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12: Cardiovascular Emergencies
Cognitive Objectives
(1 of 11)
4-3.1 Describe the structure and function of the
cardiovascular system.
4-3.2 Describe the emergency medical care of the
patient experiencing chest pain/discomfort.
4-3.3 List the indications for automated external
defibrillation (AED).
4-3.4 List the contraindications for automated external
defibrillation.
4-3.5 Define the role of EMT-B in the emergency
cardiac care system.
Cognitive Objectives
(2 of 11)
4-3.6 Explain the impact of age and weight on
defibrillation.
4-3.7 Discuss the position of comfort for patients with
various cardiac emergencies.
4-3.8 Establish the relationship between airway
management and the patient with cardiovascular
compromise.
4-3.9 Predict the relationship between the patient
experiencing cardiovascular compromise and basic
life support.
Cognitive Objectives
(3 of 11)
4-3.10 Discuss the fundamentals of early
defibrillation.
4-3.11 Explain the rationale for early defibrillation.
4-3.12 Explain that not all chest pain patients result in
cardiac arrest and do not need to be attached to an
automated external defibrillator.
4-3.13 Explain the importance of prehospital ACLS
intervention if it is available.
Cognitive Objectives
(4 of 11)
4-3.14 Explain the importance of urgent transport to a
facility with Advanced Cardiac Life Support if it is
not available in the prehospital setting.
4-3.15 Discuss the various types of automated
external defibrillators.
4-3.16 Differentiate between the fully automated and
the semiautomated defibrillator.
4-3.17 Discuss the procedures that must be taken
into consideration for standard operations of the
various types of automated external defibrillators.
Cognitive Objectives
(5 of 11)
4-3.18 State the reasons for assuring that the patient
is pulseless and apneic when using the automated
external defibrillator.
4-3.19 Discuss the circumstances which may result in
inappropriate shocks.
4-3.20 Explain the considerations for interruption of
CPR when using the automated external
defibrillator.
4-3.21 Discuss the advantages and disadvantages of
automated external defibrillators.
Cognitive Objectives
(6 of 11)
4-3.22 Summarize the speed of operation of
automated external defibrillation.
4-3.23 Discuss the use of remote defibrillation
through adhesive pads.
4-3.24 Discuss the special considerations for rhythm
monitoring.
4-3.25 List the steps in the operation of the
automated external defibrillator.
Cognitive Objectives
(7 of 11)
4-3.26 Discuss the standard of care that should be
used to provide care to a patient with persistent
ventricular fibrillation and no available ACLS.
4-3.27 Discuss the standard of care that should be
used to provide care to a patient with recurrent
ventricular fibrillation and no available ACLS.
4-3.28 Differentiate between the single rescuer and
multi-rescuer care with an automated external
defibrillator.
Cognitive Objectives
(8 of 11)
4-3.29 Explain the reason for pulses not being
checked between shocks with an automated
external defibrillator.
4-3.30 Discuss the importance of coordinating ACLS
trained providers with personnel using automated
external defibrillators.
4-3.31 Discuss the importance of postresuscitation
care.
4-3.32 List the components of postresuscitation care.
Cognitive Objectives
(9 of 11)
4-3.33 Explain the importance of frequent practice
with the automated external defibrillator.
4-3.34 Discuss the need to complete the Automated
Defibrillator: Operator’s Shift Checklist.
4-3.35 Discuss the role of the American Heart
Association (AHA) in the use of automated external
defibrillation.
4-3.36 Explain the role medical direction plays in the
use of automated external defibrillation.
Cognitive Objectives
(10 of 11)
4-3.37 State the reasons why a case review should
be completed following the use of the automated
external defibrillator.
4-3.38 Discuss the components that should be
included in a case review.
4-3.39 Discuss the goal of quality improvement in
automated external defibrillation.
4-3.40 Recognize the need for medical direction of
protocols to assist in the emergency medical care
of the patient with chest pain.
Cognitive Objectives
(11 of 11)
4-3.41 List the indications for the use of nitroglycerin.
4-3.42 State the contraindications and side effects for
the use of nitroglycerin.
4-3.43 Define the function of all controls on an
automated external defibrillator, and describe event
documentation and battery defibrillator
maintenance.
Affective Objectives
4-3.44 Defend the reasons for obtaining initial training
in automated external defibrillation and the
importance of continuing education.
4-3.45 Defend the reason for maintenance of
automated external defibrillators.
4-3.46 Explain the rationale for administering
nitroglycerin to a patient with chest pain or
discomfort.
Psychomotor Objectives (1 of 2)
4-3.47 Demonstrate the assessment and emergency
medical care of a patient experiencing chest
pain/discomfort.
4-3.48 Demonstrate the application and operation of
the automated external defibrillator.
4-3.49 Demonstrate the maintenance of an
automated external defibrillator.
4-3.50 Demonstrate the assessment and
documentation of patient response to the
automated external defibrillator.
Psychomotor Objectives (2 of 2)
4-3.51 Demonstrate the skills necessary to complete
the Automated Defibrillator: Operator’s Shift
Checklist.
4-3.52 Perform the steps in facilitating the use of
nitroglycerin for chest pain or discomfort.
4-3.53 Demonstrate the assessment and
documentation of patient response to nitroglycerin.
4-3.54 Practice completing a prehospital care report
for patients with cardiac emergencies.
Cardiovascular Emergencies
• Cardiovascular disease (CVD) claimed 931,108
lives in the US during 2001.
– 2,551 per day
– Almost two people per minute!
• CVD accounts for 38.5% of all deaths.
– One of every 2.6 deaths
Blood Flow Through the Heart
Electrical System of the Heart
Coronary Arteries
Blood Flow
Blood
Cardiac Compromise
• Chest pain results from ischemia
• Ischemic heart disease involves decreased
blood flow to the heart.
• If blood flow is not restored, the tissue dies.
Atherosclerosis
• Materials build up inside
blood vessels.
• This decreases or
obstructs blood flow.
• Risk factors place a
person at risk.
Angina Pectoris
• Pain in chest that occurs when the heart does not
receive enough oxygen
• Typically crushing or squeezing pain
• Rarely lasts longer than 15 minutes
• Can be difficult to differentiate from heart attack
Heart Attack
• Acute myocardial
infarction (AMI)
• Pain signals death of
cells.
• Opening the coronary
artery within the first hour
can prevent damage.
• Immediate transport is
essential.
Signs and Symptoms
• Sudden onset of weakness, nausea, sweating
without obvious cause
• Chest pain/discomfort
– Often crushing or squeezing
– Does not change with each breath
• Pain in lower jaw, arms, back, abdomen, or neck
• Sudden arrhythmia with syncope
• Shortness of breath or dyspnea
• Pulmonary edema
• Sudden death
Pain of Heart Attack
• May or may not be caused by exertion
• Does not resolve in a few minutes
• Can last from 30 minutes to several hours
• May not be relieved by rest or nitroglycerin
Sudden Death
• 40% of AMI patients do not reach the hospital.
• Heart may be twitching.
Arrhythmias
Bradycardia
Ventricular Tachycardia
Cardiogenic Shock
• Heart lacks power to force blood through the
circulatory system.
• Onset may be immediate or not apparent for 24
hours after AMI.
Congestive Heart Failure
•
•
•
•
•
CHF occurs when ventricles are damaged.
Heart tries to compensate.
Increased heart rate
Enlarged left ventricle
Fluid backs up into lungs or body as heart
fails to pump.
You are the Provider
• You are a volunteer EMT-B in a rural area. You are
dispatched to an older man complaining of severe
chest pain.
• ALS has been dispatched.
• You arrive to find the patient clutching his chest.
The pain is the worst he has ever had.
• The patient has nitroglycerin but has not taken it
yet.
• What is wrong with this patient?
• What must you know before administering any
medication?
• What must you specifically know before assisting a
patient with nitroglycerin?
You are the Provider (continued)
Scene Size-up
• Scene size-up
• General impression
– Is the patient responsive?
Initial Assessment
• Chief complaint on responsive patients
• A chief complaint of chest discomfort, shortness of
breath, or dizziness must be taken seriously.
• Airway and breathing
• Circulation
Transport Decision
• Is the patient a life threat?
• Stable patients
– Transport in gentle manner.
– Avoid lights and siren.
– Do not let patient exert or strain self.
• Specialty facilities
• You obtain a brief history while taking the patient’s
blood pressure.
• Your partner retrieves the nitroglycerin and obtains
permission from medical control.
• Your partner administers the nitroglycerin.
• What else can you do at this time?
You are the Provider
(continued)
Focused History and Physical Exam
•
•
•
•
SAMPLE
OPQRST
Medications are important!
Medications often prescribed for CHF:
– Furosemide
– Digoxin
– Amiodarone
Focused Physical Exam
•
•
•
•
Cardiac and respiratory systems
Look for skin changes.
Lung sounds
Baseline vital signs
– BOTH systolic and diastolic BP readings
Communication
Relay history, vital signs, changes, medications,
and treatments.
Aspirin
• Administer according to local protocol.
• Prevents clots from becoming bigger
• Normal dosage is from 162 to 324 mg.
Nitroglycerin
• Forms
– Pill, spray, skin patch
• Effects
– Relaxes blood vessel
walls
– Dilates coronary arteries
– Reduces workload of
heart
Nitroglycerin Contraindications
• Systolic blood pressure of less than
100 mm Hg
• Head injury
• Maximum dose taken in past hour
Nitroglycerin Potency
• Nitroglycerin loses potency over time.
– Especially if exposed to light
• When nitroglycerin tablets lose potency:
– May not feel the fizzing sensation
– May not experience the burning sensation and
headache
• Fizzing only occurs with a potent tablet, not in the
spray form.
Assisting With Nitroglycerin (1 of 4)
• Obtain order from medical direction.
• Take patient’s blood pressure.
Assisting With Nitroglycerin (2 of 4)
• Check that you have right medication, patient, and
delivery route.
• Check expiration date.
• Find out last dose taken and effects.
• Be prepared to lay the patient down.
Assisting With Nitroglycerin (3 of 4)
• Administer tablet or spray under tongue.
• Have patient keep mouth closed until tablet
dissolves or is absorbed.
Assisting With Nitroglycerin (4 of 4)
•
•
•
•
Recheck blood pressure.
Record each activity and time of application.
Reevaluate and note response.
May repeat dose in 3 to 5 minutes.
Detailed Physical Exam
• Perform if time allows.
• Do not gather information unless:
– Patient’s condition is stable
– Everything else is done
Ongoing Assessment
•
•
•
•
Repeat initial assessment.
Reassess vital signs every 5 minutes.
Monitor closely.
If cardiac arrest occurs, begin defibrillation or CPR
immediately.
• Record interventions, instructions from medical
control, patient’s response.
• Obtain medical control physician’s signature.
You are the Provider
(continued)
• ALS arrives and you report your interventions and
vital signs.
• ALS performs cardiac monitoring and prepares for
morphine administration.
• The patient’s pain is gone by the time you reach
the hospital.
Heart Surgeries and Pacemakers
• Coronary artery bypass graft (CABG)
• Angioplasty
• Cardiac pacemaker
Automatic Implantable Cardiac
Defibrillators (1 of 2)
• Maintains a regular
heart rhythm and
rate
• Do not place AED
patches over
pacemaker.
Automatic Implantable Cardiac
Defibrillators (2 of 2)
• Monitor heart rhythm
and deliver shocks as
needed.
• Low electricity will not
affect rescuers.
Cardiac Arrest
• The complete cessation of cardiac activity, either
electrical, mechanical, or both.
Automated External Defibrillator
(AED)
• AEDs come in various models.
• Some operator interaction
required.
• A specialized computer
recognizes heart rhythms that
require defibrillation.
Potential AED Problems
• Battery is dead.
• Patient is moving.
• Patient is responsive and
has a rapid pulse.
AED Advantages
• ALS providers do not need to be on
scene.
• Remote, adhesive defibrillator pads
are used.
• Efficient transmission of electricity
Non-Shockable Rhythms
• Asystole
• Pulseless electrical activity
Rationale for Early Defibrillation
• Early defibrillation is the third link
in the chain of survival.
• A patient in ventricular fibrillation
needs to be defibrillated within 2
minutes.
AED Maintenance
•
•
•
•
Read operator’s manual.
Check AED and battery at beginning of each shift.
Get a checklist from the manufacturer.
Report any failures to the manufacturer and the
FDA.
Medical Direction
• Should approve protocols
• Should review AED usage
• Should review speed of defibrillation
• Should provide review of skills every 3 to 6 months
Preparation
•
•
•
•
•
•
Make sure the electricity injures no one.
Do not defibrillate a patient lying in pooled water.
Dry a soaking wet patient’s chest first.
Do not defibrillate a patient who is touching metal.
Remove nitroglycerin patches.
Shave a hairy patient’s chest if needed.
Using an AED (1 of 8)
• Assess responsiveness.
• Stop CPR if in progress.
• Check breathing and pulse.
• If patient is unresponsive
and not breathing
adequately, give two slow
ventilations.
Using an AED (2 of 8)
• If there is a delay in
obtaining an AED, have
your partner start or
resume CPR.
• If an AED is close at
hand, prepare the AED
pads.
• Turn on the machine.
Using an AED (3 of 8)
• Remove clothing from
the patient’s chest
area. Apply pads to the
chest.
• Stop CPR.
• State aloud, “Clear the
patient.”
Using an AED (4 of 8)
• Push the analyze
button, if there is one.
• Wait for the computer.
• If shock is not needed,
start CPR.
• If shock is advised,
make sure that no one
is touching the patient.
• Push the shock button.
Using an AED (5 of 8)
• After the shock is delivered, begin 5 cycles of CPR,
beginning with chest compressions.
• After 5 cycles, reanalyze patient’s rhythm.
• If the machine advises a shock, clear the patient
and push shock button.
• If no shock advised, check for pulse.
Using an AED (6 of 8)
• If the patient has a
pulse, check breathing.
• If the patient is
breathing adequately,
provide oxygen via
nonrebreathing mask
and transport.
Using an AED (7 of 8)
• If the patient is not
breathing adequately,
use necessary airway
adjuncts and proper
positioning to open
airway.
• Provide artificial
ventilations with highconcentration oxygen.
• Transport.
Using an AED (8 of 8)
• If the patient has no pulse, perform 2 minutes of CPR.
• Gather additional information on the arrest event.
• After 2 minutes of CPR, make sure no one is touching
the patient.
• Push the analyze button again (as applicable).
• If necessary, repeat alternating CPR/Analyze/Shock
until ALS arrives.
• Transport and check with medical control.
• Continue to support the patient as needed.
After AED Shocks
•
•
•
•
Check pulse.
No pulse, no shock advised
No pulse, shock advised
If a patient is breathing independently:
– Administer oxygen.
– Check pulse.
• If a patient has a pulse but breathing is
inadequate, assist ventilations.
Transport Considerations
• Transport:
– When patient regains pulse
– After delivering six to nine shocks
– After receiving three consecutive “no
shock advised” messages
• Keep AED attached.
• Check pulse frequently.
• Stop ambulance to use an AED.
Cardiac Arrest During Transport (1 of 2)
• Check unconscious patient’s pulse every 30 seconds.
• If pulse is not present:
– Stop the vehicle.
– Perform CPR until AED is available.
– Analyze rhythm.
– Deliver shock(s).
– Continue resuscitation according to local protocol.
Cardiac Arrest During Transport (2 of 2)
• If patient becomes unconscious during transport:
– Check pulse.
– Stop the vehicle.
– Perform CPR until AED is available.
– Analyze rhythm.
– Deliver up to three shocks.
– Continue resuscitation according to local protocol.