ACLS/ALS Advanced Nursing Guide | GCC Nursing Platform

Recognition of Cardiac Arrest

Unresponsive: no response to voice or pain stimulus
Not breathing normally: absent or agonal (gasping) breathing — agonal breathing is NOT normal and is a sign of cardiac arrest
Pulse check: 10 seconds maximum — if in doubt, start CPR

            Key Point
            Agonal breathing (irregular, infrequent gasping) is frequently mistaken for normal breathing. It signals cardiac arrest — begin CPR immediately.
          

Immediate Actions

Call the resuscitation team / activate emergency response
Get the AED/defibrillator — bring to bedside
Start CPR without delay
Assign roles clearly as team arrives

High-Quality CPR Metrics

Parameter	Target
Rate	100–120 compressions/min
Depth	5–6 cm (sternum to spine)
Full Recoil	Allow complete chest recoil after each compression — do not lean
Interruptions	<5 seconds for any pause; aim >80% CCF
Ventilation ratio	30:2 until advanced airway secured; then continuous compressions + 10 breaths/min
Compressor rotation	Every 2 minutes — fatigue degrades quality

ALS Algorithm Flow

Start

Unresponsive + Not breathing normally → Call team + Get defibrillator → Start CPR 30:2

↓

Rhythm Check (every 2 min)

Attach defibrillator pads → Pause CPR <5 sec → Assess rhythm

↓

⚡ Shockable: VF / pVT

Shock 200J biphasic (or per device)

Resume CPR immediately for 2 min

Reassess rhythm

3rd shock → Adrenaline 1mg IV + Amiodarone 300mg IV

Adrenaline 1mg every 3–5 min thereafter

5th shock → Amiodarone 150mg IV

▷ Non-Shockable: PEA / Asystole

Resume CPR immediately for 2 min

Adrenaline 1mg IV as soon as IV access

Repeat adrenaline every 3–5 min

Treat reversible causes (4Hs & 4Ts)

Reversible Causes — 4Hs & 4Ts

4Hs

Hypoxia — ensure effective ventilation, high-flow O₂
Hypovolaemia — IV fluid bolus, find haemorrhage source
Hypo/Hyperkalaemia & metabolic — check electrolytes, ECG, calcium chloride for hyperkalaemia
Hypothermia — warm IV fluids, active external rewarming, consider ECMO

4Ts

Tension pneumothorax — needle decompression (2nd ICS MCL or 4th ICS anterior axillary)
Tamponade (cardiac) — pericardiocentesis or surgical drainage
Toxins — specific antidotes (naloxone/intralipid etc.)
Thrombosis — pulmonary embolism (thrombolysis) or coronary (cath lab)

ROSC — Signs of Return of Spontaneous Circulation

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Organised cardiac rhythm Identifiable rhythm on monitor (not VF/pVT/asystole) with palpable pulse

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SpO₂ improving Rising oxygen saturation on pulse oximetry — may take 1–2 minutes to register

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ETCO₂ rise (most reliable during CPR) Sudden rise in end-tidal CO₂ >10 mmHg strongly suggests ROSC — the gold standard indicator during ongoing CPR

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Clinical signs Patient moves, coughs, eye opening, BP recordable

            ETCO₂ During CPR
            Low ETCO₂ (<10 mmHg) despite CPR = poor cardiac output. A sudden sustained rise (>10–40 mmHg) = ROSC. ETCO₂ also confirms ET tube placement.
          

Airway Adjuncts

            OPA — Oropharyngeal Airway (Guedel)
            Sizing: corner of mouth to earlobe (or centre of mouth to angle of jaw). Use in unconscious patients with no gag reflex. Insert rotated 180°, then rotate back. Sizes: 2 (small adult), 3 (medium adult), 4 (large adult).
          

            NPA — Nasopharyngeal Airway
            Size: diameter of patient's little finger (typically 6–7mm). Tolerated in semi-conscious patients. CONTRAINDICATED in suspected base of skull fracture (signs: Battle's sign, raccoon eyes, blood/CSF from nose/ears, haemotympanum).
          

BVM Ventilation

C-E grip: C = thumb + index fingers form seal, E = remaining 3 fingers lift jaw
Tidal volume: 500–600 mL (visible chest rise only)
Rate: 10 breaths/min once advanced airway secured; 30:2 before
Two-person technique preferred for better seal and reduced fatigue
Avoid hyperventilation — increases intrathoracic pressure, reduces coronary perfusion

Suction Devices

Yankauer (rigid): oral cavity, pharynx — large bore, effective for secretions/vomit
Flexible catheter: nasotracheal/through ET tube — size = (ET tube size - 2) × 2
Suction pressure: 80–120 mmHg (adult) — apply only on withdrawal
Duration: <10 seconds per pass — re-oxygenate before/after

Surgical Airway

Needle cricothyroidotomy: 14G cannula through cricothyroid membrane, attach jet oxygenation (15L/min) — temporary (<30–45 min), buys time
Surgical cricothyrotomy: definitive emergency airway — horizontal stab incision through cricothyroid membrane, dilate, insert 6.0 cuffed ET or tracheostomy tube
Cricothyroid membrane: below thyroid cartilage, above cricoid cartilage — palpable midline landmark

Supraglottic Airways (SGAs)

Device	Key Feature	Adult Size
Classic LMA	Cuffed, reusable, first SGA	3 = small adult F, 4 = adult F/M, 5 = large M
i-gel	No inflatable cuff — soft gel seal, easier insertion, gastric drain channel	3, 4, 5 by weight
LMA ProSeal	Higher seal pressure, gastric drain port	3, 4, 5
LMA Supreme	Disposable, intubating channel, curved	3, 4, 5

            SGA Advantage in Arrest
            Faster insertion than ETI; allows continuous compressions without pausing for laryngoscopy. Preferred first-line advanced airway in many ALS protocols unless experienced intubator available.
          

Endotracheal Intubation — RSI Sequence

Step 1 — Preoxygenation

100% O₂ via BVM or NRB mask for 3–5 min; aim SpO₂ >94%

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Step 2 — Cricoid Pressure (Sellick's)

10N awake, 30N on induction — controversial but still used; reduces gastric regurgitation risk

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Step 3 — Sedation + Paralysis

e.g. Ketamine 1–2 mg/kg IV + Suxamethonium 1–1.5 mg/kg IV (or rocuronium 1.2 mg/kg if sux contraindicated)

↓

Step 4 — Laryngoscopy + Intubation

Direct or video laryngoscopy; tube size adult ♀ 7.0–7.5, ♂ 8.0–9.0; cuff inflation to 20–30 cmH₂O

↓

Step 5 — Confirm Position

5-point auscultation + ETCO₂ waveform + CXR

ET Tube Confirmation

            Oesophageal Intubation Warning
            Epigastric gurgling on auscultation = tube in oesophagus. REMOVE IMMEDIATELY. This is a life-threatening error.
          

5-point auscultation: epigastrium FIRST (gurgling = wrong), then left base, right base, left apex, right apex (bilateral equal breath sounds = correct)
ETCO₂ waveform: gold standard for confirming tracheal placement AND adequate perfusion; persistent waveform over 6 breaths = tracheal
CXR: confirm tip 3–5 cm above carina (at level of clavicular heads)
Tube depth: typically 21 cm at lips for females, 23 cm for males

            Difficult Airway Manoeuvres
            BURP (Backward-Upward-Rightward Pressure on thyroid cartilage) improves laryngeal view. Bougie (gum elastic bougie) guides tube when cords not fully visible. Videolaryngoscopy (McGrath/GlideScope) for predicted difficult airway.
          

Adverse Features — Act Immediately

            4 Adverse Features (Any = Unstable)
            1. Shock (systolic BP <90 mmHg, pale/sweaty, altered consciousness)   2. Syncope (presyncope/collapse)   3. Myocardial ischaemia (chest pain, ST changes)   4. Heart failure (acute pulmonary oedema, severe dyspnoea, raised JVP)
          

            Unstable Tachycardia — Any Cause
            IMMEDIATE synchronised DC cardioversion. Start at 120–150J biphasic, escalate (150J → 200J → 360J equivalent). Sedate with midazolam/ketamine/propofol if conscious. Synchronise to avoid R-on-T phenomenon.
          

Stable Broad Complex Tachycardia (BCT)

Regular BCT = treat as VT until proven otherwise
IV Amiodarone 300mg over 20–60 min (loading dose), then 900mg over 24h
If confirmed SVT with aberrant conduction — adenosine may be used
Avoid verapamil in BCT — may precipitate haemodynamic collapse

Stable Narrow Complex Tachycardia (SVT)

Step 1 — Vagal Manoeuvres

Modified Valsalva (most effective): 40 mmHg blowing into syringe for 15 sec, then immediately supine + legs raised 45° for 15 sec → converts ~43% SVT (REVERT trial). Carotid sinus massage (contraindicated if carotid bruit).

↓ if fails

Step 2 — Adenosine

6mg rapid IV bolus via large antecubital vein, immediately flush with 20mL saline. Warn patient: brief feeling of cardiac arrest/chest tightness (seconds). Record 12-lead ECG throughout. Repeat 12mg if no response, then 12mg again (max 3 doses).

↓ if fails or recurs

Step 3 — Consider rate control

Verapamil 5–10mg IV (if no pre-excitation) or beta-blocker IV. Seek senior/cardiology review.

AF Management

Rate control: beta-blockers (metoprolol) or rate-limiting CCBs (diltiazem/verapamil) or digoxin
Cardioversion: only if onset <48h OR anticoagulated for ≥3 weeks
Anticoagulation: heparin immediately if cardioversion planned; DOAC/warfarin long-term based on CHA₂DS₂-VASc score
If >48h onset and NOT anticoagulated — rate control only; DO NOT cardiovert (thromboembolic risk)

            WPW + AF (Pre-excited AF) — CRITICAL WARNING
            DO NOT give AV nodal blockers: adenosine, verapamil, diltiazem, digoxin, amiodarone. These block the AV node and force conduction down the accessory pathway → rapid ventricular rate → VF. Treatment: DC cardioversion (preferred) or flecainide IV.
          

Symptomatic Bradycardia

Intervention	Details
Atropine	500 mcg IV bolus; repeat every 3–5 min; max 3 mg total. First-line for all symptomatic bradycardias.
Transcutaneous pacing (TCP)	If atropine ineffective or Mobitz II/3° block. Apply pads (anterior-posterior preferred). Set rate 70–80/min; increase mA until capture (electrical + mechanical). Sedate for comfort.
Adrenaline infusion	2–10 mcg/min IV as bridge to TCP/transvenous pacing. Mix: 1mg adrenaline in 100mL 0.9% NaCl = 10 mcg/mL.
Transvenous pacing	Definitive for persistent high-degree block. Internal jugular or subclavian access; right ventricular pacing.

            Pacemaker Failure During Arrest
            Do NOT defibrillate directly over pacemaker/ICD generator. Place pads at least 8 cm away. A pacing spike on ECG with no subsequent QRS complex = capture failure — treat as arrest and continue CPR.
          

Torsades de Pointes (TdP)

Polymorphic VT on long QT background — twisting pattern around baseline
Treatment: IV Magnesium sulfate 2g (8 mmol) over 10 minutes (= 4 mL of 50% magnesium = 8 mL of 25%)
Unsynchronised shock if haemodynamically unstable/pulseless
Identify and correct precipitating cause: QT-prolonging drugs (antipsychotics/macrolides/methadone), hypokalaemia, hypomagnesaemia
Avoid amiodarone — prolongs QT further
Consider isoproterenol infusion or temporary pacing to increase heart rate (>90/min) and shorten QT

Quick Arrhythmia Reference

Arrhythmia	First Drug	Energy (if shock)
VF / Pulseless VT	Adrenaline 1mg (after 3rd shock)	200J biphasic (unsynchronised)
Haemodynamically unstable any tachycardia	Synchronised DC cardioversion	120–150J start
Stable VT (broad)	Amiodarone 300mg IV over 20–60 min	—
SVT (narrow)	Modified Valsalva → Adenosine 6mg	—
Bradycardia (symptomatic)	Atropine 500mcg IV	—
Torsades de Pointes	Magnesium 2g IV over 10 min	Unsynchronised if pulseless
WPW + AF	DC Cardioversion or Flecainide	120–150J synchronised

Targeted Temperature Management (TTM)

            Target: 32–36°C for 24 hours
            Indicated in comatose survivors of OHCA (GCS <8 after ROSC). HYPERION trial (2019): TTM at 33°C beneficial in non-shockable rhythms. TTM2 trial (2021): no significant difference between 33°C vs normothermia — but FEVER PREVENTION is essential regardless.
          

Active cooling methods: IV cold saline (4°C, 30 mL/kg) for rapid induction, external cooling blankets/vest devices (Arctic Sun, EMCOOLS), nasal high-flow cold oxygen
Temperature monitoring: continuous oesophageal thermometer (most accurate) or bladder catheter thermometer; not axillary or oral
Shivering management: sedation (propofol/midazolam/fentanyl) + neuromuscular blockade (rocuronium) if needed — shivering raises core temperature and increases O₂ consumption
Rewarming: gradual at 0.25–0.5°C/hour after 24h — avoid rebound hyperthermia
Strictly avoid fever (>37.7°C) for 72h post-arrest — worsens neurological outcome (strong evidence)

Ventilation Targets Post-ROSC

Parameter	Target	Rationale
SpO₂	94–98%	Avoid hyperoxia — free radical injury to reperfused brain
PaO₂	11–16 kPa (80–120 mmHg)	Titrate FiO₂ to achieve SpO₂ target
PaCO₂	4.5–6.0 kPa (34–45 mmHg)	Normocapnia — hypocapnia causes cerebral vasoconstriction
Tidal volume	6–8 mL/kg IBW	Lung-protective ventilation
PEEP	5–8 cmH₂O	Prevent atelectasis, optimise oxygenation

Haemodynamic Management

MAP target: ≥65 mmHg (some centres aim MAP 80–100 mmHg in cardiac arrest survivors — improves cerebral perfusion pressure)
First-line vasopressor: noradrenaline (norepinephrine) infusion — titrate to MAP target
Dobutamine/inotropes if low cardiac output (PCWP elevated, poor CO on echo)
IABP/Impella/VA-ECMO: consider in refractory cardiogenic shock post-arrest
12-lead ECG immediately post-ROSC — identify STEMI or new LBBB → cath lab activation

Coronary Angiography Post-Arrest

            Evidence: COACT (2019) & TOMAHAWK (2021) Trials
            Both trials showed NO benefit of immediate vs. delayed coronary angiography in OHCA survivors without STEMI. Current recommendation: immediate cath lab for STEMI or high suspicion of cardiac cause. For non-STEMI OHCA — delayed angiography after ICU stabilisation acceptable.
          

Activate cath lab pathway for post-arrest STEMI or new LBBB on ECG
Continue TTM during PCI — dual therapy possible
Ensure anticoagulation (heparin/bivalirudin) and antiplatelet (aspirin + P2Y12 inhibitor)

Neuroprognostication

            Multimodal Assessment at ≥72h Post-ROSC
            Single tests are unreliable. Combine: clinical exam + neurophysiology + imaging + biomarkers. TTM confounds early assessment — wait minimum 72h after ROSC and 24h after normothermia.
          

Clinical exam: pupillary light reflex (absent bilaterally at 72h = poor sign), corneal reflex, myoclonus (generalised myoclonus within 48h = poor), GCS trends, motor response
EEG: background activity (burst suppression/flat = poor), seizure activity (up to 36% post-arrest)
SSEP (Somatosensory Evoked Potentials): bilateral absent N20 waves = strong predictor of poor outcome
Neuroimaging: CT (cerebral oedema — reduced grey/white differentiation), MRI at 2–5 days (DWI for cortical injury extent)
Biomarkers: NSE (Neuron-Specific Enolase) >60 mcg/L at 48–72h = poor prognosis; S100B protein elevated = astrocyte injury
Avoid premature withdrawal of life-sustaining treatment — minimum 72h post-ROSC assessment

ICU Nursing Care Post-Arrest

Neurological observations: GCS/FOUR score hourly, pupillary light reflex and size, motor response changes
Continuous EEG monitoring for non-convulsive status epilepticus (NCSE)
Glycaemic control: target 6–10 mmol/L (avoid hypoglycaemia — worsens cerebral outcome)
Skin care: pressure area care, reposition 2-hourly, cooling device skin checks
Fluid balance: strict hourly urine output, target >0.5 mL/kg/h
Oral/ETT care: subglottic suctioning ETT, mouth care every 4h, HOB 30–45°
DVT prophylaxis: compression stockings, consider LMWH when haemostasis confirmed

Resuscitation Team Roles

Team Leader

Stand back, see whole picture. Direct team. Time-keeping. Make decisions. Summarise situation. Brief team on plan. NOT the compressor.

Chest Compressor

High-quality CPR. Rotate every 2 min without pause. Handover technique: next compressor positions hands then takes over on "switch."

Airway Operator

BVM ventilation / SGA / ETI. Confirm tube position. Coordinate ventilation rate with compressions after advanced airway.

Drugs Nurse

IV/IO access. Draw up and administer drugs. Document dose and time. Announce administration to team.

Recorder

Real-time documentation: time of arrest, CPR start, each shock (energy + time), each drug (dose + time), rhythm changes, ROSC time, outcome.

Family Liaison

Separate nurse allocated. Keeps family informed, supports them, facilitates family presence (evidence-based benefit). Cultural sensitivity in GCC.

Closed-Loop Communication

            3-Step Communication Standard
            1. Leader directs by NAME + TASK + TIME: "Sara, give 1mg adrenaline IV now."

            2. Receiver acknowledges: "Sara, giving 1mg adrenaline IV now." (read-back)

            3. Receiver confirms completion: "1mg adrenaline given at 14:32."

            Leader acknowledges: "Thank you, Sara."

Use names — reduces confusion in loud, stressful environments
No ambiguous orders — specify route (IV/IO), concentration, rate
Leader summarises status every 2 min cycle to keep all team informed
Challenge dangerous orders respectfully ("I need to confirm — you want 10mg, not 1mg?")

Resuscitation Documentation Checklist

Time of witnessed/suspected cardiac arrest
Time CPR started and by whom
Initial rhythm identified
Time and energy of each defibrillation attempt
Each drug: name, dose, route, time
IV/IO access established — site and time
Airway interventions and tube confirmation method
ROSC time (if achieved)
Post-ROSC management initiated
Time resuscitation discontinued (if applicable) + decision-maker
Family notification time and who was informed

Crew Resource Management (CRM) in Resus

Situational awareness: each team member maintains awareness of overall situation — "what is happening now, what is about to happen"
Shared mental model: all team members understand current plan and next steps
Speak up culture: psychological safety — junior can challenge senior if safety concern
Manage workload: leader redistributes tasks if team member overloaded
Avoid fixation errors: leader periodically steps back to reassess — "are we missing something?"
Re-evaluation: after each 2-min cycle — is the diagnosis correct? Any reversible causes missed?

Debriefing After Resuscitation

            Hot Debrief (Immediate — within 5 minutes)
            Brief, structured. "What went well? What could be improved? Is anyone needing support?" Led by team leader. Maximum 5 minutes. Focus on process, not blame.
          

            Cold Debrief (24–48h later)
            Formal multidisciplinary debrief. Review documentation. Identify learning points. Address emotional impact on staff. Consider resuscitation audit and feedback to team.
          

Normalise emotional responses — cardiac arrest affects all team members
Identify staff needing additional support (occupational health/chaplaincy/psychology)
Promote psychological safety — debrief is learning, not blame allocation

Dignity & Cultural Considerations (GCC)

Family presence during resuscitation: evidence supports psychological benefit for family — assign dedicated liaison nurse, offer choice, explain what is happening
GCC cultural expectation: immediate notification of direct family (parents/spouse) is both a cultural and often legal expectation — do not delay family notification
Patient dignity: screen patient from corridor, drape appropriately, limit unnecessary exposure, remove non-essential bystanders
Religious considerations: facilitate religious rites if resuscitation discontinued — chaplain/imam contact promptly
Gender considerations: same-gender resuscitation team where possible in appropriate cultural context
Documentation in Arabic: some GCC facilities require bilingual documentation — follow local policy

GCC Resuscitation Landscape

Saudi Heart Association (SHA): issues ALS guidelines closely aligned with ERC 2021. ACLS provider courses widely available in Saudi Arabia.
Emirates Cardiac Society: ERC-aligned guidelines; Dubai Health Authority (DHA) and DoH Abu Dhabi mandate ALS certification for critical care nurses.
SCFHS (Saudi Commission for Health Specialties): ALS/ACLS certification required for ICU/ED/Anaesthesia nursing licensing and specialty credentials.
Bystander CPR in GCC: historically low rates improving through public awareness campaigns, Hands-Only CPR in Arabic, and mandatory CPR training in schools in UAE/KSA.
AED placement: now mandatory in malls, mosques, airports, hotels across GCC — MOHAP UAE, MoH KSA regulations mandate AED availability and trained responders.
Public CPR campaigns: Qatar Cardiac Society, KSA Heart Association "Hands-Only CPR" drives increasing community responder rates.

ALS Drug Dose Calculator

Patient Weight (kg)

Drug / Intervention	Dose	Notes

DHA / DOH / SCFHS MCQ Practice (10 Questions)

Advanced Cardiac Life Support (ACLS/ALS)Nursing Guide

Advanced Cardiac Life Support (ACLS/ALS)
Nursing Guide