Timer and scribe (keep this person close to you and ask them to clearly tell you when each cycle ends, the cycle number and remind you when drugs are due if competent to)
Compressions (2-3 people rotating)
Airway and ventilation (anaesthetist if present)
Defibrillation (if shockable)
IV access, bloods/gases and drugs (x 2 people)
Co-ordinate above tasks
Go through reversible causes
Danger: check around patient and environment for danger
Response: question (e.g. ‘Hello, can you hear me?’), shake and command (e.g. ‘Open your eyes’)
Shout: ‘Can I get some help over here please?’ and make the bed flat
Airway: open airway with head-tilt/chin-lift or jaw-thrust and look for obstructions
Breathing: assess breathing for up to 10 seconds by listening and feeling with your ear, while watching for chest movements and palpating carotid pulse
NB: you should do this while maintaining the head-tilt/chin-lift or jaw-thrust (e.g. place your forearm on the patient’s forehead, apply positive pressure to tilt the head back, and reach around their face to pull up the angle of the jaw with the index and middle fingers, whilst palpating the carotid pulse with the other hand).
CPRand Call cardiac arrest team: if patient is not breathing, start CPR (described in detail below) and ask a helper to call 2222 and explain there is an adult/paediatric/neonatal/trauma cardiac arrest and the location. Ask the helper to bring the resuscitation trolley back with them.
Defibrillation: as described below
Tasks needing to be performed simultaneously are shown below in order of priority:
Perform 30:2 chest compressions to ventilations (until airway is secure).
Perform at a rate of 100-120/minute (i.e. 2/second) and a depth of 5-6cm. Fully extend your elbows, wrists and fingers. Have both hands palm downwards with fingers interlocked. Place the carpal area of the hand over the lower sternum and apply all pressure over this point.
ONLY stop CPR for rhythm checks, electrical shocks, and the 2 rescue breaths. Ask the person doing compressions to tell the airway person each time 30 compressions are complete.
Chest compressions should be continuous once the airway is secured with endotracheal tube
Switch CPR provider during the rhythm check every 2 minutes (or earlier if they tire)
Working around the person performing compressions, place the two defibrillation pads in the correct positions on the chest (below right clavicle and over cardiac apex). You may need to shave or dry the chest. Leave jewellery on, but move it out the way.
NB: if a pacemaker is present, ensure pads are >8cm away from it (you can put the pads on AP if needed).
Connect pads to defibrillator (and set monitoring trace to ‘pads’ if not already)
Delegate someone to manage timing, clearly tell the leader when 2 minute cycles are up and remember the cycle number. Cycle 1 starts when the defibrillator is connected.
Perform a rhythm check ± shock every 2 minutes
When pads are in place and defibrillator is on, immediately ask for CPR to be stopped for a rhythm check. Determine if the rhythm is shockable (‘wavy lines’ – VF, VT) or non-shockable (asystole, PEA).
If a rhythm that could be compatible with a pulse is seen (i.e. sinus or VT) during the rhythm check, also feel for a central pulse and stop compressions if present
Then immediately continue CPR
If shockable rhythm, follow these extra steps
Select correct energy level for device, usually150J biphasic. If unsure, give the highest energy level shock.
Ask for oxygen to be removed (unless patient intubated) and everybody except the person doing compressions to move away. Tell the person doing compressions to continue and that you will alert them to move away before the shock.
Charge defibrillator by pressing ‘charge’ (button 2) and then move hand away from machine
Once charged, ask the compressions to now be stopped and shout ‘Everybody stand clear!’
Check the area is clear (i.e. check no one is in contact with the patient/bed and that the oxygen is away)
Deliver shock by pressing ‘shock’ (button 3)
Immediately ask for CPR to be restarted
NB: while operating defibrillator, always look outwards around the bed (not at the machine) and never float your hand near the buttons.
Bag valve mask (30 compressions to 2 ventilations): if able to ventilate whilst maintaining seal and jaw-thrust, one person can do this alone. If not, one person should hold the rigid part of the mask with their thumb and index finger (‘C’) and pull the jaw up into the mask with their other fingers (‘E’), while another person ventilates.
Consider also placing an oropharyngeal (Guedel) or nasopharyngeal airway under the mask if struggling.
Supraglottic airway (usually i-gel): more secure airway and easy to insert
Intubation with endotracheal tube (gold standard): only done by experienced personel. Once placed, ventilate every 6 secondswith continuous chest compressions and oxygen does not need to be removed for shocks.
NB: if a supraglottic airway is placed and there is no air leak, compressions can also be continuous and oxygen left connected for shocks. In practice, however, there is usually still some air leak so this is usually not done.
Attach 15L/minute oxygen
Attach waveform capnography if supraglottic mask or endotracheal tube inserted
Obtain IV access and have drugs ready
If you cannot get IV access after 2 attempts, get intraosseous access via head of humerus or tibial tuberosity
Take blood from the cannula (VBG + send FBC, U&Es, Mg2+, G&S) and give IV fluids
Adrenaline 1mg IV (10ml of 1:10,000):
Shockable rhythm: give after 3rd shock (during CPR). Flush with 20ml saline.
Non-shockable rhythm: give as soon as IV access is established. Flush with 20ml saline.
NB: this is given to cause peripheral vasoconstriction and so maximise cardiac blood flow.
Repeat adrenaline dose during every other CPR cycle thereafter (i.e. repeat every 3-5 minutes once given, regardless of rhythm)
Amiodarone 300mg IV: if shockable rhythm only. Give after 3rd shock (during CPR). Repeat 150mg IV after 5th shock if ongoing.
NB: amiodarone is given to stabilise the myocardium in VF and VT.
Consider reversible causes
The team leader should assess the reversible causes by assessing the patient, speaking to nurses/relatives and reviewing their drug chart and notes. Each of the following reversible causes should be eliminated/treated (4 H’s, 4 T’s):
Return of circulation
Full ABCDE assessment
Controlled oxygenation (aim 92-96%)
Consider therapeutic hypothermia 32-36˚ for 24 hours (avoid hyperthermia)
Post-arrest investigations (CXR, 12 lead ECG, full set of bloods, echo, ABG, capillary glucose and cardiac monitoring)
Consider transfer to intensive care if still requiring ventilation or high-dependency care if not
No return of circulation
In general, CPR should be continued as long as there is a shockable rhythm (mechanical compression device may be used)
Only stop if a registrar or above makes the decision with the team
Extracorporeal CPR using extracorporeal membrane oxygenation (ECMO) device may be considered where avaliable for select patients to facilitate other definitive treatments, e.g. PCI, pulmonary thrombectomy for massive PE, rewarming for hypothermia
Afterwards → Retrospectively document everything that happened
Manually displace the uterus to the left and add left-lateral tilt if possible (prevents aortocaval compression during CPR)
Prepare for emergency C-section if >20 weeks gestation or uterus palpable above umbilicus and initial resuscitiation attemps unsucessful – should ideally be performed within 5 minutes of arrest (call for obstetric team and neonatologist immediatly)
Algorithm differences in children
Infant (<1 year): feel brachial pulse
Children (>1 year): feel carotid pulse
At birth: 3:1 ratio
Infants/children: start with 5 rescue breaths, then 15:2 ratio
Compress to at least one-third of the AP chest diameter
Infant (<1 year):
Encircling technique (preferred): performed by placing both thumbs flat on the lower sternum pointing towards the infant’s head and the fingers around the rib cage
Two-finger technique (may be easier if only one rescuer): compress the sternum with the tips of two fingers
Children (>1 year): as for an adult but only use one hand (unless need 2nd to achieve target depth)
Manual defibrillator: 4J/kg
If using automated defibrillator for child <8 years: use paediatric-attenuated adult shock energy
If using automated defibrillator for child >8 years: use adult shock energy
Infants: 4.5cm pads
Children: 8-12cm pads
If paediatric electrodes are unavailable, it is acceptable to use the adult defibrillator and settings – ensure the pads are not touching each other
Adrenaline 10mcg/kg (0.1ml/kg of 1:10,000 solution)
Amiodarone 5mg/kg – repeat same dose after 5th shock if still in shockable rhythm
Intubate the trachea early
Ventilate at higher rate when airway secure (8-10 breaths/minute) and sufficient tidal volume to cause the chest to rise
Consider tension pneumothorax
Consider higher shock energies if initial attempts fail as chest may be hyperexpanded