Emergency Cardiac Medicine: A Complete Guide to Primary and Secondary Survey

Emergency Cardiac Medicine: A Complete Guide to Primary and Secondary Survey

Emergency cardiac medicine is one of the most critical areas of modern healthcare. Every second counts when a patient collapses with a cardiac emergency, and survival often depends on how quickly and effectively resuscitation is initiated. To simplify this complex process, providers rely on a structured approach: the Primary Survey (ABCD) followed by the Secondary Survey (ABCD). This framework guides healthcare professionals through immediate, life-saving interventions before moving to advanced management strategies.

In this article, we will explore how these principles apply in practice, focusing on airway management, breathing support, circulation and CPR, defibrillation, drug therapy, and long-term considerations. By the end, you will understand how the ABCD framework can save lives and why early, coordinated action is the cornerstone of advanced cardiac life support (ACLS).

The Primary Survey: First ABCD

The Primary Survey is all about rapid assessment and immediate intervention. Its purpose is to identify and treat life-threatening conditions within seconds.

A: Airway

The airway must be opened and cleared. Use the head tilt–chin lift maneuver unless a cervical spine injury is suspected. In that case, apply the jaw-thrust technique to minimize neck movement. Remove vomitus, blood, dentures, or foreign bodies to ensure patency. A blocked airway will lead to hypoxia within minutes, making this the first critical step.

B: Breathing

Once the airway is open, assess breathing by looking, listening, and feeling for air movement. If the patient is not breathing adequately, deliver positive pressure ventilation using a bag-valve-mask (BVM). In cardiac arrest, provide two rescue breaths followed by chest compressions. If spontaneous breathing resumes, place the patient in the recovery position to maintain airway security.

C: Circulation

If no pulse is detected within 10 seconds, immediately start chest compressions. Use the heel of your hands placed on the sternum, compressing to a depth of 4–5 cm at a rate of 100–120 per minute. If only one rescuer is present, the cycle is 30 compressions to 2 breaths. If two rescuers are available, alternate compressions and ventilations in a 15:2 ratio.

D: Defibrillation

Ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT) are the most common rhythms in sudden cardiac arrest. Early defibrillation offers the best chance of survival. Apply adhesive pads or paddles, check the rhythm, and deliver a shock as soon as possible. Initial energy is typically 200 joules, repeated as necessary.

The Primary Survey is designed to be fast—completed within minutes—so that circulation of oxygenated blood can resume and critical organs are preserved.

The Secondary Survey: Second ABCD

Once basic life-saving steps are underway, the Secondary Survey expands care into advanced procedures and diagnostics.

A: Advanced Airway

Establish endotracheal intubation if trained and competent. Confirm placement by auscultating breath sounds and observing chest rise. Oxygenate the patient fully before and after intubation to minimize hypoxia. An oropharyngeal airway may be used as a temporary measure until intubation equipment is ready.

B: Breathing Support

After securing the airway, ensure adequate ventilation and oxygenation. Use pulse oximetry and capnography where available. Provide positive pressure ventilation with 100% oxygen. If mechanical ventilation is required, monitor tidal volume and respiratory rate closely to avoid barotrauma.

C: Circulation and IV Access

Insert two large-bore intravenous lines for fluids and medications. If IV access is not possible, intraosseous (IO) access is a safe alternative. Collect blood samples for biochemistry, blood count, and cross-match. Begin fluid resuscitation if indicated, but avoid excessive fluids in cardiac arrest to prevent pulmonary edema.

D: Differential Diagnosis

Construct a differential diagnosis to identify reversible causes of cardiac arrest. These are often summarized as the “H’s and T’s”:

Hypoxia

Hypovolemia

Hydrogen ion (acidosis)

Hyper-/hypokalemia

Hypothermia

Tension pneumothorax

Tamponade (cardiac)

Toxins

Thrombosis (pulmonary or coronary)

Identifying and correcting these factors is key to restoring spontaneous circulation.

Cardiac Arrest in Adults: Practical Steps

Cardiac arrest management follows a logical sequence of assessment and action.

1. Scene Safety: Ensure the environment is safe for rescuers and patient.

2. Responsiveness: Tap and talk to the victim (“Hello, can you hear me?”).

3. Call for Help: Activate emergency services and request a defibrillator.

4. Airway and Breathing: Open airway, deliver 2 breaths if not breathing.

5. Circulation: Start CPR immediately if no pulse.

6. Defibrillation: Apply the defibrillator and shock VF/pulseless VT without delay.

This chain of survival—early recognition, early CPR, early defibrillation, and advanced care—significantly improves outcomes.

Defibrillation in Detail

Defibrillation is the single most effective intervention for VF and pulseless VT. Place one pad below the right clavicle and the other in the left mid-axillary line. Deliver 200 joules unsynchronized for the first two shocks, increasing to 360 joules if VF persists. Check the rhythm after each shock. Between shocks, perform uninterrupted CPR for one minute.

Advanced Drug Therapy

When initial CPR and shocks fail, drug therapy becomes crucial.

Adrenaline (Epinephrine): 1 mg IV every 3–5 minutes during resuscitation. If no IV is available, give via endotracheal tube in double dose, diluted in saline.

Amiodarone: 300 mg IV bolus for refractory VF/VT after the third shock, followed by 150 mg if needed. Maintenance infusion may follow return of circulation.

Lidocaine: Alternative to amiodarone if unavailable, 1 mg/kg IV, max 3 mg/kg.

Magnesium: 1–2 g IV in cases of torsades de pointes or hypomagnesemia.

Sodium Bicarbonate: 1 mEq/kg IV for prolonged arrest, hyperkalemia, or metabolic acidosis.

Correct drug administration improves rhythm control and may restore effective circulation when combined with defibrillation and CPR.

Non-shockable Rhythms

Cardiac arrest is not always due to VF or VT. Two non-shockable rhythms must also be managed appropriately:

Pulseless Electrical Activity (PEA): Electrical activity is present on the monitor but no pulse is detectable. Continue CPR, give adrenaline, and correct reversible causes (H’s and T’s).

Asystole: A flat line on ECG with no cardiac activity. CPR and adrenaline every 3 minutes are indicated, but prognosis is poor unless a reversible cause is rapidly corrected.

In both cases, defibrillation is not effective. The focus is on high-quality CPR, airway management, and identifying correctable factors.

The Importance of Timing and Teamwork

The best outcomes occur when CPR begins within 4 minutes of collapse and advanced interventions are initiated within 8 minutes. Effective teamwork is essential: one rescuer provides compressions, another manages airway, a third administers drugs, and a team leader coordinates. The use of checklists and clear communication reduces errors during these high-stress situations.

Conclusion

Emergency cardiac medicine is built upon the principle of structured action under pressure. The Primary and Secondary Survey approach—ABCD followed by ABCD—provides a reliable framework for managing cardiac emergencies. From airway clearance to defibrillation, from adrenaline to amiodarone, each step is designed to stabilize the patient and restore circulation. While not every cardiac arrest will end in survival, the systematic application of ACLS protocols dramatically improves outcomes and gives patients the best chance of recovery. In cardiac emergencies, time is heart muscle, and every second matters.

Cardiac Arrest, Emergency Medicine, ACLS, Resuscitation, Healthcare

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