Chapter 05. In hospital resuscitation

1. Recognition and Immediate Response

The first step in managing a patient in suspected cardiac arrest is early recognition and immediate action to improve survival chances.

Key Steps in Recognition and Initial Response:

• Identify cardiorespiratory arrest quickly.
• Call for help using the hospital emergency number 2222 in the UK.
• Begin chest compressions immediately and attempt defibrillation within 3 minutes if indicated.

2. Factors Affecting In-Hospital Resuscitation

Hospital settings have unique challenges in responding to cardiac arrests. These include:

• Location of Arrest:
  • Patients in monitored areas (ICU, CCU, A&E) have a better survival rate due to early detection and intervention.
  • Patients in unmonitored areas (wards, bathrooms, corridors) have delayed recognition and worse outcomes.
• Skill Level of Responders:
  • In-hospital responders vary in their ALS training.
  • Early intervention by nurses, junior doctors, or healthcare assistants is essential before the resuscitation team arrives.
• Number of Responders Available:
  • More staff available during daytime than at night/weekends.
  • Lone responders should start CPR and call for help immediately.
• Availability of Equipment:
  • Resuscitation trolleys and defibrillators must be readily accessible and regularly checked.
• Hospital Emergency Response System:
  • Medical Emergency Teams (METs) or Resuscitation Teams can provide early intervention before cardiac arrest occurs.

3. Initial Assessment & ALS Algorithm

Once an unresponsive patient is found, the ALS algorithm should be followed:

A. Ensure Personal Safety

• Use personal protective equipment (PPE) as needed.
• Be aware of infection risks, hazardous substances, or electrical hazards.

B. Primary Assessment & Calling for Help

1. Check for Responsiveness:
   • Shake the patient and shout for a response.
   • If responsive → Use the ABCDE approach, administer oxygen, and monitor vital signs.
   • If unresponsive → Shout for help, place the patient on their back, and proceed with airway assessment.
2. Assess Airway & Breathing (Simultaneously ≤10 sec):
   • Open the airway: Head tilt–chin lift (or jaw thrust if C-spine injury suspected).
   • Look, listen, and feel for normal breathing.
   • If the patient is breathing normally → Place them in the recovery position and monitor.
   • If not breathing normally → Assume cardiac arrest and start CPR.
3. Check Circulation:
   • No signs of life / abnormal breathing → Start chest compressions immediately.

4. High-Quality CPR & Airway Management

Effective chest compressions and ventilation are critical for resuscitation success.

Chest Compressions:

• Rate: 100-120 compressions per minute.
• Depth: 5-6 cm (allow full recoil).
• Ratio: 30 compressions to 2 breaths.
• Minimise interruptions to compressions.

Airway and Ventilation:

• Basic airway techniques: Pocket mask or bag-valve-mask (BVM).
• Advanced airway management (if trained personnel available):
  • Supraglottic airway devices (LMA, iGel) or endotracheal intubation.
  • Use continuous waveform capnography for confirmation.

5. Defibrillation & Rhythm Management

Defibrillation is crucial for shockable rhythms (VF & pulseless VT).

Defibrillation Process:

1. Apply self-adhesive defibrillator pads while CPR continues.
2. Assess cardiac rhythm using a manual defibrillator (preferred) or AED.
3. If shockable rhythm (VF/VT) → Deliver a shock immediately (biphasic 150-200J, monophasic 360J).
4. Immediately resume CPR for 2 minutes before reassessing the rhythm.
5. If non-shockable rhythm (PEA/asystole) → Continue CPR and administer drugs as per ALS protocol.

6. Ongoing Resuscitation & Team Coordination

• Adrenaline (1 mg IV) should be given every 3-5 minutes for non-shockable rhythms (PEA/asystole) and after the 3rd shock for shockable rhythms.
• Amiodarone (300 mg IV) is given after the 3rd shock for VF/VT.
• Teamwork & communication: Effective leadership and structured handovers (SBAR or RSVP).
• Reversible causes should be identified early using the 4H’s and 4T’s:
  • Hypoxia, Hypovolaemia, Hypo-/Hyperkalaemia, Hypothermia
  • Thrombosis (MI/PE), Tension pneumothorax, Tamponade, Toxins

7. Post-Resuscitation Care

Once Return of Spontaneous Circulation (ROSC) is achieved:

1. ABC stabilization: Maintain oxygenation (SpO₂ 94-98%) and perfusion (MAP ≥65 mmHg).
2. 12-lead ECG to assess for ST-elevation myocardial infarction (STEMI).
3. Targeted Temperature Management (TTM): Consider cooling to 32-36°C for unconscious survivors.
4. Monitor for organ dysfunction (neurological, renal, cardiac).
5. Transfer to ICU or high-dependency care as needed.
6. Debrief the team to improve future responses.

Conclusion

The ALS approach in UK hospitals follows a structured protocol emphasizing:
 Early recognition & immediate CPR
 High-quality chest compressions with minimal interruption
 Rapid defibrillation for VF/VT
 Effective team coordination & drug administration
 Post-resuscitation care to optimise survival