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MASTER TEACHING NOTES 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 15 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 5 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— 5 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)— 20 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 65 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