Handle Patients in a Cardiac Crisis: Acting quickly is a matter of life and death if a patient experiences a cardiac crisis. Whether the patient is going through a heart attack or sudden cardiac arrest, there are steps you can take to keep them safe and secure transportation to the nearest emergency room.
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Identifying a Cardiac Crisis
Familiarizing yourself with the signs of a cardiac crisis will help you identify the issue quickly and respond appropriately.
Patients can experience two main types of cardiac emergencies, namely heart attacks and cardiac arrest. While there are some similarities between these two conditions, the causes and symptoms differ. With over 356,000 cases of cardiac arrests each year, cardiac emergencies are more frequent than you would think.
Risk factors include coronary artery disease, diabetes, obesity, and high blood pressure, a condition that affects almost 50% of American adults. A heart rate that exceeds 70 BPM puts patients at risk and calls for lifestyle modifications or other treatment options.
A heart attack occurs when a clogged artery blocks or restricts blood flow to the heart. The heart doesn’t stop beating like during a cardiac arrest, but it is a life-threatening condition. Unlike a cardiac arrest which signifies an electrical problem with the heart, a heart attack is a circulation problem.
The symptoms of a heart attack include chest pain, dizziness, fainting, and shortness of breath. Patients can also experience discomfort in different parts of their body, such as the arms, back, neck, or jaw.
A heart attack can be difficult to identify right away, especially if the patient experiences symptoms in their arms or back. Note that women are slightly more likely to report symptoms other than chest pain, including nausea or pain in the jaw and back.
The symptoms that precede cardiac arrest can resemble a heart attack with chest pain, dizziness, shortness of breath, and fainting. However, it differs from a heart attack since the heart stops completely and no longer supplies blood to the brain and other organs.
Handling Patients in a Cardiac Crisis: What To Do at the Scene
If the patient is unconscious and not breathing, you need to take action right away and follow the Advanced Cardiac Life Support algorithms or ACLS algorithms.
The ACLS algorithms are a go-to response you can turn to during a cardiac emergency. If a patient sustains a cardiac emergency outside of a hospital, you should follow these steps:
- The first thing to do is dial 911 and secure transportation to the nearest emergency room.
- Next, you should start administering CPR.
- If you have access to defibrillation equipment, use it after performing CPR. You might have to wait until first responders get to the scene.
- If the patient isn’t responding, the next step is to use advanced resuscitation techniques, including drug therapy and intubation.
The steps are slightly different if a patient experiences cardiac arrest in a hospital. A patient who complains of chest pain or other symptoms associated with a cardiac emergency will need monitoring and preventative treatment, including the use of a cardiopulmonary stabilization device.
If the patient goes into cardiac arrest, you should call for help immediately. Your next step should be to perform CPR and use a defibrillator if the patient doesn’t respond to CPR.
Performing CPR and Rescue Breathing
Performing CPR can save a patient’s life, but it’s important to know when and how to use CPR.
Your first step should be to check the patient’s pulse and breathing. If you can feel a pulse and the patient is breathing normally, there is no need to perform CPR.
If you can feel a pulse but the patient isn’t breathing, the ACLS algorithms recommend using rescue breathing instead of CPR. Rescue breathing consists in blowing air into the patient’s mouth so they don’t run out of oxygen. However, there is no need to perform chest compressions.
Count six seconds between each rescue breath and keep checking the patient’s pulse every two minutes. If the pulse stops, you should start performing CPR right away.
CPR and AED
If you can’t feel a pulse for more than 10 seconds, you should start CPR immediately.
While you can perform hands-only CPR in some situations, the ACLS algorithms call for using a combination of chest compressions and rescue breathing. You should perform 30 chest compressions at a rhythm of 100 or 120 compressions per minute and stop every 30 compressions for two rescue breaths.
The purpose of CPR is to keep the blood flowing until an AED (Automated External Defibrillator) is available. It’s crucial to contact 911 or activate the in-hospital emergency response as quickly as possible to guarantee fast access to an AED.
You should use the AED as soon as it’s available, but you’ll have to check that the patient has a shockable heart rhythm first.
Types of Heart Rhythms
These are some of the four most common types of abnormal heart rhythms during a cardiac emergency.
Ventricular fibrillation or v-fib, is a type of rhythm that prevents blood from pumping out of the heart into the rest of the body. It’s a shockable rhythm.
The second type of shockable rhythm is pulseless v-tach or pulseless ventricular tachycardia. This heart rhythm occurs when the heart is beating too fast, with a resting heart rate over 100 BPM.
Pulseless Electrical Activity (PEA)
The third type of heart rhythm is pulseless electrical activity. You won’t be able to use the AED. The electrical activity of the heart is normal with this type of rhythm, but the heart isn’t pumping blood, usually because of hypovolemia or hypoxia.
The other type of non-shockable rhythm is asystole, which means all electrical and mechanical activities have stopped.
If the patient has a shockable heart rhythm:
- Use the AED to deliver one shock.
- Perform CPR for two minutes.
- Check the patient’s heart rhythm again and deliver another shock.
- Repeat these steps until the patient starts moving.
If you’re not detecting a shockable heart rhythm, your best options are to continue performing CPR for two minutes and check the heart rhythm again. If available, you should inject epinephrine right away to try restoring spontaneous circulation.
As a side note, it’s important to remember that patients who are experiencing an opioid overdose will need an injection of naloxone when you begin performing CPR.
Drug Therapy and Advanced Airway
If a patient experiences cardiac arrest in a hospital, these treatment options will be available right away. However, the ACLS algorithm calls for using CPR and an AED first.
It might take a few minutes before advanced resuscitation techniques are available if a patient experiences an out-of-hospital cardiac emergency. You’ll have to keep using CPR, rescue breathing, and AED if applicable until the ambulance reaches the patient.
Drug Therapy Guidelines
The ACLS guidelines recommend intravenous and intraosseous injections for drug therapy. There are different treatment options depending on the patient’s condition.
As long as the patient has a shockable heart rhythm, you should continue performing CPR and shocking the patient’s heart every two minutes. You should inject 1mg epinephrine every three to five minutes. After applying a total of three shocks, you can inject amiodarone or lidocaine.
The first dose of amiodarone should be 300mg and the first dose of lidocaine should be 1 to 1.5mg/kg. You’ll want to reduce these doses to 150mg and 0.5 to 0.75mg/kg if you need to inject a second dose. These two drugs are antiarrhythmic drugs that can promote the return of a regular heartbeat.
ACLS Algorithms for Oxygen
You’ll also have to use advanced airway therapy to help the patient breathe. The ACLS guidelines recommend using an endotracheal tube to deliver oxygen to the trachea, or a supraglottic airway to deliver air to the pharynx.
You can use these intubation methods to keep delivering one rescue breath every six seconds, along with chest compressions.
After using drugs and advanced airway therapy, you should focus on identifying potential causes behind the cardiac emergency and treating these causes. There are different reversible causes that can lead to cardiac arrest, including a pulmonary embolism, acidosis, hypothermia, or cardiac tamponade just to cite a few examples.
If you’re unable to detect a shockable rhythm, your best option is to keep injecting epinephrine and performing CPR before focusing on reversible causes.
Return of Spontaneous Circulation and Post-Cardiac Arrest Care
Return of Spontaneous Circulation or ROSC is your primary goal when treating a cardiac arrest patient. The cardiac activity will start again and typically cause the patient to breathe, move, or cough. Note that it’s common for patients to experience difficulty breathing.
You should look for a pulse and measure the patient’s blood pressure to confirm that you have achieved ROSC.
The next step is post-cardiac arrest care. Keep monitoring the patient and continue treatment since ROSC doesn’t necessarily mean they are safe.
You’ll need to stabilize the patient. If you didn’t use airway therapy during resuscitation efforts, you’ll need to use a tube to deliver oxygen and achieve a saturation level of 92 to 98%. Blood pressure should be above 90 mm Hg.
Next, you’ll need to apply a 12-lead electrocardiogram to monitor the electrical activity of the patient’s heart. Depending on the patient’s condition and responsiveness, you might need to take additional steps for critical care, such as EEG monitoring, temperature management, or a brain CT.
Managing a cardiac crisis can be stressful and overwhelming, but familiarizing yourself with the ACLS guidelines ensures you’ll make the right decisions at every step of this process.