Chapter 7

You will almost certainly be a member of the hospital cardiac arrest team. If you are first on the scene, the absolute priority is to ensure adequate ventilation and perfusion – basic life support. It is one of the few occasions when a well-learnt plan of action is essential. Do not panic. Following the well-learnt advanced life support (ALS) algorithm is essential. For the most up-to-date information, please refer to the Resuscitation Council guidelines, available free at These are frequently updated and are fantastic learning tools.

Cardiac arrest calls

You do not have time to ‘make a diagnosis’. Stay calm and then perform DR ABC:

  1. Check for danger around the patient, and move yourself/the patient out of the way of harm.
  2. Check if the patient is responsive by performing a ‘squeeze, shake and shout’. This is exactly what it says on the tin. Squeeze the patient’s shoulder, shake them to see if they wake up, and shout in their ears. If they are unresponsive, then:

    • Shout for help – don’t be shy!
    • Turn the patient onto their back so that they are lying flat.
    • Open the airway, and check that there is nothing obstructing the airway, like dentures, chewing gum, vomit, etc. Finger sweeps are out of vogue. If you need to use suction, do so, but only suction as far as you can see, that is, not down their airway. Once you are happy the airway is clear, perform a head tilt/chin lift.

Assess the patient’s breathing (look/listen/feel for breathing/chest rise and fall for a maximum of 10 seconds.

The most up-to-date basic life support algorithm now in place does not ask people to assess for carotid pulses as it wastes time and proceeds straight to chest compressions. If the patient is making meaningful respiratory efforts, then opening the airway to avoid hypoxia is essential. It is a recognized fact that even well-trained doctors often cannot make an accurate assessment of whether a patient is in cardiac arrest or not. Agonal breathing (occasional gasps, slow, laboured or noisy breathing) is common in the early stages of cardiac arrest and is a sign of cardiac arrest and should not be confused as a sign of life/circulation.

  1. If you have confirmed cardiac arrest get help, preferably in the form of the resuscitation team. All UK hospitals should now use the standard ‘crash call’ number: 2222. You can ask someone else to do this whilst you remain with the patient, but remember that getting help is essential. State where you are (ward and bed number), that there is an adult cardiac arrest and that you require the adult cardiac arrest team.
  2. Ensure that the airway is secure by using adjuncts such as oropharyngeal airways or nasopharyngeal airways if necessary; note that the former may trigger gagging or vomiting if the patient is not truly in cardiac arrest. Administer oxygen. You should only be inserting supraglottic airway devices or attempting tracheal intubation if you are specifically trained to do so. It is definitely not the time to ‘have a go’. The dangers to the patient of delays in chest compressions, failed intubations (particularly unrecognized) and laryngeal stimulation are huge. Any attempt must be confirmed by clinical examination and capnography.
  3. Ensure someone, preferably two people working in rotations, commence adequate cardiopulmonary resuscitation (CPR, 30 chest compressions followed by 2 breaths). If you are on your own without a bag–valve–mask or oxygen, then focus on the chest compressions. These are your absolute priority. Maintaining a cardiac output is key in prolonging life, so compressions must be effective. Perform chest compressions at a rate of 100–120 beats per minute, at a depth of 5–6 cm.
  4. Attach a defibrillator, ideally with a cardiac monitor. This should be done and defibrillation attempted (if indicated) within 3 minutes of the confirming arrest. If no cardiac trolley is readily available, a portable automated external defibrillator (AED) may be available. These AEDs provide voice prompts and are portable. Make sure the pads are applied properly and in the correct position. The pads have pictures printed on them to show you where to apply them. Ensure you have good contact with the chest. If necessary, remove chest hair. Do not stop chest compressions when applying the pads. If you are going to deliver a shock (in line with the Resuscitation Council guidance), then ‘hands-off’ time, that is, the pause between stopping compressions and delivering the shock, should be minimized to less than 5 seconds.
  5. Attach cardiac monitoring and gain IV access.
  6. Use the ALS algorithm in Figure 7.1, based on the new ALS guidelines by the Resuscitation Council (United Kingdom). We strongly recommend you read the guidelines in full (available from the Resuscitation Council (United Kingdom) website or the resuscitation officer in your hospital). This also contains guidance on how to proceed if you are fortunate enough to achieve return of spontaneous circulation (ROSC) in your patient.

Figure 7.1 Protocol for (a) basic life support and (b) advanced life support (adults).

Reproduced with the kind permission of the Resuscitation Council (UK).

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