GCC Nursing — Cardiac Arrest & ALS Guide

⚡ ALS Universal Algorithm 2021 (ERC / AHA)

The universal ALS algorithm applies to all in-hospital and out-of-hospital cardiac arrests. Immediate high-quality CPR is the cornerstone — rhythm assessment every 2 minutes drives the pathway.

UNRESPONSIVE & NOT BREATHING NORMALLY — Call cardiac arrest team · Get defibrillator · Start CPR 30:2

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Attach Defibrillator / Monitor — Assign roles: compressor, airway, drugs, team lead, recorder

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ASSESS RHYTHM — Shockable (VF/pVT) or Non-Shockable (PEA/Asystole)?

SHOCKABLE — VF / pVT

SHOCK #1 — Biphasic 150–200 J · Monophasic 360 J
Clear all · Self-adhesive pads preferred

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2-min CPR immediately post-shock — no pulse check

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SHOCK #2 & #3 — same or escalated energy

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After 3rd shock: Adrenaline 1mg IV/IO + Amiodarone 300mg IV/IO

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2-min CPR → SHOCK #4 → 2-min CPR → SHOCK #5

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After 5th shock: Amiodarone 150mg · Continue adrenaline q3–5 min

NON-SHOCKABLE — PEA / Asystole

CPR 2 minutes immediately · No shock · Focus on reversible causes

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Adrenaline 1mg IV/IO — as soon as IV/IO access · Repeat every 3–5 min throughout arrest

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Reassess rhythm every 2 min → repeat loop

Asystole: Confirm leads connected · Check gain · Fine VF? → treat as shockable

PEA: Treat underlying cause (4Hs & 4Ts) · Narrow vs wide complex → different causes

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ROSC: ETCO₂ rise >40 mmHg · Pulse palpable · BP recordable → Post-Resuscitation Care Bundle

CPR Quality Metrics

100–120Compressions/min

5–6 cmDepth

FullChest Recoil

<10 sPeri-shock Pause

>80%CCF Target

📊 ETCO₂ as CPR Indicator

Target >10 mmHg during CPR — indicates cardiac output
Sudden rise to >40 mmHg = ROSC indicator
ETCO₂ <10 mmHg → improve compression quality
NaHCO₃ bolus causes false spike — confirm ROSC with pulse check
Continuous feedback without stopping compressions

💊 Drug Timing Summary

Drug	Rhythm	Timing
Adrenaline 1mg	PEA/Asystole	ASAP, q3–5 min
Adrenaline 1mg	VF/pVT	After 3rd shock, q3–5 min
Amiodarone 300mg	VF/pVT	After 3rd shock
Amiodarone 150mg	VF/pVT	After 5th shock
Lidocaine 100mg	VF/pVT	If no amiodarone

Flush all drugs with 20 mL 0.9% NaCl and elevate limb 10–20 s after peripheral IV.

⚡ ALS Decision Support & Resuscitation Timer

Step 1 — Start Arrest

ROSC ACHIEVED

Systematic identification of reversible causes is essential during every arrest. The nurse's role is to recognise clinical clues and communicate findings to the team leader using SBAR.

The 4 Hs

🫁 Hypoxia Most Common

Recognition: Low SpO₂, cyanosis, known respiratory failure, drowning, airway obstruction.

Ensure patent airway · 100% O₂ via BVM
Two-person BVM technique
Suction secretions / McGill forceps for FBA
Early advanced airway (ETT or iGEL)

SBAR: "Patient had SpO₂ 68% pre-arrest — airway likely cause."

🩸 Hypovolaemia Trauma/GI Bleed

Recognition: Known bleeding, trauma, narrow pulse pressure, fast rate PEA.

2× large-bore IV / IO access immediately
1–2 L warm crystalloid rapid bolus
Blood products 1:1:1 in major haemorrhage
Identify and control haemorrhage source
Activate major haemorrhage protocol

⚗️ Hypo/Hyperkalaemia & Metabolic Renal/Diabetic

Recognition: Known CKD/dialysis, peaked T-waves (hyperK), flat T/U waves (hypoK), recent electrolyte results.

HyperK: CaGluc 10 mL 10% IV · NaHCO₃ 50 mmol · Glucose 50% 50 mL + 10 u insulin
HypoK: KCl infusion (rapid in arrest) · MgSO₄ 2g IV
Point-of-care ABG: K⁺, pH, glucose, HCO₃⁻

🌡️ Hypothermia Drowning/Exposure

Recognition: Core temp <30°C · J-waves on ECG · Cold rigid patient · Submersion history.

"Not dead until warm and dead" — target >35°C or ECMO rewarming
Remove wet clothing · warm blankets · heated IV fluids 40°C
ECMO/CPB gold standard for core temp <28°C
Defer drug doses below 30°C (ERC 2021)

The 4 Ts

🫀 Thrombosis — Coronary (ACS) VF most common

Recognition: Chest pain pre-arrest, ST elevation, known CAD, male >45 yrs, DM/HTN.

Standard ALS — shock VF/pVT
Post-ROSC: 12-lead ECG → STEMI → Cath Lab (ROSC-to-balloon <120 min)
Aspirin 300 mg PR/NG if unconscious
Consider PCI even without clear STEMI (occult)

🫁 Thrombosis — Pulmonary Embolism PEA — wide complex

Recognition: Recent DVT/immobility/surgery, distended neck veins, sudden arrest, PEA.

Alteplase (tPA) 50 mg IV bolus during CPR if PE suspected
Continue CPR 60–90 min post-thrombolysis
Bedside echo: RV dilation, McConnell's sign

Post-lysis: avoid femoral lines, minimise invasive procedures for 24 h.

🫧 Tension Pneumothorax Trauma/Ventilated

Recognition: Absent breath sounds, JVP elevation, tracheal deviation (late), recent central line/intubation.

Immediate: needle decompression — 2nd ICS MCL (or 4th/5th ICS AAL in obese)
14–16G cannula in situ until chest drain
Bilateral decompression in trauma arrest without clear aetiology
Finger thoracostomy during active arrest

💧 Cardiac Tamponade Post-cardiac surgery/Trauma

Recognition: Beck's triad (hypotension, muffled sounds, JVP elevation), PEA, known effusion.

Pericardiocentesis: subxiphoid approach, 18G needle, echo-guided preferred
50–100 mL aspiration may restore output
Prepare kit · connect ECG to needle · position 45°
Emergency thoracotomy in traumatic tamponade (<15 min EMS)

High-quality compressions must not be delayed for airway management. For most arrests, BVM ventilation is acceptable until an experienced provider can place an advanced airway without CPR interruption.

😮‍💨 BVM Technique

Two-Person Technique (Preferred)

Person 1: Two-hand EC-clamp — C = thumbs+index on mask, E = fingers on mandible
Person 2: Squeeze bag — 500–600 mL tidal volume (avoid excess)
OPA (nose to corner of mouth) or NPA for semi-conscious patient
O₂ 15 L/min via reservoir — achieves >85% FiO₂
30:2 before advanced airway · each breath over 1 second

Do NOT hyperventilate — raises intrathoracic pressure, reduces venous return, causes cerebral vasoconstriction.

🫁 Supraglottic Airways — iGEL & LMA

First-line Advanced Airway in Many GCC Protocols

iGEL — Key Features

No cuff — pre-shaped supraglottic seal
Insert WITHOUT CPR pause — major advantage over ETT
Sizes: 3 (30–60 kg), 4 (50–90 kg), 5 (>90 kg)
Gastric port: 12–16Fr NG tube
Once in: asynchronous CPR — 10 breaths/min
AIRWAYS-2 (2018): iGEL vs ETT — no difference in neurological outcomes, faster insertion

🔬 ETT — Nursing Assistance

Pre-intubation Setup

Suction on — Yankauer ready
Cuffed ETT: 7.5F / 8.0M (±0.5)
Laryngoscope checked (blade 3, 4)
Video laryngoscope if available
Stylet/bougie, 10 mL syringe, tape
Waveform capnography connected

During Intubation

CPR pause for ETT passage only (<5 s)
BURP manoeuvre if requested
Inflate cuff to 20–30 cmH₂O
Confirm: waveform capnography (gold standard) + auscultation
Document depth at teeth (21–23 cm)
Failed ×2 → insert iGEL and continue

📈 Waveform Capnography

Reading	Meaning	Action
Normal waveform	Tracheal — tube confirmed	Secure, continue CPR
Flat / no waveform	Oesophageal intubation	Remove tube immediately
Sudden rise >40	ROSC	Check pulse, post-ROSC
Low <10 mmHg	Poor CPR quality	Improve compressions
Gradual decline	Compressor fatigue / displacement	Rotate, recheck tube

10Breaths/min (post advanced airway)

500–600Tidal Volume (mL)

AsyncCPR (no pause per breath)

ROSC Recognition: ETCO₂ sudden rise >40 mmHg · Palpable pulse · Spontaneous movement · Rising BP

Immediate Post-ROSC Priorities (ABCDE)

🫁 A — Airway & B — Breathing

Confirm/secure advanced airway — re-check ETT position
Target SpO₂ 94–98% (avoid hyperoxia — free radical injury)
Target PaCO₂ 35–45 mmHg (normocapnia)
Wean FiO₂ from 100% once SpO₂ stable
CXR: ETT position, pneumothorax, pulmonary oedema

PaO₂ >300 mmHg associated with worse neurological outcomes — titrate down.

🫀 C — Circulation

12-lead ECG within 10 min of ROSC
STEMI/LBBB: Cath Lab — ROSC-to-balloon <120 min
Target MAP >65 mmHg (some protocols >80 for brain perfusion)
Noradrenaline first-line vasopressor (0.1–0.5 mcg/kg/min)
Arterial line for continuous BP monitoring
Serial troponin, echo (LV function)

🌡️ Targeted Temperature Management (TTM) — 32–36°C for 24 h

Indicated for comatose survivors post-ROSC (GCS <8, any initial rhythm). Prevents secondary neurological injury from post-anoxic reperfusion damage.

Cooling Methods

Cold IV fluids: 30 mL/kg 4°C NaCl — rapid first-line in ED (note: sole method no longer recommended)
Surface cooling: ArcticSun/cooling blankets — circulating cool water
Intravascular catheter: Thermogard — precise control, best for ICU
Rewarming: 0.25–0.5°C/hr — avoid hyperthermia post-TTM

Nursing Monitoring During TTM

Temp: Continuous core probe (oesophageal/bladder) q30 min
CV: Bradycardia acceptable if MAP maintained · Watch QT prolongation
Glucose: Target 6–10 mmol/L · Insulin infusion · Check q1h
K⁺: Falls during cooling · Avoid aggressive replacement (rebounds on rewarming)
Shivering: MgSO₄ (target 3–4 mmol/L), paracetamol, sedation/NMB
Skin: Reposition q2h — vasoconstriction increases pressure injury risk

🩺 Neurological Prognostication

Do NOT prognosticate <72 hours post-ROSC — sedation and hypothermia confound examination.

72h Multimodal Assessment

Clinical: pupillary response, corneal reflex, GCS motor score
EEG: burst-suppression, absent cortical activity
SSEP: absent N20 bilateral = poor outcome (highly specific)
CT/MRI brain: diffuse anoxic injury
NSE >60 mcg/L at 48 h — poor prognosis biomarker

No single test sufficient — multimodal approach required (ERC 2021).

📋 Post-ROSC Care Bundle — Targets

Parameter	Target
SpO₂	94–98%
PaCO₂	35–45 mmHg
MAP	>65 mmHg (pref >80)
Temperature (TTM)	32–36°C for 24 h
Glucose	6–10 mmol/L
ETCO₂	35–40 mmHg
12-lead ECG	Within 10 min ROSC
STEMI → Cath Lab	<120 min ROSC
Prognostication	72 h post-ROSC min

🌊 Drowning Resuscitation

5 rescue breaths first (airway obstruction common)
Hypothermia protective — "not dead until warm and dead"
Early aggressive airway — aspiration and laryngospasm common
Suction pharynx; do NOT perform Heimlich manoeuvre
Consider ECMO-CPR for hypothermic drowning (<30°C)
Prolonged resuscitation justified — ROSC reported after 60+ min

🤰 Cardiac Arrest in Pregnancy

Left lateral tilt 15–30° or Manual Uterine Displacement (MUD) — push uterus left
2-finger width higher sternal compressions
IV access above diaphragm (IVC compressed by uterus)
Perimortem C-section (PMCS): start at 4 min if no ROSC — delivered by 5 min ideally
PMCS improves both maternal and foetal outcomes — do not delay
Reversible causes: eclampsia (MgSO₄), amniotic fluid embolism (tPA), PPH

Do not withhold PMCS due to foetal age — maternal ROSC more likely post-delivery.

🐝 Anaphylaxis Cardiac Arrest

Standard ALS — adrenaline 1 mg IV/IO every 3–5 min
Remove trigger (IV drug infusion, blood product)
Large volume IV fluids 2–4 L (distributive shock)
Chlorphenamine 10 mg IV + Hydrocortisone 200 mg IV (adjuncts only)
Salbutamol via ETT for bronchospasm during CPR
Prolonged resuscitation warranted — anaphylaxis is reversible

🚗 Trauma Arrest

Bilateral chest decompression immediately
Haemorrhage control: tourniquet, pelvic binder, REBOA
Damage control resuscitation: 1:1:1 (pRBC:FFP:platelets)
Permissive hypotension pre-op (MAP ~50 mmHg)
TXA 1 g IV if within 3 hours of injury
EDT in penetrating trauma if <15 min cardiac activity

⚡ Electrocution / Lightning Arrest

Scene safety first — do NOT approach until power isolated
Lightning: scene safe immediately post-strike
Standard ALS — VF most common rhythm
Cervical spine precautions (fall risk)
Rhabdomyolysis post-ROSC: aggressive fluid resuscitation
Young patients: excellent prognosis — prolonged resuscitation justified

🫀 ECMO-CPR (eCPR) Criteria

Patient Selection

Age <65 (flexible in some centres)
Witnessed arrest with bystander CPR
Shockable rhythm (VF/pVT)
Low-flow time <60 min
Reversible cause identified
Good pre-arrest functional status

GCC Availability

Cleveland Clinic Abu Dhabi · King Faisal Hospital (KSA) · HMC Doha
Alert ECMO team early — cannulation requires time
Maintain high-quality CPR throughout — do not reduce

GCC healthcare systems operate within a unique cultural, legal, and organisational environment. ALS nursing practice must be adapted to local context while maintaining international evidence-based standards.

📜 ALS Certification — GCC Requirements

Certification	Provider	Validity	Status
ACLS	AHA	2 yrs	Widely accepted
ALS	ERC / RCUK	4 yrs	Accepted UAE/Qatar/KSA
ILS	RCUK/ERC	1 yr	Min. for ward nurses
PALS	AHA	2 yrs	Required paediatric units
NLS	RCUK	4 yrs	Required NICU/Maternity

DHA, DOH/HAAD, CBAHI and MOH Qatar all recognise AHA/ACLS. Renewal is a licensing condition in most GCC jurisdictions.

🛒 Crash Trolley — JCIA Standardisation

Standardised layout across all clinical areas
Tamper-evident numbered seals — breaks documented each use
Daily check by designated nurse — signed log book
Defibrillator: daily self-test + weekly manual discharge check
Drug expiry checked monthly — any expired item triggers full restock
Restock within 30 min post-arrest and reseal

Mandatory Contents

Equipment: BVM (adult+paed), suction, OPA/NPA, iGEL set, ETT set, laryngoscope, ETCO₂ device, IO drill.
Drugs: Adrenaline, Amiodarone, Atropine, Adenosine, NaHCO₃, CaGluc, Glucose 50%, MgSO₄, Naloxone.

🏥 Community Cardiac Arrest — GCC & PAD

Survival Rates

GCC OHCA survival to discharge: 2–5% (vs 10–15% in high-performing systems)
Bystander CPR historically <15% — improving with education

PAD Programmes

UAE: AEDs mandatory in malls, airports, metro (2017)
Dubai: "Heart Safe City" — AED mapping app
Abu Dhabi: ADEK schools CPR + AED programme
Qatar: HMC community CPR training
KSA: SRCA nationwide CPR drives

Every nurse in GCC is a community resource. Bystander CPR doubles survival — advocate for training in families, workplaces, and mosques.

🌙 Cultural & Religious Considerations

Family Presence

Recitation of Shahada at time of death — designate liaison nurse to accompany family
ERC/AHA support family-witnessed resuscitation option
Prayer beads, Quran recitation, turning to face Qibla — accommodate sensitively

Islamic Medical Guidance

Islamic Medical Association: resuscitation obligatory when reasonable chance of recovery
Futile resuscitation may be withheld with physician determination
Involve imam/hospital chaplain in withdrawal discussions — family involvement culturally essential

📄 DNACPR in GCC — Complex Landscape

DNACPR orders are culturally and legally challenging. Family consent is practically required even where not legally mandated. Cultural pressure to "do everything" is common.

UAE

Federal Law 4/2016: DNACPR permitted with documented medical decision and family consent
Physicians bear legal responsibility for DNACPR decision

KSA / Qatar / Kuwait

Ethics committee common for disputed cases
Escalation pathway essential — document all discussions

Nursing rule: never act on DNACPR without written physician order. If uncertain — resuscitate and escalate. Document all resuscitation status conversations.

📊 Utstein Documentation Format

Core Data Elements

Date/time of arrest recognition
Location, witnessed/unwitnessed
Bystander CPR: Y/N + type
First monitored rhythm
Time to first shock / first adrenaline / advanced airway
Number of shocks · ROSC Y/N + time
Outcome: survived to discharge, neurological status (CPC score)

Nursing Documentation Tips

Designate recorder at arrest start — single role
Real-time documentation preferred
Record times to nearest minute
Record all drugs: name, dose, route, time
Document compressor rotations
Post-arrest debrief documentation
Submit to hospital arrest registry within 24 h

Cardiac Arrest & Advanced Life Support (ALS)