Refractory Non-Shockable Arrest at a Sports Hall
At 19:05, during a badminton match in a community sports hall, a 54-year-old man collapses. Two bystanders start chest compressions. You and a colleague arrive 3 minutes later with a defibrillator and a bag-valve mask. The man is unresponsive, making no normal breathing effort, and has no palpable carotid pulse. The AED is applied at 19:07 and announces 'no shock advised'; a second analysis at 19:09 gives the same message. The patient has a pacemaker generator visible in the left infraclavicular area, a history of hypertension, and no advance directive. The floor is polished wood; the hall is crowded with 40 onlookers. Your ambulance is 12 minutes away and the hospital is 9 minutes by road. The colleague has airway training but has never used a supraglottic airway.
1. Interpret the two 'no shock advised' messages and state your immediate actions, including pad placement with a pacemaker.
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'No shock advised' means the AED has not identified a shockable rhythm - most likely asystole or PEA, or a rhythm obscured by artefact. It is not a licence to stop.
- Continue high-quality CPR immediately and do not remove the pads; reanalyse every 2 minutes.
- With a pacemaker, place the pad at least 8 cm from the generator (anterolateral or anteroposterior), not directly over it; a pacemaker does not prevent AED use.
- Work through reversible causes: hypoxia, hypovolaemia, hypo/hyperkalaemia, hypothermia, thrombosis, tamponade, toxins, tension pneumothorax.
- Confirm the rhythm on the monitor and check for organised electrical activity with a pulse; if a pulse is present, move to post-ROSC care.
- Do not interrupt compressions to intubate; your colleague can use a supraglottic airway only if trained and authorised, otherwise continue BVM.
2. Describe the compression and ventilation standards for this two-rescuer team and how you manage fatigue and the crowd.
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Quality targets.
- Compressions 100–120/min, 5–6 cm deep, full recoil, minimal interruptions (under 10 s).
- Two rescuers: 30:2 until a supraglottic airway is in place, then continuous compressions with 10 ventilations/min. Avoid hyperventilation; each breath should just make the chest rise.
- Switch compressor every 2 minutes or sooner if quality falls; the switch should take less than 5 seconds.
- The polished floor is a hazard for rescuer positioning; kneel close, use a step or stool if available, and keep the floor around the patient clear.
- Crowd control matters: assign one person to keep the 40 onlookers back and send someone to meet the ambulance.
- The colleague has airway training but no supraglottic experience: use two-rescuer BVM technique rather than attempting an unfamiliar device under pressure.
3. At 19:14 the patient develops a pulse and spontaneous breathing, then re-arrests at 19:18. How do you manage the ROSC, the re-arrest and the transport decision, and what do you hand over?
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If ROSC occurs:
- Check pulse and rhythm; if organised with a pulse, stop compressions, titrate oxygen to 94–98%, obtain a 12-lead ECG, and support blood pressure.
- Reassess airway and breathing; keep the BVM ready.
- If he re-arrests, resume CPR immediately and reanalyse; shock only if the rhythm is shockable. Transport decision: with no ROSC and a non-shockable rhythm, load and go after the next analysis cycle rather than staying on scene; the hospital is 9 minutes away and CPR can continue in the ambulance. If ROSC is restored, transport to a facility with post-arrest care. Handover: use a structured format - age, witnessed arrest, bystander CPR, initial rhythm, number of shocks, drugs, ROSC times, airway and the pacemaker. This changes the receiving team's readiness.