Cardiovascular Emergencies

1. Cardiovascular Emergencies Chapter 12

2. 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

3. Blood Flow Through the Heart

4. Electrical System of the Heart

5. Coronary Arteries

6. Blood Flow

7. Blood

8. 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.

9. Atherosclerosis • Materials build up inside blood vessels. • This decreases or obstructs blood flow. • Risk factors place a person at risk.

10. 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

11. 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.

12. 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

13. 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

14. Sudden Death • 40% of AMI patients do not reach the hospital. • Heart may be twitching.

15. Arrhythmias • Bradycardia • Ventricular Tachycardia

16. Cardiogenic Shock • Heart lacks power to force blood through the circulatory system. • Onset may be immediate or not apparent for 24 hours after AMI.

17. 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.

18. 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?

19. Scene Size Up • Scene size-up • General impression • Is the patient responsive?

20. 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

21. 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

22. 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?

23. Focused History and Physical Exam • SAMPLE • OPQRST • Medications are important! • Medications often prescribed for CHF: • Furosemide • Digoxin • Amiodarone

24. Focused Physical Exam • Cardiac and respiratory systems • Look for skin changes. • Lung sounds • Baseline vital signs • BOTH systolic and diastolic BP readings

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

26. Aspirin • Administer according to local protocol. • Prevents clots from becoming bigger • Normal dosage is from 162 to 324 mg.

27. Nitroglycerin • Forms • Pill, spray, skin patch • Effects • Relaxes blood vessel walls • Dilates coronary arteries • Reduces workload of heart

28. Nitroglycerin Contraindications • Systolic blood pressure of less than 100 mmHg • Head injury • Maximum dose taken in past hour • Use of ED medications

29. 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

30. 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.

31. Detailed Physical Exam • Perform if time allows. • Do not gather information unless: • Patient’s condition is stable • Everything else is done

32. 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.

33. 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.

34. Heart Surgeries and Pacemakers • Coronary artery bypass graft (CABG) • Angioplasty • Cardiac pacemaker

35. 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.

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

37. Automated External Defibrillator (AED) • AEDs come in various models. • Some operator interaction required. • A specialized computer recognizes heart rhythms that require defibrillation.

38. Potential AED Problems • Battery is dead. • Patient is moving. • Patient is responsive and has a rapid pulse.

39. AED Advantages • ALS providers do not need to be on scene. • Remote, adhesive defibrillator pads are used. • Efficient transmission of electricity

40. Non-Shockable Rhythms • Asystole • Pulseless electrical activity

41. 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.

42. 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.

43. Medical Direction • Should approve protocols • Should review AED usage • Should review speed of defibrillation • Should provide review of skills every 3 to 6 months

44. 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.

45. 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.”

46. 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.

47. 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.

48. 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.

49. 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.

50. 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.