CARDIAC ARREST

Cardiac Arrest
Surprisingly many people ignore pains in their chest. The preceding events leading up to a heart attack such as, crushing pressure on the chest, shortness of breath, pins and needles in arms, usually indicate an expected problem, however people often turn up at the last minute when irreversible damage has occurred.
It’s an amazing thing to watch an emergency team attempting to save someone’s life, being part of that team and knowing what to do without panic is a commodity emergency staff rely on. Its not like ER or Casualty the TV programmes, in a heart attack situation when the person’s heart has stopped beating and the patient isn’t breathing, it’s a hub of calm organised activity. Unlike ER or Casualty the likelihood of survival is minimal unless early resuscitation has taken place. One experience that has taught me to keep on my toes happened outside Accident and Emergency.

A standby by call from the paramedics pre-warned us that a patient in cardiac arrest was to be expected by ambulance. I remember we were pretty quiet that day. The estimated arrival time of the patient was four minutes so I went to set up the resuscitation room with necessary equipment. Oxygen and suction was turned on, the defibrillation machine was on, drugs at the ready and the trauma team were called. I placed a pair of gloves on my hands and looked out of the resuscitation room windows. I remembered catching a glimpse of a green car pulling up outside and then a paramedic car. The paramedic car usually stayed at scene until ambulances arrived that could transport the patient, so I was intrigued to see it outside emergency. Also people often park illegally outside emergency to collect relatives and block the ambulance bay, so I was keen to investigate as I was due a new patient any minute through those doors.
I walked outside into the cold air and saw the paramedic was out of his car, so were the drivers of the green car and the passenger door was open at the back. I could see a man in the back and I asked the paramedic if I could help. It appeared that the paramedics had got the call to chest pains, however the patient had managed to get into the back of the car and his family drove him to the hospital, the paramedic was on route and followed the car here to A&E.
I got closer and looked at a large man in the backseat, he had his left arm clutching his chest, his skin colour was mottled purple and red, he let out a moan and slipped sideways in his seat, his arm clutching his chest has fallen onto his lap and he hung there by his seatbelt, I immediately shouted at the man to gain a response. Nothing.
He had stopped breathing and was already gaining a pale colour to his skin. The other nursing staff must have seen me going out of the paramedic doors and they followed to see what I was doing. I’d told the staff he had just arrested and asked for a trolley so we could bring the patient inside. I managed to undo the patient’s seatbelt but had no chance of getting him out of his car, or doing a sternal thump due to his awkward position and being so heavy, the two male paramedics were able to pull the man out of his car and onto the floor outside A&E. A trolley was brought out and I grabbed the bag off the bottom of the trolley that had airway equipment in it and swiftly measured a guedel airway for the patient. I put it in his mouth so that he didn’t swallow his tongue and began to give him oxygen from the portable cylinder on the trolley. One paramedic commenced CPR and the other tried to get a venflon into his vein so we could administer drugs.
By this time the other staff nurses and doctors had got a scoop board at the ready to scoop the patient up from the floor and put him onto the trolley. The family stood and watched every move that we made, on the cold damp tarmac outside Accident and Emergency; they had hands over mouths staring at the scene. Staff were assessing the patient on the floor and our scrubs had dirty patches on our knees.
About eight people assisted in lifting the patient into the scoop and onto the trolley so we could continue treating the patient inside. Once on the trolley the patient was pushed in through the paramedic doors straight into the resuscitation room and his relatives were taken by another nurse into a quiet room, to gain medical history and the preceding event information.
The man wasn’t breathing on his own and nor was his heart working, we could see on the monitors that he had no pulse and non could be felt either, no blood pressure was record able and his skin colour was changing to a mottled white and purple. The clock was started and we busily continued strenuous chest compressions, standing on the steps next to the trolley, each nurse could only efficiently administer about three minutes of effective cardiac compressions at one hundred compressions a minute before getting too tired, so we rotated often. The anaesthetist had already intubated the patient so his airway was protected and he was given automatic breaths from the noisy ventilator. Fluids were administrated via the new IV line; the doctor gave adrenalin through the patient’s intravenous line and atropine to try to raise a heart rate. However with the patient being in asystole, defibrillation of the heart is ineffective. There are only two heart rhythms that can be shocked, VT and VF and all other cardiac rhythms have to be treated with reversal drugs and CPR.
The time on the clock beeped and it indicated nine minutes had gone by, a sudden green blip occurred on the defibrillator machine, to a layperson the thin green line had changed to a continuous hopeful green squiggle. The monitor showed a window of opportunity to defibrillate this man as his heart had flipped his asytole rhythm to ventricular tachycardia. The pads were on his chest and the machine had been charged to 360joules ready to go. “Clear” was shouted and staff moved away from the trolley, oxygen was removed as it can ignite from the shock of the electric current. The patient jerked violently and threw his arms involuntarily into the air as his whole body jolted and rocked the trolley in a loud thud as the joules were administered.
All eyes focused on the green monitor and his rhythm was still in VT, his heart needed shocking again. We all moved away from the trolley and a further shock was given. The patient’s daughter had wanted to watch the resuscitation process and she stayed to one side watching the many people doing essential jobs to help her father’s lifeless body. She was so brave, she stood tall and strong and just watched us do our best; a nurse had offered her a chair she had refused and continued to watch without tears or panic.
This second attempt at getting his heart in a stable rhythm produced a pulse, felt by one of the doctors and more resuscitation drugs were given, he now had a readable blood pressure, and the monitors also confirmed he had a pulse. The drugs and defibrillation must have stimulated his heart enough to start beating again in sinus rhythm.
The ventilator controlled the patient’s respiratory rate, and monitors were in place to closely observe his vital signs post cardiac arrest. His heartbeat had returned, his cardiac output was strong and his rhythm was normal, he was motionless due to the sedation, but the monitor beeped reassuringly confirming effective resuscitation had occurred. His daughter breathed a sigh of relief, as she understood the transformed readings on the defibrillator monitor. Intensive Care Unit was informed and a bed made ready for the patient. A phone call made the next day to inquire about the patient’s progress revealed that he was breathing on his own without the ventilation tube and was stable. He had been referred to the cardiologist.

CARDIAC ARREST

LIZBO

NARRE WARREN, Australia

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