Cardiovascular Emergencies

1. Cardiovascular Emergencies …time is myocardium!

2. Statistics • Cardiovascular disease (CVD) claimed over 1 million lives in 2004. • CVD has been the leading cause of death for Americans since 1900. • Sudden cardiac death accounts for over 40% of these deaths. • The majority of our 911 responses are for chest pain.

3. Controllable Risk Factors Smoking High blood pressure Elevated cholesterol levels Elevated blood glucose levels Diet Lack of exercise Stress

4. Uncontrollable Risk Factors Age Family history Race Sex

5. Anatomy

6. Circulation

7. Blood • Red blood cells: • Carries oxygen to tissues and cells • Removes CO2 and waste • White blood cells: • Fight infection • Platelets: • Helps blood clot

8. Electrical System

9. Coronary Arteries

10. 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 (infarct). • Injury leads to inadequate heart function and death.

11. Atherosclerosis

12. So… …you are dispatched to a 67 year- old male c/o 9/10 “crushing” chest pressure that radiates to his jaw. He is also complaining of shortness of breath and nausea, with no previous cardiac history…

13. …what are YOU thinking?

14. Chest Pain Pathophysiology • Mediastinum: • Angina: stable or unstable • AMI • Esophagitis, esophageal rupture • Pericarditis • Mediastinal air • Thoracic dissection • Mitral valve prolapse

15. Chest Pain Pathophysiology • Chest Wall: • Traumatic contusion/tamponade • Cysts and infections • Rib cartilage inflammation • Shingles (Herpes Zoster) • Muscle strain, overuse syndromes

16. Chest Pain Pathophysiology • Lungs and pleura: • Pleurisy • Pneumonia • Pneumothorax, hemothorax • Pulmonary embolus • Asthma, bronchitis, URI

17. Chest Pain Pathophysiology • Abdomen: • Gallbladder (cholecystitis, stones) • Stomach (gastritis, GERD, perforated peptic ulcer) • Pancreas (pancreatitis) • Esophagitis, perforation

18. Chest Pain • Psychogenic: • Stress • Hyperventilation • Anxiety and panic attacks

19. Classic Symptoms • Pressure, fullness, heaviness, squeezing pain in center of chest with radiation • Diaphoresis • Nausea • Shortness of breath • Weakness

20. Frequency of Symptoms • Diaphoresis 78% • Chest pain 64% • Nausea 52% • Shortness of breath 47% • No signs/symptoms 25% N Engl J Med 1984;311:1144-7

21. Atypical Presentations • Common in the elderly, diabetics, and females: • Unusual fatigue • Sudden onset of unusual shortness of breath • Nausea, dizziness • Belching, burping, indigestion • Palpitations, new dysrhythmia • Pain only in jaw, neck, back, arm

22. All chest pain is considered to be an AMI until proven otherwise!

23. Angina Pectoris • Chest pain caused when heart tissues do not get enough oxygen for a brief period of time. • Typically crushing or squeezing. • Onset with the 3-E’s. • Usually resolves with rest or meds. • May be difficult to diagnose from AMI

24. Angina

25. Acute Coronary Syndrome Used to describe the range of conditions from unstable angina to AMI. Signs and symptoms usually caused by acute myocardial ischemia.

26. ACS Signs & Symptoms • Shortness of breath • Signs of inadequate perfusion • Chest pain, pressure, or discomfort (with or without radiation to back, neck, jaw, arm, wrists) • Nausea • Weakness/syncope • Dysrhythmias

27. Acute Myocardial Infarct Usually caused by the same mechanism as angina only with resulting tissue death. Time is myocardium: Consequences can be serious: Congestive heart failure Cardiogenic shock Sudden death

28. AMI

29. Cardiogenic Shock Heart lacks power to force blood through the circulatory system. Brought on when 40% of left ventricle is infarcted. Onset may be immediate or not apparent for 24 hours.

30. Signs & Symptoms • Altered LOC • Rapid, shallow breathing • Restlessness and anxiousness • Pale, cool skin • Tachycardia/dysrhythmia • Hypotension

31. Congestive Heart Failure Occurs when the ventricles are damaged. Heart tries to compensate with increased heart rate. Enlarged, ineffective left ventricle Fluid builds up into lungs or body as “pump” fails.

32. CHF

33. Signs & Symptoms • Fatigue • Cough with pink, frothy sputum • Dypsnea, tachypnea • Pulmonary edema • Agitation and confusion • Hypertension • Pedal edema, ascities

34. Signs & Symptoms

35. Thoracic Dissection

36. Aortic Aneurysm

37. Signs & Symptoms • Sudden and severe chest or upper back discomfort. “Pain shoots to the shoulder blades.” • Anxiety • Diaphoresis • Nausea

38. Cardiac Tamponade • Trauma induced, filling of the pericardial sac with blood. • Signs of shock • JVD • Decrease pulse pressures

39. Esophageal Rupture • Usually underlying alcohol abuse. • Shock signs. • Coughing up bright red blood.

40. Pericarditis • Inflammation of the pericardium caused by infection. • Usually presents as sharp discomfort. • Changes with breathing and movement.

41. Chest Pain Assessment BSI/Scene Safety Initial Assessment (Sick/Not Sick) Focused Exam Detailed Exam Assessment Treatment and Plan

42. Initial Assessment • 60second clinical picture to determine if Sick or Not Sick (Oxygen) • Based upon your initial impression: • Body position • skin signs and color • respiratory rate and effort • mental status • pulse rate and character • Correct immediate life threats!

43. Focused Exam (S) Your subjective findings are based upon what the patient or historian tells you: Patient Age Sex Chief Complaint

44. Focused Exam (S) SAMPLE History • Signs/Symptoms (associated with cardiac chest pain): • Diaphoresis (78%) • Shortness of Breath (47%) • Pain/discomfort (64%) • Nausea/vomiting (52%) • No signs or symptoms (25%) N Eng Journal Med 1984;311:11444-7

45. Focused Exam (S) • Onset – “When and at what time did it start” • Provocation – “Does anything make it better or worse?” “Does it change with position, palpitation, inspiration?” • Quality – “Describe the pain/discomfort in your own words”

46. Focused Exam (S) • Region/Radiation – “Where does it start?” “Does it radiate anywhere?” • Severity – “On a scale of 1 to 10, what was the pain/discomfort at onset?” “What is the pain/discomfort at now?’ • Time – “When did this episode start?” “How long has it been going on?”

47. Focused Exam (S) • Allergies • Medications – Cardiac meds = cardiac problems. Ask about OTC meds, natural supplements, vitamins? • Past Medical History – “Do you have any cardiac history?” “Risk factors such as smoking, diabetes, HTN, weight/diet?””

48. Focused Exam (S) • Last Oral Intake • Events Leading to Call – “What were you doing when this event started?” Think activity induce vs. non activity

49. Listen to the patient… …they will tell you exactly what is wrong!

50. Focused Exam (O) Objective findings from your physical exam of the patient. • Look for evidence of trauma/injury • Evaluate: • Level of consciousness • Skin color and temperature • Respiratory rate and effort • Pupillary reaction • Pulse rate • Blood pressure (bilateral for chest pain!)