Download Cardiovascular Emergencies

Cardiovascular Emergencies
Course
Practicum in
Health ScienceEMT
Unit Cardiac
Emergencies
Essential
Question
What is the
treatment for a
patient
experiencing
chest pain of
cardiac origin?
TEKS
§130.205(c)
(1)(A)(B)(C)(D)
(E)(F)(G)
(2)(A(B(C)
(3)(A)
(5)(A)
(6)(A)(D)
(7)(A)(C)
(8)(A)(B)(C)(D)
Prior Student
Learning
Anatomy &
Physiology,
General
Pharmacology,
Medical Patient
Assessment.
Estimated time
3 – 5 hours
Rationale
Cardiovascular Disease is the leading cause of death in the United States.
Early recognition and treatment significantly improves patient outcomes.
Objectives
Upon completion of this lesson, the student will be able to:
 Analyze cardiovascular anatomy and physiology
 Define acute coronary syndrome
 Research the pathophysiology of common cardiovascular disorders and
basic life support treatment of these conditions
Engage
Tell Students that the majority of EMS calls which they will respond to will
present with signs and symptoms of a cardiac nature. Understanding the
functions of the cardiac system and the pathophysiology of the cardiac system
will prepare the EMT to make appropriate treatment decision and provide the
patient with a better chance of survival.
Discuss the following:
According to the American Heart Association, your heart beats about 100,000
times in one day and about 35 million times in a year. During an average
lifetime, the human heart will beat more than 2.5 billion times.
Key Points
I. Cardiovascular Anatomy and Physiology – (See Cardiovascular System
Lesson Plan)
A. Review the flow of blood through the heart and through the major
vessels. Discuss the cardiovascular system.
B. Review the function of the four chambers of the heart. Deoxygenated
blood enters the heart via the vena cava, travels through the right and
left chambers, and moves to the lungs, where it receives oxygen.
Oxygenated blood returns from the lungs via the pulmonary vein. It
travels through the left chambers of the heart and enters the aorta to be
pumped out to the body.
C. Review the cardiac conduction system (the electrical impulses and
specialized muscles that cause the heart to contract). The cardiac
conduction system allows for a coordinated, rapid depolarization of
cardiac cells and is designed to facilitate mechanical contraction.
D. Review the composition of blood (red and white blood cells, platelets,
and plasma) and the flow of blood through the arteries, veins, arterioles,
venules, and capillaries. Review the names and positions of major blood
vessels and discuss the circulation of blood between the heart and the
Copyright © Texas Education Agency, 2014. All rights reserved.
Teacher Note
There are
Discussion
Questions
available to
utilize as you
are teaching the
lesson.
lungs and between the heart and the rest of the body.
II. Acute Coronary Syndrome
A. Acute coronary syndrome (ACS) is a blanket term that refers to any time
that the heart may not be getting enough oxygen.
B. An EMT should treat all patients with ACS-like signs and symptoms as
though they are having a heart problem.
C. Always have a patient describe in his own words how he is feeling.
Patients complain of radiation to the left arm more than the right, but
either (or both) is possible.
D. Always ask about shortness of breath when evaluating a potential ACS
patient. Dyspnea as a singular complaint is common in older patients
and in diabetic patients.
E. Chest discomfort, dyspnea, nausea, and anxiety are common symptoms
of ACS, but not all ACS patients present with common symptoms.
F. There is no such thing as a common finding in ACS. Between onequarter and one-third do not have the typical presentation of chest
discomfort. This is especially true in older patients and women. You may
see a patient who complains of difficulty breathing, sudden onset of
sweating or a sudden, unusual feeling of fatigue, without chest
discomfort. Because of these many possibilities and because of the
potentially severe complications of heart problems, it is important to have
a high index of suspicion and treat patients with any of these signs and
symptoms for cardiac compromise.
G. You should always inquire about onset, provocation, quality, radiation,
severity, and time.
H. Occasionally, you will see a patient who has both difficulty breathing and
hypotension. It may be very difficult to find a good position in this case.
The best way to determine the proper position is to ask the patient what
position will relieve breathing difficulty without making him weak or
lightheaded. Oxygen is especially important if the patient is hypoxic, as
reflected in signs and symptoms, including oxygen saturation level. Keep
the patient’s oxygen saturation at least at 94%.
I. Note that asthma and other anti-clotting medications are relative
contraindications. Some systems may allow the administration of aspirin
in these circumstances. Follow local protocol.
III. Causes of Cardiac Conditions
Note to Teacher: This section lends itself well to video graphics to better
illustrate pathophysiology. Describe how cardiac conditions interfere with
normal physiology. Relate this discussion to your lesson on anatomy and
physiology. Relate pathophysiology to physical findings and symptoms.
Discuss how these disorders impact patients. The American Heart
Copyright © Texas Education Agency, 2014. All rights reserved.
Association is a useful resource for this section. Its website and classes can
provide beneficial enhancements and teaching tools to improve your lesson.
A. The majority of cardiovascular emergencies are caused, directly or
indirectly, by changes in the inner walls of arteries. Conditions that
narrow or block the arteries of the heart are commonly called coronary
artery disease (CAD).
B. An aneurysm occurs when weakened sections in the arterial walls dilate
and occasionally burst.
C. The two most common sites of aneurysms are the aorta and the brain.
Tissues beyond the rupture can be damaged because the oxygenated
blood they need is escaping and not reaching them. If a major artery
ruptures, death from shock can occur very quickly.
D. Both electrical and mechanical problems can cause the heart to fail.
E. Angina pectoris and acute myocardial infarction result from an
interruption of the necessary blood flow to heart muscle. Infarction
occurs when this blood supply is fully occluded.
F. Occasionally angina pain can be seen at rest, especially in progressive
disease states.
G. Congestive heart failure occurs when the heart cannot pump properly
due to damage or a disorder. Pulmonary edema is a common symptom
of CHF.
H. When the left ventricle fails and fluid accumulates in the lungs, it is called
pulmonary edema. This edema causes a poor exchange of oxygen
between the lungs and the bloodstream, and the patient experiences
shortness of breath, or dyspnea. When the right side fails, fluids may
accumulate in the dependent (lower) extremities, the liver, and the
abdomen. Accumulation of fluid in the feet or ankles is known as pedal
edema. The abdomen may become noticeably distended. In a bedridden
patient, fluid collects in the sacral area of the spine.
Activity
I. Label a diagram of the heart.
II. Act out the flow of blood through the heart as a class. Assign roles and
have students act out the various steps.
III. Use cell phone technology to create a model of the cardiac conduction
system. Assign roles and have students text each other a specific message
in a manner that models the depolarization of the heart.
IV. Dissect a pig or cow heart. Obtain hearts from a local butcher and allow
students to visualize the structures of the heart. Assign an online scavenger
hunt. Ask students to research and present the best cardiac anatomy and
physiology graphic that they can find. Remind students to give credit to the
source.
Copyright © Texas Education Agency, 2014. All rights reserved.
V. Plot out a definitive care strategy for an ACS patient in the area. Have
students describe transport decisions and what the most effective treatment
would be based upon their local geography and care options.
VI. Have the class work in small groups. Assign each group a cause of a
specific cardiac condition. Have that group research and present the
pathophysiology of its disorder to the class.
VII. Role play Assessment Scenarios.
Assessment
Successful completion of activities
Materials
Discussion Questions
Heart Diagram
Invite CPR instructors to assist with class
Invite a patient with a prior ACS history to class
Invite a local medical director and cardiac catheterization team member to class
to discuss definitive care for an AMI and post-cardiac arrest care
Make arrangements to join with an ALS class, or invite ALS providers to assist
with class
Prepare AED trainers, manikins, and other practical equipment
Cow or pig hearts
Anatomy and physiology websites:
http://www.texasheartinstitute.org/HIC/Anatomy/
http://www.vhlab.umn.edu/atlas/index.shtml
http://www.heart.org/HEARTORG/
Brady Emergency Care 12th Edition
J&B Learning Emergency Care and Transportation of the Sick and Injured 10th
Edition.
Utah State Office of Education, (2005). Medical Anatomy and Physiology
Teacher Resource CD. Utah.
Accommodations for Learning Differences
For enrichment, the student will present case studies on the use of Mechanical
CPR Devices (i.e., Lucas, Autopulse) and Induced hypothermia after ROSC.
For reinforcement, the student will define the following vocabulary:
cardiopulmonary resuscitation(CPR), defibrillation, cardiovascular system,
acute coronary syndrome(ACS), dyspnea, bradycardia, tachycardia,
nitroglycerin(ntg),coronary artery disease(CAD), thrombus, occlusion,
embolism, aneurysm, dysrhythmia, angina pectoris, acute myocardial
infarction(AMI), sudden death, congestive heart failure(CHF), edema,
Copyright © Texas Education Agency, 2014. All rights reserved.
pulmonary edema, pedal edema, chain of survival, ventricular defibrillation,
ventricular tachycardia, pulseless electrical activity, asystole
National and State Education Standards
National Health Science Cluster Standards
1.2 Diseases and Disorders
1.21 Describe common diseases and disorders of each body system
(prevention, pathology, diagnosis, and treatment).
1.22 Recognize emerging diseases and disorders.
1.23 Investigate biomedical therapies as they relate to the prevention,
pathology, and treatment of disease.
2.1 Concepts of Effective Communication
2.11 Interpret verbal and nonverbal communication.
2.12 Recognize barriers to communication.
2.13 Report subjective and objective information.
2.14 Recognize the elements of communication using a sender-receiver model.
2.15 Apply speaking and active listening skills.
2.2 Medical Terminology
2.21 Use roots, prefixes, and suffixes to communicate information.
2.22 Use medical abbreviations to communicate information.
2.3 Written Communication Skills
2.31 Recognize elements of written and electronic communication (spelling,
grammar, and formatting)
3.14 Explain the impact of emerging issues such as technology, epidemiology,
bioethics, and socioeconomics on healthcare delivery systems.
6.32 Demonstrate respectful and empathetic treatment of ALL patients/clients
(customer service).
Texas College and Career Readiness Standards
English Language Arts
III.A.2 Adjust presentation (delivery, vocabulary, length) to particular audiences
and purposes.
III.B.1 Participate actively and effectively in one-on-one oral communication
situations.
III.B.2 Participate actively and effectively in group discussions.
III.B.3 Plan and deliver focused and coherent presentations that convey clear
and distinct perspectives and demonstrate solid reasoning.
IV.A.2 Interpret a speaker’s message; identify the position taken and the
evidence in support of that position.
IV.A.3 Use a variety of strategies to enhance listening comprehension.
IV.B. 1 Listen critically and respond appropriately to presentations.
IV.B.2 Listen actively and effectively on one-on-one communication situations.
Science
I.D.3 Demonstrate appropriate use of a wide variety of apparatuses, equipment,
techniques, and procedures for collecting quantitative and qualitative data.
I.E.2 Use essential vocabulary of the discipline being studied.
Copyright © Texas Education Agency, 2014. All rights reserved.
Cross-Disciplinary
I.C.1 Analyze a situation to identify a problem to be solved.
I.C.2 Develop and apply multiple strategies to solve a problem.
I.C.3 Collect evidence and data systematically and directly relate to solving a
problem.
I.D.1 Work independently
I.D.2 Work Collaboratively
TEKS
§130.205.(c)(1)(A)interpret data from various sources in formulating
conclusions;
§130.205.(c)(1)(B)compile information from a variety of sources to create a
technical report;
§130.205.(c)(1)(C)plan, prepare, and deliver a presentation;
§130.205.(c)(1)(D)examine the environmental factors that affect homeostasis;
§130.205.(c)(1)(E)relate anatomical structure to physiological functions;
§130.205.(c)(1)(F)distinguish atypical anatomy and physiology in the human
body systems;
§130.205.(c)(1)(G)implement scientific methods in preparing clinical case
studies; and
§130.205.(c)(1)(H)compare and contrast health issues in the global society.
§130.205.(c)(2)(A)accurately describe and report information, according to
facility policy, observations, and procedures;
§130.205.(c)(2)(B)demonstrate therapeutic communication skills to provide
quality care; and
§130.205.(c)(2)(C)employ therapeutic measures to minimize communication
barriers.
§130.205.(c)(3)(A)demonstrate proficiency in medical terminology and skills
related to the health care of an individual;
§130.205.(c)(5)(A)participate in team teaching and conflict management such
as peer mediation, problem solving, and negotiation skills;
§130.205.(c)(6)(A)integrate regulatory standards such as standard precautions
and safe patient handling;
§130.205.(c)(6)(D)apply principles of infection control and body mechanics in
all aspects of the health science industry.
§130.205.(c)(7)(A)interpret knowledge and skills that are transferable among
health science professions;
§130.205.(c)(7)(C)analyze emerging technologies in the health science
industry.
§130.205.(c)(8)(A)describe pre-procedural preparations;
§130.205.(c)(8)(B)observe therapeutic or diagnostic procedures;
§130.205.(c)(8)(C)identify care indicators of health status; and
§130.205.(c)(8)(D)record health status according to facility protocol.
Copyright © Texas Education Agency, 2014. All rights reserved.
Nation EMT BASIC STANDARD CURRICULUM
www.nhtsa.gov/people/injury/ems/pub/emtbnsc.pdf
Describe the structure and function of the cardiovascular system. EMT Basic
National Standard Curriculum 4-3.1
Custom Resources
Emergency Care the emergency medical care of the patient experiencing chest pain/discomfort.
EMT Basic National Standard Curriculum 4-3.2
Define the role of EMT-B in the emergency cardiac care system. EMT Basic
National Standard Curriculum 4-3.5
Demonstrate the assessment and emergency medical care of a patient
experiencing chest pain/discomfort. EMT Basic National Standard Curriculum
4-3.47
Copyright © Texas Education Agency, 2014. All rights reserved.
Assessment Scenarios
1. You are an EMT; you arrive on scene to find a 60 y/o female patient with respiratory distress.
Pale and diaphoretic with vitals of R-28 non-labored and clear, P-110 weak and thready, BP178/92. Pt. states that she was mowing the lawn when she began having difficulty breathing,
it has not changed, it feels like she cannot catch her breath, It is 8 out of 10 in difficulty, and
has been going on for about 15 minutes. Pt. has a history of diabetes. NKDA, MedsMetformin, She ate breakfast this morning.
 What is your differential diagnosis?
 What are the pertinent negatives?
 Using OPQRST and Sample what is your clinical diagnosis?
 What treatments would be appropriate for this patient?
 Would you consider requesting ALS?
2. You arrive on location to find a 58 y/o obese male with C/O substernal chest pain. Pt. is pale
and diaphoretic. Pt. has a PMHx of Angina and hypertension. Pt. woke from a nap with chest
pain, which he rates at 9 out of 10. Pt. states that it feels like someone sitting on his chest.
This is the worst angina he has ever had. It also radiates to his jaw and left arm. Nothing
makes the pain stop; he has taken 1 of his Nitroglycerin pills with no relief. He is allergic to
PCN. He takes ASA, NTG, and HCTZ. He was diagnosed with Angina a year ago and has
had High Blood Pressure for 2 years. He ate breakfast 3 hours ago.
 What is your differential diagnosis?
 What are the pertinent negatives?
 Using OPQRST and Sample what is your clinical diagnosis?
 What treatments would be appropriate for this patient?
 Would you consider requesting ALS?
3. You respond to a 43 y/o male that is c/o palpitations in his left chest/upper abdomen. Pt. is
A&Ox3. Pt. has no PMHx. No Allergies, and No Medications. Pt. states that he has been
feeling more tired than usual the last couple of days. He thought that they he might be
coming down with a cold or flu. Pt. stated he started having a strange pulsing in his upper
abdomen. BP 110/78, P-112, R-24.
 What is your differential diagnosis?
 What are the pertinent negatives?
 Using OPQRST and Sample what is your clinical diagnosis?
 What treatments would be appropriate for this patient?
 Would you consider requesting ALS?
4. A 54-year-old man is experiencing chest pain and SOB. The pain started approximately 45
minutes ago. The patient states the pain, which feels like tremendous pressure, is mostly on
the left side of his chest and radiating down his left arm. He has taken two Nitroglycerin
tablets with no relief. You notice he is pale and diaphoretic. You are expected to perform
patient assessment and manage the patient appropriately.
 What is your differential diagnosis?
 What are the pertinent negatives?
Copyright © Texas Education Agency, 2014. All rights reserved.



Using OPQRST and Sample what is your clinical diagnosis?
What treatments would be appropriate for this patient?
Would you consider requesting ALS?
Copyright © Texas Education Agency, 2014. All rights reserved.
THE FLOW OF BLOOD THROUGH THE HEART
A. The superior vena cava drains deoxygenated blood from the head, neck, and arms while
the inferior vena cava drains deoxygenated blood from the abdomen and the legs into the
right atrium. The coronary sinus drains deoxygenated blood from the myocardium into the
right atrium.
B. From the right atrium, deoxygenated blood flows through the tricuspid valve into the right
ventricle.
C. From the right ventricle, deoxygenated blood flows through the pulmonary semilunar
valve into the pulmonary trunk
D. The pulmonary trunk branches to form the right and left pulmonary arteries, which take
deoxygenated blood to the lungs for gas exchange. Carbon dioxide is released from the
blood while oxygen is picked up by the blood.
E. Oxygenated blood returns through the right and left pulmonary veins into the left atrium.
F. From the left atrium, oxygenated blood flows through the bicuspid (mitral) valve into the
left ventricle.
G. From the left ventricle, oxygenated blood flows through the aortic semilunar valve into the
aorta.
H. From the aorta, oxygenated blood flows into arteries, arterioles, capillaries, venules, and
veins, eventually reaching the superior and inferior vena cava once again.
I.
The body’s entire blood supply is circulated every minute.
("Medical anatomy and," 2005)
Copyright © Texas Education Agency, 2014. All rights reserved.
http://www.clipart.com/
Copyright © Texas Education Agency, 2014. All rights reserved.
Discussion
1. Discuss how pressure within the cardiovascular system is maintained. Describe how a loss
of pressure within the cardiovascular system might affect a patient.
2. Describe the flow of blood through the heart. Describe how deoxygenated blood becomes
oxygenated and is distributed out to the body.
3. Describe the heart’s electrical conduction system.
4. How does the presence of a radial pulse demonstrate a functioning heart? How does blood
pressure relate to the function of the heart?
5. Define acute coronary syndrome.
6. Why is “casting a wide net” so important with regard to ACS patients? Why is it so important
to err on the side of caution with a cardiac problem?
7. Describe the common symptoms of acute coronary syndrome. Discuss specific populations
in which “common symptoms” are not so common.
8. Occasionally, you will see a patient who has both difficulty breathing and hypotension. It may
be very difficult to find a good position in this case. The best way to determine the proper
position is to ask the patient what position will relieve breathing difficulty without making him
weak or lightheaded. Oxygen is especially important if the patient is hypoxic, as reflected in
signs and symptoms, including oxygen saturation level. Keep the patient’s oxygen saturation
at least at 94%.
9. Determining whether the patient has an ST-elevation myocardial infarction (STEMI) may be
extremely important. It may help determine the kind of treatment the patient may benefit from
and where you will transport the patient. Always follow local protocols.
10. Note that depending on your local protocols, you may administer or assist the patient with
taking nitroglycerin. Give the patient nitroglycerin if all of the appropriate conditions are met.
11. Medical control may authorize repeat doses of nitroglycerin in 5-minute intervals if the patient
experiences no relief or only partial relief and systolic blood pressure remains greater than
90–100. Administer a maximum of three doses, reassessing vital signs and chest pain after
each dose. If the blood pressure falls below 90–100 systolic, treat the patient for shock.
12. Describe the treatment of ACS. Discuss definitive care and pre-hospital care.
13. Discuss the role of coronary artery disease in ACS.
14. Discuss how an aneurysm occurs.
15. How might the symptoms of an aneurysm present like the symptoms of ACS? Can an EMT
differentiate in the field, and if so, how?
16. Describe how an electrical problem might cause the heart to fail.
17. How is CHF related to acute pulmonary edema?
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