1. Ch. 15: Cardiovascular Emergencies

2. The Heart Enclosed in pericardial sac Myocardium = heart muscle
Four chambers: two atria, two ventricles
Sides divided by septum
Atrioventricular valves: tricuspid and mitral
Semilunar valves: pulmonic and aortic
Electrical pathways cause contractions

4. Blood Vessels
Carry blood to and from the heart
Arteries: transport blood away from the heart
Aorta: largest artery in the body
Veins: bring blood to the heart
Super and inferior venae cavae
Capillaries: connect arteries and veins
Aorta – Arteries – Arterioles – Capillaries – Venules – Veins – Venae Cavae

5. Major Arteries
Major Veins

6. Blood Transports materials from one area of the body to another
Oxygen, CO2, protein building blocks, sugars, fats, hormones, waste products, etc
When engaging in physical activity, body needs more oxygen and nutrients than when at rest – heart must pump blood faster

8. © Catherine R. Gordon

9. Cardiovascular Emergencies
Most causes of CV system failure traced back to cardiovascular disease (CVD)
CVD leading cause of death worldwide
More than 1/3 of adult population in US has CVD.
Most cases of CVD attributed to coronary artery disease or atherosclerosis

10. Atherosclerosis “Hardening of the arteries”
Plaques form and build up along the inner lining of the arteries.
Heart doesn’t receive the oxygen and nutrients it needs, which causes the heart muscle to die
End result of plaque build up is coronary artery disease.
Angina pectoris
Leads to hypertension, heart failure, AMI, and sudden cardiac death.

11. Figure The progression of artery occlusion in atherosclerosis: (a) the patient's risk factors and other factors cause the inner wall to be damaged; (b) fatty deposits develop, which lead to (c) fibrous plaque, which further occludes the vessel's internal diameter; (d) platelets aggregate in these areas, forming blood clots that nearly or completely occlude the artery.

12. Hypertension Abnormally elevated blood pressure, over 140/90
Internal diameters of small arterioles narrow due to atherosclerosis or other cause that restricts blood flow through arteries
Vessel narrowing causes pressure to build
Damages blood vessels over time
Affects nearly 1B people worldwide; 1/3 in the US
If untreated, it can lead to stroke and kidney failure, and more

13. Pulmonary Edema Accumulation of fluid in the lungs
Caused by severe left-sided congestive heart failure, which in turn results from acute MI, direct trauma to the lungs, certain medical conditions, and certain drugs
As the condition worsens, the patient goes into cardiogenic shock from profound hypoxia

14. Congestive Heart Failure
Occurs when the heart can’t adequately pump blood to the body
Blood backs up into major blood vessels leading to heart, and subsequently into organs
Right-sided heart failure results in back-up into the systemic circulation, and then the dependent tissues, esp. the ankles and feet
Left-sided heart failure causes back-up into the lungs, resulting in pulmonary edema

15. S/S: Congestive Heart Failure
S/S depend on the side affected.
Right heart failure: swollen ankles that can progress up the leg, often with “pitting edema.”
Left heart failure: Shortness of breath is common. If onset is rapid, it can be life-threatening.
Patients can have right and left CHF simultaneously.

16. Angina Pectoris
Chest pain/discomfort caused by ischemia of the myocardium
Occurs when the oxygen demands of the heart exceed the available supply
Common occurrence in people with CAD due to narrowing of the arteries
Can also be caused by vasoconstriction or spasm of the coronary arterie

17. Acute Myocardial Infarction (AMI)
Mostly (90%) caused by blood clots that in turn cause blockage of the coronary arteries.
The result is ischemia and death of heart muscle served by the affected coronary artery(ies).
If enough tissue dies, life is threatened because the heart can’t pump

19. S/S: AMI Chest pain can be crushing or heavy, stationary or radiating.
Women have painless MI more often than men.
S/S can include anxiety, dizziness, nausea, diaphoresis, feeling of impending doom

21. Aortic Aneurysm A ballooning outwards of the aorta S/S:
Two types: abdominal and thoracic
S/S:
Abdominal pain radiating to the groin/back
Dizziness
Abdomen may be tender, with a pulsatile mass
Ruptured? Profound shock with hypotension and diaphoresis

22. Cardiogenic Shock Caused by damage to myocardium
Heart’s output of blood reduced
Blood pressure cannot be maintained

23. S/S: Cardiogenic Shock
Patients appear deathly ill and in shock: pale skin, diaphoresis, anxiety, respiratory distress.
If caused by AMI, the patient will be tachycardic and hypotensive
If caused by abnormal heart rhythm, the patient might be bradycardic, or tachycardic and hypotensive.

24. Pericardial Tamponade
Occurs when excess fluid builds up in the pericardial space
Compresses heart, can’t pump adequately
PT is life-threatening, requires emergency fluid removal

25. S/S: Pericardial Tamponade
Shortness of breath, anxiety or restlessness, and pale, cool, diaphoretic skin
Chest pain is common
Hypotension, distended neck veins, and muffled/distant heart tones
Patient might present with only fatigue and tachycardia.

26. Pulmonary Embolism One of the most lethal forms of thromboembolism
Passage of a blood clot (thrombus) formed in a vein through right side of heart and into pulmonary artery where it lodges
Deep venous thrombosis
Decreases or blocks blood flow—no exchange of oxygen or CO2
Arterial carbon dioxide increases, oxygen decreases
Inhibits circulation

27. S/S: Pulmonary Embolism
Sudden onset of chest pain
Shortness of breath
Tachycardia
Sharp pain that increases with deep breaths
Cyanosis and hypoxia
S/S DVT:
Severe pain, tenderness to touch, swelling in one leg

28. Sudden Cardiac Arrest (SCA)
Abrupt cessation of effective pumping of blood from heart to coronary arteries, brain, and other vital organs
Caused by AMI, ventricular fibrillation, pulseless ventricular tachycardia, asystole.

29. Arrhythmias
Irregular heart beat or heart rhythm, which can compromise normal heart function
Primary cause of life-threatening arrhythmia is ischemia of myocardium
Life-threatening arrhythmias (can lead to SCA):
Ventricular fibrillation: chaotic and ineffective contraction of that ventricles that leads to cardiac arrest
Ventricular tachycardia: rapid contraction of the ventricles that can lead to ineffective blood flow to body tissues, cardiac arrest
Asystole: complete absence of a heartbeat due to lack of electrical activity within the heart

30. Assessment Scene safety Primary assessment: ABCDs
Patients in SCA will be unresponsive, apneic, pulseless – immediately begin CPR
Secondary assessment: SAMPLE history, pay close attention to complaints of chest pain and any medications (esp. nitroglycerin or aspirin)
Patient may have difficulty communicating, talk to relative
Assess chest pain using OPQRST (cardiac pain usually described as either “heavy,” “crushing,” or “tight.”
If pain radiates into jaw or down arm, may indicate AMI
Detailed secondary physical exam
Check pulse, blood pressure, skin condition, capillary refill, level of responsiveness – evidence as to whether not tissue perfusion is effective
Assess skin for color, temperature, diaphoresis (with chest pain may indicate that heart is ischemic.
Listen to breath sounds
Reassess patient and vital signs
Every 3-5 mins if patient is unstable
Every mins if patient is stable

31. Management Evaluate ABCs and treat problems as they are found
If patient is in cardiac arrest:
Time is of the essence – Golden Hour
Request ALS immediately, and call for oxygen and an AED.
Begin CPR.

32. Management Chain of Survival
Immediate recognition of cardiac arrest, activation of EMS
Early CPR emphasizing chest compressions
Rapid defibrillation if indicated
Early, effective ALS
Integrated post-cardiac arrest care

33. Management CVD Patient NOT in Cardiac Arrest
Call for immediate assistance, oxygen, AED, and ALS.
Keep patient calm, put in position of comfort.
If hypotensive, keep supine and warm, and elevate legs
If CHF, sit patient up and put legs in dependent position

34. Other Considerations Medications: Implantable devices may be in place
Plavix: anti-platelet to prevent formation of clots
Nitroglycerin: vasodilator
Coumadin: blood thinner
Lipitor: lowers harmful cholesterol levels
Cordarone: diuretic that removes excess fluid from the body
Implantable devices may be in place
High flow oxygen therapy is crucial
Nitroglycerin -- assist patient if they have their prescription with them and conditions/protocols allow
Aspirin -- assist patient if they have aspirin and protocols allow for it