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Cardiac & Nervous System
Review of Emergencies
ECRN Mod III CE 2010
Condell Medical Center EMS System
Prepared by: FF/PMD Michael Mounts
Lake Forest Fire Department
Reviewed/revised by: Dr. Kent Bailey, EMS Medical Director
Objectives






Identify components of the nervous system
Identify signs and symptoms of a patient with a
CVA
Identify assessment & field treatment of patient
with a CVA
Identify anatomy and physiology of the cardiopulmonary system
Identify signs and symptoms of a patient with
ACS
Identify field treatment of patient with ACS
Objectives cont.





Discuss situations for using the RAD 57
tool
Identify patient care based on RAD 57
readings
Review documentation components for
discussed conditions
Identify a variety of ECG rhythm strips
Review Region X SOP’s for various
emergencies discussed
Components of the CNS

Brain - 3 major structures

Cerebrum





largest element of nervous system
occupies most of cranium
highest functional portion of brain
center of conscious thought, personality, speech,
motor control, and visual, auditory, & tactile
perception
Cerebellum


fine tunes motor control, allows smooth motion
from one position to another
responsible for balance & maintenance of muscle
tone
Components of the CNS cont.

Brainstem
• central processing center &communication
junction
• midbrain
• hypothalamus
• controls much of endocrine function, vomiting
reflex, hunger, thirst, kidney function, body
temperature
Components of the CNS cont.
•
Brainstem cont.
• pons
• medulla oblongata
• respiratory center (depth, rate, rhythm)
• cardiac center (rate & strength of cardiac
contractions)
• vasomotor center (control of distribution of blood
and maintenance of blood pressure)
Cross-section of the brain
skull
periosteum
dura
In order…
1. Skull bone
2. Periosteum of
the skull
3. Dura
4. Arachnoid
5. Subarachnoid
space
6. Pia mater
CNS Circulation



4 major arterial vessels
Capillaries unique
 walls thicker so they are
less permeable
 protected environment via
the blood-brain barrier
Cerebral perfusion
 changes in ICP are met
with compensatory changes
in blood pressure
Cerebral Perfusion Pressure

Intracranial pressure - pressure within cranium



3 major cranial contents



pressures within cranium create a natural resistance to
control the amount of cerebral blood flow
blood flow to the brain remains adequate as long as
pressures within the cranium are appropriate
brain, blood, & cerebrospinal fluid
Any changes in one of the 3 cranial contents is at the
sacrifice to one of the others
When ICP rises, the body increases the BP to maintain
the cerebral perfusion (Cushing reflex)
Brain Function By Region






Frontal Lobe - reasoning,
planning, parts of speech,
movement, emotions, and
problem solving
Parietal Lobe - movement,
orientation, recognition,
perception of stimuli
Occipital Lobe - visual processing
Temporal Lobe - perception and
recognition of auditory stimuli,
memory, and speech
Cerebellum - regulation and
coordination of movement,
posture, and balance
Brain stem - breathing, heartbeat,
and blood pressure
Remember




Wernicke’s Area
 Controls speech comprehension
Broca’s Area
 Controls speech production
Both on left side of brain
 If either of the above speech
areas are noted to be affected,
see if right sided weakness
is also present
Speech and motor problems will be reflected
on opposite sides of the body
Left vs. Right

This theory of the structure and functions of the mind
suggests that the two different sides of the brain control
two different “modes” of thinking. It also suggests that
each of us prefers one mode over the other.
Left Brain
Right Brain
Logical
Sequential
Rational
Analytical
Objective
Looks at parts
Random
Intuitive
Holistic
Synthesizing
Subjective
Looks at wholes
Left vs. Right cont.
Note: Notice how Broca & Wernicke’s area are on Left side
Hearing difference: Speech on Left vs. Music on Right
CVA Signs and Symptoms





Trouble with walking, sudden dizziness, loss of
balance or loss of coordination.
Trouble with speaking and/or understanding,
confusion, slurred words or be unable to find the right
words to explain what is happening (aphasia).
Paralysis or numbness on one side of the body or
face.
Trouble with seeing in one or both eyes. Sudden
blurred or blackened vision, or seeing double.
Headache; a sudden, severe "bolt out of the blue"
headache which may be accompanied by vomiting,
dizziness or altered consciousness.
What to do…

Initial assessment







AVPU, ABC’s, life threats, etc.
Sample history
Vitals
Pupils
Glasgow
Time of onset VERY important!
F.A.S.T. or Cincinnati Stroke Scale
 Remember… you only need to have one of
these signs for positive CVA identification.
Cincinnati Stroke Scale or FAST
F – look for facial drooping
 Have patient smile large enough to see
teeth
 A – check for arm drift
 Patient holds hands out in front for 10
seconds with eyes closed, palms up
 S – check for slurred speech
 T – teach patients to call 911 – time is
essential

Facial Drooping

Ask the patient to smile real big and show you their
teeth

Best way to see if a droop is present
Arm Drift

Demonstrate first and then have patient hold their
hands out in front, palms up, for 10 seconds
Clarity of Speech
Most likely you’ll know by now if there is a
speech problem
 Can have the patient repeat after you any
words or a sentence you give them


“You can’t teach an old dog new tricks”
7 D’S Of Stroke Care
Detection – of signs and symptoms
 Dispatch – advise to call 911
 Delivery – to the appropriate facility
 Door – emergent triage in the ED
 Data – appropriate tests
 Decision – to administer a fibrinolytic or not
 Drug – must administer the fibrinolytic within
3 hours of onset of symptoms


Intracranial Hemorrhages

Epidural – rapid onset, traumatic






Arterial bleed
Headache
Nausea/vomiting
Seizures
Focal neurologic deficits (aphasia,
weakness, numbness)
Subdural – slower onset, traumatic




Venous bleed
Symptoms are often vague
Usually altered mental status
Seen more often in elderly; brain
atrophy stretches the veins, making
them more likely to tear in trauma
*Note - White area is bleeding

Intracranial Hemorrhages

Subarachnoid – sudden onset







Usually from berry aneurysm rupture
from the base of the brain; bleeding
around the brain (mixed with the
CSF)
Usual spontaneous, non-traumatic
Sudden severe headache
Vertigo
Light sensitivity
Often altered mental status
Intraparenchymal (inside brain tissue)

Traumatic bleed or spontaneous
rupture of AVM (arteriovenous
malformation)
Region X
EMS
Protocol
Stroke
Brain
Attack
Cardio-Pulmonary A&P


We need to know what is being
affected and how that is shown as
sign and/or symptoms
Knowing the following general
A&P will assist in assessment
 Veins
 Arteries
 Other tissues
Cardiac A&P review
Coronary Circulation
Coronary arteries and veins
 Myocardium extracts the largest amount of
oxygen as blood moves into general
circulation
 Oxygen uptake by the myocardium can only
improve by increasing blood flow through the
coronary arteries
 If the coronary arteries are blocked, they must
be reopened if circulation is going to be
restored to that area of tissue supplied

The Electrical Conduction
System

SA Node

AV Node

Bundle of HIS

Purkinje Fibers
The Electrical Conduction
System cont.

SA node: Fastest rate of automaticity automaticity.
“Primary” pacemaker of the heart. Rate: 60 to 100
bpm
 AV node: Has a delay which allows for atrial
contraction and a more filling of the ventricles.
Rate: 40-60 bpm (if not driven by the rate above)
 Bundle of His: Has the ability to self-initiate
electrical activity Rate: 40-60 bpm
 Purkinje Fibers: Network of fibers that carry
electrical impulses directly to ventricular muscle.
Rate: 20-40 bpm (if not driven by the rate above)
The Electrical Conduction System
in motion
Electrocardiogram (ECG/EKG)
 It’s
name is made of 3 different
parts:
electro, because it is related to
electrical activity
 cardio, Greek for heart


gram, a Greek root meaning "to write"
12-Lead Electrodes




A lead is a tracing of the electrical activity
between 2 electrodes
Leads view the heart from the front of the body
 Top, bottom, right, and left side of heart
Leads view the heart as if it were sliced in half
horizontally
 Front, back, right, and left sides of heart
Each lead has a positive and a negative electrode
12-lead ECG

A 12-lead ECG is made up of a tracing of the electrical
activity of the heart from 12 different points of view.
The point of view comes from the location of the
positive electrode of each lead. The positioning of
these electrodes is broken down into 3 categories;
The limb leads (lead I, II & III)
 The augmented leads (aVR, aVL & aVF)
 The precordial/chest leads (V1, V2, V3, V4, V5,V6)

Standard 12-Lead EKG
 Six

Leads I, II, III, aVR, aVL, aVF
 Six

limb leads
chest leads (precordial leads)
V1, V2, V3, V4, V5, V6
 Information
from 12 leads obtained from
the attachment of only 10 electrodes
Contiguous ECG Leads

EKG changes are
significant when they
are seen in at least two
contiguous leads

Two leads are
contiguous if they look
at the same area of the
heart or they are
numerically
consecutive chest leads
12-Lead Electrode Placement
Lateral Wall MI: I, aVL, V5, V6
Source: The 12-Lead ECG in Acute Coronary Syndromes, MosbyJems, 2006.
Complications of Lateral Wall MI

I, aVL, V5,V6
Complications arise due to the conduction
components that are in the septum
 Conduction dysrhythmias most common





Second degree Type II – classical
3rd degree – complete heart block
Bundle branch blocks
Monitor patient closely for these blocks

2nd degree Type II and 3rd degree are serious
dysrhythmias that need to be treated aggressively with
TCP
Inferior Wall MI: II, III, aVF
Source: The 12-Lead ECG in Acute Coronary Syndromes, MosbyJems, 2006.
Complications of Inferior Wall MI

II, III, aVF
40% of patients with inferior MI’s have right ventricular
infarcts
 In the presence of a right ventricular infarct, there is a
high likeliness of both ventricles being damaged


Contraction capabilities will be negatively affected
Patients may present hypotensive
 Nitrates and Morphine alone will dilate blood vessels
worsening hypotension
 Under Medical Control direction patients are often
treated with a fluid challenge with the nitrates
 1st degree heart block and Second degree Type I
Wenckebach most common heart blocks

Septal MI: V1 and V2
Source: The 12-Lead ECG in Acute Coronary Syndromes, MosbyJems, 2006.
Complications of Septal Wall MI
V1 and V2
 Significant amount of conduction components
are in the septal area
 Patient predisposed to dysrhythmias

Second degree Type II – classical
rd
 3 degree heart block
 Bundle branch block

Lethal heart blocks treated aggressively - TCP
 Rare to have a septal MI alone


Common to have anterior or lateral involvement
along with septal area
Anterior Wall MI: V3, V4
Source: The 12-Lead ECG in Acute Coronary Syndromes, MosbyJems, 2006.
Complications of Anterior Wall MI

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


V3, V4
Known as the “widowmaker” due to the potential
for a massive area of infarction from blockage of
the large amount of myocardium supplied by the
LAD (left anterior descending artery)
Often the septal or lateral walls are also involved
Watch for lethal ventricular dysrhythmias and
cardiogenic shock
Second degree Type II and 3rd degree heart block
are more common than other blocks
Anterior Wall MI cont.


Early death within a few days often from CHF
 Massive area of ventricular tissue infarcted if
LAD totally occluded
Important to obtain history of recent MI diagnosis
and hospital discharge

Increased incidence of ventricular
tachycardia (VT) and ventricular fibrillation
(VF) up to 1 -2 weeks post acute anterior
MI
Posterior MI: Reciprocal Changes ST
Depression V1, V2, V3, poss V4
Source: The 12-Lead ECG in Acute Coronary Syndromes, MosbyJems, 2006.
Atypical Presentation in the Elderly



Most frequent symptoms of acute MI:

Shortness of breath

Fatigue and weakness (“I just don’t feel well”)

Abdominal or epigastric discomfort
Often have preexisting conditions making this
an already vulnerable population

Hypertension

CHF

Previous AMI
Likely to delay seeking treatment
Atypical Presentation in Women

Discomfort described as:  Frequent acute symptoms:
 Aching
 Shortness of breath
 Tightness
 Weakness
 Pressure
 Unusual fatigue
 Sharpness
 Cold sweats
 Burning
 Dizziness
 Fullness
 Nausea/vomiting
 Tingling
Often have no actual chest pain to offer as a complaint.
Often the pain is in the back, shoulders, or neck
Atypical Presentation in the Patient
With Diabetes

Atypical presentation due to autonomic
dysfunction

Common signs/symptoms:
Generalized weakness
 Generalized feeling of not being well
 Syncope
 Lightheadedness
 Change in mental status

Remember…
 Watch
out for the “triple threat”
Elderly
 Female
 Diabetic history
 How many elderly women with diabetes do
you see in your facility?


Probably lots!!!
Using Region X Cardiac SOP’s
Care is initiated for all patients based on
physical assessment
 A pediatric patient is considered under the
age of 16 (15 and less)
 EMS is not to delay care to contact Medical
Control – call after care initiated
 But, prompt communication is encouraged

Region X Cardiac SOP’s cont.
Obtaining a history and performing an
assessment can often provide valuable
information
 Consider underlying causes for all situations
 In the cardiac SOP’s, think of the 6 H’s and
5 T’s as possible causes of the problem as
you progress through assessment &
treatment for the patient

6 H’s







Hypovolemia

Hypoxia

Hydrogen ion
acidosis
Hyper/hypokalemia 
(high/low potassium
levels)
Hypothermia

Hypoglycemia

Give fluids (20 ml/kg)
Provide supplemental O2
Ventilate to blow off CO2
Difficult to determine in
the field; consider in
diabetic ketoacidosis &
renal dialysis
Attempt rewarming
Check blood glucose on all
altered mental status pts
5 T’s
Toxins (overdose)
Tamponade, cardiac
Tension pneumothorax


Thrombosis, coronary
(ACS) or Thrombosis,
pulmonary (embolism)


Trauma






Think “out of the box”
Check for JVD,  B/P
Check for JVD,  B/P,
absent/decreased breath
sounds, difficulty bagging
Obtain 12 lead when
applicable; good history
taking to lead to
suspicions (travel,
surgery, immobility)
What is history of current
status?
Region X
Protocol
Acute
Coronary
Syndrome
Assessment for CO Exposure

EMS may be summoned to monitor the air
quality for the presence of carbon monoxide


Airborne CO meters are used and documentation
made whether there is a need for patient transport
or not
A more immediate concern is the level of CO
in the patient’s blood
RAD 57 monitors are a non-invasive tool that
allows results in less than 30 seconds
 Rapid diagnosis leads to rapid and appropriate
treatment

Signs and Symptoms CO Poisoning
 Carboxyhemoglobin

Mild severity
Headache
 Nausea and vomiting
 Dizziness
 Blurred vision

levels of <15 – 20%
Signs and Symptoms CO Poisoning
 Carboxyhemoglobin

Moderate severity
Confusion
 Syncope
 Chest pain
 Dyspnea
 Tachycardia
 Tachypnea
 Weakness

levels of 21 – 40%
Signs and Symptoms CO Poisoning
 Carboxyhemoglobin

Severe
Dysrhythmias
 Hypotension
 Cardiac ischemia
 Palpitations
 Respiratory arrest
 Pulmonary edema
 Seizures
 Coma
 Cardiac arrest

levels of 41 - 59%
Signs and Symptoms CO Poisoning
 Carboxyhemoglobin

Fatal
 Cherry

levels of >60%
red skin is not listed as a sign
An unreliable finding
Increased Risks

Health and activity levels can increase the risk of signs
and symptoms at lower concentrations of CO


Infants
Women who are pregnant



Elderly
Physical conditions that limit the body’s ability to use
oxygen



Fetus at greatest risk because fetal hemoglobin has a greater affinity
for oxygen and CO compared to adult hemoglobin
Emphysema, asthma
Heart disease
Physical conditions with decreased O2 carrying capacity

Anemia – iron-deficiency & sickle cell
Patient Assessment Tools

Continuously monitor SpO2 and SpCO levels
Remember that SpO2 may be falsely normal
 If EMS has a CO-oximeter (ie: Rad 57), EMS will
report the findings to the ED staff


Generally, results >3% indicate suspicion for
CO exposure in non-smoker
Cardiac monitor
 12 lead EKG obtained and transmitted to ED

Pulse Oximetry
Device to analyze infrared signals
 Measures the percentage of oxygenated
hemoglobin (saturated Hgb)
 Can mistake carboxyhemoglobin for
oxyhemoglobin and give a false normal
level of oxyhemoglobin
 Never rely just on the pulse oximetry
reading; always correlate with clinical
assessment

Pulse CO-oximeter Device
(ie: RAD 57)



Hand-held device
Attaches to a finger tip similar to pulse ox
device
Most commonly measured gases in
commercial devices include
Carbon monoxide (SpCO)
 Oxygen (SpO2)
 Methemoglobin (SpMet)



Other combustible gases
Without the device, need to draw a venous
sample of blood to test for CO levels
Pulse CO-oximeter Tool

Firefighters have an increased exposure risk
Active firefighting
 Inhaled products of combustion in structure fire
 Inhaled exhaust from vehicles and power tools


Rehab operations more efficient when
firefighter can be screened at the scene and
released back to duty

Pulse rate, oxygen saturation, carboxyhemoglobin
level evaluated
Treatment CO Poisoning
Increasing the concentration of inhaled
oxygen can help minimize the binding of CO
to hemoglobin
 Some CO may be displaced from hemoglobin
when the patient increases their inhaled
oxygen concentrations
 Treatment begins with high index of
suspicion and removal to a safer environment
 Immediately begin 100% O2 delivery

Treatment CO Poisoning

Some guidelines indicate to initiate treatment
when SpCO levels exceed 10%; some at 12%
Treatment levels vary significantly
 If you do not have a CO-oximeter to use,
maintain a heightened level of suspicion and base
treatment on symptoms


Monitor for complications related to CO
exposure
Seizures
 Cardiac dysrhythmias
 Cardiac ischemia

CO Poisoning and CPAP
 CPAP
could assist in fully oxygenating
hemoglobin
 If considered, EMS must call Medical
Control for permission to use CPAP
ECRN will obtain report with patient
information
 ECRN must discuss with ED MD to
obtain order to use CPAP in the field

Region
X SOP
CO /
Smoke
Inh
Additions to CO / Smoke Inhalation
SOP




SpCO levels < 5% 3 - not treatment
SpCO levels ≥ 5% with symptoms 4
 100% O2; ED evaluation
SpCO levels ≥ 10%
 100% O2; ED evaluation
SpCO levels ≥ 25%
 100% O2; ED evaluation
 Consider hyperbaric chamber
Footnotes: see next page
Key Comments of CO / Smoke
Inhalation SOP
2. Do not rely on pulse oximetry to indicate degree of hypoxia with
CO exposure and consider cyanide poisoning in presence of
smoke / fire situations. See Carbon Monoxide/Smoke Inhalation
SOP.
3. A normal SpCO level does not negate the need for further
management of the symptomatic patient as other diagnoses may
still be present.
4. ≥ 5% Mild headache
6-10% Mild headache, shortness of breath with exertion
11-20% Moderate headache, shortness of breath
21-30% Worsening headache, nausea, dizziness, fatigue
31-40% Severe headache, vomiting, vertigo, altered judgment
41-50% Confusion, syncope, tachycardia
51-60% Seizures, shock, apnea, coma
NOTE: If indicated, consider conscious sedation intubation.
Consider cyanide poisoning in presence of smoke/fire situations.
Case #1
45 year-old patient who complains of chest
heaviness & lightheadedness
 VS: 90/56; P – 86; R - 22
 Is there ST elevation (EKG next slide):
 If so, where?


What are you going to do for this patient?
Case #1 – ST ElevationV2 – V5
Case #2




Patient’s spouse called EMS
Patient dropping silverware at lunch, unable to sit
up straight, unable to complete sentences
Vital signs: 170/110; P – 64; R – 16; GCS -14
EKG monitor below
Case #2
What is your impression?
 What is the cardiac rhythm?

Atrial fibrillation
 How does this rhythm relate to any impressions?


What assessments need to be done?
Blood sugar level for all patients with altered level
of consciousness
 Cincinnati stroke scale

Case #2

Cincinnati stroke scale
Ask the patient to smile real big showing you
their teeth
 Ask the patient to put their hands out in front,
palms up, and close their eyes



Hold the position for 10 seconds
Ask the patient to repeat a saying

“You can’t teach an old dog new tricks”
Case #2

What’s the most important question to ask
the patient?
 When
did the symptoms begin?
Case #3
58 year-old male patient who complains of
chest pain radiating down the left arm after
working out in the gym
 VS: 110/72; P – 100; R - 18
 Is there ST elevation (EKG next slide):
 If so, where?


What are you going to do for this patient?
Case #3 – ST Elevation II, III, aVF
Case #4
36 year-old patient who passed out standing
in line at a bank
 VS: 128/78; P – 80; R - 20
 Is there ST elevation (EKG next slide):
 If so, where?


What are you going to do for this patient?
Case #4 – ST elevation II, III, aVF
Case #5

Received call from a 10 year-old child that he could
not wake up his mother. On arrival the 34 year-old
female was unconscious with signs of seizure
activity. 2 other children are in the home.
What are your general
impressions/suspicions?
 What is included in your assessment?
 What is your treatment?

Case #5




Upon scene arrival, a faint odor of exhaust was
noted
Evaluate the patient for normal reasons of altered
level of consciousness including history of seizure
disorder and suicide attempt
After 5 minutes on scene, rescue personnel began
complaining of headache
A car was found running in the garage directly
under the bedroom/bathroom
Bibliography



Various on-line photos
eHow.com
Previous EMS CE packets




2006 Condell CE Module
February 2009 Condell CE
February LFFD CE add-on (Jon Bardi)
CMC SOP pages