Emergency Care Readiness Programme
When the heart stops,
the team starts.
High-quality CPR, safe defibrillation, and a code team that knows exactly who does what — the three things that decide whether a collapse in this centre ends in a transfer or a death certificate. Aligned with the AHA 2025 Guidelines for CPR & ECC.
By the end of today you can…
Six things, and we will test every one of them
Recognise & Respond
Every minute between collapse and defibrillation, with no CPR in progress, costs roughly 7–10% of the chance of survival from a shockable arrest. Nothing you learn later today matters if the first thirty seconds are spent standing still. Recognition is the intervention.
One Chain of Survival AHA 2025
The 2025 guidelines merge adult and paediatric, in- and out-of-hospital arrest into a single chain — one shared mental model and one language for every arrest, anywhere.
Our centre owns the first three links. In a primary health centre survival is decided in the first four to five minutes — before any ambulance arrives at the door. There is no cavalry coming. Everyone in this room is the resuscitation team.
Recognising cardiac arrest — you have ten seconds
SECONDS
Check and act — simultaneously, not sequentially
Look for responsiveness, normal breathing and a carotid pulse at the same time. Ten seconds is the ceiling, not the target. If you are still deciding at second eleven, you have already decided wrongly.
The technique — both checks, one movement
Eyes on the chest. Fingers on the carotid. Count aloud.
You do not check breathing and then check the pulse. You check both at once, from the patient's side, level with the chest — and you stop at ten seconds whatever you have found.
- Stand or kneel at the patient's side, level with the chest — not above the head. Movement of the chest is far easier to see along its line than from above.
- Two fingers — index and middle — onto the trachea, in the midline. Never the thumb: your thumb has a pulse of its own and you will feel yourself.
- Slide them laterally, towards you, into the groove between the trachea and the strap muscle of the neck. That groove is where the carotid lies.
- Press gently but definitely. Too light and you feel nothing; too hard and you occlude the artery you are feeling for.
- Eyes on the chest while your fingers work. Count the seconds aloud so the whole room knows where you are.
Checking both carotids together can reduce cerebral blood flow. One side only — the side nearest you.
Occasional gasping, snoring or a slow irregular gulp is a sign of cardiac arrest, not a sign of life. It is the commonest reason CPR is delayed — and the reason is that it looks like the patient is still trying. If you are asking yourself whether that was a breath, it was not. Start compressions.
If you are not certain there is a pulse at ten seconds, there is no pulse. Begin compressions. A patient who did not need them will move, groan or push you away. A patient who needed them and did not get them will die. These two errors are not equal.
Check — max 10 seconds
- Unresponsive?
- Shout and tap both shoulders — no response.
- Not breathing normally?
- Watch the chest for ≤10 s. Agonal gasps are not breathing.
- No definite pulse? (healthcare provider)
- Carotid check at the same time as the breathing check. If unsure — treat as arrest.
Then — act immediately
- Shout for help & activate Code Blue
- Name a person: "You in the blue — bring the crash cart and the AED." Never "somebody call for help".
- Start compressions NOW
- Hard surface, centre of the chest. No delay for the airway, the trolley, or the doctor.
- Attach the AED the moment it lands
- Compressions continue while the pads go on.
Mistaking agonal gasps for breathing, and waiting. Agonal breathing is noisy, irregular, snoring or fish-like — and it is a sign of arrest, not of life. If in doubt, compress. CPR on a beating heart does far less harm than no CPR on an arrested one.
Adult BLS — our centre's sequence
High-quality CPR — the numbers that save lives
Rate and depth are not opinions. Set the tempo before you start — use this metronome, the defibrillator's prompt, or a device with feedback. Untrained hands drift to about 80/min under stress, which is not CPR.
Depth — at least 5 cm, never past 6 cm
One third of the chest's depth in an adult. Too shallow and you move no blood; past 6 cm and you start breaking things without gaining output. Hands on the lower half of the sternum, heel of one hand, the other on top, arms locked, shoulders over the hands.
Leaning on the chest between compressions is one of the commonest quality failures in real codes, alongside inadequate depth. The chest must come all the way back — that is when the heart fills. Lift the heel of your hand slightly if you catch yourself leaning.
Switch compressor every 2 minutes
Quality falls off sharply after two minutes even when the rescuer swears they are fine — and the rescuer is always the last to notice. Switch during the rhythm check so the pause costs you nothing.
Do not over-ventilate
One second per breath, just visible chest rise. Hyperventilation raises intrathoracic pressure, chokes venous return and drops cardiac output. Over-bagging an arrest is actively harmful, not merely wasteful.
Chest compression fraction
Hands on the chest for as much of the code as possible. The AHA sets the floor at ≥60%; high-performing teams audit themselves against ≥80%. That is the LIMA PULSE target.
Minimise every pause
Pre-charge the defibrillator during compressions, plan the role change before it happens, and resume compressions the instant the shock is delivered. Every pause is measured in the audit.
Defibrillation
Time-to-first-shock is the single strongest modifiable predictor of survival in a shockable rhythm. Everything else in this section exists to protect that one number. Our target: under 3 minutes from collapse to first shock — a realistic first step for this centre. The AHA in-hospital benchmark is ≤2 minutes, and that is where we go next.
Illustrative curve based on the widely cited 7–10% absolute fall in survival per minute without defibrillation. Actual figures vary with bystander CPR, witnessed status and rhythm — the shape, not the precise value, is the teaching point. Where CPR is in progress the decline is roughly halved, which is exactly why compressions never stop while the pads go on.
AED & manual defibrillator — safe use in six steps
Pad placement
Anterolateral is the default
Pad 1 — right upper chest, just below the clavicle, beside the sternum. Pad 2 — left mid-axillary line, below and lateral to the left nipple, roughly at the level of the 5th–6th intercostal space. The heart must sit between them; two pads side by side on the front of the chest shock nothing but skin.
| Situation | What you do |
|---|---|
| Wet chest | Dry it fast with a towel. Water bridges the pads and diverts current across the skin. |
| Very hairy chest | Press pads firmly first; if they will not stick, rip them off (they take the hair) or shave with the razor in the cart. Do not spend a minute on grooming. |
| Pacemaker / ICD | Visible lump below the clavicle — never place a pad over the device; keep a clear margin (8 cm is the usual working figure). Do not skip the shock. |
| Medication patch | Remove it and wipe the skin. GTN patches can arc and burn. |
| Pads will not fit / paediatric | Use anterior–posterior placement, or paediatric pads & attenuator per the device. |
"Oxygen away — I'm clear — you're clear — everybody clear."
Visual sweep head to toe · free-flowing oxygen off the chest · compressor's hands lifted · the shock is delivered only by the person at the defibrillator · then announce "Shock delivered — resume compressions." The compressor's hands should be back on the chest before the words finish.
Shockable vs non-shockable — read the monitor
The AED decides for you. On a manual defibrillator, you decide. Either way your job is the same: quality CPR, a safe shock, and a relentless hunt for the cause. Click through the four rhythms you will actually meet.
Ventricular fibrillation (VF)
- Shock immediately
- Biphasic at the manufacturer's setting (typically 120–200 J); monophasic 360 J. Then straight back to compressions — do not pause to look for a pulse.
- Adrenaline 1 mg IV/IO
- Give after the initial defibrillation attempts have failed — in practice, after the second shock — then every 3–5 minutes.
- Amiodarone 300 mg IV/IO
- After the third shock; a further 150 mg may follow. Lidocaine 1–1.5 mg/kg (then 0.5–0.75 mg/kg) is an equally acceptable alternative under the 2025 guidance.
- Rhythm check every 2 minutes
- Switch the compressor at the same moment. Pre-charge during compressions so the peri-shock pause is a second or two, not ten.
- No shock — ever
- Shocking asystole does not help and costs compressions. Confirm the flat line: check leads, turn up the gain, look at a second lead.
- Adrenaline 1 mg IV/IO as early as possible
- The moment access is available, then every 3–5 minutes. Early adrenaline matters more here than anywhere else.
- No routine antiarrhythmic
- Amiodarone and lidocaine have no role in a non-shockable rhythm.
- Hunt the reversible cause — hard
- PEA is a diagnosis waiting to be made. Someone is assigned the Hs & Ts and reads them aloud. This is where the save actually lives.
Sodium bicarbonate, calcium, magnesium and steroids are not routine drugs in undifferentiated cardiac arrest. They are reserved for a specific indication — hyperkalaemia, known overdose, torsades — identified during the Hs & Ts. Reaching for them reflexively wastes hands and time.
What changed
The AHA 2025 CPR & ECC update — what actually affects you
30:2 · rate 100–120/min · depth 5–6 cm · full recoil · minimal interruptions · early defibrillation. The 2025 update refines high-quality BLS. It does not replace it. If you remember nothing else from today, remember that list.
The arrest algorithm, in order
Two branches. The difference between them is when adrenaline is given, and it is the thing teams most often get the wrong way round. Shockable: shock first. Non-shockable: adrenaline first.
Shockable
VF · pulseless VT
Nothing comes before the first shock. Not access, not drugs, not an airway.
Non-shockable
Asystole · PEA
No shock will help. Adrenaline goes in as soon as you have access — and the cause is the whole game.
An organised rhythm with no pulse means something is stopping the heart filling or emptying. Find it, or the arrest will not reverse.
The drugs — dose, route, timing
Every dose is repeated back before it is given, and the time is called aloud so the recorder can log it and the leader knows when the next one is due.
| Drug | Dose | Route | When |
|---|---|---|---|
| Adrenaline epinephrine |
1 mg 10 mL of 1:10 000 |
IV / IO flush 20 mL, lift the arm |
Non-shockable: as soon as possible. Shockable: after the second shock. Then every 3–5 minutes throughout. |
| Amiodarone | 300 mg first dose 150 mg second dose |
IV / IO bolus | After the third shock; second dose after the fifth. |
| Lidocaine alternative to amiodarone |
1–1.5 mg/kg first 0.5–0.75 mg/kg second |
IV / IO bolus | Same points as amiodarone. Use one or the other — not both. |
Doses are for adult cardiac arrest. Always read the ampoule aloud before drawing up, and repeat the dose back before giving it.
Shock energy
Biphasic — follow the manufacturer
Typically an initial 120–200 J, or the maximum the machine offers. Monophasic: 360 J.
A range is not an instruction. Find the setting for our defibrillator, write it on the machine, and teach that single number.
Minimising the pause
- Charge during compressions. The compressor keeps going while the machine charges.
- Clear, shock, resume — compressions restart immediately after the shock, not after a rhythm check.
- Every pause under 10 seconds. Someone watches the clock and says so.
The Code Blue Team
Resuscitations rarely fail on knowledge. They fail on coordination — two people doing the same job, nobody doing another, an order given to the room and picked up by no one. Seven roles, one leader, closed-loop communication.
Where everyone stands
Position is not decoration — it decides who can reach what. Take your place before you take your role, and stay out of the compressor's swing.
The leader stands at the foot of the bed and does not touch the patient. The moment the leader starts compressing, the team loses its only pair of eyes on the whole picture.
Now the same thing, in our room
That diagram is not somebody else's department. Here is the bay as you will find it — tap it and put the team where they belong.
The bay — empty
Tap the photo
Seven roles — know them all, take any of them
Closed-loop communication
An order given to the room is an order given to nobody. Watch the loop close, step by step — then we will run it out loud in the simulation this afternoon.
The person waiting to take over compressions is not idle. They are the CPR coach: watching rate, depth, recoil and pauses, and saying so out loud — "a little faster", "let the chest come all the way back", "ten seconds, hands ready". A compressor cannot see their own compressions. Somebody else has to, and that somebody is already standing there.
No orders into the air. An undirected order is an ungiven drug. Use a name and make eye contact.
Anyone may speak up. "I'm not comfortable — can we re-check that?" is a protected sentence in this centre, whoever says it and whoever it is said to.
Share what you know. "She's diabetic, last seen well ten minutes ago." The leader cannot ask for information they don't know exists.
Summarise every 2 minutes. Rhythm · cycle count · drugs given · next action. Out loud, to everyone.
Reversible causes — the Hs & Ts
In every non-shockable arrest the leader assigns one named person to work through this list aloud. Not silently, not "in their head" — aloud, so the team can correct them and act on it.
Airway — what we actually do in a code
Not an anaesthetic course. No scoring systems, no grading of laryngoscopy. This is the airway work that happens in our resus bay, by our staff, during an arrest: open it, keep it open, and ventilate it well enough — without doing harm.
1 · Open it
- Head tilt + chin lift — the standard manoeuvre. One hand on the forehead, two fingertips under the bony point of the chin.
- Jaw thrust where cervical spine injury is possible — fingers behind the angles of the jaw, lifting it forward without moving the neck.
- Suction ready before you need it, not after. Vomit arrives without warning.
In an unconscious patient the obstruction is almost always the tongue. Position fixes more airways than equipment does.
2 · Keep it open — OPA and NPA
Oropharyngeal — OPA / Guedel
- Only if there is no gag reflex. A gag means the patient will vomit — use an NPA instead.
- Too small pushes the tongue back and makes things worse.
- Too large obstructs the airway itself.
Nasopharyngeal — NPA
- Tolerated by patients who still gag — its advantage over the OPA.
- Insert along the floor of the nose, not upwards.
- Caution where a base-of-skull fracture is suspected.
3 · Ventilate — bag-valve-mask
Two people. Always, if two are available.
One-person bag-mask leaks, and most of the volume never reaches the lungs. One person holds the seal with both hands; the second squeezes the bag.
- C — thumb and index finger form a C around the mask connector.
- E — middle, ring and little fingers form an E along the bony jaw. Not the soft tissue under the chin — that pushes the tongue back.
- Lift the jaw into the mask, rather than pressing the mask onto the face.
- One breath over about one second, just enough for visible chest rise.
- Highest oxygen concentration available, with the reservoir filled.
4 · Rate — the part people get wrong
No advanced airway
Thirty compressions, then two breaths. Compressions pause for the breaths — keep that pause as short as you can.
Advanced airway in place
Continuous compressions, no pausing — with one breath every 6 seconds.
Every breath raises the pressure inside the chest. Raised intrathoracic pressure reduces venous return — which reduces the blood your compressions can move — which reduces coronary perfusion. An over-ventilated arrest is a poorly perfused arrest. Under stress, everyone bags too fast. Slow down, and watch for chest rise rather than counting squeezes.
Airway photographs reproduced from the Emergency Airway Course — Basic Airway Management teaching material (M. Elsady), used for internal staff education at Lima Health Centre. To be replaced with photographs of our own team and equipment.
After ROSC — the job is not finished
Return of spontaneous circulation is a milestone, not an ending. The next twenty minutes decide the neurological outcome, and in a primary health centre they are almost entirely about stabilise and move.
Targeted temperature management, advanced neuro-prognostication and vasopressor infusions belong to the receiving ICU, not to us. Our job is airway, oxygenation, blood pressure, glucose, a 12-lead, and a fast, well-handed-over transfer. Avoid fever; do not attempt active cooling here.
Watch it before you do it
Every link below is a free, public resource from the AHA or the Resuscitation Council UK, or an official algorithm PDF. Watch the relevant clip the night before the skills station.
The AHA HeartCode / eLearning video library is licensed per named user and cannot be embedded or redistributed here — doing so would put the centre's provider status at risk. Where AHA course video is required, staff complete it inside the AHA platform under their own login and this page links out to it. Everything below is the free, publicly shareable tier.
Film your own — this is the one that changes behaviour
Generic video teaches the concept. Footage of your own
corridor, your own crash cart and your own defibrillator teaches the job. The three slots below are
placeholders — replace the #
with the LIMA link once filmed, and the card lights up automatically.
This afternoon
Three stations — everyone passes individually
Observers complete the Day 1 audit checklist during every simulation. Results are anonymised, discussed in the debrief the same afternoon, and re-audited at the next unannounced mock code. Training that is not re-measured is training that decays.
Four letters and seven marks
A summary you read is forgotten by the weekend. A summary you say out loud stays. Two things to carry out of this room — the word you already say every day, and the floor you already stand on.
LOOK
Ten seconds. Unresponsive · not breathing normally · no pulse.
Agonal gasps are not breathing. If you are asking, it was not a breath.
IMMEDIATELY COMPRESS
Centre of the chest. 100–120 a minute · 5–6 cm · let it come all the way back.
Nothing waits for compressions. Not the trolley, not the doctor, not the airway.
MACHINE ON
Pads on, eyes on the monitor. Charge during compressions, never in a pause.
The rhythm decides everything that happens next.
ACT ON THE RHYTHM
Shock first. Adrenaline after the second shock, then every 3–5 min. Amiodarone 300 mg after the third.
Adrenaline now — 1 mg, then every 3–5 min. Work the reversible causes aloud.
L·I·M·A — the name on the door, and the order of the first four minutes. It holds for both branches: the rhythm is read before the drug is chosen.
The floor is the map
Every number in today belongs to somebody's feet. Learn the seven marks and you are not remembering facts any more — you are remembering places in a room you stand in every shift. Tap a mark to hear what that position owns.
Shock first, or adrenaline first. Never compresses.
100–120 · 5–6 cm · full recoil · swap at 2 min
30:2 · 10/min with an airway · never over-ventilate
VF/pVT are shockable · charge during compressions
Adrenaline 1 mg every 3–5 min · amiodarone 300 then 150
Times, cycles, and when the next dose is due
Rate · depth · recoil · every pause under 10 seconds
You remember best in the place where you learned. Most courses teach in a classroom and test in a hospital, and lose that advantage entirely. We learn in the room where the arrest will happen — so the walls themselves become the reminder. Stand on mark 5 and the adrenaline dose arrives with the floor.
Key take-homes
Six things to carry out of this room
Assessment
Twenty questions, twice
The same twenty items are answered before the lecture and again after the simulations. The difference between the two scores is the outcome measure for Day 1 — for each person, and for the centre. Nothing is named; everything is counted.
Runs entirely in the browser — no server, no account, no data leaves the device. Each participant downloads a small result file that the trainer collects.
Sources & further reading