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

Electrical System of the Heart

Coronary Arteries

Coronary Arteries

Blood Flow

Blood

Chest pain results from ischemia 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.

Typically crushing or squeezing pain 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.

ALS has been dispatched. 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.

You are the Provider (continued) 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)

Is the patient responsive? Scene Size-up Scene size-up General impression Is the patient responsive?

Chief complaint on responsive patients 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

Is the patient a life threat? Stable patients 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 are the Provider (continued) 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

Cardiac and respiratory systems Look for skin changes. Lung sounds Focused Physical Exam Cardiac and respiratory systems Look for skin changes. Lung sounds Baseline vital signs BOTH systolic and diastolic BP readings

Relay history, vital signs, changes, medications, and treatments. 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. © Photos.com

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

Repeat initial assessment. Reassess vital signs every 5 minutes. 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.

Read operator’s manual. 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.

Should approve protocols Should review AED usage 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.

If the machine advises a shock, deliver a second shock. Using an AED (5 of 8) After the shock is delivered, most AEDs will automatically reanalyze the rhythm; if not, push the analyze button again. If the machine advises a shock, deliver a second shock. Reanalyze the rhythm. If the machine advises a shock, deliver a third shock.

Using an AED (6 of 8) Check for pulse. 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 high-concentration oxygen. Transport.

Using an AED (8 of 8) If the patient has no pulse, perform 1 minute of CPR. Gather additional information on the arrest event. After 1 minute of CPR, make sure no one is touching the patient. Push the analyze button again (as applicable). If necessary, repeat one cycle of up to three stacked shocks. 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. If a patient has a pulse but breathing is inadequate, assist ventilations.

Transport Considerations 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.