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ACLS Secondary Survey (Respiratory Arrest)



The secondary survey in ACLS addresses advanced assessments and actions that are critical to treatment of a patient in respiratory distress. Placement of an advanced airway normally interrupts chest compressions, so the value of the advanced airway must be weighted against the benefit of bag-valve mask ventilation.


After determining the need for an advanced airway, IV access, and monitoring, using the ACLS secondary survey, you should know which measures are critical to implement.


Continue to perform high quality CPR (each cycle consists of 30 compressions and 2 ventilations). Throughout the BLS Survey and ACLS Survey, ensure that chest compressions are not interrupted for more than 10 seconds. Team members are working together to ensure that all protocol steps are followed in an organized and rapid fashion. The team leader coordinates the ACLS Adult Cardiac Arrest Algorithm to insure rapid treatment with minimal time lapse.

Remember: Chest Compressions should not be stopped for more than 10 seconds when checking the rhythm!

Airway Options

There are 5 basic airway skills used to ventilate a patient. Basic ventilation skills are discussed in the BLS course and will not be discussed in detail here.

This is a list of the 5 basic airway skills:

  1. Head tilt-chin lift;
  2. Jaw thrust without head extension for possible cervical spine injury;
  3. Mouth-to-Mouth ventilation;
  4. Mouth-to-Barrier device (using a pocket mask); and
  5. Bag-Mask Ventilation

Bag-Mask Ventilation is the most common method of providing positive-pressure ventilation. Both the oropharyngeal airway and the nasopharyngeal airway may be used as adjuncts to improve effectiveness of patient ventilation. The oropharyngeal airway may only be used on the unconscious patient because it can stimulate gagging and vomiting in a conscious patient. The nasopharyngeal airway may be used on the unconscious patient or on the semiconscious patient and is also indicated if a patient has massive trauma around the mouth or wiring of the jaws.

If the airway is being maintained with the basic airway skills listed above, blood, secretions, and vomit are the primary causes of an obstructed airway in the unconscious patient. Suctioning should be used to clear the airway when it becomes occluded with these body fluids. Suction should be limited to 10 seconds or less to reduce risk of hypoxemia. While suctioning, monitor for changes in heart rate, because vasovagal stimulation may result from suctioning the oropharynx. This can result in bradycardia.

Advanced Airways used during ACLS include Combitube, LMA (Laryngeal mask airway), and ET tube (endotracheal tube). When an advanced airway is in place, chest compressions are no longer interrupted for ventilations. 1 breath should be given every 6-8 seconds (8-10 breaths per minute).

Vascular Access

During the secondary ACLS Survey, intravenous or interosseous access can be established without interruption of chest compressions, in order to administer drug therapy if the patient does not respond to initial treatment.