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Basic Life Support (BLS) Primary Survey for

Respiratory Arrest
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The main focus of the BLS

Primary Survey (see Figure 1) is
on early CPR and early
defibrillation, if needed. For a
patient in respiratory arrest,
however, the focus is on
breathing and airway issues. The
process is to assess the patient, and then perform an appropriate action. Each step in the
survey has an assessment and actions to follow.
Figure 1. Basic Life Support Decision Tree


Is the patient breathing?

Look for the rise and fall of the patient's chest.

Does the patient have a


The healthcare provider can take 5-10 seconds to check

for a pulse.


When the AED arrives, place it on the patient and follow

the prompts

Is the patient breathing NORMALLY? (small gasping breaths are not considered normal.
If no Pulse BEGIN COMPRESSIONS at a rate of at least 100/min
If not sure if a pulse is present, BEGIN COMPRESSIONS AT AT LEAST 100/min

If pulse is present and breathing absent, begin ventilation at a rate of 8-10/min using
mouth to mouth or bag valve mask.
The last step, defibrillation, is part of the primary survey, but is not required for
respiratory arrest, as the patient has a pulse for this case. Therefore the AED will advise
the user "no shock advised, continue CPR if necessary."

ACLS Secondary Survey for a Patient in

Respiratory Arrest
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Using the ACLS

Primary Survey for a Patient in Respiratory Arrest
The ACLS Secondary Survey takes you through the advanced assessments and actions
you need to accomplish for a patient in respiratory arrest (see Figure 1). Placing an
advanced airway interrupts chest compressions and takes many seconds. If the patient is
pulseless, advanced airway should be deferred until return of spontaneous circulation
(absent special situations, like aspiration risk, etc. )Your assessment guides you in finding
the answers and taking appropriate next steps.

The assessments follow the CAB format of the primary





Figure 1. Advanced Cardiac Life Support Secondary Survey



To open the airway for unconscious patients, use the head-tilt,

Is the patient's airway chin lift. Insert an oropharyngeal airway (OPA) or a
nasopharyngeal airway (NPA) if needed to keep the airway
Does the patient need If yes, use an LMA, Combitube, or endotracheal intubation to
an advanced airway? secure the airway.
Is the patient

Give bag-mask ventilations every 5 to 6 seconds (about 10 to

12 breaths per minute).

No. If bag-mask ventilation is adequate, defer the insertion of

an advanced airway until it becomes essential (patient fails to
Is an advanced airway
respond to initial CPR or until spontaneous circulation
returns). Yes. Insert the advanced airway device that is most
apprppriate to your scope of practice.
Confirm correct placement of advanced airway device by a
Is the advanced airway
observing the patient, confirming the presence of lung sounds
device placed
in at least 4 lung fields and using a confirmation device, such
as an exhaled CO2 detector.
Is the advanced airway Secure the advanced airway device so it does not dislodge,
device secured
especially in patients who are at risk for movement. Secure
the ET tube with tape or a commercial device.
What was the patient's
Attach ECG leads. Identify patient's rhythm.
initial cardiac rhythm?
What is the patient's
current cardiac

Monitor patient for arrhythmias or cardiac arrest rhythms

(ventricular fibrillation, pulseless ventricular tachycardia,
asystole, and PEA).

Does the patient need

Establish IV or IO access.
an IV?

Does the patient need

Start IV/IO fluids, if needed.
Does the patient need
medications for
rhythm or blood
pressure control?

Give appropriate medications to manage rhythm (eg,

amiodarone, lidocaine, atropine) and blood pressure (eg,
Dopamine or Epinephrine (used with caution as it increases
myocardial oxygen demand).

Is a reversible cause
responsible for the

Search for reversible causes of the arrest. Find and treat

reversible causes of the arrest.

If the patient is not deeply unconscious, you must use a nasoparhygeal airway as an OPA
will activate the gag reflex
The appropriate airway will depend no only on the patients condition, but the
experience level of the provider as well.
Avoid commercial devices that are circumferential
If the patient is in cardiac arrest, placing an advanced airway is a significant interruption
to chest compressions. You must weigh the need for an advanced airway against the need
for continued chest compressions. If bag-mask ventilation is working and seems
adequate, you may want to put off inserting an advanced airway until the patient fails to
respond to initial CPR and defibrillation, or until spontaneous circulation returns.

Pulseless Arrest Algorithm for Managing

Using the Pulseless Arrest Algorithm for Managing Asystole
Management of a patient in cardiac arrest with asystole follows the same pathway as
management of PEA. The top priorities stay the same: Following the steps in the ACLS
Pulseless Arrest Algorithm and identifying and correcting any treatable, underlying
causes for the asystole. The algorithm assumes that scene safety has been assured,
personal protective equipment is being used, and no signs of obvious death are present.

Begin with the primary survey to assess the patient's


In the absence of respirations and a pulse in the presence of asystole (present in

two leads) consideration of termination of efforts should take place

Follow the ACLS Pulseless Arrest Algorithm for asystole:

Check the patient's rhythm, taking less than 10 seconds to assess.

Verify the presence of asystole in at least two leads

Resume CPR at a rate of at least 100/minute. Rotate team members every 2

minutes with rhythm breaks to help maintain high quality CPR.

As soon as IV or IO access is available, administer epinephrine 1mg IV/IO. Do

not stop CPR to administer drugs.

During CPR, search for and treat possible contributing causes (H's and T's in
Figure 1).

Check rhythm.

If no electrical activity is present (patient is in asystole), resume CPR.


If electrical activity is present, see if the patient has a pulse.


If the patient does not have a pulse or there is some doubt about the pulse,
resume CPR.

If a good pulse is present and the rhythm is organized, begin postresuscitative care.

IV/IO access is a priority over advanced airway management. If an advanced airway is

placed, change to continuous chest compressions without pauses for breaths. Give 8 to 10
breaths per minute and check rhythm every 2 minutes.
Without a pulse or electrical activity on the ECG, the emergency care team needs to
decide when resuscitation efforts should stop. The patient's wishes and the family's
concerns need to be considered.