ACLS Secondary Survey for a Patient in

Respiratory Arrest
Using the ACLS Primary Survey for a Patient in
Respiratory Arrest
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. If the patient
is pulseless, advanced airway should be deferred until return of spontaneous circulation
(absent special situations, like aspiration risk, etc. )Your 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

Figure 1. Advanced Cardiac Life Support

Secondary Survey
Assessment

Action

Is the patient's airway

To open the airway for unconscious patients, use the head-

obstructed?

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

to secure the airway.

Is the patient
breathing?

Give bag valve mask ventilations every 6 seconds or 10

breaths per minute

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 the advanced airway device
that is most apprppriate to your scope of practice.

Is the advanced airway

device placed
properly?

Confirm correct placement of advanced airway device by a

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
devices to secure the airway device that are circumferential.

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, using a crystalloid

Does the patient need

medications for rhythm
or blood pressure
control?

Give appropriate medications to manage rhythm (eg,

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.

If the patient is not deeply unconscious, you must use a nasoparhygeal airway as an
OPA will activate the gag reflex
The appropriate airway will depend not only on the patients condition, but the
experience level of the provider as well.
Avoid commercial devices that are circumferential
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.