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ACLS Secondary Survey (Respiratory Arrest)

Using the ACLS Primary Survey for a Patient in Respiratory Arrest

Before proceeding, it is a good idea to view our terms.

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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. You decide if an advanced airway is necessary for the patient to maintain respirations. Your assessments guide you in finding answers and taking appropriate next steps.

The assessments follow the ABCD format of the primary survey:


  • Airway
  • Breathing
  • Circulation
  • Differential diagnosis

Figure 1. Advanced Cardiac Life Support Secondary Survey


Assessment Action
Is the patient's airway obstructed? To open the airway for unconscious patients, use the head-tilt, chin lift.
Insert an oropharyngeal airway (OPA) or a nasopharyngeal airway (NPA) if needed to keep the airway open.
Does the patient need an advanced airway? If yes, use an LMA, Combitube, or endotracheal intubation, among others.
Is the patient breathing? Give bag-mask ventilations every 5 to 6 seconds (about 10 to 12 breaths per minute without chest compressions).
Is an advanced airway indicated? No.
If bag-mask ventilation is adequate, defer the insertion of an advanced airway until it becomes essential (patient fails to respond to initial CPR or until spontaneous circulation returns).
Yes. Insert an advanced airway device.
Is the advanced airway device placed properly? Confirm correct placement of advanced airway device by a observing the patient and using a confirmation device, such as an exhaled CO2 detector or an esophageal detector.
Is the advanced airway device secured correctly? Secure the advanced airway device so it does not dislodge, especially in patients who are at risk for movement. Secure the ET tube with tape or a commercial device.
What was the patient's initial cardiac rhythm? Attach ECG leads. Identify patient's rhythm.
What is the patient's current cardiac rhythm? Monitor patient for arrhythmias or cardiac arrest rhythms (ventricular fibrillation, pulseless ventricular tachycardia, asystole, and PEA).
Does the patient need an IV? Establish IV or IO access.
Does the patient need fluid? 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, magnesium) and blood pressure (eg, epinephrine, vasopressin, dopamine).
Is a reversible cause responsible for the arrest? Search for reversible causes of the arrest.
Find and treat reversible causes of the arrest.

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.