Level 1 of 6Core
Cardiac arrest and advanced life support
The core to-do list — diagnose and manage, at a glance
Diagnose— recognise it
- Diagnose in ten seconds on two findings: the patient is unresponsive and is not breathing normally — nothing else is required, and nothing else may delay the first compression. A pulse check adds information only if completed within those same ten seconds.
- Agonal breathing is the great trap: slow, noisy, irregular gasping or snoring is a sign of cardiac arrest, not of life — if you have to ask whether that is breathing, the answer is no. A brief convulsion at collapse is common and regularly gets the arrest labelled as epilepsy.
- Four rhythms in two groups: shockable — ventricular fibrillation and pulseless VT; non-shockable — asystole and pulseless electrical activity. Fine VF mimics asystole: check leads, turn up the gain, look in a second lead — and if in any doubt, shock.Not available at your setup — Defibrillator.
- ROSC means an organised rhythm WITH a palpable central pulse, a measurable blood pressure, or a sudden sustained rise in end-tidal CO₂ — an organised complex on the monitor without any of those is PEA, not ROSC.
- Hunt the reversible causes in every cycle — the four Hs and four Ts: hypoxia; hypovolaemia; hypo-/hyperkalaemia and metabolic derangement; hypothermia; thrombosis (coronary and pulmonary); tension pneumothorax; tamponade; toxins. The highest-yield test during an arrest is a blood gas.Not available at your setup — Arterial blood gas.
- An infant or child with a heart rate below 60/min and signs of poor perfusion is in arrest for practical purposes and requires chest compressions — paediatric arrest is hypoxic until proved otherwise.
Manage now— do this, in order
- Start compressions immediately: centre of the chest (lower half of the sternum), depth 5–6 cm, rate 100–120/min, complete recoil, 30 compressions to 2 ventilations, change the compressor every 2 minutes at each rhythm check.
- Ventilate with a bag-valve-mask and reservoir at 15 L/min oxygen, two-handed with a second operator squeezing, an oropharyngeal airway sized incisors-to-angle-of-jaw; each breath over about one second, just enough to make the chest visibly rise.
- Access: large peripheral cannula in the antecubital fossa first; after two failed attempts or two minutes, place an intraosseous needle — every drug and fluid may be given IO at the same dose. Flush every drug with 20 mL of 0.9% sodium chloride and elevate the limb 10–20 seconds.Doctor / Nurse
- Shockable rhythm — shock at once: 150 J for the first biphasic shock, then 150–200 J for every subsequent shock (360 J for every shock if only monophasic). Charge during compressions, keep the pre-shock pause under five seconds, and resume compressions immediately for 2 minutes without checking pulse or rhythm.Doctor / NurseNot available at your setup — Defibrillator.
- Shockable drug timing is precise: after the third shock give adrenaline 1 mg IV/IO and amiodarone 300 mg IV/IO; then adrenaline 1 mg every 3–5 minutes; after the fifth shock a further amiodarone 150 mg. If amiodarone is unavailable, lidocaine 1 mg/kg (about 100 mg) with a further 50 mg after the fifth shock — never give both.Doctor / Nurse
- Non-shockable rhythm — do not shock. Give adrenaline 1 mg IV/IO immediately as soon as access is achieved, then every 3–5 minutes, and spend the whole of every cycle working through the reversible causes — in asystole and PEA the treatment is the cause.Doctor / Nurse
- Treat the cause with its dose: hyperkalaemia — calcium chloride 10% 10 mL IV, sodium bicarbonate 8.4% 50 mmol IV, 10 units soluble insulin in 50 mL of 50% glucose IV; tension pneumothorax — immediate needle decompression or finger thoracostomy on clinical grounds, then a drain; hypothermia — below 30°C withhold drugs and limit defibrillation to three shocks, continue CPR until core temperature is at least 32°C; suspected massive PE — thrombolysis, then continue CPR 60–90 minutes.Doctor / Nurse
- Once any advanced airway is in place, abandon 30:2: continuous compressions at 100–120/min with 10 breaths per minute — and waveform capnography is not optional, because unrecognised oesophageal intubation is uniformly fatal.Doctor / NurseNot available at your setup — Endotracheal intubation kit.
- Paediatric: 5 rescue breaths first; ratio 15:2 with two rescuers; defibrillate at 4 J/kg for every shock; adrenaline 10 microgram/kg IV/IO = 0.1 mL/kg of 1:10,000 (maximum 1 mg) — never give 1:1000 adrenaline intravenously to a child. Check the blood glucose in the first minute of every collapsed child.Doctor / Nurse
- After ROSC, treat the first ten minutes as more dangerous than the arrest — pads stay on, drugs stay drawn up. Targets: SpO₂ 94–98%; PaCO₂ 4.5–6.0 kPa (35–45 mmHg); MAP ≥ 65 mmHg; glucose 6–10 mmol/L; a constant temperature between 32°C and 37.5°C for 24–72 hours with fever actively prevented; 12-lead ECG immediately.Doctor / Nurse
Two pathways
| Shockable (VF / pulseless VT) | Non-shockable (asystole / PEA) | |
|---|---|---|
| Shock | 150 J biphasic, then 150–200 J (monophasic 360 J) | Never shock |
| Adrenaline 1 mg IV/IO | After the 3rd shock, then every 3–5 min | Immediately, then every 3–5 min |
| Amiodarone | 300 mg after 3rd shock; 150 mg after 5th | — |
| Focus | Minimal interruption, pre-shock pause < 5 s | Hunt the 4 Hs and 4 Ts every cycle |
Refer / escalate
Call the arrest team and a critical care bed at the moment of recognition; escalate to cardiology for immediate angiography where there is ST elevation after ROSC or a shockable initial rhythm, to obstetrics for perimortem caesarean if no ROSC within about 4 minutes beyond 20 weeks of pregnancy, and to a centre offering extracorporeal support for refractory, hypothermic or PE-related arrest — where unclear, start: a resuscitation can be stopped, a life cannot be restarted.
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