Resuscitation in special situations · Consultation center
Cardiac arrest in the beach chair position: perfusion, resuscitation, and teamwork
The semi-seated position changes patient access and blood pressure interpretation. This space gathers evidence, resuscitation decisions, and team preparation for shoulder surgery and other procedures in the beach chair position.
Adults · Operating room · Educational summary for professionals
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Three situations to distinguish
The same position can accompany different problems. Not all hypotension is cardiac arrest, nor does all bradycardia have a vagal cause.
Hypotension or bradycardia with circulation
Interpret perfusion and look for the cause. Heart rate or an isolated pressure value alone are not enough to explain deterioration.
Established cardiac arrest
Activate the response, continue life support, and address reversible causes. Resolving the position is part of the work; it does not replace resuscitation.
Simulation-based preparation
Rehearse roles and equipment use in the real environment. Improving confidence or transfer times does not demonstrate better clinical outcomes.
What changes in the beach chair position
Elevated head, patient fixation and drapes may hinder access to the chest, airway, and table controls. Before operating, the team needs to know how to overcome these obstacles in their environment. Preparation is not just about remembering an algorithm; it requires rehearsing the interaction between people, table, and devices.
Context and preparation
Sources: [1]
Cerebral perfusion: interpreting where pressure is measured
With the head above the arm, there is a hydrostatic gradient: a brachial pressure can overestimate the arterial pressure at the brain level. The latter does not by itself equate to cerebral flow either. Interpretation must consider height, anesthetic context, and patient condition. A universal pressure figure or an isolated oximetry reading does not guarantee adequate perfusion.
Physiology and perioperative safety
Sources: [4]
Bradycardia and hypotension: do not close the diagnosis with “vagal”
Before attributing deterioration to a reflex, assess circulation, oxygenation, ventilation, bleeding, and temporal relation to drugs or interventions. A proposed mechanism does not exclude other causes. Bradycardia with circulation and established cardiac arrest are different situations; they require identifying what is occurring and acting according to algorithms and context.
General guidelines and clinical interpretation
Sources: [2]
Recognize cardiac arrest and maintain focus on the cause
The monitor provides information, but an organized rhythm does not demonstrate effective circulation. The team must recognize and communicate the cardiac arrest, activate help, and continue life support while investigating reversible causes. In the operating room, airway security, capnography, and hemodynamic information must be integrated into the assessment; moving the patient does not by itself correct the cause.
Intraoperative Cardiac Arrest Guide
Sources: [2]
Defibrillation and repositioning: tasks that must be coordinated
Early defibrillation of a shockable rhythm is a general priority. If access and safety allow, preparing an indicated shock while others free the table can prevent delays. This is an operational inference requiring local planning, not a sequence specifically validated in the beach chair position. An indicated intervention should not be delayed to complete an unnecessary maneuver.
Compressions: the goal is quality and safe access
AHA guidelines prefer supine on a firm surface when feasible without delaying compressions. They do not state that resuscitating seated is equivalent. Angle, backrest stability, and access to the sternum may limit quality. Preparing coordinated repositioning should be accompanied by monitoring interruptions and resuscitation effectiveness, without automatically transferring prone recommendations.
General guidance; limited specific evidence
Sources: [3]
Reposition without losing resuscitation
Freeing the head, protecting the airway and accesses, controlling the field, and managing the table are tasks that require responsible persons. Speed alone does not define a safe maneuver. In local training, compression pauses, displaced devices, and interrupted causal treatments must also be observed. This is a QxALS implementation proposal to convert simulation findings into verifiable agreements.
REASEL Institutional Preparation
Sources: [1]
What the Sundelin Study Found
At an orthopedic surgery center, 63 professionals divided into five teams participated in a 3.5-hour in situ course with seven stations. After three months, increased self-reported confidence was observed. The transfer exercises compared the first and best attempts within the session; they did not measure a real emergency nor the retention of that speed after three months.
Single-center prospective educational study
Sources: [1]
What simulation still does not demonstrate
Anonymous questionnaires did not link individual responses between times; the instrument was not formally validated and there was no control group. Transfers were exploratory, with five teams. Confidence does not equal competence. The work does not prove increased survival, ROSC, or neurological recovery; nor does it set a universal repositioning time.
Study limitations
Sources: [1]
After ROSC: the response continues
Return of spontaneous circulation (ROSC) opens another stage of evaluation, stabilization, and communication. In the studied program, post-ROSC care and information delivery were rehearsed. For REASEL, debriefing should review the entire process: recognition, response, cause, movement, and continuity of care, not just whether the table ended horizontal.
Study content and educational proposal
Sources: [1]
QxALS preparation: questions for the team
REASEL educational proposal for local training. Roles and maneuvers must be agreed upon with surgery, anesthesia, and nursing using the center's table and devices.
- Who identifies the cardiac arrest, communicates the rhythm, and coordinates the priorities?
- Who manages the airway and protects accesses, cables, and circuits when moving the table?
- Who releases the head and trunk supports and knows the normal and emergency controls?
- Who prepares the defibrillator and checks for safe access to the thorax?
- Who maintains the treatment of the cause while repositioning is organized?
- How will we measure recognition, indicated shock, interruptions of compressions, and loss of devices, in addition to transport time?
- What threat detected in the simulation exercise requires changing a local instruction and retesting it?
Dive deeper with Rafael on Substack
These readings develop the beach chair scenario, team preparation, and related physiological topics. They are editorial analyses; scientific sources are presented separately. Some articles require a subscription.
Central scenario
Arrest doesn’t wait for you to lower the beach chair
The intraoperative arrest scenario with the patient semi-seated and the questions it raises for the team.
Team organization
From algorithm to table: the QxALS method for resuscitating outside supine
Editorial analysis of preparation, role distribution, and repositioning in situations outside the supine position.
Related context
Regional anesthesia is not synonymous with low risk...
A reading on perioperative risk and cardiovascular deterioration in the context of regional anesthesia.
Related physiology
Perioperative bradycardia: “vagal” may be an incomplete diagnosis
Discussion of bradycardia and the need to specify the context before attributing a mechanism.
Related Physiology
When the heart 'brakes' to survive: the Bezold-Jarisch reflex in sedation and anesthesia
Reading perioperative physiology to deepen the proposed mechanisms of bradycardia and hypotension.
Original studies and guides
Consult the design, results, and recommendations in their sources. An educational study and a clinical guide answer different questions.
- Sundelin A, Wiklund A, Ruiz M, Stålman A, Djärv T. Improving surgical team confidence for intraoperative cardiac arrest in non-standard positions (sitting beach chair and prone): a prospective in-situ simulation study with three-month follow-up. Resuscitation Plus. 2026;30:101374.
Prospective educational intervention at a single center; self-reported confidence and exploratory transfers. Does not demonstrate survival benefits.
- Lott C y colaboradores. European Resuscitation Council Guidelines 2025: Special Circumstances in Resuscitation. Resuscitation. 2025;215:110753.
ERC 2025 guideline on special circumstances: intraoperative cardiac arrest, causes, and human factors.
- American Heart Association. 2025 Adult Basic Life Support: posición y superficie para RCP.
AHA 2025 basic life support guideline: quality, position, and surface for CPR; not a beach chair protocol.
- Cullen DJ, Kirby RR. Beach Chair Position May Decrease Cerebral Perfusion. APSF Newsletter. 2007.
APSF safety analysis on hydrostatic gradient and brain pressure. It is a source of physiological context, not a resuscitation trial.
Frequently Asked Questions
Does CPR in a beach chair position equal CPR in prone?
No. They are different scenarios. The prone literature does not validate an equivalent technique with the patient seated. Access, stability, and possibility of effective compressions must be assessed.
Do you have to finish lowering the table before defibrillating?
An avoidable delay should not be added to an indicated shock. The possibility of preparing it while repositioning depends on rhythm, access, and safety. This operational application has not been validated as a specific strategy in a beach chair.
Does arm pressure reflect pressure at the cerebral level?
In a semi-sitting position, there is a hydrostatic difference between the two levels. Arm pressure requires context; it is not a direct measurement of cerebral perfusion.
Did the simulation study demonstrate increased survival?
No. It evaluated self-reported confidence and exploratory transfer exercises. It did not demonstrate benefits in survival, ROSC, or neurological recovery.