Advanced life support in hospital

What it is

In-hospital cardiac arrest is usually preceded by hours of deterioration, so early warning scores and rapid response teams aim to prevent it. When it happens, survival depends on early recognition, immediate high-quality chest compressions and early defibrillation of a shockable rhythm. Advanced life support adds a structured team approach on top of basic life support. The rhythm is checked about every two minutes and sorted into two pathways. Shockable rhythms, ventricular fibrillation and pulseless ventricular tachycardia, are treated with a shock followed at once by compressions; adrenaline and an antiarrhythmic (amiodarone or lidocaine) are added after repeated shocks. Non-shockable rhythms, asystole and pulseless electrical activity, are treated with compressions and adrenaline as soon as possible. Throughout, the team manages the airway step by step, uses waveform capnography to confirm tube position and judge compression quality, and searches for reversible causes, the four Hs and four Ts, often with focused ultrasound during rhythm checks. Return of spontaneous circulation starts post-arrest care. The decision to stop is made by the team leader with the whole team, considering the cause, the duration, the response and the patient's known wishes and limits of treatment.

How to recognise it

• Unresponsive patient who is not breathing normally (agonal gasps count as not normal).
• No definite central pulse found within about ten seconds; do not delay compressions to keep searching.
• Monitor or pads show ventricular fibrillation, pulseless ventricular tachycardia, asystole or organised activity without a pulse.
• Warning signs often precede arrest: rising respiratory rate, falling pressure, falling consciousness, new hypoxaemia.
• Capnography falls sharply when circulation stops in an intubated patient.

Why it happens

• Ventricular fibrillation is chaotic electrical activity with no output; a shock depolarises the myocardium so the sinus node can take over.
• Compressions create a small forward flow to the brain and heart; each pause drops coronary perfusion pressure, which takes time to rebuild.
• Adrenaline's alpha effect constricts peripheral vessels and raises coronary and cerebral perfusion pressure during compressions.
• Pulseless electrical activity usually reflects a severe reversible problem: empty heart, blocked outflow, tamponade or severe metabolic disturbance.

What to do at once

1. Call the arrest team, note the time and start compressions at once — every minute without flow lowers survival.
2. Attach pads and check the rhythm with minimal pause — early defibrillation is the main treatment for VF and pulseless VT.
3. Shockable: shock, then resume compressions immediately without a pulse check — the heart needs flow while it recovers.
4. Non-shockable: continue compressions and give adrenaline as soon as access is ready — it raises coronary perfusion pressure.
5. Gain intravenous or intraosseous access — the drugs reach the circulation only through a reliable line.
6. Open the airway with bag-mask, then a supraglottic device or tube by a skilled person — avoid long pauses and over-ventilation.
7. Use waveform capnography — it confirms the tube, shows compression quality and may give the first sign of returning circulation.
8. Rotate compressors and check the rhythm every two minutes — tired compressors lose depth and rate.
9. Search for and treat the four Hs and four Ts with history, gas and ultrasound — a reversible cause may be the only way back.
10. After return of circulation, start post-arrest care; if efforts stop, decide as a team and record the time and reasons.

The two pathways of advanced life support

Costly mistakes

• Long pauses for rhythm checks, intubation or line placement; keep every pause as short as possible.
• Over-ventilation raises intrathoracic pressure and reduces venous return.
• Checking for a pulse straight after a shock instead of resuming compressions.
• Missing a reversible cause such as hyperkalaemia, tension pneumothorax, tamponade or massive pulmonary embolism.
• Not confirming tube position with capnography; an oesophageal tube is lethal.
• Starting resuscitation without checking known decisions about limits of treatment, or stopping without involving the team.

Next step

• After return of circulation: secure the airway, aim for normal oxygen and CO2, support the pressure, get a 12-lead ECG and move to intensive care.
• Call cardiology urgently when the ECG shows ST elevation or a coronary cause is likely.
• Debrief the team soon after the event, noting what went well and what to improve.
• Speak with the family, record the event clearly, and report it to the hospital's resuscitation committee.
• Review and document decisions about future resuscitation and limits of treatment with the patient or family.

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Elsewhere in DurgiPedia

• Defibrillation and synchronised cardioversion
• Broad-complex tachycardia, VF and the arrest rhythms
• Basic life support from the nursing side
• Medical futility and do-not-resuscitate orders
• Advance directives (Documento de Voluntad Anticipada)

Connections

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Educational content; it does not replace supervised training, your institution's protocols or the anaesthetist's or intensivist's decision. It contains no doses and no ventilator or infusion settings.

Sources: Advanced Cardiac Life Support (ACLS) (StatPearls (NCBI Bookshelf), 2025).

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