For Professionals · Emergency cognitive aids
Code blue & peri-arrest aids
The emergencies an anaesthetist runs — cardiac arrest, anaphylaxis, malignant hyperthermia, LAST and major haemorrhage. Pick a scenario for the immediate steps, drugs and the 4 Hs / 4 Ts; enter a weight for live paediatric and weight-based doses.
Medically reviewed by
Dr. Saurabh Shukla, MBBS, DNB Anesthesiology
· Last updated June 2026
Weight-based doses appear on the relevant cards.
Cardiac arrest — VF / pulseless VT
ShockableDo this now
- Confirm arrest, start CPR, attach defibrillator
- Shock as soon as charged, minimise pauses
Shock: Biphasic 200 J (or device-specific) CPR: 30:2 if no advanced airway; continuous compressions once intubated
Drugs
- Adrenaline 1 mg IV — every 3–5 min, starting after the 2nd shock
- Amiodarone 300 mg IV bolus — after the 3rd shock; further 150 mg after the 5th
- Lidocaine 1–1.5 mg/kg IV — alternative to amiodarone
Reversible causes — 4 Hs / 4 Ts
Hypoxia — Confirm airway, 100% O₂, check tube/ventilation
Hypovolaemia — Stop bleeding, fluid/blood, vasopressors
Hypo/hyperkalaemia & metabolic — ABG/VBG, calcium, insulin-dextrose, bicarbonate
Hypothermia — Core temperature, active rewarming
Thrombosis (coronary / pulmonary) — Consider PCI / thrombolysis for suspected PE
Tension pneumothorax — Needle / finger thoracostomy
Tamponade (cardiac) — Echo; pericardiocentesis / thoracotomy
Toxins — Antidotes; lipid emulsion for LAST
Cardiac arrest — PEA / asystole
Non-shockableDo this now
- Confirm arrest, start CPR
- Adrenaline as soon as access is available
- Hunt and treat reversible causes
Shock: Not indicated — do not shock CPR: 30:2 or continuous once intubated
Drugs
- Adrenaline 1 mg IV — every 3–5 min, give as soon as possible
Reversible causes — 4 Hs / 4 Ts
Hypoxia — Confirm airway, 100% O₂, check tube/ventilation
Hypovolaemia — Stop bleeding, fluid/blood, vasopressors
Hypo/hyperkalaemia & metabolic — ABG/VBG, calcium, insulin-dextrose, bicarbonate
Hypothermia — Core temperature, active rewarming
Thrombosis (coronary / pulmonary) — Consider PCI / thrombolysis for suspected PE
Tension pneumothorax — Needle / finger thoracostomy
Tamponade (cardiac) — Echo; pericardiocentesis / thoracotomy
Toxins — Antidotes; lipid emulsion for LAST
Bradycardia — symptomatic / unstable
Peri-arrestDo this now
- Assess for adverse signs: shock, syncope, ischaemia, heart failure
Pacing: Transcutaneous pacing if drugs fail; expert help for transvenous
Drugs
- Atropine 1 mg IV — repeat q3–5 min to a maximum of 3 mg
- Adrenaline 2–10 mcg/min infusion — if atropine ineffective
- Dopamine 5–20 mcg/kg/min — alternative chronotrope
Tachycardia — unstable
Peri-arrestDo this now
- Unstable = hypotension, altered mentation, ischaemia or shock → synchronised cardioversion
Drugs
- Synchronised DC cardioversion — Narrow regular 50–100 J · narrow irregular 120–200 J · wide regular 100 J · wide irregular → defibrillate (not sync)
- Amiodarone 300 mg IV over 10–20 min — after cardioversion if needed, then infusion
Anaphylaxis
EmergencyDo this now
- Remove the trigger
- Adrenaline IM early — repeat at 5 min if no improvement
- ABC, high-flow O₂, lie flat with legs raised
Drugs
- Adrenaline 0.5 mg IM (adult) — anterolateral thigh; repeat every 5 min as needed
- Adrenaline 10 mcg/kg IM (paeds) — max 0.5 mg
- Adrenaline IV 50–100 mcg boluses, titrated — by an anaesthetist/critical-care; arrest dose 1 mg if arrest
- Crystalloid 500–1000 mL IV bolus (adult) — 20 mL/kg in children
- Hydrocortisone 200 mg IV / Chlorphenamine 10 mg IV — adjuncts, slow onset
- Salbutamol 5 mg nebulised — for bronchospasm
Don't miss
- Anticipate airway angioedema — call for senior airway help early
- Send mast-cell tryptase at 1 h, 4 h and 24 h
Malignant hyperthermia
EmergencyDo this now
- Stop the volatile agent and suxamethonium IMMEDIATELY
- 100% O₂ at high flow, hyperventilate; change circuit + soda lime
- Call for the MH cart (dantrolene — 36 vials minimum) and extra help
- Declare and abandon/finish surgery as quickly as safe
Drugs
- Dantrolene 2.5 mg/kg IV bolus — repeat every 5 min until controlled; up to ~10 mg/kg total
- Active cooling — cold IV saline, ice to groin/axillae — stop at 38 °C to avoid overshoot
- Sodium bicarbonate 1–2 mEq/kg IV — for metabolic acidosis
- Insulin + dextrose, calcium — treat hyperkalaemia
Don't miss
- Treat hyperkalaemia, arrhythmias, acidosis and rhabdomyolysis
- Monitor core temp, ABG, K⁺, CK, coagulation and urine output
Local anaesthetic systemic toxicity (LAST)
EmergencyDo this now
- Stop injecting local anaesthetic
- Call for help; manage airway with 100% O₂
- Control seizures (benzodiazepine); start CPR if arrest
Drugs
- Lipid emulsion 20% — bolus 1.5 mL/kg over 1 min — lean body weight
- Lipid emulsion 20% — infusion 0.25 mL/kg/min — double the rate if BP remains low
- Repeat bolus ×2 q5min if persistent collapse — max ~12 mL/kg total
- Adrenaline — small boluses ≤1 mcg/kg — AVOID the standard arrest dose
Don't miss
- Avoid vasopressin, calcium-channel blockers, β-blockers and further local anaesthetic
- Consider cardiopulmonary bypass / ECMO if refractory after ~5 min CPR
Massive transfusion / major haemorrhage
EmergencyDo this now
- Activate the major-haemorrhage protocol
- Control bleeding (pressure, tourniquet, surgery, IR)
Products & targets
- PRBC : FFP : platelets = 1 : 1 : 1 — fixed-ratio resuscitation
- Cryoprecipitate if fibrinogen < 1.5 g/L — < 2.0 g/L in obstetrics
- Tranexamic acid 1 g IV over 10 min, then 1 g over 8 h — within 3 h of trauma / PPH
- Calcium gluconate 1 g IV per ~4 units PRBC — citrate-related hypocalcaemia
- Targets: temp > 35 °C, pH > 7.2, ionised Ca > 1.1, K < 5.5 — avoid the lethal triad
Activation triggers
- Loss > 150 mL/min
- Loss > 50% blood volume in 3 h
- Anticipated > 10 units PRBC / 24 h
- Shock index > 1.0 with ongoing haemorrhage
Key sources
- Resuscitation Council UK / AHA ACLS adult & paediatric algorithms (current).
- Resuscitation Council UK / ANZAAG anaphylaxis guidance.
- AAGBI/MHAUS malignant hyperthermia crisis management.
- AAGBI / ASRA management of severe local anaesthetic toxicity (LAST).
Cognitive aids for trained clinicians. Doses are typical defaults and may differ by region, patient and institution — always follow your local resuscitation protocol and current guidelines, and confirm every dose before administration. No data is stored.