Version control: This document is current with respect to 2016 American Heart Association® Guidelines for CPR and ECC. Updated 2020 guidelines have been published by AHA, by enrolling in our courses you will receive the current learning materials (2016 guidelines) now and also AUTOMATICALLY have free access to the 2021 guidelines when available. Please note that our company typically implements new training guidelines up to a year before AHA releases their updates.

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Using the ACLS Primary Survey for a Patient in Respiratory Arrest

The ACLS Secondary Survey takes you through the advanced assessment and actions you need to accomplish for a patient in respiratory arrest (see Table 1). The assessment guides you in finding the answers and taking appropriate next steps.

The assessments follow the CAB format of the primary survey:

  • Circulation
  • Airway
  • Breathing

If a cervical spine injury is suspected and you are familiar with the technique, you should utilize a jaw thrust to open the airway while maintaining cervical stabilization

Table 1. Advanced Cardiac Life Support Secondary Survey

Assessment Action

Is the patient's airway obstructed?

To open the obstructed airway for unconscious patients, use the head-tilt, chin lift. Insert an oropharyngeal airway (OPA) or nasopharyngeal airway (NPA) if needed to keep the airway open. The oral airway is ONLY indicated in patients who are deeply unconscious as they stimulate the gag reflex and thus cause risk of aspiration.

Does the patient need an advanced airway?

If yes, use the airway that is appropriate to your skill level. King Airway System™, LMA, Combitube™, and or endotracheal intubation.

Is the patient breathing?

Give bag valve mask ventilations every 6 seconds or 10 breaths per minute.

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).

Is the advanced airway device placed properly?

Confirm correct placement of the advanced airway device by observing the patient, confirming the presence of lung sounds in at least 4 lung fields and using waveform capnography.

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. Do not use circumferential devices to secure the airway.

What was the patient's initial cardiac rhythm?

Attach ECG leads. Identify the patient's rhythm.

What is the patient's current cardiac rhythm?

Monitor the 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, using a crystalloid.

Does the patient need medications for rhythm or blood pressure control?

Give appropriate medications to manage rhythm (e.g., 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 arrest?

Search for reversible causes of the arrest. Find and treat reversible causes of the arrest.

The appropriate airway will depend not only on the patient’s condition, but the experience level of the provider as well.

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.