Pre‐procedure

ActionRationale

1. 1.Show
   Shake the patient's shoulders and loudly ask whether they are okay.
   To rouse the patient (if possible) and determine the need for emergency support (RCUK [232], C).
2. 2.Show
   If the above does not illicit a response, shout for help or press the emergency alarm bell.
   The patient is acutely unwell and so requires immediate medical attention. E

Procedure

1. 3.Show
   Look, listen and feel for breathing. If trained to do so, palpate the carotid pulse.
   To check that there are no signs of life to confirm cardiac arrest (RCUK [232], C).
2. 4.Show
   If no help is available, leave the patient and call/fast‐bleep the cardiac arrest team before commencing CPR. If help is available, ask a member of staff to call/fast‐bleep the cardiac arrest team. Another member of staff should bring the cardiac arrest trolley and screen off the area.
   To ensure expert help is called prior to commencing CPR. E

   To ensure CPR starts as soon as possible after cardiac arrest is confirmed. E
3. 5.Show
   Position the patient flat on a firm surface or bed. If the patient is in a chair, lower the patient to the floor while supporting their head. If the patient is nursed on a pressure‐relieving mattress, pull the CPR cord to deflate the mattress.
   Effective external cardiac massage can only be performed on a hard surface (RCUK [232], C).
4. 6.Show
   Note the time of cardiac arrest (if witnessed) or the time CPR is commenced.
   Lack of cerebral perfusion for approximately 3–4 minutes can lead to irreversible brain damage; therefore, it is important to know the patient's ‘down time’ (RCUK [232], C).
5. 7.Show
   Stand directly over the patient's chest. Place the heel of one hand on the lower half of the sternum. Place the heel of the other hand on top and interlock the fingers. Keep arms straight and lock the elbows out (see Figure 12.62). If necessary, stand on a stool or kneel on the side of the patient's bed.
   Performing direct chest compressions with a downward force improves patient outcome (ERC [73], C).

   Positioning oneself at a height where effective chest compressions can be delivered improves patient outcome (RCUK [232], C).
6. 8.Show
   The sternum should be depressed sharply by 5–6 cm, with the chest allowed to fully recoil between each compression. Chest compressions should be sustained at a rate of 100–120 per minute.
   Giving chest compressions at a depth of 5–6 cm and a rate of 100–120 per minute delivers an adequate cardiac output to the brain and other vital organs (RCUK [232], C).
7. 9.Show
   Do not remove well‐fitted dentures.
   Dentures help to create a mouth‐to‐mask seal during ventilation. E
8. 10.Show
   The BVM should be attached to an oxygen source as soon as possible. The flow should be set at 15 L/min. If oxygen is not immediately available, the BVM can deliver ambient air.
   An oxygen flow of 15 L/min and the use of a BVM (which incorporates a reservoir) delivers 85% oxygen to the patient during resuscitation (RCUK [232], C).
9. 11.Show
   Apply the face‐mask with the BVM over the patient's nose and mouth and create a seal using the thumbs and forefingers to push the mask down onto the patient's face. The remaining fingers should pull the jaw up and into the mask.
   A good seal around the mouth and nose ensures optimal ventilation of the lungs. E
10. 12.Show
    Maintain cardiac compressions and ventilation at a ratio of 30:2. Allow a slight pause after each ventilator breath is delivered. Count aloud the number of chest compressions and BVM breaths delivered.
    The delivery of chest compressions and ventilation at a ratio of 30:2 maintains circulation and oxygenation of the brain and other vital organs during cardiac arrest (RCUK [232], C).

    A slight pause after each delivered breath allows the rescuer to observe whether the patient's chest rises. E

    Counting aloud will ensure co‐ordination of compression and ventilation ratio, and minimize any delay in the delivery of effective CPR. E

Defibrillation

1. 13.Show
   As soon as an AED arrives, apply the electrodes/pads onto the patient's chest without disrupting CPR. It may be necessary to shave the chest if very hairy and adhesion of the electrode to the patient's skin is unlikely.
   Timely defibrillation improves patint outcomes in patients who are in a shockable rhythm. To ensure the electrodes/pads are applied correctly and are in direct contact with the patient's skin, optimizing electrical conduction (RCUK [232], C).
2. 14.Show
   The person leading the cardiac arrest should advise the other practitioners to stop CPR to allow the AED to analyse the rhythm and determine whether the patient is in a shockable or non‐shockable rhythm.
   Any movement will interfere with the AED's ability to interpret the rhythm. E
3. 15.Show
   The AED will advise whether a shock is appropriate. In the event of a shockable rhythm, the AED will advise that the shock button be pressed. A countdown will follow before a single shock is delivered to the patient.
   Defibrillation is required to terminate pulseless VT or VF and restart the heart by depolarizing the electrical conduction system (ERC [73], C).
4. 16.Show
   While the AED analyses the rhythm, charges and delivers the shock, the team and any relatives/visitors must stand clear of the patient and bed. The person delivering the shock must ensure everyone is standing clear before pressing the shock button.
   To ensure that no one is in contact with the patient or the bed, minimizing the risk of injury. E
5. 17.Show
   Oxygen should be moved at least 1 metre away from the patient unless they are intubated.
   To reduce the risk of sparks igniting the oxygen source (Sjoberg and Singer [258], C).
6. 18.Show
   If a shock is not advised by the AED, CPR should recommence for a further 2 minutes.
   A patient who is in a non‐shockable rhythm does not require defibrillation. CPR should recommence (RCUK [232], C).

Intravenous access

1. 19.Show
   Venous access must be established through a large vein as soon as possible.
   To allow the administration of emergency drugs and fluid replacement. E
2. 20.Show
   The administration of drugs and solutions infused must be accurately recorded.
   To maintain accurate records, provide a point of reference in the event of queries and prevent any duplication of treatment (NMC [198], C).

Post‐procedure

1. 21.Show
   On the arrival of the cardiac arrest team, deliver a succinct and detailed handover and ensure roles are re‐established.
   To allow open communication of roles and responsibilities (RCUK [232], C).
2. 22.Show
   If the patient is in bed, remove the bed head and ensure adequate space between the back of the bed and the wall.
   To allow easy access for the anaesthetist to facilitate intubation. E
3. 23.Show
   Once the anaesthetist has established a definitive airway, the team must conduct cardiac compressions and ventilator breaths continually. Ventilations should continue at approximately 10–12 breaths per minute. CPR should be stopped every 2 minutes to re‐analyse the rhythm using the AED.
   To minimize interruptions and maximize the circulation of oxygenated blood (RCUK [232], C).
4. 24.Show
   Complete the cardiac arrest audit form.
   To ensure all trust cardiac arrests are audited so services can be evaluated (RCUK [232], C).