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Chapter 22
Cardiovascular
Emergencies
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22-1
Objectives
22-2
Anatomy Review
22-3
Circulatory System
• Components
– Cardiovascular system
– Lymphatic system
22-4
Cardiovascular System
1. Pump (the heart)
2. Fluid (blood)
3. Container (the blood vessels)
22-5
Lymphatic System
•
•
•
•
•
•
Lymph
Lymph nodes
Lymph vessels
Tonsils
Spleen
Thymus gland
22-6
Circulatory System Functions
• Transport
• Maintenance of body temperature
• Protection
22-7
Heart
22-8
Heart Valves
22-9
Conduction System
[Insert figure 22-3]
22-10
Major Blood Vessels
22-11
Arteries
22-12
Coronary Arteries
22-13
Carotid Arteries
22-14
Brachial and Radial Arteries
22-15
Lower Extremity Arteries
22-16
Arterioles and Capillaries
• Arterioles
– Smallest branches of arteries
• Capillaries
– Walls are one cell thick
– Exchange wastes, fluids, and nutrients
between the blood and tissues
– Connect arterioles and venules
22-17
Venules and Veins
• Venules
– Smallest branches of veins
• Veins
– Low-pressure vessels
– Major veins
• Pulmonary veins
• Superior vena cava
• Inferior vena cava
22-18
Blood
• Formed elements
– Red blood cells (erythrocytes)
– White blood cells (leukocytes)
– Platelets (thrombocytes)
• Plasma
22-19
Physiology of Circulation
22-20
Double Pump
22-21
Perfusion
• Pulse
– Central
– Peripheral
• Perfusion
– Hypoperfusion
(shock)
• Blood pressure
– Systolic
– Diastolic
22-22
Signs and Symptoms of Shock
• Restlessness,
• Nausea and
anxiety, or altered
vomiting
mental status
• Reduction in total
• Pale, cyanotic,
blood volume
cool, clammy skin • Low or
• Rapid, weak
decreasing blood
pulse
pressure
• Rapid, shallow
breathing
22-23
Cardiovascular Disease
22-24
Terminology
• Cardiovascular disease
• Coronary heart disease (CHD)
• Coronary artery disease (CAD)
• Acute Coronary Syndrome (ACS)
22-25
Acute Coronary Syndromes
• Conditions caused by temporary or
permanent blockage of a coronary artery
• Common causes
• Arteriosclerosis
• Atherosclerosis
22-26
Arteriosclerosis and Atherosclerosis
22-27
Risk Factors
•
•
•
•
•
•
Modifiable
Factors
Diabetes
mellitus
High blood
pressure
Elevated blood
cholesterol
Tobacco smoke
Lack of exercise
Obesity
•
•
•
•
Nonmodifiable
Factors
Family history
Gender
Race
Increasing age
Contributing
Factors
• Stress
• Depression
• Heavy alcohol
intake
22-28
Myocardial Ischemia
• Ischemia
– A reduced blood supply to an organ
or tissue
22-29
Angina Pectoris
• Angina pectoris
– “Choking in the chest”
– Symptom of coronary artery disease
– Heart’s need for oxygen exceeds its supply
22-30
Angina Pectoris
• Stable angina
• Unstable angina
22-31
Acute Myocardial Infarction
22-32
Chest Discomfort
•
•
•
•
•
•
“Pressing”
“Tight”
“Squeezing”
“Viselike”
“Aching”
“Heaviness”
• “Dull”
• “Burning”
“Crushing”
• “Smothering”
• Indigestion-type
symptoms
22-33
Associated Symptoms
•
•
•
•
•
Palpitations
Fainting
Sweating
Shortness of breath
Nausea
22-34
Atypical Presentation
Older Adults
• Unexplained newonset or worsened
difficulty breathing
with exertion
• Unexplained nausea,
vomiting
• Sweating
• Unexplained tiredness
• Change in mental
status
• Weakness
• Fainting
• Abdominal discomfort
Diabetic
Individuals
Women
• Change in
• Pain or discomfort
mental status
in the chest, arms,
• Weakness
back, shoulders,
• Fainting
neck, jaw, or
• Lightheadedness stomach
• Shoulder/back
• Anxiety, dizziness
pain
• Shortness of
breath
• Weakness
• Unusual tiredness
• Cold sweats
• Nausea, vomiting
22-35
Congestive Heart Failure
• Congestive heart failure = CHF
– CHF = pump failure
– Left ventricular failure
• Blood backs up into the lungs (pulmonary
edema)
– Right ventricular failure
• Blood backs up and causes congestion in
organs and tissues
22-36
Congestive Heart Failure
• Possible assessment
findings and symptoms
–
–
–
–
Fatigue
Nausea
Palpitations
Unexplained weight
gain
– Shortness of breath
– Dyspnea with
exertion
– Paroxysmal
nocturnal dyspnea
– Orthopnea
– Swelling of the feet
and ankles
– Swelling around the
lower back
– Jugular venous
distention
22-37
Hypertensive Emergencies
• Hypertension
– Sustained elevation of the
systolic or diastolic blood
pressure
– Sustained systolic blood
pressure of 140 mm Hg or
higher
or
– Sustained diastolic pressure
of 90 mm Hg or higher
22-38
Hypertensive Emergencies
• Prehypertension
– Systolic blood pressure
between 120 and 139
or
– Diastolic blood pressure
between 80 and 89 on
multiple readings
22-39
Hypertensive Emergencies
• Essential hypertension
– No identifiable cause
• Secondary hypertension
– Identifiable cause
22-40
Hypertensive Emergencies
• Hypertensive emergencies
– Situations that require rapid lowering of
blood pressure to prevent or limit organ
damage
• Systolic blood pressure greater than 160 mm Hg
• Diastolic pressure greater than 94 mm Hg
22-41
Hypertensive Emergencies
• Possible assessment
findings and symptoms
– Responsive, altered
mental status, or
unresponsive
– Strong, bounding pulse
– Skin color may be
normal, pale, or flushed
– Skin hydration may be
dry or moist
– Skin temperature may be
warm or cool
–
–
–
–
–
–
Headache
Ringing in the ears
Nausea/vomiting
Dizziness
Shortness of breath
Paroxysmal nocturnal
dyspnea
– Orthopnea
– Nosebleed
– Seizures
22-42
Cardiogenic Shock
• Pump failure
22-43
Cardiogenic Shock
• Possible assessment
findings and
symptoms
– Altered mental status
– Jugular venous
distention
– Labored breathing
– Tachycardia
– Hypotension
– Crackles, with or
without wheezes
– Pale, cool, clammy
skin
– Pulmonary edema
22-44
Patient Assessment
22-45
Patient Assessment
• Scene size-up
• General impression
• Primary survey
22-46
Patient Assessment
• Establish patient priorities.
• Determine the need for additional
resources.
• Make a transport decision.
22-47
Patient Assessment
• Secondary survey
– SAMPLE history
– OPQRST
– Physical exam
• Focused exam if patient responsive
• Rapid medical assessment if unresponsive
22-48
Emergency Care
• Position of comfort
• Provide reassurance
• MONA
– Morphine (ALS only)
– Oxygen
– Nitroglycerin
– Aspirin
22-49
Emergency Care
• Aspirin
– If ordered by medical direction (and there
are no contraindications), give as soon as
possible after onset of chest discomfort.
22-50
Emergency Care
• Nitroglycerin
– Find out if the patient has prescribed
nitroglycerin.
– Find out if the medication is with the
patient.
– Find out when the last dose was taken.
– Contact medical direction.
– If instructed to do so, assist the patient
with its use.
22-51
Cardiac Arrest
22-52
•
•
•
•
•
•
Cardiac Arrest
Possible Causes
Heart and blood
• Severe electrical
vessel diseases
shock
Choking or
• Poisoning or drug
respiratory arrest
overdose
Seizures
• Drowning
Diabetic
• Suffocation
emergency
• Trauma
Severe allergic
• Severe bleeding
reaction
Abnormalities
present at birth
22-53
Sudden Cardiac Death
• Sudden cardiac death
– The unexpected death from cardiac
causes early after symptom onset
(immediately or within 1 hour) or without
the onset of symptoms
22-54
Chain of Survival
1. Early recognition and activation of the
EMS system
22-55
Chain of Survival
2. Early CPR
22-56
Chain of Survival
3. Early defibrillation (if indicated)
22-57
Chain of Survival
4. Effective advanced life support
5. Integrated post-cardiac arrest care
22-58
The EMT and the Chain of Survival
• Standard
precautions
• Using an AED
• Requesting ALS
backup
• Suctioning
• Airway adjuncts
• Bag-mask device
• Flow-restricted,
oxygen-powered
ventilation device
• Safe lifting/ moving
• Interviewing
techniques
• Performing effective
CPR
• Assisting ALS
personnel
22-59
If no pulse, begin CPR unless …
• Valid Do Not Resuscitate (DNR) order
exists
• Signs of obvious death
– Decapitation or other obvious mortal injury
– Putrefaction (decomposition)
– Extreme dependent lividity
– Rigor mortis
22-60
Assessment and Emergency Care
• Scene size-up
• General impression
• Assess responsiveness
– If responsive, perform primary survey
– If unresponsive, check breathing
• If not breathing, check pulse for up to 10 sec
22-61
CPR Review
Adult
Patient Age
More than 12- 1 to 12–14
14 years
years
Rescue Breaths 10–12
Location of
Pulse Check
Chest
Compressions
Child
breaths/min
1 every 5–6
sec
Carotid
Heel of one
hand, other
hand on top
Infant
Under 1 year
12–20
12–20
breaths/min
breaths/min
1 every 3–5 sec 1 every 3–5 sec
Carotid or
femoral
Brachial
Heel of 1 hand
or same as for
adult
2 fingers (1
rescuer) or 2
thumbs with the
fingers of both
hands encircling
the chest
(2 rescuers)
22-62
CPR Review
Depth of Chest
Compressions
Rate of Chest
Compressions
Ratio of Chest
Compressions
to Rescue
Breaths (One
Cycle)
Adult
At least 2 in
(5 cm)
Child
Infant
At least ⅓ the chest At least ⅓ the
depth
chest depth
(about 2 in [5 cm]) (about 1.5 in [4
cm])
At least 100/minute (all ages)
1 or 2
rescuers:
30 compressions to 2
breaths (30:2)
1 rescuer:
1 rescuer:
30 compressions
30 compressions
to 2 breaths (30:2) to 2 breaths (30:2)
2 rescuers:
2 rescuers:
15 compressions
15 compressions
to 2 breaths (15:2) to 2 breaths (15:2)
22-63
Defibrillation
• Manual defibrillators
22-64
Defibrillation
• Implantable cardioverter-defibrillator
(ICD)
22-65
Defibrillation
• Automated external defibrillator (AED)
22-66
Automated External Defibrillators
• Fully automated external defibrillator
• Semiautomated external defibrillator
22-67
Automated External Defibrillators
[Insert figure 22-16]
22-68
EMTs and AEDs
• Not all patients who have chest pain
experience a cardiac arrest
• An AED should only be applied to a
patient who is unresponsive, apneic,
and pulseless
22-69
AEDs
Advantages
• Easy to operate
• Less training required to operate than
with a manual defibrillator
• Remote, hands-free, hands-off
defibrillation
22-70
Medical Direction and
Quality Management
• AED use requires authorization from a
medical director.
• Quality management review of calls
involving use of an AED
22-71
Special Considerations
• Place AED pads at least 3 in (8 cm) from a
pacemaker or implanted defibrillator.
• AED pads—ensure no air pockets
• Do not use the AED when patient or rescuers
are in contact with water or metal.
• Remove medication patches from patient’s
chest.
• Make sure oxygen is not flowing over
patient’s chest before delivering shocks.
22-72
AED Operation
[Insert skill drill 22-3 step 1]
22-73
AED Operation
[Insert skill drill 22-3 step 2]
22-74
AED Operation
[Insert skill drill 22-3 step 3]
22-75
AED Operation
[Insert skill drill 22-3 step 4]
22-76
Inappropriate Delivery of Shocks
• To avoid delivering inappropriate
shocks:
– Attach an AED only to unresponsive,
apneic, pulseless patients
– “Analyze” only when cardiac arrest has
been confirmed and all movement has
stopped
– Avoid using cell phones, radios, or other
devices that emit electrical signals during
rhythm analysis
22-77
Interruption of CPR
• CPR must be stopped while you are
analyzing the patient’s rhythm and
delivering shocks.
• Resume CPR immediately after
delivering a shock or when no shock is
indicated.
22-78
Postresuscitation Care
• If the patient begins moving, check pulse and
breathing.
• Give supplemental oxygen.
• Secure patient to stretcher.
• Use proper lifting and moving techniques.
• Keep AED attached to patient during transport.
• Reassess every 5 minutes en route.
22-79
Cardiac Arrest During Transport
• If a patient stops breathing and
becomes pulseless during transport
– Stop the vehicle
– Start CPR and apply the AED
– Analyze the rhythm as soon as the AED is
ready
– Deliver a shock, if indicated
– Immediately resume CPR
– Continue resuscitation (and transport) per
local protocol
22-80
Support of the Family
• Allow family members to be present,
unless they interfere with resuscitation
efforts.
• Be sympathetic.
• Listen with empathy.
• Do not give false hope or reassurance.
22-81
When to Stop CPR
• You should stop CPR only if
– Effective breathing and circulation have
returned
– The scene becomes unsafe
– You are too exhausted to continue
– You transfer patient care to a healthcare
professional with equal or higher
certification
– A physician assumes responsibility for
the patient
22-82
AED Maintenance
• Perform maintenance procedures
according to the manufacturer’s
recommendations.
• AED self-test
• Manual AED self-test
• Always have extra batteries on hand.
22-83
Training and Sources of Information
•
•
•
•
American Heart Association
The Health & Safety Institute
American Red Cross
National Safety Council
• Use practice drills to maintain skill
proficiency.
22-84
Questions?
22-85