Download Mosby`s EMT-Basic Textbook

Chapter 18
Cardiovascular Emergencies
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 1
Case History
You respond to a nursing home for a “heart attack.”
On arrival, you find a 64-year-old female complaining
of “crushing” chest pain and shortness of breath for
the last 40 minutes. The patient tells you that she has
had two heart attacks in the past and the pain is now
similar.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 2
Sudden Cardiac Death

Heart disease is #1 cause of
death in U.S.

340,000 prehospital deaths
annually


EMS cannot save all victims.
The community is the “ultimate
coronary care unit” for sudden
death.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 3
Ventricular Fibrillation



Most common rhythm of sudden death
Can only be treated with electric shock
Early defibrillation is critical
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 4
AED and the Chain of Survival




Early access
Early CPR
Early defibrillation
Early ACLS
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 5
Role of EMT-B in
Cardiovascular Emergencies







Administer oxygen.
Assist with the administration of
nitroglycerin.
Perform CPR.
Provide early defibrillation.
Request ALS assistance, as needed.
Provide prompt transportation.
Communicate assessment findings to
hospital.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 6
Review of Anatomy and
Physiology
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 7
Chambers of the Heart and
Conduction System
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 8
Systemic and Pulmonary
Circulation
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 9
Cardiac Output

Stroke volume  heart rate

Either parameter can increase or decrease cardiac
output.

Varies with activity and other factors
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 10
Blood Pressure

Measured in every patient > 3 years old

Pressure exerted on the walls of arteries

Cardiac output  resistance of vessels

Contributing factors

Force of contraction
 Heart rate
 Status of blood vessels
(dilated vs. constricted)
 Blood volume
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 11
Inadequate Circulation –
Shock


Shock (hypoperfusion)
Signs and symptoms





Pale, cyanotic, cool clammy skin
Rapid, weak pulse
Rapid and shallow breathing
Restlessness, anxiety, or mental
dullness
Nausea and vomiting
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 12
Arteriosclerosis

Narrowing of the arteries

Caused by buildup of fatty
deposits and plaque

Less blood can flow.

First signs of disease may
occur with physical exertion
or stress.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 13
Myocardial Oxygen Supply
and Demand

Normally oxygen supply via coronary arteries meets demand.

Mismatch occurs when increased demand is not met by an
increase in blood supply.
 May be due to narrowed coronary arteries
 Angina pectoris

Problem can be addressed in two ways.


Decrease demand (rest, nitroglycerin)
Increase supply (oxygen, nitroglycerin)
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 14
Angina Pectoris

Chest pain

Commonly caused by
increased oxygen demands
on the heart

Stress
 Exertion
 Exercise

Relieved by rest and
nitroglycerin
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 15
Myocardial Ischemia and
Infarction

Ischemia


Myocardial ischemia


State of decreased blood flow to
tissues
Not enough blood flow to meet the
oxygen needs of the myocardium
Myocardial infarction

Necrosis or death of heart cells
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 16
Ischemic Chest Pain

Center of the chest

May radiate to the neck, jaw,
or arms

Patients may complain of
abdominal pain or indigestion.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 17
Ischemic Heart Disease
Signs and Symptoms

Sudden onset of sweating

Difficulty breathing (dyspnea)

Anxiety, irritability

Loss of consciousness
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 18
Cardiac Compromise
Signs and Symptoms



Feeling of impending
doom

Palpitations

Lightheadedness

Weakness

Dizziness
Epigastric pain
Nausea/vomiting
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 19
Initial Assessment

Identify need for priority care.

Identify life-threatening conditions.

Chest pain patient with altered mental status
 Consider impending cardiac arrest.
 Have CPR equipment and AED available.

Patients with chest pain may prefer sitting position.

Patients with altered mental status should be placed in supine position.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 20
Initial Assessment

Consider need for oxygen, airway,
and ventilation.



Nonrebreather
Positive-pressure ventilation
Check for signs of poor perfusion.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 21
SAMPLE History






Signs and symptoms
Allergies
Medications
Past medical history
Last oral intake
Events surrounding the
chief complaint
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 22
Important Questions






Onset
Provocation
Quality
Radiation
Severity
Time
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 23
Focused Physical Exam

Patient may deny symptoms.

Make every attempt to convince the
patient to seek help.

Altered mental status may be caused by
low cardiac output.

Examine neck veins and accessory
muscles.

Check breath sounds.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 24
Baseline Vital Signs

A range of vital signs are possible

Normal vital signs
 Abnormal pulses related to arrhythmias
 Hypotension and other signs of
hypoperfusion
 Cardiac arrest

Preexisting medical conditions may alter
vitals signs (e.g., hypertension)
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 25
Emergency Care of
Responsive Cardiac Patient

Perform the initial assessment.

Ensure an open airway and consider the need for:



Manual maneuvers (head tilt/chin lift, jaw thrust)
An oropharyngeal or nasopharyngeal airway
Suction
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 26
Emergency Care of
Responsive Cardiac Patient

Evaluate the adequacy of breathing and consider need
for positive-pressure ventilation.

Administer supplemental oxygen.

Reduce activity and anxiety.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 27
Emergency Care of
Responsive Cardiac Patient

Carry the patient to the ambulance in a
position of comfort.

Prioritize transport.

Consider administration of nitroglycerin.

Perform ongoing assessment en route to
the hospital.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 28
Nitroglycerin

Generic name


Nitroglycerin
Trade name

Nitrostat™
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 29
Indications and
Contraindications

Indications



Patient exhibits signs and symptoms of chest pain.
Has physician prescribed sublingual tablets?
• Specific authorization by medical direction
Contraindications




Blood pressure < 100 mm Hg systolic
Head injury
Infants and children
Patient has already met maximum prescribed dose.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 30
Actions and Side Effects

Actions



Relaxes blood vessels
Decreases workload of heart
Side effects



Hypotension
Headache
Pulse rate changes
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 31
Nitroglycerin

BP > 100 systolic

Administer one dose.
 Repeat in 3-5 minutes, if no relief.
 Give up to a maximum of three doses.
 Reassess after each dose.

BP < 100 systolic or no NTG


Continue focused assessment.
Transport promptly.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 32
Administering Nitroglycerin

Perform a focused assessment of
the cardiac patient.

Take blood pressure (must be >100
mm Hg).

Question the patient regarding
administration of the last dose.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 33
Administering Nitroglycerin

Ensure that patient understands the route
of administration.

Contact medical direction.

Ensure right patient, right medication, right
dose, right route.

Ensure medication is not expired.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 34
Administering Nitroglycerin

Place tablet or spray under the
tongue.

Recheck blood pressure within 2
minutes.

Record activity and times.

Perform reassessment.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 35
Reassessment Strategies

Monitor blood pressure.

Ask patient about effect on
pain relief.

Seek medical direction
before readministering.

Record reassessments.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 36
Summary of Management of
Patients with Chest Pain

Place in the position of comfort.

Administer oxygen.

Assist with prescribed nitroglycerin.

May be repeated every 3-5 minutes up to
a total of three doses.

If the systolic BP >100 mm Hg
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 37
Heart Failure

Condition resulting from a
damaged or weak heart
muscle

Caused by severe myocardial
infarctions, chronic
hypertension, and/or other
causes
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 38
Heart Failure

Left-sided





Backup in lungs
Pulmonary edema
Dyspnea
Accessory muscle use
Rales on auscultation
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 39
Heart Failure

Right-sided


Backup in systemic
circulation
Swelling of body tissues
• Ankles, sacrum,
abdomen
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 40
Cardiac Arrest Management
Skills of the EMT-Basic

One- and two-rescuer CPR

Use of AED

Request for ALS backup when
appropriate

Use of BVM or mouth-to-mask with
oxygen attached

Use of flow-restricted, oxygen-powered
ventilatory devices
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 41
Cardiac Arrest Management
Skills of the EMT-Basic

Lifting and moving patients

Suctioning airways

Use of airway adjuncts

Use of BSI

History and physical assessment
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 42
Rationale for Early
Defibrillation

Ventricular fibrillation is the most common initial rhythm of
cardiac arrest.

Defibrillation is the only effective treatment of ventricular
fibrillation.

EMS systems have demonstrated increased survival through
early defibrillation programs.

Survival is associated with implementation of the chain of
survival.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 43
Time and AEDs




Survival rate is approximately 50% after 5 minutes.
Survival reduced by 7% to 10% each minute.
Rapid defibrillation is key.
CPR helps extend survival time.
100
80
60
Survival
40
20
0
1
min.
3
min.
6
min.
10
min.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 44
Patient Age and Use of AED

Medical patient >8 years old

CPR
 AED with adult pads

Medical patient 1-8 years old

CPR
 AED with pediatric pads

Consider transport or ALS intercept
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 45
AED Analysis of Cardiac
Rhythms

Microprocessor confirms rhythms for which a shock is indicated.



Analysis is dependent on properly charged defibrillator batteries.
Inappropriate delivery of shocks



Accuracy is high.
Human error, mechanical error
Ventricular tachycardia
Attach defibrillator only to unresponsive, pulseless, nonbreathing
patients.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 46
Interruption of CPR

Do not touch patient during
analysis and shocks.

Resume CPR immediately after
every shock.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 47
Advantages of AEDs

Initial training and continuing education

Speed of operation

First shock can be delivered within 1 minute of arrival at the
patient’s side.

Remote defibrillation through adhesive pads

Rhythm monitoring

Option on some defibrillator models
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 48
If AED Advises No Shock

Perform CPR for 5 cycles.

If patient is awake and breathing
adequately



Give high-concentration oxygen.
Transport.
If patient is awake and not breathing
adequately


Artificially ventilate with high-concentration
oxygen.
Transport.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 49
Standard Operational
Procedures

Defibrillation comes first
when a collapse occurs
in your presence.

Do not do anything that
delays analysis.

EMT must be familiar
with device.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 50
Standard Operational
Procedures


Patient contact must be avoided
during analysis.
State “Clear the patient” before
delivering shocks.

Check batteries at beginning of
shift.

Carry extra batteries.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 51
Recurrent Ventricular
Fibrillation

If patient wakes up after shocks:

Check pulse frequently.

If pulse is not present:





Stop vehicle.
Start CPR, if defibrillator is not immediately ready.
Analyze rhythm.
Deliver shock, if indicated.
Continue resuscitation per protocol.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 52
Conscious Patient
Becomes Pulseless and Apneic

Stop vehicle.

Start CPR if defibrillator is not immediately ready.

Attach AED, analyze rhythm.

Deliver shock.

Continue resuscitation per protocol.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 53
No Shock Message

Start or resume CPR.

Analyze rhythm.

After 5 cycles of CPR
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 54
Coordination with ALS Personnel

EMS system design establishes protocols.

AED usage does not require ALS on scene.

ALS should be notified as soon as possible.

Transport vs. await ALS per local protocols.

Safety considerations
Water – rain
 Metal

Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 55
Postresuscitation Care

Manage airway.

Assess need for ventilation.

Consider ALS backup.

Keep AED attached to patient en route.

Perform focused assessment and reassessment en route.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 56
Defibrillator Maintenance

Regular maintenance for defibrillators

Daily operators shift checklist

Defibrillator failure



Improper device maintenance
Battery failure
Ensure proper battery maintenance and battery replacement
schedules.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 57
Medical Direction

Medical direction is essential part of AED program.

AED event must be reviewed by the medical director.

Reviews of events

Written report
 Review of voice-ECG tape recorders
 Solid-state memory modules
 Magnetic tape recordings stored in device

Quality improvement
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 58
Cardiac Arrest

Caused by heart rhythms that result in no blood flow




Asystole
Pulseless electrical activity
Ventricular fibrillation/ventricular tachycardia
Ventricular fibrillation is a useless quivering of the heart.


Results in no blood flow
Defibrillation is only effective treatment.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 59
AED

Computerized device that can
recognize shockable vs.
nonshockable heart rhythms

Advises operator to deliver an
electric shock when appropriate
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 60
AED Operation: 4 Steps
1. Turn on the device.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 61
AED Operation: 4 Steps
2. Attach the electrode pads.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 62
AED Operation: 4 Steps
3. Clear the patient and allow the device to analyze.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 63
AED Operation: 4 Steps
4. When advised, clear the patient and push the shock
button.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 64
AED Electrode Pads

Right pad




Right upper chest
Below the clavicle
Right border of the
sternum
Left pad


Left chest
2 to 3 inches below the
armpit
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 65