This is EM Cases Best Case Ever 61 Biohazard Preparedness: The Protected Code Blue

In anticipation of EM Cases Main Episode 100 on Disaster Medicine with Laurie Mazurik, David Kollek and Joshua Bezanson, Dr. Mazurik, head of Disaster Medicine at Sunnybrook Health Sciences in Toronto, tells of her experience as a disaster medicine leader with keeping health care workers safe during the SARS era. If you were faced with a patient with suspected Ebola or drug resistant TB or any other biohazard patient who required intubation, would you know how to handle the situation so that you and your colleagues were safe…

Published by Anton Helman, August 2017

Top 10 Principles in Biohazard Preparedness and Safety to Prevent Contamination – The Protected Code Blue

  1. Develop a Protected Code Blue protocol in your hospital
  2. Use a Powered Air Purifying Respirator (PAPR) or if unavailable use a “double double” set up (double mask, double eye protection, double gloves, double gown, double hair protection, double shoes)
  3. Avoid high risk situations whenever possible e.g. early intubation before the patient becomes combative/agitated, early transfer to ICU
  4. Avoid bagging, NIPPV, nebulized solutions, high frequency oscillation ventilators and bronchoscopy which all spread biohazard particles
  5. Consider HiOx (high flow non-humidified oxygen face mask with filter on exhalation port)
  6. Minimize the number of people in the room
  7. Paralyze the coughing patient
  8. High risk procedures should be performed by the most experienced person available
  9. Consider placing a speakerphone or intercom in patient rooms to allow resuscitation team to communicate with personnel outside room (e.g. two-way baby monitor)
  10. Make up a biohazard intubation kit (see below) and have additional equipment (cardiac arrest cart, difficult airway cart outside the negative air pressure room)

HiOx mask

Regular simulation training for Protected Code Blue is required to effectively don protective equipment in a timely manner and to be sure that all members of the the team are adequately prepared.

To review how to recognize the presentation of ebola and how to don personal protective equipment visit the special EM Cases post and podcast A Rational Approach to Emergency Ebola Preparedness


Biohazard Intubation Kit

  • Laryngoscope handle
  • Macintosh and Miller 3 and 4 blades
  • Magill forceps
  • Stylette
  • Oral airways #8, #9, #10
  • Endotracheal tubes 6.0, 7.5, 8.0, 8.5
  • Scalpel
  • Bougie
  • Lubricating gel
  • Scissors
  • Yankeur suction tip
  • Pink tape
  • Disposable CO2 detector
  • Esophageal detection device
  • In-line suction catheter
  • 10 cc syringe
  • Induction, paralytic, analgesic, sedation and push-dose pressor meds


Take ownership of what is required to protect yourself in a potential biological disaster because each situation requires unique actions. Emergency Medicine should own Disaster Medicine.


The details: Laurie Mazurik’s Protected Code Blue talk



Fischer WA, Hynes NA, Perl TM. Protecting health care workers from Ebola: personal protective equipment is critical but is not enough. Ann Intern Med. 2014;161(10):753-4.

Personal Protective Equipment Guidelines for Health Care Facility Staff. Ann Emerg Med. 2016;68(3):406-7.

Seto WH et al. Effectiveness of Precautions against Droplets and Contact in Prevention of Nosocomial Transmission of Severe Acute Respiratory Syndrome (SARS). Lancet 2003; 361: 1519-20.

Health Canada. Infection Control Guidance If There Is a SARS Outbreak Anywhere in the World, When an Individual Presents a Health Care Institution With a Respiratory Infection. 17 Dec 2003.

US Centers for Disease Control. Infection control precautions for aerosol-generating procedures on patients who have suspected severe acute respiratory syndrome (SARS). March 20, 2003.