The minutes before anyone else arrives
This is the subject where the interval between recognising and acting is measured in seconds rather than hours, and where a nurse who hesitates because they are unsure of the sequence produces a worse outcome than one who acts imperfectly but immediately. It is also the subject most students believe they know from a video and most fail to perform under observation.
Every other subject in nursing allows you to think, check and consult. This one does not. When a patient's circulation stops, the brain begins to suffer within minutes, and the difference between a person who recovers and a person who does not is very often made before anyone senior arrives. That means the competency being taught is not a body of knowledge, it is a trained response — a sequence that runs when you are frightened, and that runs fast enough to matter. Students routinely underestimate this and revise it like a chapter. It is closer to a physical skill than to a topic.
A great deal of teaching effort goes into the exact depth, rate and ratio of chest compressions, and that precision is worth learning. But it must not be learned in a way that produces a student who stands still because they cannot remember the number. Compressions that are slightly too shallow still move blood. Compressions that never start move nothing. This is why public guidance in many countries now teaches compression-only resuscitation for untrained bystanders: the barrier that costs lives is hesitation, not technique. A nursing student should aim for correct technique and should understand that the floor is immediate action.
A cardiac arrest in a tertiary hospital brings a team, a defibrillator and an airway within a minute. The same arrest in a rural health post may bring nobody for an hour. This manual is written for both, because SUNYRA's readers work in both. The recognition and the sequence are the same; what differs is how long you must sustain it, when transport becomes the priority, and what you do with your hands when there is no equipment to reach for.
Compression depth cannot be judged from a page. Neither can the feel of an airway opening, the resistance of a bag-valve-mask, or the discipline of swapping rescuers before fatigue degrades the compressions. This manual is designed to make your practical training efficient by ensuring you arrive understanding why each step exists. It is not designed to replace that training, and anyone who tells you a document can certify you in resuscitation is selling something.
The first assessment in any emergency is not of the patient. It is of the scene, and it is for your own safety. A rescuer who becomes a second casualty has doubled the problem and removed the only person who was helping. In hospital this means looking for spilled fluids, unsecured equipment, an aggressive situation, an electrical hazard or a fire. Outside hospital it means traffic, unstable structures, water, electricity and violence. Students find this counter-intuitive because the instinct is to run towards the person on the floor. The discipline of a two-second scan before you commit is trained, not natural.
Speak loudly and clearly, and squeeze the shoulders. A person who responds has an airway and circulation good enough to support consciousness, which immediately narrows what you are dealing with. A person who does not respond is a patient whose airway and breathing you must now assess directly. The check takes seconds and it sorts every emergency into two very different pathways, which is why it comes before anything else you might want to do.
The most common failure in observed assessment is not a technical one. It is a candidate who works alone for far too long before calling for help, because calling feels like an admission that they cannot manage. Help takes time to arrive, and the call must therefore be made at the moment you suspect you will need it, not at the moment you are certain. In a hospital this means pulling the emergency call or sending a specific named person for the team; outside it means directing one identified individual to call emergency services rather than appealing to a crowd, because a request addressed to everybody is a request accepted by nobody.
This order is a ranking by how fast each problem kills. An obstructed airway kills in minutes, inadequate breathing in minutes to tens of minutes, circulatory failure over a longer period, and so on down the sequence. Following it means you never become absorbed in an interesting finding while something faster is killing the patient. It is not a checklist to complete once but a loop to return to, and when a patient deteriorates the correct response is always to start again at the beginning rather than to continue from where you were.
With the airway opened, look for chest movement, listen for breath sounds and feel for air on your cheek, taking no more than ten seconds. The specific trap here is agonal breathing: occasional, gasping, noisy breaths that occur in the first minutes after circulation stops. They look like breathing to an untrained observer and they are not. Mistaking them for normal breathing is one of the commonest reasons resuscitation is delayed, and recognising them is one of the most valuable things a student can take from this chapter.
Air has to get in before anything else you do has any value. Compressions circulate blood that carries no oxygen if the airway is closed, and every medicine given further down the line assumes lungs that can be reached. This is why the airway heads the sequence and why it is reassessed constantly rather than opened once and forgotten.
In an unresponsive patient the most common cause of obstruction is the tongue falling back against the pharynx as muscle tone is lost. A head tilt with chin lift moves the tongue forward and opens the passage, and it is the single most valuable manoeuvre in basic life support. Where the mechanism of injury suggests possible cervical spine injury, a jaw thrust is used instead, because it opens the airway with less neck movement. A student should know both and should also know the principle that governs the choice: a patent airway takes precedence, because a protected spine in a patient who is not breathing is of no use to anybody.
Visible fluid or debris in the mouth is removed under direct vision, by suction where it is available and by careful finger sweep only when the obstruction is visible and reachable — a blind sweep can push material further in. A patient who is unresponsive but breathing normally is placed in the recovery position, which uses gravity to keep the tongue forward and lets vomit drain out of the mouth rather than into the lungs. It is a simple manoeuvre that prevents a common and entirely avoidable death.
Oropharyngeal and nasopharyngeal airways hold the passage open where a manual manoeuvre is not enough, and each has situations in which it is not appropriate. Both are adjuncts, not protections: neither prevents aspiration, and a patient with one in place still requires positioning and observation. Knowing what a device does not do is as important as knowing what it does, because a nurse who believes the airway is secured will stop watching it.
The question is not only whether a patient is breathing but whether the breathing is achieving anything. Rate, depth, symmetry of chest movement, effort, the use of accessory muscles, the ability to speak in full sentences, and colour all contribute. A patient breathing very fast and very shallowly may be moving less air than one breathing slowly and deeply. Counting a respiratory rate properly, over a full minute, unobtrusively, is an unglamorous skill that detects deterioration earlier than almost anything else on the observation chart.
Where trained and willing, rescue breaths are delivered with the airway open, each given over about a second and each just enough to make the chest visibly rise. Over-inflation is the error to avoid: it forces air into the stomach, causes regurgitation, and raises the risk of aspiration. Where a barrier device or a bag-valve-mask is available it is used; where it is not, and the rescuer is unwilling to give mouth-to-mouth, compression-only resuscitation is an accepted and effective alternative for adults and is far better than standing back.
Almost every student overestimates their ability to achieve a seal alone. In practice one rescuer holds the mask with both hands while a second squeezes the bag, and this arrangement delivers far more air than one person attempting both. Knowing this in advance changes how you deploy the people who arrive to help, which is a leadership skill as much as a technical one.
In an emergency, high-concentration oxygen is given to a patient who is critically unwell and is adjusted once the situation is controlled and measurements are available. In some chronic respiratory conditions sustained high-concentration oxygen carries its own risk, which is why targets are set and reviewed rather than left at maximum. The nursing point is that oxygen is a treatment with indications and an endpoint, not a comfort measure to be left running unmonitored.
Resuscitation begins in an unresponsive patient who is not breathing normally. Note that this does not require you to find no pulse. Pulse checks are unreliable even among experienced clinicians and they consume time, which is why lay and basic-level guidance across most of the world removes them from the decision. The trained response is: unresponsive, not breathing normally, start compressions. Agonal gasping counts as not breathing normally, and this is the case that most often causes delay.
Compressions generate blood flow both by squeezing the heart between the sternum and the spine and by raising pressure throughout the chest. Two consequences follow that students should understand rather than memorise. First, depth matters, because shallow compressions generate very little flow. Second, interruptions matter enormously, because pressure in the circulation falls away within seconds of stopping and takes several compressions to rebuild. Every pause to reassess, move equipment or discuss has a cost measured in perfusion of the brain.
Effective compressions require the correct hand position in the centre of the chest, adequate depth, full recoil between compressions so the heart can refill, a steady rate, and minimal interruption. All five degrade with rescuer fatigue and they degrade much sooner than the rescuer believes. This is why rescuers swap at regular intervals during a resuscitation, ideally at a natural pause, and why the swap is planned rather than left until somebody is exhausted. The exact rate and depth taught to you will be your council's figures; the principle that quality falls away silently is universal.
Leaning on the chest between compressions is one of the most frequent faults seen in practical assessment. It prevents the chest from recoiling fully, which prevents the heart from filling, which means the next compression ejects less blood. The rescuer feels as though they are working hard and the patient receives less circulation than they would from shallower compressions with complete release. Being told this before your first manikin session saves a great deal of correction.
An automated external defibrillator is applied as soon as one is available, switched on, and followed. It analyses the rhythm and advises whether a shock is indicated; the rescuer's job is to keep compressions going until the moment of analysis, ensure nobody is touching the patient at the moment of shock, and resume compressions immediately afterwards without waiting to see a result. The single most useful thing a student can know about these devices is that they are designed to be used by people with no training and that hesitating to fetch one costs more than any error in using it.
Many nurses work where there is none. Compressions and ventilation continue while help or transport is organised, and the decision about how long to continue is a clinical and often a local one. This manual will not print a duration, because it depends on cause, temperature, age, the resources reachable and local guidance. What it will say is that the decision to stop is made deliberately, with whoever holds the authority to make it in your setting, and documented — not drifted into because everybody is tired.
The whole of choking management turns on one distinction. A person with a mild obstruction can cough, can speak and can breathe; the correct action is to encourage coughing and stay with them, because a cough generates far more force than anything you can apply from outside. A person with a severe obstruction cannot speak, cannot cough effectively and cannot breathe; this is the situation that requires intervention. A student who cannot tell these apart will either intervene unnecessarily, which causes harm, or watch somebody suffocate.
With severe obstruction, back blows are delivered between the shoulder blades with the heel of the hand, the patient leaning forward so that anything dislodged comes out rather than falling back. If these do not clear it, abdominal thrusts are applied from behind. The two are then alternated, checking the mouth between attempts, while help is summoned. Anyone who has received abdominal thrusts should be medically assessed afterwards because of the risk of internal injury, even if they feel entirely well.
The principles are the same and the technique is not. Infants are supported head-down along the forearm for back blows, and chest thrusts are used in place of abdominal thrusts because an infant's abdominal organs are unprotected by the rib cage and would be injured. This is one of several places where applying adult technique to a child causes harm, and it is a favourite of examiners for exactly that reason.
A choking person who loses consciousness is managed as a cardiac arrest: lower them carefully to the ground, call for help and begin chest compressions. Compressions generate pressure in the chest that can itself dislodge an obstruction, and the patient now needs circulation regardless. Continuing to attempt thrusts on an unresponsive patient on the floor is a common and understandable error that delays the thing that will actually help.
Severe external bleeding is controlled by firm, direct, sustained pressure over the wound, with the limb elevated where that is possible and appropriate. Pressure works, it works quickly, and it fails mostly because it is applied too gently, moved too often to look at the wound, or abandoned in favour of something more elaborate. If blood soaks through, more dressing goes on top rather than removing what is already there, because removing it removes the clot that was forming.
Where bleeding from a limb is life-threatening and cannot be controlled by pressure, a tourniquet applied correctly and tightly enough to stop arterial flow is appropriate, and the time of application is recorded. A tourniquet applied half-heartedly is worse than none, because it obstructs venous return while allowing arterial inflow and increases blood loss. This is an area where local protocols and available equipment vary widely and where you should know your own service's position.
Shock is inadequate perfusion of the tissues, and its early signs are subtle and easy to attribute to anxiety: a rising pulse, cool and pale peripheries, prolonged capillary refill, restlessness and thirst. Blood pressure is a late sign, particularly in the young and the previously fit, whose compensation holds a normal reading until it fails suddenly. A student who waits for hypotension before escalating will escalate late in exactly the patients who deteriorate fastest.
Wounds are assessed for what caused them and what lies beneath as well as for their appearance. Burns are cooled with running water for a sustained period and then covered with a clean non-adherent covering; ice, butter, toothpaste and other traditional applications cause further injury and are still widely used, which makes teaching against them a public health act as much as a clinical one. Embedded objects are left in place and stabilised rather than removed, because the object may be the only thing preventing catastrophic bleeding.
The correct actions are to protect the person from injury, cushion the head, remove hazards, time the event and stay with them. Nothing is placed in the mouth, restraint is not applied, and the person is placed in the recovery position once the movements have stopped. Timing matters because duration is what determines whether this is an emergency requiring immediate escalation, and it is the detail most often missing from the account given to the arriving team.
Hypoglycaemia can present as confusion, aggression, sweating, tremor or reduced consciousness, and it is frequently mistaken for intoxication or for a behavioural problem. It is rapidly reversible and rapidly harmful, which makes it one of the few conditions where a nurse's speed of recognition changes the outcome within minutes. A conscious person able to swallow safely is given a fast-acting carbohydrate by mouth; an unconscious one is not given anything by mouth, and is managed as an emergency. Specific products and quantities are set by local protocol.
Anaphylaxis is recognised by rapid onset with airway, breathing or circulatory compromise, usually with skin changes and usually after an exposure. It is a call-for-help-immediately condition. Nursing actions are to stop the trigger, call for emergency assistance, position the patient appropriately — lying flat with legs raised where there is circulatory compromise, sitting up where breathing is the main problem, and never standing them up suddenly — and to assist the emergency response. Treatment itself is prescribed and is outside the scope of this manual.
Both are conditions where time to definitive treatment determines how much function is lost, which makes recognition and escalation the nursing contribution. Facial weakness, arm weakness and speech disturbance are the recognised warning signs for stroke and any one of them warrants immediate escalation. Chest pain that is severe, persistent or associated with sweating, breathlessness or collapse is treated as an emergency until proven otherwise. In neither case does the nurse diagnose; in both cases the nurse decides how fast the system responds.
A simple faint resolves quickly when the person is laid flat with legs raised, and a person who does not recover quickly was not simply fainting. This is the general principle behind recognising deterioration: the patient who does not follow the expected course is the patient to worry about, and escalating on the basis of a course that does not fit is legitimate and correct even when you cannot name the cause.
Children have proportionally larger heads and tongues, narrower and more compressible airways, and a far greater tendency to arrest from respiratory causes rather than cardiac ones. The practical consequences follow directly: airway positioning differs, ventilation is given a higher priority in the sequence, and compression technique and the depth aimed for are scaled to the child. A student who applies adult technique unmodified will both open the airway incorrectly and injure the child.
Children compensate impressively and then fail abruptly. The signs that matter are work of breathing, colour, responsiveness, feeding in infants, and the parent's assessment — a parent who says this is not how their child usually is should be believed, and dismissing that account is a recognised cause of preventable death. Capillary refill, respiratory rate and level of alertness detect deterioration earlier than blood pressure, which falls very late in children.
Neutral head position rather than full extension, chest thrusts rather than abdominal thrusts for choking, compressions delivered with two fingers or with two thumbs encircling the chest depending on the number of rescuers, and a much greater emphasis on ventilation because respiratory failure is the usual path to arrest. Newborn resuscitation immediately after birth is different again and belongs to a separate course.
In late pregnancy the uterus compresses the great vessels when the woman lies flat, which reduces the blood returning to the heart and makes resuscitation less effective. The correction is manual displacement of the uterus to the left, or a left lateral tilt, and it is applied during resuscitation as well as during the management of collapse or shock. It is a small manoeuvre with a large effect and it is frequently forgotten because it does not appear in the general adult sequence.
The team that arrives needs a structured account, and a structured tool is used in almost every service for exactly this reason: what the situation is, the relevant background, your assessment, and what you are recommending or requesting. Delivered in that order it takes twenty seconds and it works. Delivered as a narrative beginning with what the patient ate this morning, it wastes the minutes that were the point of calling.
Times are the part of the record that matter most and the part most often reconstructed afterwards from memory. When the patient was last seen well, when they were found, when help was called, when compressions started, when the defibrillator was applied, when the team arrived. Someone should be given the specific job of recording these during the event where staffing allows, because nobody remembers them accurately afterwards and the record is what allows the event to be reviewed honestly.
Resuscitation attempts are distressing for the staff who carry them out, for other patients who heard it, and for relatives who may have witnessed it. Debriefing is a clinical activity rather than a courtesy, and services that do it well have staff who continue to respond well. A student should expect to be affected, should know that being affected is not a sign of unsuitability, and should know what support exists in their service before they need it.
Reviewing a resuscitation asks what happened, what went well, what was difficult and what would be done differently — about the system as much as about individuals. A review that identifies a person to blame reliably produces staff who report less and a service that learns nothing. A review that identifies that the defibrillator was three corridors away produces a defibrillator that is not.
Resuscitation competence decays measurably within months of training, which is why every service requires periodic reassessment rather than a single certificate. Treating that requirement as a formality is how a nurse arrives at a real arrest with a skill that expired quietly two years ago. Short, frequent practice holds the skill far better than a long course every few years, and asking for it is a reasonable professional request.
Nearly every resuscitation text is written on the assumption that a team, a defibrillator and an ambulance are minutes away. For an enormous number of nurses worldwide this assumption is false, and a manual that quietly adopts it teaches a sequence that breaks down at exactly the point the reader needs it most. Where the nearest hospital is two hours by road, the nearest defibrillator does not exist, and you are the only trained person present, the sequence does not change but the shape of the task does: you are sustaining, not stabilising, and the decisions about transport, about who helps you, and about how long to continue are yours to make and to document.
Untrained people at the scene are a resource, not an obstruction, and they are wasted by anyone who tries to do everything alone. Give individual people individual jobs, by name or by pointing, and make each job concrete: you call for the ambulance and come back and tell me you have called, you fetch the blanket, you two are going to take turns pressing on the chest and I will show you how. Compression-only resuscitation can be taught to an adult in under a minute, and a rotating pair of bystanders doing adequate compressions while you manage the airway and organise transport achieves far more than one exhausted professional doing everything at declining quality.
Where equipment is absent, the principles still direct what to do with your hands. A firm surface can be found or made. A cloth and firm pressure control bleeding. Gravity and positioning protect an airway. Clean running water cools a burn. None of this is a reason to accept a service that has no equipment, and a nurse who improvises should also be a nurse who reports the shortfall in writing, because a gap that is worked around silently is a gap that is never funded. Improvising guided by the physiology is nursing; improvising guided by hope is not.
The emergency trolley is checked on a schedule in every service that has one, and the check is delegated to whoever is least busy, which usually means it is the task most likely to be signed without being done. A student should understand what that signature is for. The moment you discover the bag-valve-mask is missing, the defibrillator pads are out of date or the suction has no tubing is not a moment you can afford to spend looking. Doing the check properly once a week is a few minutes; discovering a gap during an arrest costs something that cannot be recovered. Knowing where the trolley is, and what is on it, is part of arriving on a new ward.
In a setting with no definitive care on site, the question of when to move becomes clinical. Moving a patient interrupts compressions and interrupting compressions costs perfusion, so the decision is rarely obvious and should not be made alone where a senior colleague can be reached by telephone. What a student can carry is the principle: the patient goes where the treatment they need actually exists, the journey is planned rather than improvised, and someone continues care throughout rather than watching from the front of the vehicle.
A person who is unresponsive cannot consent, and every legal system provides for treatment to be given in an emergency on the basis of necessity and the person's best interests. A nurse should not hesitate over this. What the principle requires is that the treatment given is what is immediately necessary, that it stops when the emergency does or when a person with authority to decide becomes available, and that a patient who is conscious and has capacity may refuse care even when the refusal seems unwise. Capacity is assumed in an adult unless there is reason to doubt it, and it is assessed for the decision in front of you rather than declared globally.
Many patients have documented decisions about resuscitation, recorded under names that differ between countries. Where such a decision exists and is valid, following it is not withholding care; it is delivering the care the patient chose. Where the document cannot be found, where its validity is unclear, or where the situation does not match what it describes, resuscitation is started and the question is resolved while it continues. Nobody should die because a form was in another folder, and nobody should be resuscitated against a clear, valid, applicable decision because a nurse felt uncomfortable honouring it.
Relatives increasingly remain present during resuscitation, and the evidence on this is more favourable than most staff expect. What makes it work is having a member of staff assigned to be with them, explaining what is happening in plain words, and ensuring they are not standing where they obstruct the work. What makes it harmful is nobody being with them at all. If you are the person asked to do this, understand that it is a clinical role with a purpose, not a way of keeping a junior out of the way.
The decision to stop a resuscitation attempt is made by whoever holds that authority in your service, on clinical grounds, and it is one of the hardest moments in nursing. Students should know in advance that it happens, that it is not a failure of the people present, and that the care does not end at that point — it changes into care of the body, care of the family, and care of the staff who were in the room. A nurse who understands that the work continues is a nurse who manages the moment better than one who believes everything is over.
Practical resuscitation assessment scores a small number of things heavily: did you check for danger, did you establish unresponsiveness, did you open the airway correctly, did you recognise abnormal breathing, did you call for help early and specifically, did you start compressions without delay, was the technique adequate and sustained, and did you minimise interruptions. Almost every failure is one of these rather than a subtle error of knowledge. Candidates fail for working alone too long, for hesitating over the pulse, and for stopping compressions to talk.
The sequence must be practised until it runs without being recalled, because recall is the first thing that fails under stress. Saying the steps aloud while performing them, practising in a slightly noisy and uncomfortable setting rather than a quiet room, and rehearsing the call for help as carefully as the compressions all help. Short sessions repeated often build a response that holds; a single long session before the examination builds one that lasts until the door opens.
Resuscitation competence measurably declines within months of training, in every professional group studied. This is why services require periodic reassessment and why treating it as paperwork is a genuine risk to patients. A nurse who last practised two years ago will be slower, will compress less effectively and will hesitate longer, and will not feel any of those things happening. Asking for more frequent short practice is a reasonable professional request and a good one to make early in a post.
Nurses are the people who teach resuscitation to families, to healthcare assistants, to community volunteers and to schoolchildren, and in many countries they are the only people who ever will. This is not an optional extra to the subject; survival from out-of-hospital arrest depends overwhelmingly on whether a bystander starts compressions before any professional arrives, and bystanders only start if somebody taught them. Teaching it well means stripping it to the part that matters for an untrained person — recognise, call, push hard and fast in the centre of the chest, keep going — and resisting the urge to include everything you know. A family member who remembers four steps and acts is worth more than one who was taught twelve and freezes.
Almost everybody is frightened the first time, and a number of experienced nurses are frightened every time. Fear is not evidence that you are unsuited to this work; it is evidence that you understand what is at stake. What training does is give the frightened person something to do with their hands while the fear is happening, which is why the sequence is drilled rather than discussed. Expect to shake afterwards. Expect to replay it. Speak to somebody about it rather than carrying it, and know that the nurses who last longest in emergency work are not the ones who feel nothing but the ones who have somewhere to put it.
Three things. That recognition, not technique, is what most often delays resuscitation, and that agonal gasping is the trap. That calling for help early is a skill to practise rather than an admission of inadequacy. And that the quality of compressions decays silently, so the discipline of swapping rescuers and minimising pauses matters as much as anything you do with your hands. A student who leaves with those three will do more good in a real emergency than one who has memorised every number in the guideline and never rehearsed the first ten seconds.