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Cardiovascular Emergencies. Chapter 12. Cardiovascular Emergencies. Cardiovascular disease (CVD) claimed 931,108 lives in the US during 2001. 2,551 per day Almost two people per minute! CVD accounts for 38.5% of all deaths. One of every 2.6 deaths. Blood Flow Through the Heart.

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Cardiovascular emergencies1
Cardiovascular Emergencies

  • Cardiovascular disease (CVD) claimed 931,108 lives in the US during 2001.

    • 2,551 per day

    • Almost two people per minute!

  • CVD accounts for 38.5% of all deaths.

    • One of every 2.6 deaths







Cardiac compromise
Cardiac Compromise

  • Chest pain results from ischemia

  • Ischemic heart disease involves decreased blood flow to the heart.

  • If blood flow is not restored, the tissue dies.


Atherosclerosis
Atherosclerosis

  • Materials build up inside blood vessels.

  • This decreases or obstructs blood flow.

  • Risk factors place a person at risk.


Angina pectoris
Angina Pectoris

  • Pain in chest that occurs when the heart does not receive enough oxygen

  • Typically crushing or squeezing pain

  • Rarely lasts longer than 15 minutes

  • Can be difficult to differentiate from heart attack


Heart attack
Heart Attack

  • Acute myocardial infarction (AMI)

  • Pain signals death of cells.

  • Opening the coronary artery within the first hour can prevent damage.

  • Immediate transport is essential.


Signs and symptoms
Signs and Symptoms

  • Sudden onset of weakness, nausea, sweating without obvious cause

  • Chest pain/discomfort

    • Often crushing or squeezing

    • Does not change with each breath

  • Pain in lower jaw, arms, back, abdomen, or neck

  • Sudden arrhythmia with syncope

  • Shortness of breath or dyspnea

  • Pulmonary edema

  • Sudden death


Pain of heart attack
Pain of Heart Attack

  • May or may not be caused by exertion

  • Does not resolve in a few minutes

  • Can last from 30 minutes to several hours

  • May not be relieved by rest or nitroglycerin


Sudden death
Sudden Death

  • 40% of AMI patients do not reach the hospital.

  • Heart may be twitching.


Arrhythmias
Arrhythmias

  • Bradycardia

  • Ventricular

    Tachycardia


Cardiogenic shock
Cardiogenic Shock

  • Heart lacks power to force blood through the circulatory system.

  • Onset may be immediate or not apparent for 24 hours after AMI.


Congestive heart failure
Congestive Heart Failure

  • CHF occurs when ventricles are damaged.

  • Heart tries to compensate.

  • Increased heart rate

  • Enlarged left ventricle

  • Fluid backs up into lungs or body as heart fails to pump.


You are the provider
You are the provider

  • You are a volunteer EMT-B in a rural area. You are dispatched to an older man complaining of severe chest pain.

  • ALS has been dispatched.

  • You arrive to find the patient clutching his chest. The pain is the worst he has ever had.

  • The patient has nitroglycerin but has not taken it yet.

  • What is wrong with this patient?

  • What must you know before administering any medication?

  • What must you specifically know before assisting a patient with nitroglycerin?


Scene size up
Scene Size Up

  • Scene size-up

  • General impression

    • Is the patient responsive?


Initial assessment
Initial assessment

  • Chief complaint on responsive patients

  • A chief complaint of chest discomfort, shortness of breath, or dizziness must be taken seriously.

  • Airway and breathing

  • Circulation


Transport decision
Transport Decision

  • Is the patient a life threat?

  • Stable patients

    • Transport in gentle manner.

    • Avoid lights and siren.

    • Do not let patient exert or strain self.

  • Specialty facilities


You are the provider1
You are the provider

  • You obtain a brief history while taking the patient’s blood pressure.

  • Your partner retrieves the nitroglycerin and obtains permission from medical control.

  • Your partner administers the nitroglycerin.

  • What else can you do at this time?


Focused history and physical exam
Focused History and Physical Exam

  • SAMPLE

  • OPQRST

  • Medications are important!

  • Medications often prescribed for CHF:

    • Furosemide

    • Digoxin

    • Amiodarone


Focused physical exam
Focused Physical Exam

  • Cardiac and respiratory systems

  • Look for skin changes.

  • Lung sounds

  • Baseline vital signs

    • BOTH systolic and diastolic BP readings


Communication
Communication

  • Relay history, vital signs, changes, medications, and treatments.


Aspirin
Aspirin

  • Administer according to local protocol.

  • Prevents clots from becoming bigger

  • Normal dosage is from 162 to 324 mg.


Nitroglycerin
Nitroglycerin

  • Forms

    • Pill, spray, skin patch

  • Effects

    • Relaxes blood vessel walls

    • Dilates coronary arteries

    • Reduces workload of heart


Nitroglycerin contraindications
Nitroglycerin Contraindications

  • Systolic blood pressure of less than 100 mmHg

  • Head injury

  • Maximum dose taken in past hour

  • Use of ED medications


Nitroglycerin potency
Nitroglycerin Potency

  • Nitroglycerin loses potency over time.

    • Especially if exposed to light

  • When nitroglycerin tablets lose potency:

    • May not feel the fizzing sensation

    • May not experience the burning sensation and headache

  • Fizzing only occurs with a potent tablet, not in the spray form


Assisting with nitroglycerin
Assisting With Nitroglycerin

  • Obtain order from medical direction.

  • Take patient’s blood pressure.

  • Check that you have right medication, patient, and delivery route.

  • Check expiration date.

  • Find out last dose taken and effects.

  • Be prepared to lay the patient down.

  • Administer tablet or spray under tongue.

  • Have patient keep mouth closed until tablet dissolves or is absorbed.

  • Recheck blood pressure.

  • Record each activity and time of application.

  • Reevaluate and note response.

  • May repeat dose in 3 to 5 minutes.


Detailed physical exam
Detailed Physical Exam

  • Perform if time allows.

  • Do not gather information unless:

    • Patient’s condition is stable

    • Everything else is done


Ongoing assessment
Ongoing Assessment

  • Repeat initial assessment.

  • Reassess vital signs every 5 minutes.

  • Monitor closely.

  • If cardiac arrest occurs, begin defibrillation or CPR immediately.

  • Record interventions, instructions from medical control, patient’s response.

  • Obtain medical control physician’s signature.


You are the provider2
You are the provider

  • ALS arrives and you report your interventions and vital signs.

  • ALS performs cardiac monitoring and prepares for morphine administration.

  • The patient’s pain is gone by the time you reach the hospital.


Heart surgeries and pacemakers
Heart Surgeries and Pacemakers

  • Coronary artery bypass graft (CABG)

  • Angioplasty

  • Cardiac pacemaker


Automatic implantable cardiac defibrillators
Automatic Implantable Cardiac Defibrillators

  • Maintains a regular heart rhythm and rate

  • Do not place AED patches over pacemaker.

  • Monitor heart rhythm and deliver shocks as needed.

  • Low electricity will not affect rescuers.


Cardiac arrest
Cardiac Arrest

  • The complete cessation of cardiac activity, either electrical, mechanical, or both.


Automated external defibrillator aed
Automated External Defibrillator (AED)

  • AEDs come in various models.

  • Some operator interaction required.

  • A specialized computer recognizes heart rhythms that require defibrillation.


Potential aed problems
Potential AED Problems

  • Battery is dead.

  • Patient is moving.

  • Patient is responsive and has a rapid pulse.


Aed advantages
AED Advantages

  • ALS providers do not need to be on scene.

  • Remote, adhesive defibrillator pads are used.

  • Efficient transmission of electricity


Non shockable rhythms
Non-Shockable Rhythms

  • Asystole

  • Pulseless electrical activity


Rationale for early defibrillation
Rationale for Early Defibrillation

  • Early defibrillation is the third link in the chain of survival.

  • A patient in ventricular fibrillation needs to be defibrillated within 2 minutes.


Aed maintenance
AED Maintenance

  • Read operator’s manual.

  • Check AED and battery at beginning of each shift.

  • Get a checklist from the manufacturer.

  • Report any failures to the manufacturer and the FDA.


Medical direction
Medical Direction

  • Should approve protocols

  • Should review AED usage

  • Should review speed of defibrillation

  • Should provide review of skills every 3 to 6 months


Preparation
Preparation

  • Make sure the electricity injures no one.

  • Do not defibrillate a patient lying in pooled water.

  • Dry a soaking wet patient’s chest first.

  • Do not defibrillate a patient who is touching metal.

  • Remove nitroglycerin patches.

  • Shave a hairy patient’s chest if needed.


Using an aed 1
Using an AED (1)

  • Assess responsiveness.

  • Stop CPR if in progress.

  • Check breathing and pulse.

  • If patient is unresponsive and not breathing adequately, give two slow ventilations.

  • If there is a delay in obtaining an AED, have your partner start or resume CPR.

  • If an AED is close at hand, prepare the AED pads.

  • Turn on the machine.

  • Remove clothing from the patient’s chest area. Apply pads to the chest.

  • Stop CPR.

  • State aloud, “Clear the patient.”


Using an aed 2
Using an AED (2)

  • Push the analyze button, if there is one.

  • Wait for the computer.

  • If shock is not needed, start CPR.

  • If shock is advised, make sure that no one is touching the patient.

  • Push the shock button.

  • After the shock is delivered, begin 5 cycles of CPR, beginning with chest compressions.

  • After 5 cycles, reanalyze patient’s rhythm.

  • If the machine advises a shock, clear the patient and push shock button.

  • If no shock advised, check for pulse.

  • If the patient has a pulse, check breathing.

  • If the patient is breathing adequately, provide oxygen via nonrebreathing mask and transport.


Using an aed 3
Using an AED (3)

  • If the patient is not breathing adequately, use necessary airway adjuncts and proper positioning to open airway.

  • Provide artificial ventilations with high-concentration oxygen.

  • Transport.

  • If the patient has no pulse, perform 2 minutes of CPR.

  • Gather additional information on the arrest event.

  • After 2 minutes of CPR, make sure no one is touching the patient.

  • Push the analyze button again (as applicable).

  • If necessary, repeat alternating CPR/Analyze/Shock until ALS arrives.

  • Transport and check with medical control.

  • Continue to support the patient as needed.


After aed shocks
After AED Shocks

  • Check pulse.

  • No pulse, no shock advised

  • No pulse, shock advised

  • If a patient is breathing independently:

    • Administer oxygen.

    • Check pulse.

  • If a patient has a pulse but breathing is inadequate, assist ventilations.


Transport considerations
Transport Considerations

  • Transport:

    • When patient regains pulse

    • After delivering six to nine shocks

    • After receiving three consecutive “no shock advised” messages

  • Keep AED attached.

  • Check pulse frequently.

  • Stop ambulance to use an AED.


Cardiac arrest during transport
Cardiac Arrest During Transport

  • Check unconscious patient’s pulse every 30 seconds.

  • If pulse is not present:

    • Stop the vehicle.

    • Perform CPR until AED is available.

    • Analyze rhythm.

    • Deliver shock(s).

    • Continue resuscitation according to local protocol.

  • If patient becomes unconscious during transport:

    • Check pulse.

    • Stop the vehicle.

    • Perform CPR until AED is available.

    • Analyze rhythm.

    • Deliver up to three shocks.

    • Continue resuscitation according to local protocol.


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