ACLS Secondary Survey Overview

In this lesson, we'll get into some details on performing a secondary assessment for ACLS healthcare providers. And at the end of the lesson, we'll discuss some common questions, with answers, you may encounter during the assessment phase.

Performing a secondary assessment in ACLS is different than performing a primary assessment in ACLS. And it's significantly different than performing a  basic life support assessment.

In a nutshell, an ACLS secondary assessment is the process of differentiating between two or more conditions that share similar signs and symptoms. This includes a focused medical history, as well as thoroughly searching through the H's and T's for any intriguing underlying causes that may have contributed to the patient's condition.

S - What are the patient's Signs and Symptoms?
A - Does the patients have any Allergies?
M - Is the patient taking any Medications, including the last dose?
P - Is there anything in the patient's Past medical history that could be related?
L - What was the Last food or drink that the patient had?
E - What Events led to the patient's current condition?

The answers to the above questions during your secondary assessment may help lead you to a correct and informed diagnosis and an appropriate course of treatment to help reverse the patient's condition and restore their health.

Of particular importance are the H's and T's. To help you discover and treat any underlying causes that may have led to this event, consider the H's and T's to ensure you aren't overlooking any likely or dangerous possibilities. The H's and T's can help create a road map for you as you attempt to find possible diagnoses and the ensuing interventions and treatment options for your patient.

The H's and T's are a tried and true reminder that can help you rule out some possibilities and also confirm other possibilities, and it's the focus of the next lesson.

Some Helpful Q&A that May Help You During Your Secondary Assessment and Beyond

In this section, we'll go over some common questions you may encounter in ACLS and specifically during the assessment phases.

What are the most common causes of cardiac arrest?

This is where the H's and T's can help you in identifying potential reversible causes of cardiac arrest as well as emergency cardiopulmonary conditions.

The most common causes of cardiac arrest are:

Should I start CPR if I'm not sure if the patient has a pulse?

If you aren't sure about the presence of a pulse, you should still begin cycles of compressions and ventilations. Unnecessary compressions are less harmful than failing to provide compressions if the patient needs them, as delaying or failing to start CPR in a patient without a pulse greatly reduces the chance of their survival.

How can I differentiate agonal gasps from normal breathing?

As you know, agonal gasps are not considered normal breathing. And they may be present in the first minutes after sudden cardiac arrest.

A patient with agonal gasps usually appears to be drawing air in very quickly. The mouth may be open, and the jaw, head, and/or neck will sometimes move with the gasps. Gasps can appear forceful or weak.

Some time may pass between each gasp because they usually happen at a very slow rate. The sound of the gasp can resemble a snort, snore, or groan. The important thing to remember is that gasping is not normal breathing and, instead, is a sign of cardiac arrest.

What are some things to be aware of when trying to minimize CPR interruptions?

As an ACLS provider, you must make every effort to minimize any interruptions in chest compressions. When you do have to interrupt compressions, try to limit those interruptions to no longer than 10 seconds, except in extreme circumstances, such as removing the patient from a dangerous environment.

When you interrupt chest compressions, blood flow to the brain and heart stops. To this end, try and avoid the following:

• Prolonged rhythm analysis
• Frequent or inappropriate pulse checks
• Taking too long to give breaths to the patient
• Unnecessarily moving the patient
• Poor communication around pauses

How should I handle patients with DNAR or DNR orders?

During basic life support, primary assessments, and secondary assessments, you should be aware of the reasons to stop or withhold resuscitative efforts, such as:

• Obvious death such as rigor mortis or lividity
• Legal do-not-attempt-resuscitation (DNAR) status, like discovering a bracelet, anklet, or written documentation. Be sure to follow your state's legal requirements and your agencies policies
• There is a threat to the safety of providers

Out-of-hospital providers need to be aware of EMS-specific policies and protocols applicable to these situations. In-hospital providers and high-performance teams should be aware of any directives or specific limits to resuscitation attempts that are in place.

For instance, some patients may consent to CPR and defibrillation but not to intubation or invasive procedures. Many hospitals will record this in the medical record. 

Finally, know when DNARs are not applicable. State's have legal requirements for who can revoke a DNAR. DNARs do not take effect until the patient loses their pulse. So if a patient has a pulse, but is not breathing, even if a patient has a DNAR, every effort must be provided until the patient loses their pulse.