🚧 Under construction — VoTechWorks is being built. A free tech program — complimentary, as our commitment to get America working.
voTechWorksGrade 13 · a vocational technology learning center, by urbanicity
newSchoolWorks.com › VoTechWorks › Health & Personal Services › Respiratory Therapy › Respiratory Therapy Clinicals: Integrated Patient Care Practice › Lesson 10
HLT-RESP80-06 · Lesson 10 · 40 clock hours · practice

Cardiopulmonary Emergency Response and BLS/ACLS Support

Objective. Students will demonstrate BLS-level response to a simulated cardiac arrest, including high-quality CPR, BVM ventilation, and AED use, and correctly perform the respiratory therapist's ACLS-support role during a simulated code blue, including ETT management and ventilator initiation post-ROSC.

⚠ Pending professional review

This lesson, its worked examples and its practice questions has not yet been verified by a licensed clinician in the field or by a certification or approval body. It is a study draft and may contain errors. Do not use it to make decisions about any patient or medication. Always follow your instructor, your supervising professional, and current official references and regulations.

VoTechWorks program approval and accreditation are still in progress. Credentials are issued only by the certifying bodies named in each program, after their own exams.

Cardiopulmonary Emergency Response and BLS/ACLS Support

As a respiratory therapist (RT), you are a critical member of the resuscitation team. Your hands manage the airway — the skill no other team member is as well prepared to perform. This lesson prepares you to respond to a cardiac arrest, deliver high-quality BLS care, and fulfill your specific ACLS-support role during a code blue.

BLS Foundations: Why Quality Matters

High-quality CPR is the single intervention most linked to survival from cardiac arrest. The key elements are:

AED use follows a clear sequence: power on, attach pads (upper right chest, lower left lateral chest), analyze rhythm, deliver shock if advised, and immediately resume CPR. Do not delay the first shock.

The RT's Role in a Code Blue

When a code blue is called, the RT is expected to arrive quickly and take ownership of airway management. Your responsibilities include:

1. Initial airway management: Open the airway (head-tilt/chin-lift or jaw thrust if trauma is suspected) and begin bag-valve-mask (BVM) ventilation with 100% oxygen.

2. BVM technique: Use a two-person technique whenever possible — one person maintains a mask seal with both hands using the E-C clamp technique while the second person squeezes the bag. This dramatically improves tidal volume delivery.

3. Assist with endotracheal intubation: Hand the laryngoscope, ETT, and stylet to the intubating provider. Apply cricoid pressure only if specifically requested by the team leader. Have suction immediately available.

4. Confirm tube placement: After intubation, confirm ETT placement using both primary and secondary methods. Primary: direct visualization of the tube passing through the cords. Secondary: waveform capnography (the preferred method — a persistent waveform confirms tracheal placement) plus bilateral auscultation and chest rise. If waveform capnography is unavailable, use a colorimetric CO₂ detector. An absent waveform or color change in a perfusing patient means the tube is not in the trachea — remove it immediately and re-ventilate by BVM.

5. Secure the tube: Note the depth marking at the lip (typically 21–23 cm in adult males, 19–21 cm in adult females) and secure with a commercial tube holder or tape.

6. Communicate: Verbally confirm tube placement and depth to the team leader. Give brief, clear updates on ventilation status throughout the code.

Initiating the Ventilator After ROSC

Return of spontaneous circulation (ROSC) is the goal of resuscitation, but it is also the beginning of post-resuscitation care. Transitioning from manual BVM ventilation to mechanical ventilation is an RT responsibility.

Initial ventilator settings after ROSC (general guidance):

Post-ROSC Ventilation Goals

Post-cardiac arrest care guidelines generally target:

Obtain an arterial blood gas (ABG) approximately 20 minutes after initiating mechanical ventilation and adjust settings accordingly. Document your settings, the ABG results, and the rationale for any change.

Safety Points

Key terms8

Return of Spontaneous Circulation (ROSC)The restoration of a palpable pulse and effective cardiac output following cardiac arrest, marking the transition from active resuscitation to post-resuscitation care.
Waveform CapnographyContinuous measurement and graphic display of exhaled CO₂; the preferred method to confirm endotracheal tube placement and to monitor ventilation during and after resuscitation.
E-C Clamp TechniqueA hand position for BVM mask seal in which the third, fourth, and fifth fingers (E) lift the jaw while the thumb and index finger (C) press the mask to the face, creating an airtight seal.
Ideal Body Weight (IBW)A calculated weight based on height and sex, used to set tidal volume in mechanical ventilation to avoid lung overdistension regardless of the patient's actual weight.
NormocapniaA PaCO₂ in the normal range (approximately 35–45 mmHg); a target of post-ROSC ventilation management to protect cerebral blood flow.
BVM (Bag-Valve-Mask)A self-inflating manual resuscitation device consisting of a face mask, one-way valve, and compressible bag used to deliver positive-pressure ventilation with supplemental oxygen.
Lung-Protective VentilationA mechanical ventilation strategy using low tidal volumes (typically 6–8 mL/kg IBW) to minimize ventilator-induced lung injury, recommended for critically ill patients including post-cardiac arrest.
Code BlueA hospital emergency designation indicating a patient is in cardiopulmonary arrest requiring immediate resuscitation by a multidisciplinary team.

Worked examples3

1. Calculate the target tidal volume range for a post-ROSC patient. The patient is male, 5 ft 10 in tall. IBW formula for males: IBW (kg) = 50 + 2.3 × (height in inches above 60). Target tidal volume: 6–8 mL/kg IBW.
  1. Convert height to inches: 5 ft 10 in = 70 inches.
  2. Calculate IBW: 50 + 2.3 × (70 − 60) = 50 + 2.3 × 10 = 50 + 23 = 73 kg.
  3. Calculate low end of tidal volume range: 6 mL/kg × 73 kg = 438 mL.
  4. Calculate high end of tidal volume range: 8 mL/kg × 73 kg = 584 mL.
  5. Set initial tidal volume within 438–584 mL; a mid-range starting point of approximately 500–520 mL is reasonable.
Answer: Target tidal volume range is 438–584 mL; a reasonable initial setting is approximately 500 mL.
2. A post-ROSC patient is on the ventilator at rate 12, VT 500 mL, FiO₂ 1.0. The 20-minute ABG returns: pH 7.52, PaCO₂ 28 mmHg, PaO₂ 310 mmHg, HCO₃ 22 mEq/L. Identify the acid-base problem, explain the cause, and describe two ventilator adjustments needed.
  1. Interpret pH: 7.52 is above 7.45, indicating alkalosis.
  2. PaCO₂ is 28 mmHg (normal 35–45), confirming respiratory alkalosis — the patient is being over-ventilated.
  3. PaO₂ is 310 mmHg on FiO₂ 1.0 — this is significant hyperoxia; target SpO₂ is 94–99%, so FiO₂ must be reduced.
  4. Adjustment 1 — Correct respiratory alkalosis: Decrease respiratory rate (for example, from 12 to 10 breaths/min) or slightly decrease tidal volume to raise PaCO₂ toward 35–45 mmHg. Document rationale: targeting normocapnia to protect cerebral perfusion post-arrest.
  5. Adjustment 2 — Correct hyperoxia: Reduce FiO₂ (for example, titrate down toward 0.40–0.50) while monitoring SpO₂ to maintain 94–99%. Document rationale: avoiding hyperoxia to minimize potential reperfusion/oxidative injury.
Answer: Respiratory alkalosis and hyperoxia are both present. Decrease ventilator rate (or tidal volume) to correct hypocapnia, and reduce FiO₂ to eliminate hyperoxia while maintaining SpO₂ 94–99%.
3. During a code blue, CPR has been ongoing for 2 minutes. The team delivers a shock at minute 2. What is the maximum allowable pause in chest compressions surrounding shock delivery, and what must happen immediately after the shock?
  1. Current resuscitation guidelines state that interruptions to chest compressions should be kept to less than 10 seconds.
  2. The pre-shock pause (from stopping compressions to shock delivery) should be minimized — ideally under 5 seconds; combined with post-shock delay, total peri-shock pause should remain under 10 seconds.
  3. Immediately after shock delivery, resume chest compressions without stopping to check for a pulse — compressions restart first, then rhythm check occurs after the next 2-minute cycle.
Answer: Total peri-shock pause in compressions must be less than 10 seconds. Chest compressions must resume immediately after shock delivery without stopping to check for a pulse.

The math in this lesson1

Learners compute IBW from height and a 6–8 mL/kg tidal volume range for post-arrest ventilation.
F-IF.2
In class: BLS refresher mega-code: working in teams of three on a CPR manikin with AED trainer, each student cycles through the roles of compressor, airway manager (BVM), and team leader/AED operator; instructor uses a standardized BLS performance checklist to score each role. · Simulated code blue scenario: a full team scenario is staged in the lab (manikin, monitor, crash cart, ventilator); one student serves as the RT while peers play physician and nurse roles; the RT student manages airway, assists intubation, confirms tube placement, initiates ventilator post-ROSC, and provides verbal status updates to the team. · Post-resuscitation care exercise: after the simulated ROSC, students adjust ventilator settings per a provided post-cardiac arrest care protocol (targeting normocapnia and appropriate oxygenation), draw a simulated ABG at 20 minutes, interpret results, and make one further adjustment, documenting the rationale.
Materials: Adult CPR manikin with feedback device, AED trainer, BVM (adult), crash cart with simulated medications (placebo), cardiac monitor/defibrillator trainer, mechanical ventilator with training lung, ETT and laryngoscope (for practice placement), BLS performance checklist, post-ROSC protocol reference card
Check: BLS mega-code performance checklist: all three roles must be demonstrated with no critical errors (missed shock, inadequate compression depth, unrecognized airway failure); code-blue scenario: RT role checklist scored by instructor — at least 14 of 17 steps correct required to pass; either critical error triggers mandatory retest.

Practice check8

Answer each question, then check it. Nothing is recorded; this is your own practice.

Airway Management
1. During a code blue, the RT has just assisted with endotracheal intubation. Waveform capnography shows a flat (absent) CO₂ waveform across three ventilation attempts. What is the correct immediate action?
Emergency and Critical Care
2. What is the recommended adult chest compression depth during high-quality CPR?
Therapeutic Procedures
3. After ROSC, a patient is placed on mechanical ventilation. The FiO₂ is set at 1.0. Once the patient is stabilized, why should FiO₂ be titrated downward?
Therapeutic Procedures
4. A female patient who is 5 ft 4 in tall (IBW = 54 kg using the standard formula) is post-ROSC on volume-control AC ventilation. Using a tidal volume of 6 mL/kg IBW, what is the correct initial tidal volume?
Airway Management
5. During BVM ventilation in a two-rescuer scenario, what is the primary advantage of using two people rather than one?
Evaluation and Monitoring
6. Following ROSC, a post-cardiac arrest patient's ABG shows PaCO₂ of 52 mmHg and pH of 7.31. The patient is on the ventilator at rate 10, VT 500 mL. Which adjustment is most appropriate to address the primary problem?
Emergency and Critical Care
7. What is the recommended ventilation rate when an advanced airway is in place during continuous chest compressions in adult cardiac arrest?
Emergency and Critical Care
8. After delivering a defibrillation shock during a code blue, what must the team do immediately?
Record this lesson on my transcript. Sign in with your key and enrollment email to record lessons (enroll free if you have no key). This page stays open to read and practise.
← Previous lessonProgram planNext lesson →