13.3 Resuscitation Priorities & Rapid Response

The Primary Survey: ABCDE

When a patient deteriorates, the CCRN expects a disciplined primary survey in fixed priority order: Airway (patent, protected), Breathing (rate, effort, oxygenation), Circulation (pulse, perfusion, hemorrhage control), Disability (neurologic status, Glasgow Coma Scale, pupils, glucose), and Exposure (fully expose, prevent hypothermia). You fix each threat before moving to the next: an obstructed airway is corrected before assessing breathing. The single most common test trap is choosing a definitive diagnostic step (a CT scan, a 12-lead) over securing a compromised ABC — always stabilize the airway and circulation first.

Recognizing Deterioration: Rapid Response

Most in-hospital arrests are preceded by hours of abnormal vital signs. Strengthening the afferent limb of the chain of survival — recognizing and escalating deterioration — is where nurses have the greatest impact. Early warning scores such as the National Early Warning Score (NEWS) and Modified Early Warning Score (MEWS) aggregate respiratory rate, oxygen saturation, temperature, blood pressure, heart rate, and level of consciousness into a single number that triggers escalation. Rapid Response Teams (RRTs) and Medical Emergency Teams (METs) bring critical-care expertise to the bedside before arrest and are associated with fewer out-of-ICU cardiac arrests. Classic triggers include a respiratory rate below 8 or above 28, SBP below 90, a new drop in level of consciousness, or simply nurse concern — a legitimate, guideline-endorsed criterion.

Code Management

Once a patient is pulseless, the priority becomes high-quality cardiopulmonary resuscitation (CPR) and rhythm-based Advanced Cardiovascular Life Support (ACLS):

Rhythm dictates the pathway. Shockable rhythms — ventricular fibrillation (VF) and pulseless ventricular tachycardia (pVT) — receive immediate unsynchronized defibrillation, resumed CPR, epinephrine 1 mg IV every 3-5 minutes, and an antiarrhythmic (amiodarone 300 mg then 150 mg, or lidocaine). Non-shockable rhythms — asystole and pulseless electrical activity (PEA) — are NOT shocked; give CPR and epinephrine as early as possible while systematically treating the reversible H's and T's (hypovolemia, hypoxia, hydrogen ion/acidosis, hypo/hyperkalemia, hypothermia; tension pneumothorax, tamponade, toxins, thrombosis of coronary or pulmonary origin). Contrast this with the conscious patient: unstable tachycardia with a pulse gets synchronized cardioversion, and symptomatic bradycardia gets atropine 1 mg (repeat to a 3 mg maximum) then pacing.

Post-Resuscitation Care and TTM

Return of spontaneous circulation (ROSC) begins a fragile phase requiring bundled care: avoid hypoxia and hyperoxia (titrate SpO2 to 92-98 percent), support hemodynamics (MAP above 65, treating the cause such as percutaneous coronary intervention for STEMI), control glucose, and obtain an EEG if seizures are suspected. For comatose survivors, Targeted Temperature Management (TTM) improves neurologic outcome: maintain a constant target temperature between 32 and 37.5 C for at least 24 hours, then actively prevent fever for at least 72 hours. Shivering is controlled with sedation, analgesia, and if needed neuromuscular blockade. Neuroprognostication is delayed at least 72 hours after normothermia to avoid premature withdrawal, because sedation and hypothermia confound the exam.

Family Presence

AACN and current resuscitation guidelines support offering family presence during resuscitation. Evidence shows it aids grieving without disrupting care or increasing litigation. The standard is to assign a dedicated staff member to accompany and support the family, explain interventions, and remove them if care is compromised — a caring-practices and advocacy competency that the CCRN links to the Synergy Model.

Monitoring CPR Quality and Detecting ROSC

Quantitative waveform capnography (end-tidal CO2, EtCO2) is the CCRN's preferred tool for both CPR quality and ROSC detection. A persistently low EtCO2 below 10 mmHg during CPR signals inadequate compressions or poor cardiac output and predicts failure to achieve ROSC — the fix is to improve compression depth/rate and rotate a fatigued compressor. A sudden abrupt rise in EtCO2 (often to 35-40 mmHg) frequently signals ROSC, prompting a pulse and rhythm check. Capnography also confirms endotracheal tube placement. For defibrillation, use the manufacturer-recommended energy (commonly 120-200 J biphasic) and resume compressions immediately after the shock rather than pausing to reassess the rhythm.

The Chain of Survival and a Worked Scenario

The in-hospital chain of survival is: surveillance and prevention, recognition and activation of the emergency response, high-quality CPR, defibrillation, and post-arrest care. A worked example: a ward patient trends over four hours to a respiratory rate of 30, SpO2 of 88 percent, and new confusion, giving a NEWS that crosses the escalation threshold. The correct action is to activate the rapid response team early, apply oxygen, and treat the deterioration — not to wait and "monitor." Early activation here can prevent the arrest entirely, which is why the afferent limb is emphasized so heavily on the CCRN.

Common Traps

Test traps in this domain include: choosing a diagnostic study over securing the airway or circulation; pausing compressions excessively (any interruption lowers the compression fraction); giving atropine or attempting cardioversion in a pulseless rhythm (both are wrong — pulseless patients need CPR and, if shockable, defibrillation); and delaying rapid-response activation because vital signs are only "slightly" abnormal. When in doubt, return to the ABCs and treat the immediate threat to life first.