: 94% with bag-valve mask.
- Carotid pulse present
- Occasional spontaneous breaths
- Does not yet follow commands
- Skin colour improving
- Confirm a pulse and recheck blood pressure, rhythm and oxygen saturation
- Support breathing; keep oxygen saturation at 92% to 98%
- Get a 12-lead ECG and expect labs, a chest X-ray and transfer to intensive care
- Expect potassium and magnesium replacement to start
- Update the wife in plain words and arrange for someone to stay with her
- Complete the code record with times
If missed: If no one reassesses after the pulse returns, the blood pressure drifts to 78/46 and the monitor alarms.
Provider orders
- Full code
- Continuous telemetry monitoring
- Oxygen by nasal cannula to keep oxygen saturation at or above 94%
- Troponin every 6 hours for 3 draws
- Potassium chloride 40 mEq by mouth now
- Magnesium sulfate 2 g IV over 2 hours
- Nitroglycerin 0.4 mg under the tongue every 5 minutes for chest pain, up to 3 doses; call the provider if pain continues
Medication administration record
- Aspirin, 81 mg, By mouth, Daily
- Metoprolol tartrate, 25 mg, By mouth, Twice a day
- Atorvastatin, 40 mg, By mouth, At bedtime
- Enoxaparin, 80 mg, Under the skin, Every 12 hours
- Potassium chloride, 40 mEq, By mouth, Now (not yet given)
- Magnesium sulfate, 2 g, IV, Over 2 hours (not yet started)
Lab results
- Troponin I, 0.42 ng/mL, High
- Potassium, 3.2 mEq/L, Low
- Magnesium, 1.6 mg/dL, Low
- Glucose, 168 mg/dL, High
- Creatinine, 1.1 mg/dL
Debrief guide (PEARLS)
Reactions
- How are you feeling right now?
- What stood out to you most?
Description
- In a few sentences, what happened to Mr. Hayes?
- What was the first thing that told you this was a cardiac arrest?
Analysis
- How long was it from finding him to the first compression? What helped or slowed that?
- When were compressions paused, and for how long? What could shorten those pauses?
- How did you decide who did what? Did everyone hear and confirm their instructions?
- What did you tell the code team when they arrived? What would you add or leave out next time?
- What in his chart could have contributed to the arrest? Who needed to know, and when?
- How was his wife included? What would you say to a family member in that moment?
Summary
- What is one thing you will do the same with a real patient, and one thing you will do differently?
Evaluation rubric
- Recognizes arrest and calls the code: Checks responsiveness, breathing and pulse within 10 seconds and activates the code with the room number
- Compressions: Starts within 30 seconds of recognition; correct rate and depth; compressors switch every 2 minutes
- Defibrillation: Pads on without stopping compressions; clears the patient out loud and by looking; shock delivered; compressions resume at once
- Teamwork and communication: Roles are named; instructions are repeated back; times are recorded; handoff to the code team is structured and complete
- Clinical reasoning: Links the low potassium and magnesium to the arrest; reassesses after circulation returns and names next priorities
- Family: Speaks to the wife briefly and honestly, or asks a staff member to stay with her
Notes for faculty
- Check every step against your facility's policy and the current resuscitation guidelines your program teaches before you run it. Shock energy and who may give medications vary by device and by policy.
- To make it easier: start with the code cart in the room and assign roles in the prebrief. To make it harder: remove the saline lock so IV access must be established, or have the first rhythm be pulseless electrical activity.
- This scenario is for education only. It is not clinical guidance for patient care.
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