Systematic Approach

For optimal care, healthcare providers use a systematic approach to assess and treat arrest and acutely ill or injured
patients. For a patient in respiratory or cardiac arrest, high-performance teams aim to support and restore effective
oxygenation, ventilation, and circulation with return of intact neurologic function. An intermediate goal of resuscitation
is ROSC. These teams guide their actions by using the following systematic approaches:
• Initial assessment (visualization and scene safety)
• BLS Assessment
• Primary Assessment (A, B, C, D, and E)
• Secondary Assessment (SAMPLE, H’s and T’s)

Before you approach any patient, rapidly verify scene safety (no threat to the provider). Once you’ve determined that
the scene is safe, use the systematic approach (Figures 6 and 7) to determine the patient’s level of consciousness.
• If the patient appears unconscious, use the BLS Assessment for the initial evaluation, and use the
Primary and Secondary Assessments for more advanced evaluation and treatment.
• If the patient appears conscious, use the Primary Assessment for your initial evaluation.

Figure 6. The systematic approach.

Figure 7. The expanded systematic approach.

BLS Assessment

The BLS Assessment is a systematic approach to BLS for trained healthcare providers. This approach stresses early
CPR with basic airway management and defibrillation but not advanced airway techniques or drug administration.
By using the BLS Assessment, any healthcare provider can support or restore effective oxygenation, ventilation, and
circulation until the patient achieves ROSC or advanced providers intervene. Performing the BLS Assessment
substantially improves a patient’s chance of survival and a good neurologic outcome.

Remember to assess first, and then perform the appropriate action.

Although the BLS Assessment requires no advanced equipment, you can use readily available supplies, such as a
bag-mask ventilation device if it is available. Whenever possible, place the patient faceup on a firm, flat surface to
maximize the effectiveness of chest compressions. Table 2 is an overview of the BLS Assessment, and Figures
8 through 12 illustrate the steps needed during the BLS Assessment.

Table 2. BLS
Assessment

Assessment Assessment technique and action

Check • Tap and shout, “Are you OK?”

responsiveness.

Shout for nearby • Shout for nearby help.

help/activate the • Activate the emergency response system.
emergency • Get an AED if one is available, or send someone to activate the emergency
response response system and get an AED or defibrillator.
system and get
the
AED/defibrillator.
 Check for • To check for absent or abnormal breathing (no breathing or only gasping) scan
breathing and the chest for rise and fall for at least 5 but no more than 10 seconds.
pulse. • Feel for a pulse for at least 5 but no more than 10 seconds.
• Perform the pulse check simultaneously with the breathing check within 10
seconds to minimize delaying CPR.
• If you find no breathing and no pulse within 10 seconds, start CPR, beginning with
chest compressions.
• If you find a pulse, start rescue breathing at 1 breath every 6 seconds. Check pulse
about every 2 minutes.

Defibrillate. • If pulse is not felt, check for a shockable rhythm with an AED/defibrillator as soon
as it arrives.
• Provide shocks as indicated.
• Follow each shock immediately with CPR, beginning with compressions.

Critical Concepts: High-Quality CPR

To perform high-quality CPR, rescuers should
• Compress the chest hard and fast at least 2 inches (5 cm) at a rate of 100 to 120/min (30:2 or another
advanced protocol that maximizes CCF).
• Allow the chest to completely recoil after each compression.
• Switch compressors about every 2 minutes or earlier if fatigued—the switch should only take about 5
seconds.
• Minimize interruptions in compressions to 10 seconds or less (high CCF).
• Avoid excessive ventilation.

Caution: Chest Compression Depth

Chest compressions are more often too shallow than too deep. However, research suggests that compressing
deeper than 2.4 inches (6 cm) in adults may not be optimal for survival from cardiac arrest and may cause injuries. If
you have a CPR quality feedback device, target your compression depth from 2 to 2.4 inches (5 to 6 cm).

Tailoring the Response

Single rescuers may tailor the sequence of rescue actions to the most likely cause of arrest. For example, a
healthcare provider who sees an adolescent suddenly collapse (eg, after a blow to the chest) can assume that the
patient has had a sudden cardiac arrest. In this case, the rescuer should activate the emergency response system via
mobile device, get an AED if nearby, return to the patient to attach the AED, and then provide CPR. However, if the
rescuer believes hypoxia caused the cardiac arrest (such as in a drowning victim), he or she may perform about 2
minutes of CPR, including breaths, before activating the emergency response system.

Critical Concepts: Minimizing Interruptions in Chest Compressions

When you stop chest compressions, blood flow to the brain and heart stops, so you must minimize the number of
interruptions. Additionally, try to limit the duration of interruptions for defibrillation or rhythm analysis to no longer than
10 seconds unless you are moving the patient from a dangerous environment. Refer to Figure 13.

Figure 13. Relationship of quality CPR to coronary perfusion pressure demonstrating the need to minimize
interruptions in compressions.

Avoid
• Prolonged rhythm analysis
• Frequent or inappropriate pulse checks
• Prolonged ventilation
• Unnecessary movement of the patient
Coronary perfusion pressure (CPP) is aortic relaxation (diastolic) pressure minus right atrial relaxation (diastolic)
pressure. During CPR, CPP correlates with both myocardial blood flow and ROSC. In 1 human study, ROSC did not
occur unless a CPP of 15 mm Hg or greater was achieved during CPR. Because ETCO2 is related to cardiac output
with chest compressions during cardiac arrest, ROSC is similarly unlikely with a persistent ETCO2 of less than 10 mm
Hg.

Starting CPR When You Are Not Sure About a Pulse

If you aren’t sure whether you feel a pulse, start CPR. Unnecessary compressions are better than no compressions
at all in a patient with no pulse, and delayed CPR reduces the chance of survival.

Agonal Gasps

You may see agonal gasps in the first minutes after sudden cardiac arrest, but agonal gasps are not normal
breathing. They are a sign of cardiac arrest. A patient who gasps may appear to be drawing air in very quickly. The
mouth may be open, and the jaw, head, or neck may move with gasps. These gasps may appear forceful or weak,
and some time may pass between them because they usually happen at a slow, irregular rate. An agonal gasp may
sound like a snort, snore, or groan. If you identify agonal gasps, begin chest compressions without delay.

Caution: Agonal Gasps

• Agonal gasps may be present in the first minutes after sudden cardiac arrest.
• Agonal gasps are not normal breathing.
The gasp may sound like a snort, snore, or groan. Gasping is a sign of cardiac arrest.

Primary Assessment

In the Primary Assessment, you continue to assess the patient and perform appropriate actions until the patient is
transferred to the next level of care. Members of a high-performance team often perform assessments and actions in
ACLS simultaneously.

For unconscious patients in arrest (cardiac or respiratory), complete the BLS Assessment before the Primary
Assessment. For conscious patients who may need more advanced assessment and management, conduct the
Primary Assessment first. Table 3 provides an overview of the Primary Assessment.

Remember to assess first, and then perform the appropriate action.

Table 3. Primary Assessment

Assessment Action

Airway • Maintain an open airway in unconscious patients by using a head tilt–

• Is the patient’s airway patent? chin lift, an oropharyngeal airway, or a nasopharyngeal airway.
• Is an advanced airway • Use advanced airway management if needed (eg, laryngeal mask
indicated? airway, laryngeal tube, endotracheal tube).
• Have you confirmed proper o –Weigh the benefits of placing an advanced airway
placement of the airway against the adverse effects of interrupting chest
device? compressions. If bag-mask ventilation is adequate, you
• Is the tube secured, and are may defer inserting an advanced airway until the
you reconfirming placement patient does not respond to initial CPR and
frequently and with every defibrillation or until ROSC. Advanced airway devices
transition? such as a laryngeal mask airway, a laryngeal tube, or
an esophageal-tracheal tube can be placed while chest
compressions continue.
o –If using advanced airway devices:
 § Confirm the proper integration of CPR
and ventilation
§ Confirm the proper placement of
advanced airway devices by physical
examination and quantitative waveform
capnography
§ Secure the device to prevent dislodgment
§ Monitor airway placement, effectiveness
of CPR, and ROSC with continuous
quantitative waveform capnography

Breathing • Give supplemental oxygen when indicated.

• Are ventilation and o –For cardiac arrest patients, administer 100% oxygen.
oxygenation adequate? o –For others, adjust the oxygen administration to
• Are quantitative waveform achieve oxygen saturation of 95% to 98% by pulse
capnography and oximetry (90% for ACS and 92% to 98% for post–
oxyhemoglobin saturation cardiac arrest care).
monitored? • Monitor the adequacy of ventilation and oxygenation by
o –Clinical criteria (chest rise and cyanosis)
o –Quantitative waveform capnography
o –Oxygen saturation
o –Avoid excessive ventilation
Circulation • Monitor CPR quality.
• Are chest compressions o –Quantitative waveform capnography (if the partial
effective? pressure of CO2 in exhaled air at the end of the
• What is the cardiac rhythm? exhalation phase, or PETCO2, is less than 10 mm Hg,
• Is defibrillation or attempt to improve CPR quality). Waveform
cardioversion indicated? capnography should be as high as possible with
improved CPR quality. Continuous quantitative
• Has intravenous
(IV)/intraosseous (IO) access waveform capnography provides an indirect measure
been established? of cardiac output during chest compressions because
the amount of carbon dioxide exhaled is associated
• Is ROSC present?
with the amount of blood that passes through the
• Is the patient with a pulse lungs. An ETCO2 less than 10 mm Hg during chest
unstable? compressions rarely results in ROSC.
• Are medications needed for o –A sudden increase in ETCO2 to more than 25 mm Hg
rhythm or blood pressure? may indicate ROSC.
• Does the patient need volume o –Intra-arterial pressure (if relaxation phase [diastolic]
(fluid) for resuscitation? pressure is less than 20 mm Hg, attempt to improve
CPR quality). Inter-arterial pressure should be as high
as possible with improved CPR quality. If intra-arterial
pressure monitoring is available, strive to optimize
blood pressure. Relaxation phase (diastolic) pressures
less than 20 during chest compressions rarely results
in ROSC.
• Attach monitor/defibrillator for arrhythmias or cardiac arrest rhythms
(eg, VF, pVT, asystole, PEA).
• Provide defibrillation/cardioversion.
• Obtain IV/IO access.
• Give appropriate drugs to manage rhythm and blood pressure.
• Give IV/IO fluids if needed.
• Check glucose and temperature.
• Check perfusion issues.

Disability • Check for neurologic function.

• Quickly assess for responsiveness, levels of consciousness, and
pupil dilation.
• AVPU: Alert, Voice, Painful, Unresponsive
 Exposure • Remove clothing to perform a physical examination.
• Look for obvious signs of trauma, bleeding, burns, unusual markings,
or medical alert bracelets.

Secondary Assessment

The Secondary Assessment involves the differential diagnosis, including a focused medical history and searching for
and treating underlying causes (H’s and T’s). Gather a focused history of the patient, if possible. Ask specific
questions related to the patient’s presentation.

SAMPLE

Consider using the memory aid SAMPLE:

• Signs and symptoms
o –Breathing difficulty
o –Tachypnea, tachycardia
o –Fever, headache
o –Abdominal pain
o –Bleeding
• Allergies
o –Medications, foods, latex, etc
o –Associated reactions
• Medications (including the last dose taken)
o –Patient medications, including over-the-counter, vitamins, inhalers, and herbal
supplements
o –Last dose and time of recent medications
o –Medications that can be found in the patient’s home
• Past medical history (especially relating to the current illness)
o –Health history (eg, previous illnesses, hospitalizations)
o –Family health history (in cases of ACS or stroke)
o –Significant underlying medical problems
o –Past surgeries
o –Immunization status
• Last meal consumed
o –Time and nature of last intake of liquid or food
• Events
o –Events leading to current illness or injury (eg, onset sudden or gradual, type of injury)
o –Hazards at scene
o –Treatment during interval from onset of disease or injury until evaluation
o –Estimated time of onset (if out-of-hospital onset)

The answers to these questions can help you quickly identify likely or suspected diagnoses. Look for and treat the
underlying cause by considering the H’s and T’s to ensure that you are not overlooking common possibilities. The H’s
and T’s create a guide for possible diagnoses and interventions for your patient.

H’s and T’s

The H’s and T’s are a memory aid for potential reversible causes of cardiac arrest and emergency cardiopulmonary
conditions. The ACLS cases provide details on these components:

H’s
• Hypovolemia
• Hypoxia
• Hydrogen ion (acidosis)
 • Hypo-/hyperkalemia
• Hypothermia

T’s
• Tension pneumothorax
• Tamponade (cardiac)
• Toxins
• Thrombosis (pulmonary)
• Thrombosis (coronary)

Critical Concepts: Common Underlying Causes of PEA

• Hypovolemia and hypoxia are the 2 most common underlying and potentially reversible causes of PEA.
• Look for evidence of these problems as you assess the patient and treat immediately.

Diagnosing and Treating Underlying Causes

Patients in cardiac arrest (VF/pVT/asystole/PEA) need rapid assessment and management to determine if an
underlying, potentially reversible problem caused the arrest. If you can quickly identify a specific condition, you may
achieve ROSC. Identifying the underlying cause is crucial in cases of cardiac arrest. Addressing the underlying cause
will provide the best chance for a successful resuscitation. Ultrasound may help with identifying the underlying cause
quickly and can also provide information to help determine the next step for treatment. Paying attention to the
patient’s response to interventions may also help you narrow the differential diagnosis.

To search for the underlying cause, do the following:

• Consider the underlying causes by recalling the H’s and T’s
• Analyze the ECG for clues to the underlying cause
• Recognize hypovolemia
• Recognize drug overdose/poisonings

Hypovolemia

Hypovolemia, a common cause of PEA, initially produces the classic physiologic response of a rapid, narrow-complex
tachycardia (sinus tachycardia) and typically increases diastolic and decreases systolic pressures. As loss of blood
volume continues, blood pressure drops, eventually becoming undetectable, but the narrow QRS complexes and
rapid rate continue (ie, PEA).

Consider hypovolemia as a cause of hypotension, which can deteriorate to PEA. Providing prompt treatment can
reverse the pulseless state by rapidly correcting the hypovolemia. Common nontraumatic causes of hypovolemia
include occult internal hemorrhage and severe dehydration. Consider volume infusion for PEA associated with a
narrow-complex tachycardia.

Cardiac and Pulmonary Conditions

ACS that involve a large amount of heart muscle can present as PEA, VF, pVT, or asystole. That is, occlusion of the
left main or proximal left anterior descending coronary artery can present with cardiogenic shock rapidly progressing
to cardiac arrest and PEA. However, in patients with cardiac arrest and without known pulmonary embolism (PE) or
suspected PE or STEMI, giving routine fibrinolytic treatment during CPR shows no benefit and is not recommended.

Massive or saddle PE obstructs flow to the pulmonary vasculature and causes acute right heart failure. In patients
with cardiac arrest due to presumed or known PE, it is reasonable to administer fibrinolytics.

Pericardial tamponade may be reversible with pericardiocentesis, and during periarrest, volume infusion may help
while definitive therapy is initiated. Once you recognize tension pneumothorax, you should effectively treat it with
needle decompression and chest tube insertion.
You cannot treat cardiac tamponade, tension pneumothorax, and massive PE unless you recognize them. A skilled
provider can perform bedside ultrasound to help rapidly identify tamponade, pneumothorax, and echocardiographic
evidence of PE.

Drug Overdoses or Toxic Exposures

Certain drug overdoses and toxic exposures may lead to peripheral vascular dilatation and/or myocardial dysfunction
with resultant hypotension and cardiovascular collapse. Treat poisoned patients aggressively because the toxic
effects may progress rapidly, but during this time, the myocardial dysfunction and arrhythmias may be reversible.

Treatments that can provide support include

• Prolonged basic CPR in special resuscitation situations (such as accidental hypothermia)
• Extracorporeal CPR
• Intra-aortic balloon pump therapy
• Renal dialysis
• Intravenous lipid emulsion for lipid-soluble toxins
• Specific drug antidotes (digoxin immune Fab, glucagon, bicarbonate)
• Transcutaneous pacing
• Correction of severe electrolyte disturbances (potassium, magnesium, calcium, acidosis)
• Specific adjunctive agents

Remember, if the patient shows signs of ROSC, begin post–cardiac arrest care.