Advanced Life Support

Guidelines for resuscitation of an  adult or  child who is unconscious and not breathing, are given by the Resuscitation Council.

Anaphylactic shock

A severe hypersensitivity reaction to drugs or allergens, which can lead to asphyxia, cardiovascular collapse, and cardiac arrest. The reaction is sudden, severe, and involves the whole body.
 Resuscitation Council   ||   Description


The drawing of a substance, such as the gastric contents, into the respiratory tract, during  inhalation.
Also, the removal of fluid or gas from a body cavity, using suction equipment.


Absence of electrical and mechanical activity in the heart - a non-shockable cardiac arrest.   Algorithm

Atrial Fibrillation

An arryhthmia: Rapid and asynchronous contractions of the atrium, causing irregular contraction of the ventricles. The pulse will be irregular in rate and strength, and the wrist and Apex pulse rates will be asymmetrical.  AF details


Injury due to excess pressure in tissues.

Basic Life Support

Support Guidelines for resuscitation of an  adult or a  child who is unresponsive and not breathing, are given by the Resuscitation Council. There is also an algorithm for  newborn infants.

Beta (β) blockers

Negative inotropic drugs which block the affect of Adrenaline on the heart and blood vessels, by weakening effects of the Sympathetic Nervous System on heart conductivity, and reducing blood pressure and heart rate.  Example


Slow heart rate/pulse. Antimuscarinics, such as Glycopyrronium and Atropine, can be used to counter the bradycardia caused by Neostigmine.  Algorithm


Sudden difficulty in breathing caused by constriction of plain muscle in the walls of the bronchi. Spontaneously breathing patients may have an audible wheeze.  Actions

Can't intubate, can't ventilate

When intubation fails, and the patient suffers hypoxaemia and difficult ventilation, a rescue algorithm must be followed, as described by the  Difficult Airway Society

Cardiac arrest

The heart stops pumping blood around the body, resulting in unconsciousness and abnormal breathing, which requires immediate cardiopulmonary resuscitation. 
User manual ||  Youtube ||  Dealing with an arrest

Cardiac (pericardial) tamponade)

A condition in which gas or fluid, such as blood or pus, accumulates in the pericardium faster than the pericardial sac can stretch. If the fluid/gas significantly elevates the pressure on the heart, it will prevent the heart's ventricles from filling properly, leading to a low stroke volume, shock, and death.  Actions


The Resuscitation Council provides the algorithms for treating choking in  adults and  children over 1 year.

Code Red

A protocol for managing massive haemorrhage. (Blood bank: 3640)  What to do


(Cricothyrotomy) An emergency procedure, to provide a temporary emergency airway, via the cricothyroid membrane (in the adult: 10 mm high, 22 mm wide), when there is obstruction at, or above, the larynx.   Action to take

Difficult intubation

When routine intubation failure is unanticipated, any further attempts must be made according to the algorithm provided by the  Difficult Airway Society.
Note: ventilating the patient has priority over intubation.


Hypertensive disorder of pregnancy and toxaemia of pregnancy. Pre-eclampsia is characterized by high blood pressure and significant amounts of protein in the urine, and this can develop into Eclampsia, where the patient may suffer tonic-clonic seizures.
 NICE guidelines

Emergency airway


Emergency anaesthesia

An emergency case, such as a ruptured aortic aneurysm, demands minimum delay to anaesthetic induction (typically by RSI), and surgical intervention.  Equipment etc

Epileptic fit

A neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions.
 First aid

Failed Rapid Sequence Induction

When routine RSI is unanticipated, follow the algorithm, as described by the  Difficult Airway Society.

Febrile convulsion

A seizure (rarely serious) which occurs in a child with a fever over 39°C (102.2°F).  Recommended steps

Gastric reflux

Reflux of gastric contents. If the contents reach the lungs, permanent damage may occur. If the contents are very acidic, death can result.  Considerations for surgery

Glasgow Coma Score

A system for rating a patient's level of consciousness, based on an assessment of 3 response types: Eye opening, Motor response, and Verbal response.  Ratings

Heart block

Impaired conduction between the atria and ventricles.

Heart failure (congestive heart failure)

Heart failure is a global term for the state in which cardiac output is insufficient in meeting the needs of the body. Most commonly caused when cardiac output is low, and the body becomes congested with fluid.

Hypercapnia (hypercarbia)

Increased level of carbon dioxide in the blood.


A high level of serum potassium: the normal range is 3.5 – 5.3 mmol/L.
For raised levels, give 10ml of calcium gluconate 10% intravenously over 2-5 minutes; then 10 IU Actrapid + Glucose 50%, 50 mls.

ECG characteristics of hyperkalemia:
  • P-waves are widened and low amplitude due to slowed conduction.
  • Tall tented T waves.
  • QRS widening
  • Fusion of QRS-T
  • Loss of the ST segment


Blood pressure which is above the normal range for a particular category of person, according to such factors as age and weight. Typical treatment is by a Beta-blocker, such as Atenolol, Esmolol, or Labetalol.

Hyperventilation (hyperpnoea)

Abnormally deep breathing or excessive ventilation of the lungs, usually accompanying emotional stress.  Description


A low level of serum potassium. Normal range is 3.5 – 5.3 mmol/L. Treat with rapid infusion of potassium. ECG indications are:
  • Flattened T waves
  • Negative T waves
  • Sometimes, prominent U waves
  • ST depression


Blood pressure which is below the normal range for a particular category of person, according to such factors as age and weight. Typically treated by a vasoconstrictor. Low diastolic pressure suggests arterial vasodilation, as with sepsis or anaphylaxis. A small pulse pressure could be due to arterial vasoconstriction, such as with hypovolaemia, or cardiogenic shock

Example Vasoconstrictors...
  • Mataraminol
  • Ephedrine
  • Noradrenaline
  • Phenylepharine

Cardiovascular concepts


Core body temperature below (35°C). Consequences can vary from minor to severe.  Mitigations

Hypoventilation (hypopnoea)

Hypoventilation refers to inadequate breathing and impaired gas exchange, which prevents the body from being able to remove carbon dioxide appropriately. As a consequence, there develops an increase in the level of carbon dioxide (hypercapnia) in the blood, together with a decreased level of oxygen.  Significance


Reduced circulating blood volume, typically caused by shock.

  • Dry mouth
  • Dry axillary skin
  • Thirst
  • Postural hypotension

The immediate goal is to raise systolic blood pressure to 100 mmHg, by administering 250-1,000 ml isotonic (0.9%) saline solution.


Low level of oxygen in the tissues (cellular level).  Anaesthetic significance


Low level of oxygen in arterial blood.


A reflexive prolonged contraction of the laryngeal muscles, and closing of the vocal chords, characterised by noisy inspiration. If the vocal chords are completely closed, there will not be any airway noise.  Dealing with Laryngospasm

Local anaesthetic toxicity

See  AAGBI guidelines.

Malignant Hyperthermia

An abnormality of the muscle fibre membrane. The two most powerful triggers are Suxamethonium and volatile agents (N2 has no effect). Also triggered by Lignocaine, Atropine, Diazepam, Pancuronium, Phenothiazines, and stress.
Initial signs are tachycardia and increased CO2 production; spontaneously breathing patient will deal with the CO2 by breathing more rapidly; IPPV patients will have higher end tidfal CO2.
Arterial Blood Gas shows hypercarbia, respiratory and metabolic acidosis.
  Recommended actions

Myocardial Infarction

Heart attack: Necrosis of part of the heart muscle, due to interrupted blood supply, usually following a coronary thrombosis (artery occlusion).  Immediate actions

Opioid overdose

Causes respiratory depression, signified by a low minute volume, with resultant hypercapnia.

  • Pin-point pupils
  • Slow respiratory rate
  • Sighing
  • Hypercapnia, then hypoxia

Reverse with Naloxone, or stimulate respiration with eg, Doxapram.

Oxygen toxicity

A condition resulting from the harmful effects of breathing molecular oxygen at elevated partial pressures (hyperoxia). Severe cases can result in cell damage and death, with effects most often seen in the central nervous system, lungs and eyes. Oxygen toxicity is a concern for those on high concentrations of oxygen (particularly premature babies), and those undergoing hyperbaric oxygen therapy. Symptoms may include disorientation, breathing problems, burning sensation with deep breathing, anxiety, vomiting, and vision changes.

Paediatric Advanced Life Support

Resuscitation Council

Paediatric Basic Life Support

Resuscitation Council

Paediatric Choking

Resuscitation Council

Paediatric emergency treatment

Resuscitation Council

Paediatric Immediate Life Support

Resuscitation Council

Panic attack

Psychological state, indicated by hyperventilation, tachycardia, and erythematous rash (redness), but without hypotension, pallor, wheeze, or urticarial rash.


Conditions which may precede or follow a cardiac arrest.  Resuscitation Council


Aspiration of fluid through fifth intercostal space.


Accumulation of air (or other gas) in the pleural cavity, which may lead to collapse of the lung. Usually accompanied by sudden sharp pain in one side of the chest, during inspiration. The pneumothorax can clear of it's own accord.  Details

Post operative nausea and vomiting

A side effect of general anaesthesia, suffered by 1 in 4 patients. If unmanaged, can lead to pulmonary aspiration of gastric contents. Younger patients are more susceptible than older ones, as are gynaecological, urological, strabismus correction, and middle ear surgery patients. Treatment is by  antiemetics, dispensing a combination of agents, until efficacy is achieved.  Drugs and actions

Postpartum Haemorrhage (PPH)

The loss of 500 ml or more of blood from the genital tract, within 24 hours of giving birth.   Description

Precordial thump

An attempt to interrupt an arrhythmia, such as Ventricular Fibrillation or pulseless Ventricular Tachycardia, by making a single strike, with the fist, to the centre of the patient's sternum. The thump is only effective if made at the onset of a witnessed and monitored adverse rhythm (VF/pVT), and a defibrillator is not immediately available. Latest resuscitation guidelines de-emphasise use of the precordial thump.

Pregnancy complications

See  NI Direct

Primary survey

Steps to take when assessing an unconscious patient.

Order of steps
DangerAssess Dangers to yourself and casualties
ResponseUse the Glasgow Coma Scale to ascertain the level of consciousness
AirwayExamine the Airway for obstructions
BreathingLook, listen, and feel for adequate respiratory effort. Supplement with oxygen to correct hypoxia, if saturations are below 95%
CirculationIf a carotid pulse is not palpable, then resuscitation should be commenced

Pulmonary embolism

An embolism which usually originates from the proximal veins of the thigh and pelvis.
Details   ||   Emergency steps

Pulmonary oedema

Excess of watery fluid in the lungs, which collects in the air sacs, making it difficult to breathe. Pulmonary oedema is most often caused by heart failure (cardiogenic pulmonary oedema), but it may be caused by other conditions, which do not directly affect the heart (non-cardiogenic pulmonary oedema).

Pulseless Electrical Activity (PEA)

A cardiac arrest where the patient has cardiac electrical activity, which would otherwise produce cardiac output and an obvious pulse. PEA usually has an underlying treatable cause which, in emergency situations, is most often hypovolemia. Performing a pulse check after a rhythm/monitor check will ensure that PEA is identified.  Cardiac issues

QuickTrach Cricothyrotomy kit

For making an airway opening during a "can't ventilate" emergency. 

Respiratory failure

When the respiratory system fails in oxygenation and/or carbon dioxide (CO2) elimination.   Actions

Secondary survey

A more in depth survey of the patient than the primary survey.  Steps to take


Failure of the cardiovascular system to deliver adequate blood flow necessary to properly supply oxygen and nutrients to vital organs, particularly to the kidneys and brain. This inadequate tissue perfusion causes an accumulation of lactic acid in the tissues. If untreated, shock can lead to multiple organ failure.  Recognition and treatment


A harsh vibrating sound, during inspiration, caused by tumour, infection, or partial obstruction of the larynx or trachea.

• Oxygen and positioning the head of the bed 45 - 90 degrees.

• Nebulized racemic Adrenaline (0.5 to 0.75 ml of 2.25% racemic Adrenaline added to 2.5 to 3 ml of normal saline) in cases where airway oedema may be the cause of the stridor.

• Dexamethasone (Decadron) 4-8 mg IV q 8 - 12 h in cases where airway oedema may be the cause of the stridor; note that some time (hours) may be needed for dexamethasone to work fully.

• Inhaled Heliox (70% helium, 30% oxygen); the effect is almost instantaneous. Helium, being a less dense gas than nitrogen, reduces turbulent flow through the airways.

• Always ensure an open airway.

Suxamethonium apnoea

Prolonged effect of Suxamethonium, which means a patient may reverse from anaesthesia, but remain paralysed.  Anaesthesia protocol


A brief period of unconsciousness, due to reduced blood flow to the brain.


Fast heart rate/pulse.

Causes include...
  • Anaemia
  • Fever
  • Hypovolaemia
  • Myocarditis
  • Pain
  • Vasodilation
  • Vagolytic drugs, such as Atropine

  Adult treatment  algorithm

Tension pneumothorax

Pneumothorax due to air escaping into the pleural cavity, typically as a consequence of a penetrating injury.   What to do


Puncturing the Thorax to aspirate pleural fluid or gas.


A procedure to make an airway opening through the second or third tracheal ring, typically because of upper airway obstruction.
  • A lateral cut is made, superior to the sternal notch.
  • The skin is separated and surrounding tissues dissected, exposing the trachea.
  • The 2nd or 3rd tracheal ring is incised, and the tracheostomy tube placed.
  • The tube cuff is then inflated (2-5 ml).
  • The incision is sutured at the side of the tracheostomy tube.

Ventricular Fibrillation (VF)

Heart rhythm is chaotic - the heart is in a state of electrical chaos. No blood is pumped from the heart, and the patient has no pulse. The ECG trace lacks P-waves, QRS complexes, or T-waves. Action is electrical defibrillation.
See  Advanced Life Support

Ventricular Tachycardia (VT)

A pulseless ryhthm, characterised by regular fast beating of the ventricles (120 beats/min), which is too fast for them to fill with sufficient blood betweeen beats. Pulseless VT can lead to Ventricular Fibrillation, which is a more serious condition. Action for pulseless VT is electrical defibrillation.
See  Advanced Life Support