4.2 Basic Life Support (BLS) & In-Hospital Cardiac Arrest

Basic Life Support (BLS) & In-Hospital Cardiac Arrest

Universal Emergency Number: In all acute hospitals across the Republic of Ireland, the standardized internal telephone number to summon the cardiac arrest resuscitation team is 2222. When calling, the nurse must clearly state: "Cardiac Arrest / Adult Medical Emergency, [Ward Name], [Bed Number / Room]."

1. The In-Hospital Chain of Survival

Adult in-hospital cardiac arrest (IHCA) protocols in Ireland follow the guidelines established by the Irish Resuscitation Council (IRC) in conjunction with the European Resuscitation Council (ERC). The in-hospital chain of survival comprises five interdependent links:

1. Early Recognition and Prevention: Utilizing the Irish National Early Warning System (INEWS) to detect physiological deterioration hours before cardiac arrest occurs.
2. Early Call for Help: Dialing 2222 immediately upon finding an unresponsive, non-breathing patient to mobilize the multidisciplinary resuscitation team.
3. Early High-Quality CPR: Commencing chest compressions without delay to preserve coronary and cerebral perfusion.
4. Early Defibrillation: Rapid rhythm analysis and shock delivery within 3 minutes of arrest for shockable rhythms.
5. Post-Resuscitation Care: Targeted temperature management, haemodynamic stabilization, coronary reperfusion (PCI), and neuroprotection in the intensive care unit.

2. The Systematic BLS Sequence (Step-by-Step)

When encountering a collapsed or acutely unresponsive patient in an Irish hospital ward:

[1. Danger] Confirm scene safety for patient and staff
      │
      ▼
[2. Response] Shake shoulders gently & ask: "Are you alright?"
      │ (If unresponsive)
      ▼
[3. Shout for Help & Dial 2222] Activate emergency call bell & dial internal crash line
      │
      ▼
[4. Airway] Open airway: Head tilt-chin lift (or Jaw thrust if c-spine injury suspected)
      │
      ▼
[5. Breathing & Carotid Pulse] Look, listen, feel breathing AND palpate carotid pulse (Max 10 seconds)
      │ (No pulse OR abnormal/agonal gasping)
      ▼
[6. CPR] Begin 30 chest compressions : 2 ventilations + Attach Defibrillator / AED

Detailed Action Steps:

1. Danger: Check for hazards (electrical wires, spilled fluids, bed mechanisms, violent bystanders).
2. Response: Gently shake the patient's shoulders and speak loudly into both ears: "Hello, can you hear me? Are you alright?"
3. Call for Help: If unresponsive:
   • Press the ward emergency call bell immediately.
   • Instruct a designated colleague: "Dial 2222 for the adult cardiac arrest team to Ward 3, Bed 4, and bring the crash trolley and defibrillator."
4. Airway:
   • Place the patient supine on a firm surface (flatten the electric hospital bed; insert CPR backboard if available).
   • Perform head tilt-chin lift (place one hand on the forehead, fingertips under the bony point of the chin, and tilt back gently).
   • If cervical spine trauma is suspected, use the jaw thrust maneuver without neck extension.
   • Inspect the oral cavity quickly: clear visible foreign bodies or copious fluids using a wide-bore Yankauer suction catheter.
5. Breathing and Pulse Check (Max 10 Seconds):
   • Simultaneously look for chest rise, listen at the mouth for breath sounds, and feel for air on your cheek.
   • Concurrently palpate the carotid artery (in the groove between the trachea and sternocleidomastoid muscle).
   • Agonal gasping (infrequent, noisy, labored gasps) is a sign of cardiac arrest, not normal breathing.
   • If there is no normal breathing and no definite pulse within 10 seconds, commence CPR immediately.

3. High-Quality CPR Metrics

Chest compressions generate only 25–30% of normal cardiac output; hence, high technical precision is required:

• Hand Placement: Heel of one hand on the center of the chest (lower half of the sternum), with the heel of the second hand interlocking on top.
• Compression Depth: 5 to 6 cm in adults (approximately one-third of the anterior-posterior diameter of the chest), avoiding depths exceeding 6 cm.
• Compression Rate: 100 to 120 compressions per minute (matching the rhythm of "Stayin' Alive").
• Complete Chest Recoil: Allow the chest wall to re-expand fully after each compression. Do not lean on the patient's chest, as residual pressure impedes venous return and coronary filling.
• Minimize Interruptions: Keep hands-off intervals under 10 seconds (only pausing for rhythm analysis, shock delivery, or advanced airway insertion).
• Compression-to-Ventilation Ratio: 30 compressions followed by 2 ventilations.
  • Deliver ventilations via a bag-valve-mask (BVM) connected to high-flow oxygen ($15\text{ L/min}$ with reservoir bag) or a pocket resuscitation mask with a one-way valve.
  • Each ventilation should be delivered gently over 1 second, providing sufficient tidal volume ($500\text{--}600\text{ mL}$) to produce visible chest rise.
  • Avoid hyperventilation: excessive tidal volumes or respiratory rates elevate intrathoracic pressure, decrease venous return, and reduce cardiac output.
• Compressor Rotation: Chest compression quality declines markedly after 2 minutes of continuous exertion. Compressors must switch every 2 minutes (during defibrillator rhythm re-analysis) with minimal interruption ($<5\text{ seconds}$).

4. Defibrillation & Cardiac Arrest Rhythms

As soon as the emergency resuscitation trolley arrives, attach the defibrillator self-adhesive pads while CPR continues:

• Pad Placement (Anterolateral):
  • Sternal Pad: Below the right clavicle, to the right of the upper sternum.
  • Apical Pad: Mid-axillary line, 5th or 6th left intercostal space (lateral to the left breast/nipple).
  • Alternative: Anteroposterior placement (front and back of chest) if the patient has a permanent pacemaker or implantable cardioverter-defibrillator (ICD) under the right clavicle (pads must be placed at least $8\text{ cm}$ away from the device generator).

                    [Cardiac Arrest Confirmed]
                                │
                     [Attach Defibrillator]
                                │
                     [Pause CPR: Analyze Rhythm]
                                │
             ┌──────────────────┴──────────────────┐
             ▼                                     ▼
     [Shockable Rhythm]                   [Non-Shockable Rhythm]
     • Ventricular Fibrillation (VF)      • Asystole
     • Pulseless VT (pVT)                 • Pulseless Electrical Activity (PEA)
             │                                     │
             ▼                                     ▼
     Deliver 1 Shock (150-200 J)          Immediate CPR for 2 minutes
             │                                     │
     Immediate CPR for 2 minutes          Adrenaline 1 mg IV as soon as access
             │                            Repeat Adrenaline every 3-5 min
     Adrenaline 1 mg + Amiodarone 300 mg           │
     after 3rd shock; Amiodarone 150 mg   Assess & Treat 4 Hs & 4 Ts
     after 5th shock

Shockable Rhythms

1. Ventricular Fibrillation (VF): Chaotic, disorganized baseline without identifiable P waves, QRS complexes, or T waves; myocardium quivers without coordinated pumping action.
2. Pulseless Ventricular Tachycardia (pVT): Rapid, wide, bizarre, regular QRS complexes without a palpable pulse.

• Intervention:
  • Deliver 1 biphasic shock (typically $150\text{--}200\text{ Joules}$ depending on manufacturer).
  • Ensure physical safety: Shout clearly: "Stand clear, oxygen away!", visually confirm all staff are clear of the bed.
  • Immediately resume CPR (30:2) for 2 minutes starting with chest compressions without pausing to check rhythm or pulse.
  • Adrenaline (Epinephrine): Give $1\text{ mg}$ IV/IO (10 mL of 1:10,000) after the 3rd shock, and repeat every 3–5 minutes (alternate cycles).
  • Amiodarone: Give $300\text{ mg}$ IV/IO bolus (diluted in $5%$ Dextrose) after the 3rd shock. Give an additional $150\text{ mg}$ IV/IO after the 5th shock for refractory VF/pVT.

Non-Shockable Rhythms

1. Asystole: Complete absence of electrical and mechanical cardiac activity ("true flatline"). Check lead connections, gain settings, and switch to another lead to rule out fine VF.
2. Pulseless Electrical Activity (PEA): Coordinated electrical activity on the ECG monitor (narrow or wide complexes) in the total absence of a detectable central pulse.

• Intervention:
  • Defibrillation is contraindicated. Shocks cause electrical stunning and eliminate residual pacemaking cells.
  • Immediately resume CPR (30:2) for 2 minutes.
  • Adrenaline: Give $1\text{ mg}$ IV/IO as soon as venous/intraosseous access is confirmed, then repeat every 3–5 minutes (every second 2-minute cycle).
  • Search actively for reversible causes (4 Hs and 4 Ts).

5. Reversible Causes: The 4 Hs and 4 Ts

Successful resuscitation in cardiac arrest—particularly non-shockable PEA and asystole—hinges on identifying and treating the underlying pathology.

6. Nursing Roles in the In-Hospital Resuscitation Team

When the emergency arrest call is activated, the ward nurse must assume organized roles until the dedicated resuscitation team arrives:

• First Responder (Compressor): Verifies unresponsiveness, calls 2222, initiates chest compressions immediately.
• Second Responder (Airway & Defibrillator): Brings the crash trolley, powers on the defibrillator, attaches monitoring pads, manages airway with pocket mask or BVM connected to $15\text{ L/min } \text{O}_2$.
• Third Responder (Scribe & Timekeeper): Opens the hospital resuscitation record sheet. Accurately documents:
  • Time arrest was recognized and time 2222 call placed;
  • Time and rhythm of each 2-minute cycle;
  • Energy and timing of every shock delivered;
  • Doses and exact times of all medications administered (Adrenaline, Amiodarone);
  • Reversible causes discussed and interventions performed.
• Fourth Responder (IV Access & Medications): Establishes wide-bore IV access ($16\text{--}18\text{G}$) or prepares intraosseous (IO) needle. Draws up and labels emergency drugs, administers $20\text{ mL}$ normal saline flushes after each IV push, and elevates the extremity for 10–20 seconds to promote central venous delivery.
• Team Leader (Usually Registrar / Medical Lead): Coordinates the team, ensures closed-loop communication, oversees safe shock delivery, maintains uninterrupted 2-minute loops, and guides decisions on resuscitation cessation or transfer to ICU.