What is the proper protocol for Basic Life Support (BLS) in the emergency department for a patient in cardiac arrest?

Basic Life Support Protocol in the Emergency Department for Cardiac Arrest

Healthcare providers in the emergency department should immediately begin high-quality chest compressions at 100-120 compressions per minute with a depth of 5-6 cm, simultaneously activating the resuscitation team and retrieving the defibrillator, following the C-A-B sequence (compressions-airway-breathing) rather than the traditional A-B-C approach. 1

Initial Recognition and Scene Assessment

• Verify scene safety first before approaching any patient to prevent becoming a second victim 2, 3
• Check for responsiveness by shouting and tapping the victim on the shoulder 1, 2
• Simultaneously assess breathing and pulse within 10 seconds—look for absent breathing or only gasping while checking the carotid pulse 1
• If the patient is unresponsive with no breathing or only gasping, assume cardiac arrest even if pulse check is uncertain after 10 seconds 1

Critical caveat: Agonal gasps are commonly mistaken for normal breathing and can delay recognition of cardiac arrest—these gasps indicate cardiac arrest, not adequate breathing 1

Immediate Activation and Team Coordination

In the ED setting with multiple providers available:

• One provider should immediately begin chest compressions 1, 2
• A second provider activates the resuscitation team (if not already present) 1
• A third provider retrieves the defibrillator and emergency equipment 1
• A fourth provider prepares for airway management 1

This simultaneous, choreographed team approach minimizes delays and is specifically recommended for healthcare settings 1

High-Quality Chest Compressions (The Foundation of BLS)

Chest compressions are the absolute priority and should begin immediately—the C-A-B sequence (compressions first) replaced A-B-C specifically to minimize time to first compression 1

Compression Technique:

• Rate: 100-120 compressions per minute (not just "at least 100") 1, 2, 4
• Depth: 5-6 cm (at least 2 inches) in adults 1, 2, 4
• Hand position: Center of the chest (lower half of sternum) on a firm surface 1, 2
• Allow complete chest recoil between compressions—incomplete recoil prevents cardiac refilling and is a critical error 1, 2, 3
• Minimize interruptions—keep pauses to less than 10 seconds 2, 3
• Avoid leaning on the chest between compressions 2, 3

Compression-to-Ventilation Ratio:

• 30:2 ratio for healthcare providers (30 compressions followed by 2 breaths) 1, 4
• Continue this cycle until the defibrillator arrives or advanced airway is placed 1

Common pitfall: Healthcare providers often provide inadequate compression depth or rate—compressions must be "hard and fast" to generate adequate perfusion pressure 1, 2

Early Defibrillation

• Apply the AED/defibrillator as soon as it arrives, ideally without interrupting chest compressions 1
• Check rhythm immediately 1, 2

For Shockable Rhythms (VF/Pulseless VT):

• Deliver one shock immediately 1, 4
• Resume CPR immediately for 2 minutes before rechecking rhythm 1, 2
• Do not pause to check pulse or rhythm immediately after shock 1

For Non-Shockable Rhythms (Asystole/PEA):

• Resume CPR immediately for 2 minutes 1, 2
• Recheck rhythm every 2 minutes 2, 4, 3

Key principle: Minimizing interruptions in chest compressions is more important than immediate rhythm assessment—even brief pauses reduce coronary perfusion pressure significantly 1

Airway and Ventilation Management

• Provide 2 breaths after every 30 compressions if using basic airway management 1, 4
• Each breath should be delivered over 1 second with visible chest rise 1
• Avoid excessive ventilation—this increases intrathoracic pressure and reduces venous return 1

For Patients with Pulse but No Normal Breathing:

• Provide rescue breathing at 1 breath every 5-6 seconds (10-12 breaths/minute) 1, 4
• Recheck pulse every 2 minutes 1
• If pulse becomes absent, immediately begin full CPR 1

Pulse Check Considerations for Healthcare Providers

• Limit pulse checks to no more than 10 seconds to avoid delaying compressions 1
• If uncertain about pulse presence after 10 seconds, begin CPR immediately 1, 4, 3
• Pulse detection is unreliable even for trained providers—when in doubt, start compressions 1, 4

Critical pitfall: Prolonged pulse checks are a common error that delays life-saving compressions 4, 3

Special Considerations in the ED

Suspected Opioid Overdose:

• Administer intranasal or intramuscular naloxone if available and appropriately trained, but only after initiating CPR 1, 2
• For respiratory arrest with pulse present, naloxone administration is reasonable alongside rescue breathing 1
• Never delay chest compressions to administer naloxone in cardiac arrest 1

Transition to Advanced Life Support:

Once the resuscitation team arrives with advanced equipment:

• Continue high-quality compressions without interruption 1
• Establish IV/IO access without interrupting compressions 2
• Administer epinephrine every 3-5 minutes for all cardiac arrest rhythms 2, 4, 3
• Consider amiodarone or lidocaine for refractory VF/pulseless VT 2, 4, 3

Quality Metrics to Monitor

The 2015 AHA Guidelines emphasize that CPR quality directly impacts survival 1:

• Compression fraction (percentage of time compressions are performed) should exceed 60% 1
• Coronary perfusion pressure improves with continuous compressions and deteriorates rapidly during pauses 1
• Real-time feedback devices can help maintain quality 1

Key Differences from Lay Rescuer BLS

Healthcare providers in the ED differ from lay rescuers in that they:

• Perform pulse checks (lay rescuers do not) 1
• Work as coordinated teams performing simultaneous actions 1
• Use bag-mask ventilation rather than mouth-to-mouth 1
• Integrate advanced interventions while maintaining high-quality compressions 1

The fundamental principle remains unchanged: immediate recognition of cardiac arrest followed by immediate, high-quality chest compressions with minimal interruptions provides the best chance for survival. 1, 2