Download Chapter 17

MASTER TEACHING NOTES
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Detailed Lesson Plan
Chapter 17
Cardiovascular Emergencies
270–300 minutes
Case Study Discussion
Teaching Tips
Discussion Questions
Class Activities
Media Links
Knowledge Application
Critical Thinking Discussion
Chapter 17 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
I.
5
Master Teaching Notes
Introduction
Case Study Discussion
A. During this lesson, students will learn about assessment and emergency
care for a patient suffering from cardiovascular emergencies such as chest
discomfort or pain and cardiac arrest.
B. Case Study
1. Present The Dispatch and Upon Arrival information from the chapter.
2. Discuss with students how they would proceed.
II. Review of the Circulatory System Anatomy and Physiology—The
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Circulatory System
A. Circulatory system—Heart, blood vessels, and blood
B. Conduction system
1. Heart contains conductive tissue or cells.
a. Conductive cells are grouped in three areas of the heart, or
pacemaker sites
i. Sinoatrial (SA) node
ii. Atrioventricular (AV) node
iii. Purkinje fibers or network
b. Heart’s electrical impulses travel through the heart from the
pacemaker site via a conduction pathway that is comprised of cells
that rapidly conduct each impulse to the rest of the heart.
2. Heart contains contractile tissue or cells.
a. Primary purpose is to contract in response to the electrical impulses
provided by the conduction system.
b. Characteristics of both smooth and skeletal muscle
3. The autonomic nervous system (sympathetic and parasympathetic)
monitors the heart’s activity and modifies it as necessary to ensure the
heart performs its sole purpose—pumping blood—effectively.
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 17

What is your general impression of the
patient?
 What questions should you ask the
patient to find out more about what is
going on?
Teaching Tip
An anatomical model of the heart will be
helpful in explaining the concepts of this
section.
Discussion Question
How do the sympathetic and
parasympathetic nervous systems influence
the heart?
PAGE 1
Chapter 17 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
C. Heart
1. Made up of atria (top two chambers) and ventricles (bottom two
chambers)
2. Right atrium receives deoxygenated blood from the inferior and superior
venae cavae.
3. Blood then travels through the tricuspid valve and into the right ventricle.
4. Deoxygenated blood is then ejected through the pulmonic semilunar
valve and into the pulmonary arteries.
5. After the blood is oxygenated in the alveoli of the lungs, it returns to the
left atrium via the pulmonary veins and is ejected through the mitral
valve into the left ventricle.
6. Then the blood is ejected through the aortic semilunar valve and into the
aorta before it is distributed throughout the body.
7. Failure of the right ventricle is known as right ventricular heart failure
(cor pulmonale), and failure of the left ventricle is known as left-sided
ventricular failure (congestive heart failure).
8. Pulmonary edema is a condition resulting from a severe gas exchange
problem caused when the left ventricle cannot eject blood effectively.
D. Vessels
1. Arteries carry oxygenated blood to the arterioles and then to the
capillaries.
2. Veins carry deoxygenated blood from the capillaries and to the right
ventricle through the inferior and superior vena cava. (Exception is
pulmonary veins which carry oxygenated blood from the lungs).
3. Coronary arteries are the first two arties to originate off the aorta, supply
the heart with oxygenated blood, and are associated with many cardiac
emergencies.
E. Blood
1. Liquid portion, or serum, serves as the transport medium for the formed
elements.
2. Red blood cells carry oxygen to the tissues of the body.
3. White blood cells serve to protect the body and eliminate infections from
viruses or bacteria.
4. Platelets are old fragments of destroyed red blood cells whose job is to
help with the clotting process to stop bleeding.
5. Platelets, thrombin, and fibrin all help to form a clot, or thrombus.
6. A thrombus may form where plaque has built up and ruptured, partially
or completely occluding the coronary artery and cutting off or reducing
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 17
Critical Thinking Discussion
What are the consequences of the heart
working against chronically increased
resistance?
Discussion Question
How can a coronary artery become
blocked?
PAGE 2
Chapter 17 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
the oxygenated blood to the heart muscle.
F. Cardiac contraction
1. Heart’s electrical impulse is first generated in the sinoatrial (SA) node.
2. It travels through the Bachman’s bundle, and both atria contract
simultaneously as a result of the electrical impulse (atrial systole),
ejecting blood into the ventricles.
3. Impulse then travels to the atrioventricular node (AV) by way of the
intranodal tract. The impulse is briefly inhibited to allow blood to fill the
ventricles.
4. Then the impulse travels down the bundle of His, to the left and right
ventricles, to the Purkinje fibers (ventricular systole). Blood from the right
ventricle is propelled toward the lungs, and blood from the left ventricle
is propelled throughout the body.
5. After the systolic phases, the diastolic phase allows the heart cells to
repolarize and await the next impulse.
6. Occluded arteries may lead to dysrhythmias and possibly sudden death.
Discussion Question
Describe the conduction of an impulse from
the SA node through the heart.
III. Review of the Circulatory System Anatomy and Physiology—The
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Electrocardiogram
A. The electrocardiogram (ECG or EKG) is a graphic representation of the
heart’s electrical activity as detected from the chest wall surface.
B. Depolarization is when electrical charges of the heart muscle change from
positive to negative and cause heart muscle contraction.
C. Repolarization is when the electrical charges of the heart muscle return to a
positive charge and cause relaxation of the heart muscle.
D. Waves, or deflections, of a normal ECG
1. P wave—First wave form of the ECG and represent depolarization of the
atria
2. QRS complex—Second wave form and represents the depolarization of
the ventricles and main contraction of the heart
3. T wave—Third wave form and represents the repolarization of the
ventricles
E. PRI represents the time it takes the heart’s electrical impulse to travel from
the atria to the ventricles.
F. Normal electrical activity is called normal sinus rhythm (peaks that occur
between 60 and 100 times each minute, separated by nearly flat lines.
G. Premature ventricular complexes (PVCs) in succession may produce
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 17
Discussion Question
What do the p, qrs, and t waves represent
on the ECG?
Animation
Go to www.bradybooks.com and click on
the mykit link for Prehospital Emergency
Care, 9th edition to access an animation
PAGE 3
Chapter 17 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
ventricular tachycardia (V-Tach) and degenerate into ventricular fibrillation
(V-Fib).
reviewing some cardiac rhythms.
IV. Review of the Circulatory System Anatomy and Physiology—Blood
5
Pressure
A. Blood pressure is defined as the amount of pressure exerted against the
arterial wall during circulation.
B. Systolic blood pressure is the measured force exerted during the contraction
of the heart.
C. Diastolic blood pressure is the pressure inside the artery when there is no
contraction.
D. Vasoconstriction increases vessel resistance and blood pressure, and
vasodilation causes resistance to decrease and the pressure to fall.
V. Review of the Circulatory System Anatomy and Physiology—
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Inadequate Circulation
A. Perfusion is the delivery of oxygen and nutrients from the blood through the
thin capillary walls into the cells and the removal of carbon dioxide and other
wastes.
B. Hypoperfusion (shock), or a profound depression of cell perfusion, results
from inadequate circulation.
1. Hypovolemia
2. Heart failure
3. Vasodilation (leaking)
VI. Cardiac Compromise and Acute Coronary Syndrome (ACS)—
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Atherosclerosis
A. It is important for the EMT to recognize the signs and symptoms of the many
possible cardiac conditions, referred to collectively as cardiac compromise.
B. EMT should also provide emergency care and expeditious transport to a
medical facility that is prepared to manage such a condition (fibrinolytics,
antiplatelet agents, angioplasty).
C. Arteriosclerosis is a condition that causes the smallest of arterial structures
to become stiff and less elastic.
D. Atherosclerosis, a type of arteriosclerosis, is an inflammatory disease that
starts with the intimal lining of the blood vessels, where endothelial cells
become damaged. This eventually leads to fibrous caps that attempt to close
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 17
Class Activity
To reinforce important concepts, ask
students to write down questions they
predict will be on their next examination or
quiz. Also have them write their answer to
the questions. You can use these questions
to assess whether or not students are
focusing on important concepts, and you
may get some ideas for quiz questions.
PAGE 4
Chapter 17 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
off the fatty streaks created by different cells responding to the irritated and
inflamed blood vessels. These fibrous caps may rupture and possibly lead to
a thrombus occluding the blood vessel.
E. When a patient has a build up of fatty deposits (atherosclerosis) on the
inside of the coronary arteries, the condition is called coronary artery
disease (CAD).
VII. Cardiac Compromise and Acute Coronary Syndrome (ACS)—Acute
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Coronary Syndrome
A. Acute coronary syndrome (ACS) results from any of a variety of conditions
that can affect the heart in which the coronary arteries are narrowed or
occluded by fat deposits (plaque), clots, or spasms.
1. Unstable angina
2. Myocardial infarction
3. Cardiac cell hypoxia (myocardial ischemia) results when heart muscle is
not receiving an adequate amount of oxygenated blood.
a. Typical response is chest discomfort.
b. Patient describes as crushing chest pressure that is dull and aching.
B. Angina pectoris
1. Pathophysiology
a. Symptom of inadequate oxygen supply to the heart muscle, or
myocardium
b. Generally occurs during periods of physical or emotional stress
c. Lasts about two to 15 minutes
2. Assessment—Signs and symptoms
a. Steady discomfort in center of chest
b. Discomfort usually described as pressure, tightness, aching,
crushing, or heavy
c. Discomfort that radiates to shoulders, arms, neck, jaw, back, or
epigastric region.
d. Cool, clammy skin
e. Anxiety
f. Dyspnea
g. Diaphoresis
h. Nausea and/or vomiting
i. Complaint of indigestion pain
j. Possible unusual presentation for women, diabetics, or elderly
3. Emergency medical care
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 17
Teaching Tip
Provide examples from your experience to
illustrate atypical presentations of ACS.
Video Clip
Go to www.bradybooks.com and click on
the mykit link for Prehospital Emergency
Care, 9th edition to access a video on
coronary heart disease.
Discussion Question
What is the pathophysiology of angina
pectoris?
Animations
Go to www.bradybooks.com and click on
the mykit link for Prehospital Emergency
Care, 9th edition to access animations
reviewing coronary artery disease, angina
pectoris, and nitroglycerin.
PAGE 5
Chapter 17 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
a. Recognize acute coronary syndrome emergency versus classic
angina (length of time; worsening pain).
b. Establish an open and patent airway.
c. Provide oxygen via nonrebreather mask at 15 lpm.
d. Provide positive pressure ventilation, if necessary.
e. Apply the pulse oximeter.
f. Administer nitroglycerin if patient has prescription and cleared by
medical direction.
g. Administer 160–325 of aspirin if you suspect coronary artery
occlusion and protocol allows it.
h. Consider ALS and continue to perform reassessment.
C. Acute myocardial infarction (heart attack)
1. Pathophysiology
a. Occurs when a portion of the heart muscle dies because of the lack
of an adequate supply of oxygenated blood.
b. Result of coronary artery disease that causes severe narrowing or
complete blockage of the coronary arteries
c. Rarely a heart attack occurs from a spasm of the coronary artery.
d. Heart muscle becomes ischemic and tissue becomes irritable,
producing abnormal beats which could lead to possibly fatal
dysrhythmias.
2. Assessment—Signs and symptoms
a. Symptoms similar to angina but last longer
b. Chest discomfort radiating to jaw, arms, shoulders, or back
c. Anxiety
d. Dyspnea
e. Sense of impending doom
f. Diaphoresis
g. Nausea and/or vomiting
h. Lightheadedness or dizziness
i. Weakness
j. Possibly atypical presentation for diabetics, elderly, or women
3. Emergency medical care
a. Rapidly proceed with management
b. Keep vigilant eye on patient since he has the potential to go into
cardiac arrest.
c. Ensure a patient airway and provide positive pressure ventilation
with oxygen.
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 17
Critical Thinking Discussion
Is it necessary to differentiate between
angina pectoris and myocardial infarction in
the prehospital setting?
Video Clip
Go to www.bradybooks.com and click on
the mykit link for Prehospital Emergency
Care, 9th edition to access a video on
myocardial infarctions.
Weblinks
Go to www.bradybooks.com and click on
the mykit link for Prehospital Emergency
Care, 9th edition to access web resources
on acute myocardial infarction and
American Heart Association heart attack
information.
PAGE 6
Chapter 17 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
d. If respiratory rate and tidal volume are adequate, apply a
nonrebreather mask at 15 lpm.
e. Apply a pulse oximeter if available.
f. Place the patient in a position of comfort.
g. Administer nitroglycerin if patient has prescription.
h. If protocol allows, administer 160–325 mg of aspirin.
i. Notify hospital early if suspected MI.
j. Contact ALS and continue to reassess.
D. Aortic aneurysm or dissection
1. Aortic aneurysm occurs when a weakened section of the aortic wall,
usually resulting from atherosclerosis, begins to dilate or balloon
outward from the pressure exerted by the blood flowing through the
vessel.
a. May occur for a long time without symptoms or signs
b. Most often occurs in the abdominal region
c. Administer oxygen and transport immediately.
2. Aortic dissection occurs when there is a tear in the inner lining of the
aorta and blood enters the opening and causes separation of the layers
of the aortic wall.
a. Most often occurs in the thorax
b. Pain is described as “sharp”, “tearing”, or “ripping”.
c. May lead to myocardial infarction
d. Administer oxygen and assist the patient with prescribed
nitroglycerin if the blood pressure is greater than 90 mmHg and no
signs of hypovolemia.
e. Do not administer aspirin.
E. Acute coronary syndrome in females
1. Coronary heart disease in females is now the single largest cause of
death of females in the United States.
2. “Classical” findings for females suffering from a cardiac ischemia or
infarction
a. Dull substernal chest pain or discomfort
b. Respiratory distress
c. Nausea, vomiting
d. Diaphoresis
3. “Nonclassical” or “atypical” findings for females suffering from a cardiac
ischemia or infarction
a. Neck ache
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 17
Discussion Question
What is the difference between an aortic
aneurysm and aortic dissection?
Discussion Questions


What are signs and symptoms of ACS?
What are the treatments provided for
patients with ACS?
PAGE 7
Chapter 17 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
b. Pressure in the chest
c. Pains in the back, breast, or upper abdomen
d. Tingling of the fingers
e. Unexplained fatigue or weight gain (water weight gain)
f. Insomnia
4. Since the death rate for females who suffer heart attacks is higher than
males when the event occurs, have a high index of suspicion of ACS
when gathering a history from the female patient.
5. Note that diabetics and the elderly are also high-risk groups that may
present with atypical findings.
VIII. Cardiac Compromise and Acute Coronary Syndrome (ACS)—Other
65
Causes of Cardiac Compromise
A. Heart failure
1. Pathophysiology
a. Occurs when the heart no longer has the ability to adequately eject
blood out of the ventricle
b. Caused by heart attack, valve disorder, hypertension, pulmonary
embolism, and certain drugs
c. Can be left ventricular failure or right ventricular failure
i. Left ventricular failure causes reduced blood flow to the arteries
and perfusion to the cells and causes increased blood pressure
in the left atrium which ultimately leads to pulmonary edema.
ii. Right ventricular failure causes blood to back up into the venous
system and may be caused the left ventricular failure,
hypertension, or chronic obstructive pulmonary disease.
iii. See Table 17-1.
d. Cardiogenic shock occurs when the left ventricle or right ventricle
fails to pump out enough blood to meet the demands of the body
and includes a drop in systolic blood pressure, diminished or absent
peripheral pulse amplitude, altered mental status, changes in the
heart rate, poor urinary output, respiratory distress, inspiratory rales,
and possible pulmonary edema.
e. Congestive heart failure (CHF) is a medical diagnosis that refers to
the condition in which there is a build-up of fluid in the body resulting
from the pump failure of the heart and commonly leads to pulmonary
edema and edema in other areas of the body (liver, abdomen).
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 17
Knowledge Application
Given several different scenarios, students
should be able to recognize cardiac
compromise and develop a treatment plan
for specific patients.
PAGE 8
Chapter 17 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
2. Assessment
a. Marked or severe dyspnea
b. Tachycardia
c. Difficulty breathing when supine
d. Suddenly waking at night with dyspnea
e. Fatigue on any type of exertion
f. Anxiety
g. Tachypnea
h. Diaphoresis
i. Upright position with legs, feet, arms, and hands dangling
j. Cool, clammy, and pale skin
k. Chest discomfort
l. Cyanosis
m. Agitation and restlessness due to hypoxia
n. Edema to the hands, ankles, and feet
o. Crackles and possibly wheezes on auscultation
p. Decreased SpO2 reading
q. Signs and symptoms of pulmonary edema
r. Blood pressure may be normal, elevated, or low
s. Distended neck veins—jugular venous distention (JVD)
t. Distended and soft spongy abdomen
3. Emergency medical care
a. Basically the same as for patient with acute myocardial infarction
b. Continuously reassess the patient and be prepared for respiratory
failure and cardiac arrest.
B. Hypertensive emergencies
1. Pathophysiology
a. Severe, accelerated hypertension episode with a systolic pressure
greater than 160 mmHg, and a diastolic blood pressure greater than
94 mmHg
b. Hypertensive emergencies are rare.
c. Primary hypertension is characterized by a hypertensive state in
which no specific cause for the hypertension has been identified
(idiopathic).
d. Secondary hypertension is said to occur when a patient is
hypertensive from some other underlying disease process (e.g.,
renal disease, thyroid disorder).
2. Assessment
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 17
Weblink
Go to www.bradybooks.com and click on
the mykit link for Prehospital Emergency
Care, 9th edition to access a web resource
on CDC hypertension data.
PAGE 9
Chapter 17 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
a. Remember that if the patient has the signs and symptoms listed
next, with a blood pressure consistent with his normal blood
pressure, treat the underlying cause. If the patient’s blood pressure
is significantly higher than his normal blood pressure, consider the
findings to be related to hypertension.
b. Signs and symptoms of a hypertensive emergency
i. Strong, bounding pulse
ii. Warm, dry, or moist skin
iii. Severe headache
iv. Ringing in the ears
v. Nausea and/or vomiting
vi. Elevated blood pressure
vii. Respiratory distress
viii. Chest pain
ix. Seizures
x. Focal neural deficits
xi. Indications of organ dysfunction
xii. Possible nose bleed
3. Emergency medical care
i. Support lost functions related to airway, breathing, or circulation.
ii. If the patient is breathing inadequately, provide positive pressure
ventilation with supplemental oxygen.
iii. Place patient in a position of comfort (semi-Fowler’s if no airway
concerns.)
iv. Consider contacting ALS for back-up
C. Cardiac arrest
1. Worst manifestation of cardiac compromise
2. Occurs when heart, for any variety of reasons, is not pumping effectively
or at all, and no pulses can be felt
15
IX. Nitroglycerin
A. A potent vasodilator that works in seconds to relax the muscles of the blood
vessel walls, increasing the blood flow and oxygen supply to the heart
muscle and decreasing the workload of the heart
B. Normally can be found in a sublingual tablet or a sublingual spray
C. Obtain authorization from medical direction before administering
nitroglycerin to a patient with a prescription.
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 17
Discussion Question
What are indications of a hypertensive
emergency?
Teaching Tip
Cover your specific protocols for
administering nitroglycerin.
Discussion Questions

How does nitroglycerin benefit the
patient with ACS?
PAGE 10
Chapter 17 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
D. Contraindications for nitroglycerin
1. Patient with a systolic blood pressure below 90 mmHg
2. Patient with a blood pressure no more than 30 mmHg lower than the
baseline systolic blood pressure
3. Patient with extreme bradycardia or tachycardia
4. Patient who has taken tadalafil, vardenafil, or sildenafil within the last 24
hours
E. Have the patient lie or sit down prior to administration.
F. If the patient experiences no relief after one dose, another may be
administered after three to five minutes if authorized by medical direction, to
a maximum of three doses (including any taken before your arrival).
G. Ask patient for “fresh” supply of nitroglycerin.

What are contraindications for
administering nitroglycerin?
Class Activity
Have pairs of students role play instructing
patients to take nitroglycerin, including an
explanation of its actions and side effects.
Knowledge Application
Give several patient descriptions and have
students determine whether or not it would
be appropriate to assist the patient in taking
nitroglycerin.
Critical Thinking Discussion

Why can nitroglycerin cause a
headache?
 How is lowering the blood pressure too
much detrimental to the patient?
X. Age-Related Variations: Pediatrics and Geriatrics—Pediatric
8
Considerations
A. A pediatric patient is more likely to experience a cardiac disturbance from
some congenital heart condition than a myocardial infarction or ischemic
episode. In these cases, contact medical direction immediately and support
any lost function to the patient’s airway, breathing, or circulation.
B. Cardiac arrest may be caused by airway occlusion or ventilatory
insufficiency.
C. Remain vigilant about establishing and maintaining an airway in a pediatric
to prevent cardiac arrest.
Discussion Question
What are the most common causes of
cardiac problems in children?
Knowledge Application
Given several scenarios involving atypical
ACS presentations, students should
recognize the potential for ACS.
Weblink
Go to www.bradybooks.com and click on
the mykit link for Prehospital Emergency
Care, 9th edition to access a web resource
on congenital heart defects.
Animation
Go to www.bradybooks.com and click on
the mykit link for Prehospital Emergency
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 17
PAGE 11
Chapter 17 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
Care, 9th edition to access an animation
reviewing congenital heart defects.
XI. Age-Related Variations: Pediatrics and Geriatrics—Geriatric
7
Considerations
A. Geriatric patients will represent the highest number of patients you treat who
are experiencing some form of acute coronary syndrome.
B. Review Table 17-2.
Discussion Question
How can an elderly patient’s medications or
medical history affect the presentation and
management of ACS?
XII. Assessment and Care: General Guidelines—Assessment-Based
50
Approach: Cardiac Compromise and Acute Coronary Syndrome
A. Remember that any adult patient with chest pain or chest discomfort should
be treated as a cardiac emergency until proven otherwise.
B. Scene size-up—Make sure scene is safe.
C. Primary assessment
1. Form a general impression of the patient and his mental status.
2. Encountering an unresponsive patient with no respiration and no pulse
a. For infants, begin chest compressions and artificial ventilations
(CPR).
b. For children between the ages of one and eight, if the cardiac arrest
was not witnessed, begin CPR immediately for about two minutes
(five cycles). Then apply the AED (with dose attenuating system if
possible).
c. For patient eight years or older, apply two minutes of CPR (five
cycles) followed by AED application if the time of arrest has been
longer than four to five minutes. If the time of arrest has been
shorter than four minutes, apply the AED as soon as it is available.
3. Encountering a responsive patient
a. Ensure adequate airway, breathing, oxygenation, and circulation.
b. Note the patient’s skin color, temperature, and condition.
c. Note the type, location, and intensity of any pain and presence of
other signs and symptoms related to acute coronary syndrome.
d. Apply oxygen at 15 lpm via a nonrebreather mask if necessary.
e. Make a decision on whether early transport is needed and contact
ALS as appropriate.
D. Secondary assessment
1. History
a. Gather history from family or bystanders if the patient has an altered
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 17
Discussion Question
What should you look for in the primary
assessment?
Teaching Tip
Role play the assessment and
management of a patient with ACS or
cardiac compromise.
Knowledge Application
Give students ample opportunity to practice
assessment and management of patients
with ACS and cardiac compromise.
PAGE 12
Chapter 17 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
mental status and is unable to answer questions.
b. Onset: What were you doing when the chest discomfort started?
What triggered the discomfort? What the onset sudden or gradual?
c. Provocation or palliation: What makes the chest discomfort worse?
What makes the chest discomfort better?
d. Quality: Describe the chest discomfort. Is it a dull, aching, pressuretype discomfort? Is it pressure, squeezing, crushing, or burning? Is it
sharp or stabbing? (Levine’s sign)
e. Radiation: Does the discomfort radiate, that is, does it travel to any
other part of the body? Do you feel it anywhere else in the body?
f. Severity: On a one to ten scale, with ten being the worst, describe
the discomfort.
g. Time: When did the chest discomfort start? How long have you had
the discomfort? Has the discomfort been constant or does it come
and go (intermittent)?
2. Fibrinolytic therapy and the EMT’s role
a. Gather information to help the hospital determine whether the
patient is a candidate for fibrinolytic therapy.
b. Fibrinolytics are a type of drug that, upon administration, dissolve
the newly formed clot that is occluding the coronary artery and
causing the heart attack.
c. The drug can help resume distal perfusion and minimize or inhibit
myocardial damage.
d. EMTs should have a fibrinolytic check list to document the patient’s
history and present it to the emergency department staff as soon as
possible.
e. Absolute contraindications
i. History of prior intracranial hemorrhage
ii. Known diagnosis of a cerebral vascular lesion
iii. Diagnosis of a malignant intracranial neoplasm
iv. Suspected aortic dissection
v. Active bleeding (excluding menstrual cycle)
vi. Bleeding disorders
vii. Closed head trauma or facial trauma within the past three
months
viii. Ischemic stroke within the past three months (except acute
ischemic stroke within the past three hours)
f. Relative contraindications
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 17
Discussion Question
What are key questions in the history of a
patient with possible ACS or cardiac
compromise?
PAGE 13
Chapter 17 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
i. History of chronic, severe, or poorly controlled hypertension
ii. Uncontrolled systolic hypertension (> 180 mmHg) on
presentation
iii. Uncontrolled diastolic hypertension (>110 mmHg) on
presentation
iv. History of intracranial pathology not covered in absolute
contraindications
v. Traumatic or prolonged CPR (> ten minutes)
vi. Major surgery (< three weeks)
vii. Internal bleeding within last two to four weeks
viii. Noncompressible vascular punctures
ix. For streptokinase/anistreplase: prior exposure (> five days ago)
or prior documented allergic reaction to these agents
x. Pregnancy
xi. Active peptic ulcer disease
xii. Current use of anicoagulants
g. Treat the following patients as cardiac compromise and acute
coronary syndrome patients and transport immediately.
i. A patient who has a history of angina who is having chest
discomfort at rest that lasts longer than 20 minutes
ii. Recent onset of angina that progressively worsens
iii. Nocturnal angina
iv. Angina unrelieved by rest or three nitroglycerin tablets over ten
minutes
v. Chest discomfort that lasts greater than five to ten minutes after
rest
h. Remember that some patients may have atypical presentations or
“silent” heart attacks.
3. Physical exam and baseline vital signs
a. Pupils—Sluggish or dilated pupils may suggest hypoxia and poor
perfusion.
b. Oral cavity—Cyanotic mucous membranes indicate hypoxia.
c. Neck—Congestive heart failure or cardiac tamponade may produce
jugular vein distention.
d. Chest—Auscultate for abnormal breath sounds, especially crackles,
which may indicate fluid in the alveoli from left ventricular heart
failure.
e. Lower and upper extremities—Assess for peripheral edema,
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 17
Animation
Go to www.bradybooks.com and click on
the mykit link for Prehospital Emergency
Care, 9th edition to access an animation on
ventricular fibrillation.
PAGE 14
Chapter 17 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
suggesting heart failure, and peripheral cyanosis, usually indicating
vessel disease.
f. Posterior body—Presacral edema to the lower back would be
another indicator of heart failure that may be more prominent in the
patient who is sedentary and commonly in a supine or lying position.
g. Obtain patient’s vital signs.
4. Signs and symptoms
a. Chest discomfort or pain that radiates to any of the following areas:
chest, neck, jaw, arm, or back; epigastric pain
b. Sudden onset of sweating
c. Cool, pale skin
d. Difficulty in breathing
e. Lightheadedness or dizziness
f. Anxiety or irritability
g. Feelings of impending doom
h. Abnormal or irregular pulse rate
i. Abnormal blood pressure
j. Nausea and/or vomiting
E. Emergency medical care
1. Do not take the time to diagnose the type of cardiac emergency.
2. Administer oxygen if breathing is adequate or provide positive pressure
ventilation with supplemental oxygen if breathing is inadequate.
3. Decrease patient’s anxiety by providing calm reassurance and placing
him in a position of comfort (often sitting up).
4. Assist the patient who has prescribed nitroglycerin.
5. If local protocol permits and the patient does not have a known aspirin
allergy, administer 160–235 mg of nonenteric aspirin.
6. Call for ALS backup; initiate early transport.
F. Reassessment
1. Be ready for a patient with chest pain/discomfort or cardiac compromise
to deteriorate into cardiac arrest.
2. Closely reassess breathing and pulse as you perform reassessment
during transport.
XIII. Assessment and Care: General Guidelines—Summary:
10
PREHOSPITAL EMERGENCY CARE,
Emphasize that patients do not need to
have all signs and symptoms of ACS to be
experiencing ACS.
Video Clips
Go to www.bradybooks.com and click on
the mykit link for Prehospital Emergency
Care, 9th edition to access videos on
dysrhythmias and AEDs.
Discussion Questions

What are the key treatments for patients
with ACS?
 How may CPAP benefit the patient with
pulmonary edema?
 Why is oxygen an important treatment
for patients with cardiac compromise?
Critical Thinking Discussion
Why is early administration of aspirin an
important treatment in ACS?
Knowledge Application
Given a number of scenarios, students
Assessment and Care
9TH EDITION
Teaching Tip
DETAILED LESSON PLAN 17
PAGE 15
Chapter 17 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
A. Review assessment findings that may be associated with cardiac
compromise and emergency care for cardiac compromise.
B. See Figures 17-20a and b and 17-21.
10
XIV. Follow-Up
A. Answer student questions.
B. Case Study Follow-Up
1. Review the case study from the beginning of the chapter.
2. Remind students of some of the answers that were given to the
discussion questions.
3. Ask students if they would respond the same way after discussing the
chapter material. Follow up with questions to determine why students
would or would not change their answers.
C. Follow-Up Assignments
1. Review Chapter 17 Summary.
2. Complete Chapter 17 In Review questions.
3. Complete Chapter 17 Critical Thinking.
D. Assessments
1. Handouts
2. Chapter 17 quiz
should be able to recognize ACS and
cardiac compromise and intervene
appropriately.
Case Study Follow-Up Discussion
Why did the EMT partner leave to
retrieve the stretcher rather than
assisting with the assessment and
treatment of the patient?
 What is significant in Mr. Antak’s
history?
 Why was Mr. Antak defibrillated prior to
performing CPR?

Class Activity
Alternatively, assign each question to a
group of students and give them several
minutes to generate answers to present to
the rest of the class for discussion.
Teaching Tips

Answers to In Review and Critical
Thinking questions are in the appendix.
Advise students to review the questions
again as they study the chapter.
 The Instructor’s Resource Package
contains handouts that assess student
learning and reinforce important
information in each chapter. This can be
found under mykit at
www.bradybooks.com.
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 17
PAGE 16