IN-HOSPITAL RESUSCITATION

Collapsed/ sick patient

MAINTAIN
PERSONAL
SAFETY
Shout for help and assess patient

Signs of life?
Check for responsiveness
and normal breathing
Experienced ALS providers should
simultaneously check for carotid pulse

No or if any doubt Yes

(Cardiac arrest) (Medical emergency)

Call and collect* Call and collect*

Call resuscitation /
Call resuscitation team medical emergency team if needed
Collect resuscitation equipment Collect resuscitation equipment

High-quality CPR* Assess*

Give high-quality CPR with oxygen ABCDE assessment- recognise and treat
and airway adjuncts* Give high-flow oxygen
Switch compressor at every (titrate to SpO2 when able)
rhythm assessment Attach monitoring
Obtain IV access
Consider call for resuscitation/ medical
emergency team (if not already called)

Defibrillation*
Apply pads/ turn on AED
Attempt defibrillation if indicated**
Handover
Handover to resuscitation/ medical
emergency team using SBAR format

Advanced life support

When sufficient skilled personnel
are present

Handover
Handover to resuscitation team
using SBAR format

* Undertake actions concurrently if sufficient staff available

**Use a manual defibrillator if trained and device available
BASIC LIFE SUPPORT
STEP-BY-STEP
SEQUENCE/ACTION TECHNICAL DESCRIPTION
SAFETY
• Make sure that you, the victim and any bystanders
are safe

RESPONSE
Check for a response Hello! • Shake the victim gently by the shoulders and ask
loudly: “Are you all right?"

AIRWAY
• If there is no response, position the victim on their
Open the airway
back
• With your hand on the forehead and your fingertips
under the point of the chin, gently tilt the victim’s
head backwards, lifting the chin to open the airway

BREATHING • Look, listen and feel for breathing for no more than
Look, listen and feel 10 seconds
for breathing
• A victim who is barely breathing, or taking
infrequent, slow and noisy gasps, is not breathing
normally

ABSENT OR
ABNORMAL BREATHING
Alert emergency services
• If breathing is absent or abnormal, ask a helper to
112 call the emergency services or call them yourself
• Stay with the victim if possible
• Activate the speaker function or hands-free option
on the telephone so that you can start CPR whilst
talking to the dispatcher

SEND FOR AED

• Send someone to find and bring back an AED if
Send someone to get an AED
available
• If you are on your own, DO NOT leave the victim,
but start CPR

CIRCULATION
• Kneel by the side of the victim
Start chest compressions
• Place the heel of one hand in the centre of the
victim’s chest - this is the lower half of the victim’s
breastbone (sternum)
• Place the heel of your other hand on top of the first
hand and interlock your fingers
• Keep your arms straight
• Position yourself vertically above the victim’s chest
and press down on the sternum at least 5 cm (but
not more than 6 cm)
• After each compression, release all the pressure
on the chest without losing contact between your
hands and the sternum
• Repeat at a rate of 100-120 min-1
BASIC LIFE SUPPORT
STEP-BY-STEP
SEQUENCE/ACTION
COMBINE RESCUE BREATHING WITH
CHEST COMPRESSIONS
COMPRESSION-ONLY CPR
WHEN AED ARRIVES
Switch on the AED and
attach the electrode pads
FOLLOW THE SPOKEN/
VISUAL DIRECTIONS
TECHNICAL DESCRIPTION
• If you are trained to do so, after 30 compressions,
open the airway again, using head tilt and chin lift
• Pinch the soft part of the nose closed, using the
index finger and thumb of your hand on the
forehead
• Allow the victim’s mouth to open, but maintain chin
lift
• Take a normal breath and place your lips around the
victim’s mouth, making sure that you have an airtight
seal
• Blow steadily into the mouth whilst watching for the
chest to rise, taking about 1 second as in normal
breathing. This is an effective rescue breath
• Maintaining head tilt and chin lift, take your mouth
away from the victim and watch for the chest to fall
as air comes out
• Take another normal breath and blow into the
victim’s mouth once more to achieve a total of two
rescue breaths
• Do not interrupt compressions by more than 10
seconds to deliver the two breaths even if one or
both are not effective
• Then return your hands without delay to the correct
position on the sternum and give a further 30 chest
compressions
• Continue with chest compressions and rescue
breaths in a ratio of 30:2
• If you are untrained, or unable to give rescue
breathes, give chest-compression-only CPR
(continuous compressions at a rate of 100-120 min-1)
• As soon as the AED arrives switch it on and attach
the electrode pads to the victim’s bare chest
• If more than one rescuer is present, CPR should
be continued whilst the electrode pads are being
attached to the chest
• Follow the spoken and visual directions given by the
AED
• If a shock is advised, ensure that neither you nor
anyone else is touching the victim
• Push the shock button as directed
• Then immediately resume CPR and continue as
directed by the AED
BASIC LIFE SUPPORT
STEP-BY-STEP
SEQUENCE/ACTION
IF NO SHOCK IS ADVISED
Continue CPR
IF NO AED IS AVAILABLE
Continue CPR
IF UNRESPONSIVE BUT BREATHING
NORMALLY
Place in the Recovery Position
TECHNICAL DESCRIPTION
• If no shock is advised, immediately resume CPR
and continue as directed by the AED
• If no AED is available, OR whilst waiting for one to
arrive, continue CPR
• Do not interrupt resuscitation until:
• A health professional tells you to stop OR
• The victim is definitely waking up, moving,
opening eyes, and breathing normally
• OR
• You become exhausted
• It is rare for CPR alone to restart the heart. Unless
you are certain that the victim has recovered
continue CPR
• Signs that the victim has recovered
• Waking-up
• Moving
• Opening eyes
• Breathing normally
• If you are certain that the victim is breathing
normally but still unresponsive, place them in the
recovery position SEE FIRST AID SECTION
• Be prepared to restart CPR immediately if the victim
becomes unresponsive, with absent or abnormal
breathing
BASIC LIFE SUPPORT

Unresponsive with absent

or abnormal breathing

Call emergency services

Give 30 chest compressions

Give 2 rescue breaths

Continue CPR 30:2

As soon as AED arrives –

switch it on and follow
instructions
ADVANCED LIFE SUPPORT
Unresponsive with absent
or abnormal breathing

Call EMS/Resuscitation team

CPR 30:2
Attach defibrillator/monitor

Assess rhythm

Shockable Non-shockable
(VF/PULSELESS VT) (PEA/ASYSTOLE)

1 shock

Immediately resume chest Return of spontaneous Immediately resume chest

compressions for 2 minutes circulation (ROSC) compressions for 2 minutes

Give high-quality chest compressions and Identify and treat reversible causes
• Hypoxia
• Give oxygen
• Use waveform capnography • Hypovolaemia
• Hypo-/hyperkalemia/metabolic
• Continuous compressions if advanced airway
• Hypo-/hyperthermia
• Minimise interruptions to compressions • Thrombosis – coronary or pulmonary
• Intravenous or intraosseous access • Tension pneumothorax
• Give adrenaline every 3-5 min • Tamponade- cardiac
• Give amiodarone after 3 shocks • Toxins
Consider ultrasound imaging to identify
• Identify and treat reversible causes
reversible causes
Consider
• Coronary angiography/percutaneous coronary
intervention
• Mechanical chest compressions to facilitate transfer/treatment
• Extracorporeal CPR
After ROSC
• Use an ABCDE approach
• Aim for SpO2 of 94-98% and normal PaCO2
• 12 Lead ECG
• Identify and treat cause
• Targeted temperature management
TACHYCARDIA
Synchronised shock up to 3 attempts
ASSESS with ABCDE approach
Life-threatening features? • Sedation, anaesthesia if conscious
• Give oxygen if SpO2 < 94% and obtain IV access
1. Shock YES If unsuccessful:
• Monitor ECG, BP, SpO2. Record 12 lead ECG
2. Syncope
• Identify and treat reversible causes
• Amiodarone 300 mg IV over 10-20 min,
or procainamide 10-15 mg/kg IV over 20
UNSTABLE
3. Myocardial ischaemia
(e.g. electrolyte abnormalities, hypovolaemia min;
4. Severe heart failure
causing sinus tachycardia) • Repeat synchronised shock

NO

STABLE
Is QRS narrow (<0.12 s)? SEEK EXPERT HELP

Broad
BroadQRS
QRS Narrow QRS
IsIsrhythm regular?
QRS regular? Is QRS regular?

Irregular Regular Regular Irregular

Possibilities include:
• Atrial fibrillation with bundle
branch block — treat as for irregu-
lar narrow complex
• Polymorphic VT
(e.g. torsades de pointes) — give
magnesium 2 g over 10 min
Vagal manoeuvres Probable atrial fibrillation:
If VT (or uncertain rhythm):
• Procainamide 10-15 mg/kg IV over 20 • Control rate with beta-blocker or
min diltiazem
or If ineffective: • Consider digoxin or amiodarone if
• Amiodarine 300 mg IV over 10-60 min Adenosine (if no pre-excitation) evidence of heart failure
• 6 mg rapid IV bolus; • Anticoagulate if duration > 48h
• If unsuccessful give 12 mg
If previous certain diagnosis of SVT
• If unsuccessful give IV 18 mg
with bundle branch block/
aberrant conduction:
• Treat as for regular narrow complex
tachycardia If ineffective:
• Verapamil or beta-blocker

If ineffective:
• Synchronised DC shock
up to 3 attempts
• Sedation, anaesthesia
if conscious
 BRADYCARDIA

ASSESS with ABCDE approach

ABCDE approach • Give oxygen if SpO2 < 94% and obtain IV access
oxygen if hypoxic
• Monitor ECG, BP, SpO2 Record 12 lead ECG
nd record 12-lead ECG
• Identify and treat reversible causes
(e.g. electrolyte abnormalities, hypovolaemia)
ible causes
alities)

Life-threatening features?
1. Shock
2. Syncope
3. Myocardial ischaemia
4. Severe heart failure

YES

NO
Atropine 500 mcg IV

YES
Satisfactory response? Risk of asystole?
• Recent asystole
NO • Mobitz II AV block
• Complete heart block
YES with broad QRS
Consider interim measures: • Ventricular pause > 3 s
• Atropine 500 mcg IV repeat to
maximum of 3 mg
• Isoprenaline 5 mcg min-1 IV
• Adrenaline 2-10 mcg min-1 IV NO
• Alternative drugs*
and / or
• Transcutaneous pacing

Seek expert help

Observe
Arrange transvenous pacing

* Alternatives include:
• Aminophylline
• Dopamine
• Glucagon (if bradycardia is caused by beta-blocker or calcium channel blocker)
• Glycopyrrolate (may be used instead of atropine)
ACCIDENTAL HYPOTHERMIA
Core temperature <35°C or cold to touch

Vital signs present

YES NO

• Obvious signs off irreversible death (1)

Impaired consciousness YES TO ANY Consider
• Valid DNR order withholding
NO YES • Conditions unsafe for rescuer or termination
• Avalanche burial >60 min, airway packed of CPR
with snow and asystole

Prehospital cardiac instability Witnessed NO TO ALL

Transport to nearest hospital hypothermic
if injured; consider onsite or • SBP <90 mm Hg (2) cardiac arrest - • Start CPR, do not delay transport
hospital treatment if uninjured • Cardiocirculatory instability Start CPR • If continuous CPR is not possible, consider intermittent
• Core temperature <32°C in old and or delayed CPR in difficult or dangerous rescue
multimorbid or <30°C in young and healthy • Airway management
• Core temperature <30°C max 3 defibrillations,
HT I (3) no epinephrine
NO TO ALL YES TO ANY
• Warm environment and dry clothing • Gather information of mechanism of accident
• Warm sweet drinks
• Active movement
YES
Transport to nearest
Cardiac arrest from alternative appropriate hospital or
cause prior to cooling manage as per
Transport to nearest Transport to hospital
• Avalanche burial <60 min supervising MD
appropriate hospital with ECLS (4)

NO

Transport to hospital with ECLS

HT II or III (3) (4); do NOT terminate CPR
• Minimal and cautious movements to avoid rescue
collapse
• Prevent further heat loss Consider prognostication to NO TO ANY
• Active external and minimally invasive rewarming determine benefit of ECLS (6)
techniques (5) • HOPE survival probability ≥10
• Airway management as required • ICE score <12

YES TO ANY
Cardiac
instability HT IV (3)
• Prepare for multi-organ failure and resolved No ROSC Consider
need for ECLS respiratory support • Rewarm with ECLS termination
• Post-resuscitation care • If ECLS not available within 6 hrs, CPR and of CPR
non-ECLS rewarming in peripheral hospital
• Rewarm to core temperature ≥32°C
12/10/2020
HYPERTHERMIA
YES
Universal ALS
Require CPR?
algorithm TIME IS KEY: COOL AND RUN APPROACH

NO • Cool first, transfer to hospital after

Bathtub, ½ to ¾ filled • Immediate cooling
water & ice, 1-17°C, • Rapidly cool to <39°C until symptoms resolve
stirred or circulated
Use a YES
Core temperature
temperature
>40.5ºC
probe Continue monitoring for at least
15 min after cooling
NO Rapid cooling (cold Stop cooling at core
water immerssion) temperature <39°C • Rehydrate as required
• Check for improved mental status
Core temperature
≤40.5ºC, & confused/ • Avoid accidental hypothermia
desoriented YES (<35°C)

NO

If abnormal mental state initiate IV

YES 100ml bolus of 3% saline at 10 min
Blood sodium Hyponatraemia
intervals, 2nd and 3rd bolus only
<130 mEq/L algorithm
if required. If normal mental state
administer oral sodium
NO

If abnormal mental state administer

YES IV normal saline or Ringer’s lactated.
Severely
dehydrated? If normal mental state provide oral
rehydration and sodium
NO

NO YES
Release with exercise Appropriate algorithm
Other symptoms
restrictions e.g. Hypoglycaemia
EMERGENCY TREATMENT
OF HYPERKALAEMIA
• Assess using ABCDE approach
• 12-lead ECG and monitor cardiac rhythm if serum potassium (K+) ≥ 6.5 mmol/L
• Exclude pseudohyperkalaemia
• Give empirical treatment for arrhythmia if hyperkalaemia suspected

Mild Moderate Severe

K 5.5 - 5.9 mmol/L
+ K+ 6.0 - 6.4 mmol/L K+ ≥ 6.5 mmol/L
Consider cause and need Treatment guided by clinical Emergency treatment
for treatment condition, ECG and rate of rise indicated

Seek expert help

ECG Changes?
Peaked T waves Broad QRS Bradycardia
Flat/ absent P waves Sine wave VT

NO YES

IV Calcium
10ml 10% Calcium Chloride IV OR
Protect the 30ml 10% Calcium Gluconate IV
heart • Use large IV access and give over 5 min
• Repeat ECG
• Consider further dose after 5 min if ECG changes persist

Insulin–Glucose IV Infusion
Glucose 25g with 10 units soluble insulin over 15 - 30 min IV
(25g = 50ml 50% glucose; 125ml 20% glucose, 250ml 10% glucose)
If pre-treatment BG < 7.0 mmol/L:
Shift K+ Start 10% glucose infusion at 50ml/ hour for 5 hours (25g)
into cells
Risk of
Consider
hypoglycaemia

Salbutamol 10 – 20 mg nebulised
Consider Life-threatening
hyperkalaemia

*Sodium zirconium cyclosilicate *Sodium zirconium cyclosilicate

10g X3/day oral for 72 HRS OR 10g X3/day oral for 72 HRS OR
Remove K+ *Patiromer *Patiromer
from body 8.4G /day oral OR 8.4G /day oral
*Calcium resonium
15g X3/day oral
Consider Dialysis
*Follow local practice
Seek expert help

Monitor K+
and blood Monitor serum K+ and blood glucose
glucose K+ ≥ 6.5 mmol/L
despite medical
therapy

Prevention Consider cause of hyperkalaemia and prevent recurrence

Emergency treatment of hyperkalaemia. ECG – electrocardiogram; VT ventricular tachycardia. BG Blood Glucose

TOXIC EXPOSURE

Toxic exposure

NO Risk of contamination? YES PPE1

Cardiac arrest/peri arrest? Universal ALS

YES algorithm
NO

Poison centre

If indicated:
• Avoid mouth-to-mouth breathing
Decontamination
• Continue resuscitation
Enhanced elimination
• Higher dose of medication
Antidote

• Try to identify the poison

• Consider hypo- or hyperthermia
• Exclude all reversible causes
CORONARY THROMBOSIS

1. Prevent and be prepared

• Encourage cardiovascular prevention to reduce the risk of acute events
• Promote health education to reduce delay to first medical contact
• Promote laypeople BLS to increase the chance of bystander CPR
• Ensure adequate resources for better management
• Improve quality management systems & indicators for better quality monitoring

2. Detect parameters suggesting coronary thrombosis &

Activate STEMI network
• Chest pain prior to arrest
• Known coronary artery disease
• Initial rhythm VF or pVT
• Post-resuscitation ECG: ST elevation

3. Resuscitate and treat possible causes

Sustained ROSC No Sustained ROSC

STEMI patients No STEMI patients Assess setting & patient

Time from conditions and available
Individualise decisions
diagnosis to PCI resources
considering patient
< 120 min characteristics, OHCA If futility:
setting, ECG findings
Activate PCI Consider stopping CPR
laboratory Quick diagnostic work up
Discard non-coronary If no futility:
Transfer for
immediate PCI causes Consider transfer to PCI
Chest patient condition centre with on-going CPR
> 120 min
If there is on Consider mechanical
Perform pre-hospital going ischaemia compressions and extra-
fibrinolysis or haemodynamic corporeal CPR
Transfer to PCI compromise?
centre Consider PCI
Yes – immediate PCI
No - consider delayed PCI
NEUROPROGNOSTICATION FOR THE
COMATOSE PATIENT AFTER RESUSCITATION
FROM CARDIAC ARREST

Targeted temperature
management and rewarming

Unconscious patient,
M≤3 at ≥72h without confounders (1)

YES

At least TWO of:

• No pupillary (2) and corneal reflexes at ≥72h
• Bilaterally absent N20 SSEP wave YES Poor
• Highly malignant (3) EEG at >24h outcome
likely (*)
• NSE >60 µg/L (4) at 48h and/or 72h
• Status myoclonus (5) ≤72h
• Diffuse and extensive anoxic injury on brain CT/MRI

NO

Observe and re-evaluate

1
Major confounders may include analgo-sedation, neuromuscular blockade, hypothermia,
severe hypotension, hypoglycaemia, sepsis, and metabolic and respiratory derangements
2
Use an automated pupillometer, when available, to assess pupillary light reflex
3
Suppressed background ± periodic discharges or burst-suppression, according to American Clinical
Neurophysiology Society
4
Increasing NSE levels between 24h-48h or 24/48 and 72h further support a likely poor outcome
5
Defined as a continuous and generalised myoclonus persisting for 30 minutes or more
* Caution in case of discordant signs indicating a potentially good outcome (see text for details).
RECOMMENDATIONS FOR IN-HOSPITAL
FUNCTIONAL ASSESSMENTS, FOLLOW-UP
AND REHABILITATION AFTER CARDIAC
ARREST

BEFORE HOSPITAL DISCHARGE

Perform functional assessments of

physical and non-physical impairments

Refer to rehabilitation
if necessary

AT FOLLOW UP
Within 3 months from
hospital discharge

Perform Provide information

Perform
screening for and support to
screeening for
emotional problems the survivor and
cognitive problems
and fatigue their family

Consider referral to
further specialised
care if indicated