Non-shockable Rhythm Arm of The ALS Algorithm – Further Issues

A number of issues relate to the resuscitation of patients in cardiac arrest, regardless of the underlying rhythm:

1. Should I intubate the patient and if so, when?

There is insufficient evidence to support or refute the use of any specific technique to maintain an airway and provide ventilation in adults with cardiorespiratory arrest. The key advantage intubation confers is enabling continuous chest compressions. Once intubated, compress the chest at a rate of 100-120/minute and ventilate at a rate of 10 breaths per minute (i.e do not stop compressions for ventilation). The disadvantage of securing the airway with a tracheal tube is pausing for chest compressions whilst intubation is attempted. No tracheal intubation attempt should interrupt compressions for more than 10 seconds.

Unrecognised oesophageal intubation is the most serious complication of attempted tracheal intubation. Primary confirmation (seeing the tube pass through the cords, bilateral air entry in the axillae, no breath sounds heard over the epigastrium) and secondary confirmation (exhaled carbon dioxide or oesophageal detection device) to confirm correct placement of the tube will reduce this risk.

Learning bite

If bag-mask ventilation is effective, tracheal intubation may be deferred.

2. Should I insert a central line?

Central venous cannulation is a defined skill, requires a pause in chest compressions for successful completion and is prone to complication.

If intravenous access cannot be established within the first 2 minutes of resuscitation, consider gaining intraosseous access (IO) instead, rather than a central line.

3. When should I stop resuscitation?

Of those patients who suffer out-of-hospital cardiac arrest, less than 10% will ultimately reach ‘discharge from hospital’ [1]. The vast majority of patients arriving in the ED in sustained cardiac arrest, i.e. unresponsive to paramedic efforts (notably defibrillation), will not achieve a return of spontaneous circulation. The decision to stop resuscitation is ultimately that of the team leader. The decision is not necessarily straightforward. The patient’s background, medical history and quality of life are important, though accurate details are not usually readily available. Consideration of downtime (the time from patient collapse to the provision of basic life support) is of limited value, since patients may not have been in cardiac arrest from the outset. The provision of basic life support, and advanced life support may be of variable quality.

In general, it is futile to continue resuscitation in those patients who have been in asystole for 20 minutes despite full ALS measures, either by out-of-hospital or ED teams.

On the other hand, continued resuscitation should be considered whilst the patient remains in a shockable rhythm or other reversible cause of cardiac arrest exist (e.g. hypothermia).

Learning bite

Abandon resuscitative attempts if the patient has been asystolic for 20 minutes despite advanced life support measures.

4. What is the role of the team leader?

The key roles are as follows:

• Directing the cardiac arrest team
• Taking responsibility for safety, especially during defibrillation
• Stopping the resuscitation appropriately
• Effecting post-resuscitation care for those patients with ROSC
• Communicating with relatives and notifying the coroner and the patient’s general practitioner
• Documentation

Individual assuming the role & further duties of the team leader

For the individual assuming the role, the ALS manual (2021) [1] gives excellent advice to the team leader:

• Knows everyone in the team by name and knows their capability
• Accepts the leadership role
• Is able to delegate tasks appropriately
• Is knowledgeable and has sufficient credibility to influence the team through role modelling and professionalism
• Recognises their own limitations and ask for support from the team
• Is a good communicator – not just good at giving instructions, but is also a good listender and decisive in action
• Stays clam, keeps everyone focused and controls distractions
• Is empathetic towards the whole team
• Is assertive and authoritative when required
• Shows tolerance towards hesitancy or nervousness in the emergency setting
• Has good situational awareness; able to constantly monitor the situation, with an up-to-date overview, listening and deciding on a course of action.

Specifically at a cardiac arrest the leader should:

• Follow current resuscitation guidelines or explain a reason for any significant deviation from standard protocols
• Consult with the team or call for senior advice and assistance if unsure about an intervention
• Play to the strengths of team members and allow them some autonomy if their skills are adequate
• Allocate roles and tasks throughout the resuscitation and be specific – this limits the risks of nobody, or alternatively too many people, attempting the task
• Use the two minute periods of chest compressions to plan tasks and safety aspects of the resuscitation attempt with the team
• Thank the team at the end of the resuscitation attempt and ensure that staff and relatives are being supported
• Complete all documentation and ensure an adequate handover.