18 Cardiac Emergencies.

18 Cardiac Emergencies

Multimedia Directory Slide 102 Ventricular Fibrillation and AED Video Slide 103 Cardiac Arrest Animation Slide 104 AED Video Slide 105 Coronary Heart Disease Video These videos appear later in the presentation; you may want to preview them prior to class to ensure they load and play properly. Click on the links above in slideshow view to go directly to the slides.

Topics Cardiac Anatomy and Physiology Acute Coronary Syndrome
Causes of Cardiac Conditions Cardiac Arrest Planning Your Time: Plan 180 minutes for this chapter. Cardiac Anatomy and Physiology (20 minutes) Acute Coronary Syndrome (20 minutes) Causes of Cardiac Conditions (70 minutes) Cardiac Arrest (70 minutes) Note: The total teaching time recommended is only a guideline. Core Concepts: Aspects of acute coronary syndrome (ACS) Conditions that may lead to a cardiac emergency Cardiac arrest and the chain of survival Management of a cardiac arrest patient Use of an automated external defibrillator (AED) Special considerations in AED use Use of mechanical cardiopulmonary resuscitation (CPR) devices

Cardiac Anatomy and Physiology
Teaching Time: 20 minutes Teaching Tips: Students should review the cardiovascular section of Chapter 6 prior to beginning this chapter. This section lends itself well to video graphics. Excellent anatomy and physiology websites abound and may significantly enhance understanding of these concepts. Use anatomical models or even cow or pig hearts to add a "hands on" element to this discussion. Relate the heart to the concept of blood pressure. Discuss the importance of pressure within the cardiovascular system.

Review of the cardiovascular system: Flow of blood through the chambers of the heart Cardiac conductive system Composition of the blood Flow of blood through arteries, veins, arterioles, venules, and capillaries Covers Objective: 18.2 Point to Emphasize: Adequate pumping of the heart is necessary to maintain pressure within the cardiovascular system. When the pump fails, shock occurs. Discussion Topics: Discuss how pressure within the cardiovascular system is maintained. Describe how a loss of pressure within the cardiovascular system might affect a patient. Describe the heart's electrical conduction system. Knowledge Applications: Have students label a blank diagram of the heart, either in class or as an online assignment. As this section is primarily a review, assign small groups of students specific topics and have them review anatomy and physiology concepts with the class. Class Activity: Use cell phone technology to create a model of the cardiac conduction system. Assign roles and have students text each other a specific message in a manner that models the depolarization of the heart. continued on next slide

Review of the cardiovascular system: Circulation of blood between heart and lungs, and between heart and the rest of body How heart function and circulation of blood relate to pulse and blood pressure Shock (hypoperfusion) Covers Objective: 18.2 Knowledge Applications: Dissect a pig or cow heart. Obtain hearts from a local butcher and allow students to visualize the structures of the heart. Assign an online scavenger hunt. Ask students to research and present the best cardiac anatomy and physiology graphic that they can find. Remind students to give credit to the source. Critical Thinking: How does the presence of a radial pulse demonstrate a functioning heart? How does blood pressure relate to the function of the heart?

Four Chambers of the Heart
Covers Objective: 18.2 Discussion Topics: Describe the flow of blood through the heart. Describe how deoxygenated blood becomes oxygenated and is distributed out to the body. Class Activity: Have the class act out the flow of blood through the heart. Assign roles and have students act out the various steps. Cross-section of the heart showing chambers, layers, valves, and major associated blood vessels.

Four Chambers of the Heart
Covers Objective: 18.2 Discussion Topics: Describe the flow of blood through the heart. Describe how deoxygenated blood becomes oxygenated and is distributed out to the body. Class Activity: Have the class act out the flow of blood through the heart. Assign roles and have students act out the various steps. The path of blood flow through the heart.

Think About It How does the normal function of the heart and blood vessels relate to blood pressure and distal pulses? How is shock related to the function of the heart and blood vessels? Covers Objective: 18.2 Talking Points: The heart is the pump and the blood vessels are the container for blood and the cardiovascular system as a whole. The size of the container and the force of the pump create pressure within this system to circulate blood. This pressure is measurable when we use a sphygmomanometer and assess blood pressure and it is also palpable by feeling for distal pulses. Shock occurs when pressure within this system falls and blood fails to circulate properly.

Acute Coronary Syndrome
Teaching Time: 20 minutes Teaching Tips: Relate the signs and symptoms of acute coronary syndrome (ACS) to anatomy and physiology discussions. Describe how ACS interferes with normal function and how this dysfunction manifests as symptoms. Reinforce the need to "cast a wide net." In many cases it will not be possible to rule out ACS in the field. EMTs always should err on the side of caution and treat more aggressively, not less. Describe the mechanism of action of oxygen, nitroglycerine, and aspirin. Discuss why they are important to an ACS patient. Invite a member of a cardiac catheterization team to class to discuss definitive treatment of a blocked artery. Relate this treatment to the actions of prehospital providers.

Sometimes called cardiac compromise Refers to any time the heart may not be getting enough oxygen Many different kinds of problems under the ACS heading Covers Objective: 18.3 Point to Emphasize: Acute coronary syndrome (ACS) is a blanket term that refers to any time that the heart may not be getting enough oxygen. Discussion Topic: Define acute coronary syndrome. continued on next slide

Symptoms often mimic non-cardiac conditions. Treat all patients with ACS-like signs and symptoms as though they are having a heart problem. Covers Objective: 18.3 Point to Emphasize: An EMT should treat all patients with ACS-like signs and symptoms as though they are having a heart problem. Knowledge Application: Have each student plot out a definitive care strategy for an ACS patient in his area. Have students describe transport decisions and what the most effective treatment would be based upon their local geography and care options. continued on next slide

Chest pain is best-known symptom. Can be described as crushing, dull, heavy, or squeezing Sometimes described only as pressure or discomfort Radiates along arms, down to upper abdomen, or up to jaw Covers Objective: 18.3 Knowledge Application: Invite ACS patients to class, or visit a cardiac rehab center. Have students interview patients and discuss the symptoms of ACS. Critical Thinking: Why is "casting a wide net" so important with regard to ACS patients? Why is it so important to err on the side of a cardiac problem? continued on next slide

Dyspnea also found in ACS May be the only finding in some patients Covers Objective: 18.3

Other symptoms Anxiety, feeling of impending doom Nausea and pain or discomfort in upper abdomen (epigastric pain) Sudden onset of sweating Abnormal pulse (tachycardia/bradycardia) Abnormal blood pressure Covers Objective: 18.3 Point to Emphasize: Chest discomfort, dyspnea, nausea, and anxiety are common symptoms of ACS, but not all ACS patients present with common symptoms. Discussion Topic: Describe the common symptoms of acute coronary syndrome. Discuss specific populations in which "common symptoms" are not so common.

Management of Acute Coronary Syndrome
Patient assessment Perform primary assessment. Obtain history and physical exam. Use OPQRST to get history of present illness. Obtain past medical history. Take baseline vital signs. Covers Objective: 18.3 continued on next slide

Patient care Place patient in position of comfort (typically sitting up). Determine if oxygen should be administered. Transport. Covers Objective: 18.4 Points to Emphasize: In the past everyone with chest pain or discomfort was given oxygen by nonrebreather mask. You may hear people talk about this or even see protocols that still mention high-concentration oxygen. Laboratory and animal studies suggest that administering more oxygen than necessary may lead to the production of certain chemical entities that can be harmful. The current recommendation is to administer only enough oxygen to bring that patient's oxygen saturation level up to 94 percent.

Treatment Covers Objective: 18.4 Points to Emphasize: In the past everyone with chest pain or discomfort was given oxygen by nonrebreather mask. You may hear people talk about this or even see protocols that still mention high-concentration oxygen. Laboratory and animal studies suggest that administering more oxygen than necessary may lead to the production of certain chemical entities that can be harmful. The current recommendation is to administer only enough oxygen to bring that patient's oxygen saturation level up to 94 percent. Provide high-concentration oxygen by nonrebreather mask if necessary to raise the oxygen saturation to 94 percent. Perform the history and physical exam for a medical patient. Document the findings.

Patient care If trained, equipped, and authorized to do so, obtain a 12-lead electrocardiogram (ECG). Follow local protocol as to whether to transmit it to hospital for interpretation. Covers Objective: 18.4 Knowledge Application: Use programmed patients to present ACS scenarios. Have students work in small groups to practice decision-making and treatment strategies. continued on next slide

Patient care Indications for administering nitroglycerin Chest pain History of cardiac problems and prescribed nitroglycerin Physician has prescribed nitroglycerin to patient. Patient has nitroglycerin with him. Covers Objective: 18.5

Treatment Covers Objective: 18.5 Nitroglycerin

Patient care Indications for administering nitroglycerin Systolic blood pressure meets protocol criteria. Patient has not had Viagra or similar drug for erectile dysfunction within forty-eight to seventy-two hours. Medical direction authorizes administration of the medication. continued on next slide

Patient care After giving one dose of nitroglycerin, repeat dose in 5 minutes if: Patient experiences no relief or only partial relief. Systolic blood pressure remains greater than 90 to 100 systolic. Medical direction authorizes another dose of medication. Covers Objective: 18.5 continued on next slide

Patient care Indications for administering aspirin Chest pain Patient not allergic to aspirin No history of asthma Patient not taking medications to prevent clotting Covers Objective: 18.6 Discussion Topic: Describe the treatment of ACS. Discuss definitive care and prehospital care. Class Activity: Have each student plot out a definitive care strategy for an ACS patient in his area. Have students describe transport decisions and what the most effective treatment would be based upon their local geography and care options. continued on next slide

Patient care Indications for administering aspirin No other contraindications to aspirin Ability to safely swallow Medical direction authorization Covers Objective: 18.6 Discussion Topic: Describe the treatment of ACS. Discuss definitive care and prehospital care. Class Activity: Have each student plot out a definitive care strategy for an ACS patient in his area. Have students describe transport decisions and what the most effective treatment would be based upon their local geography and care options.

Treatment Aspirin

Causes of Cardiac Conditions
Teaching Time: 70 minutes Teaching Tips: This section lends itself well to video graphics to better illustrate pathophysiology. Describe how cardiac conditions interfere with normal physiology. Relate this discussion to your lesson on anatomy and physiology. Relate pathophysiology to physical findings and symptoms. Discuss how these disorders impact patients. The American Heart Association is a useful resource for this section. Its website and classes can provide beneficial enhancements and teaching tools to improve your lesson.

Causes of Cardiac Conditions
Heart problems caused by a number of disorders affecting condition and function of blood vessels and heart Covers Objective: 18.7 Class Activity: Have the class work in small groups. Assign each group a cause of a specific cardiac condition. Have that group research and present the pathophysiology of its disorder to the class.

Coronary Artery Disease
Conditions that narrow or block arteries of heart Often result from fatty deposit buildup on inner walls of arteries Buildup narrows inner vessel diameter, restricting flow of blood. Covers Objective: 18.7a Point to Emphasize: The majority of cardiovascular emergencies are caused, directly or indirectly, by changes in the inner walls of arteries. Conditions that narrow or block the arteries of the heart are commonly called coronary artery disease (CAD). Knowledge Application: Use programmed patients to present cardiac scenarios. Have students practice assessment and discuss symptom patterns associated with cardiac conditions. continued on next slide

Thrombus Occlusion of blood flow caused by formation of a clot on rough inner surface of diseased artery Can break loose and form an embolism Emboli can move to occlude flow of blood downstream in a smaller artery. Covers Objective: 18.7a continued on next slide

Reduced blood supply to myocardium causes emergency in majority of cardiac-related medical emergencies Chest pain is most common symptom of reduced blood supply. Covers Objective: 18.7a Discussion Topic: Describe how artery disease leads to heart problems. Discuss the role of coronary artery disease in ACS.

Aneurysm Weakened sections of arterial walls begin to dilate (balloon). Bursting can cause rapid, life-threatening internal bleeding. Covers Objective: 18.7b Point to Emphasize: An aneurysm occurs when weakened sections in the arterial walls dilate and occasionally burst. Discussion Topic: Define aneurysm. Discuss how an aneurysm occurs. Critical Thinking: How might the symptoms of an aneurysm present like the symptoms of ACS? Can an EMT differentiate in the field, and if so, how?

Aneurysm Covers Objective: 18.7b Point to Emphasize: An aneurysm occurs when weakened sections in the arterial walls dilate and occasionally burst. Discussion Topic: Define aneurysm. Discuss how an aneurysm occurs. Critical Thinking: How might the symptoms of an aneurysm present like the symptoms of ACS? Can an EMT differentiate in the field, and if so, how? A weakened area in the wall of an artery will tend to balloon out, forming a saclike aneurysm, which may eventually burst.

Electrical Malfunction of the Heart
Malfunction of heart's electrical system generally results in dysrhythmia. Dysrhythmias include bradycardia, tachycardia, and rhythms that may be present when there is no pulse. Covers Objective: 18.7c Point to Emphasize: Both electrical and mechanical problems can cause the heart to fail. Discussion Topic: Describe how an electrical problem might cause the heart to fail. Knowledge Application: Have students work in small groups. Assign each group a symptom commonly associated with ACS and have group members research and present how their symptom might be related to a cardiac cause discussed in this section.

Mechanical Malfunctions of the Heart
Angina pectoris Acute myocardial infarction (AMI) Congestive Heart Failure (CHF) Covers Objective: 18.7d

Angina Pectoris Chest pain caused by insufficient blood flow to the myocardium Typically due to narrowed arteries secondary to coronary artery disease Pain usually during times of increased myocardial oxygen demand, such as exertion or stress Covers Objective: 18.7e Point to Emphasize: Angina pectoris and acute myocardial infarction result from an interruption of the necessary blood flow to heart muscle. The chest pain associated with angina pectoris will often diminish when the patient stops the exertion.

Acute Myocardial Infarction (AMI)
Death of a portion of the myocardium due to lack of oxygen Coronary artery disease is usually the underlying reason. Covers Objective: 18.7f Discussion Topic: Define angina pectoris and acute myocardial infarction. How are they related, and how do they differ?

Acute Myocardial Infarction (AMI)
Covers Objective: 18.7f Discussion Topic: Define angina pectoris and acute myocardial infarction. How are they related, and how do they differ? Cross-section of a myocardial infarction.

Congestive Heart Failure
Inadequate pumping of the heart Often leads to excessive fluid buildup in lungs and/or body May be brought on by diseased heart valves, hypertension, obstructive pulmonary disease Often a complication of AMI Covers Objective: 18.7g Point to Emphasize: Congestive heart failure occurs when the heart cannot pump properly due to damage or a disorder. Pulmonary edema is a common symptom of CHF. Discussion Topic: Define congestive heart failure (CHF). How is CHF related to acute pulmonary edema? Knowledge Application: Split the class into thirds. Assign one group the topic of stroke, one group the topic of ACS, and one group the topic of peripheral vascular disease. Have each group research pathophysiology and present its findings. Compare and contrast. continued on next slide

Progression Patient sustains AMI Myocardium of left ventricle dies Because of damage to left ventricle, blood backs up into pulmonary circulation and lungs If untreated, left heart failure commonly causes right heart failure Covers Objective: 18.7g continued on next slide

Signs and symptoms Tachycardia Dyspnea Cyanosis Normal or elevated blood pressure Diaphoresis Pulmonary edema Covers Objective: 18.7g continued on next slide

Signs and symptoms Anxiety or confusion due to hypoxia Pedal edema Engorged, pulsating neck veins (late sign) Enlarged liver and spleen with abdominal distention (late sign) Covers Objective: 18.7g

Cardiac Arrest Teaching Time: 70 minutes
Teaching Tips: A great deal of research on cardiac arrest has been conducted. Relate current data to your discussion. Consider reviewing the Ontario Prehospital Advanced Life Support (OPALS) Study as it specifically underscores the importance of basic life support providers. Utilize CPR instructors to assist you with this lesson. They will have insight on both the topic and the teaching of the topic. This section is heavily weighted in skills. Be sure that you have enough assistance to ensure proper technique and orderly practice. Invite local ALS providers to class or join with an ALS class to practice integrating BLS and ALS in a cardiac arrest scenario. Invite your medical director to discuss post-arrest care and options available in your region.

Chain of Survival Five elements Teamwork Coordination
Immediate recognition and activation Early CPR Rapid defibrillation Effective advanced life support Integrated post-cardiac arrest care Teamwork Coordination Covers Objective: 18.8 Points to Emphasize: The American Heart Association has summarized the most important factors that affect survival of cardiac arrest patients in its chain of survival. The elements are: (1) immediate recognition and activation, (2) early CPR, (3) rapid defibrillation, (4) effective advanced life support and (5) integrated post-cardiac arrest care. To maximize outcomes of cardiac arrest, EMTs must use teamwork to coordinate high-quality CPR with the use of early defibrillation. Talking Points: An underlying theme of the chain of survival is teamwork. There must be coordination for combined activities to work in the patient's favor. An EMS system where each of these links is strong is much more likely to bring back a patient from cardiac arrest than a system with weaknesses anywhere along the chain.

Immediate Recognition and Activation
Requires prompt notification of EMS system Most likely a bystander responsibility Covers Objective: 18.8a Knowledge Application: Assign the Ontario Prehospital Advanced Life Support (OPALS) Study as a reading assignment. Have students write a summary paper on the study's conclusions. Discuss.

Early CPR Increases survival chances significantly
Three ways CPR can be delivered earlier Get CPR-trained professionals to patient faster. Train laypeople in CPR. Train dispatchers to instruct callers how to perform CPR. Covers Objective: 18.8b Point to Emphasize: The most important element of cardiac arrest care is the administration of high-quality chest compressions. Knowledge Application: Have groups of students team with local CPR instructors to assist with the teaching of a basic life support class. continued on next slide

Early CPR High-Performance CPR
Changes implemented in resuscitation efforts Compressing the chest at least 2 inches in adults Allowing for full relaxation on the upstroke of compressions Spending half of each compression on the downstroke and half on the upstroke Covers Objective: 18.8b Point to Emphasize: The most important element of cardiac arrest care is the administration of high-quality chest compressions. Knowledge Application: Have groups of students team with local CPR instructors to assist with the teaching of a basic life support class. continued on next slide

Early CPR High-Performance CPR Using correct hand position
Compressing the chest at least 100 times per minute Spending no more than one second on each ventilation Minimizing interruptions of CPR to no more than 10 seconds each Covers Objective: 18.8b Point to Emphasize: The most important element of cardiac arrest care is the administration of high-quality chest compressions. Knowledge Application: Have groups of students team with local CPR instructors to assist with the teaching of a basic life support class. continued on next slide

Early CPR High-Performance CPR Key is increasing cardiac output.
Since most cardiac arrests in adults are the result of cardiac problems, not respiratory problems, there is enough oxygen in the bloodstream to maintain metabolic processes for several minutes. Covers Objective: 18.8b Point to Emphasize: The most important element of cardiac arrest care is the administration of high-quality chest compressions. Knowledge Application: Have groups of students team with local CPR instructors to assist with the teaching of a basic life support class.

Rapid Defibrillation The sooner defibrillator arrives, the more likely the patient will survive cardiac arrest. Covers Objective: 18.8c

Rapid Defibrillation Covers Objective: 18.8c Turn on the AED power.

Effective Advanced Life Support
Generally provided by EMT-Paramedics who respond to scene or rendezvous with BLS unit en route to hospital. Rapid transport to hospital may be the most time-efficient means of obtaining ALS. Covers Objective: 18.8d

Integrated Post-Cardiac Arrest Care
Coordinating numerous means of assessment and interventions that, together, maximize the chance of neurologically intact survival Covers Objective: 18.8e continued on next slide

Integrated Post-Cardiac Arrest Care
Maintaining adequate oxygenation Avoiding hyperventilation Performing 12-lead ECG Finding and managing treatable causes of arrest Determining appropriate destination for patient Possibly inducing hypothermia Covers Objective: 18.8e Discussion Topic: Describe the components of the AHA chain of survival. Class Activity: Divide the class into five groups. Assign each group an element of the AHA's chain of survival. Have each group research and present the importance of its topic.

Management of Cardiac Arrest
EMT provides two links in the chain of survival. Early CPR Rapid defibrillation Covers Objective: 18.9

Covers Objective: 18.9 There is usually enough oxygen in the bloodstream to postpone ventilations for several minutes while chest compressions are performed.

Perform one- and two-rescuer CPR. Take Standard Precautions. Use an automated external defibrillator. Request ALS (when available) to continue the chain of survival. Use a bag-valve mask device with oxygen. Covers Objective: 18.9 continued on next slide

Use flow-restricted, oxygen-powered ventilation device. Lift and move patients. Suction patient's airway. Use airway adjuncts. Interview bystanders and family members. Covers Objective: 18.9

Automated External Defibrillator (AED)
Types of AEDs Semi-automatic Advises EMT to press button that causes machine to deliver shock through pads Fully automatic Does not advise EMT to take any action Delivers shock automatically Covers Objective: 18.10 continued on next slide

Types of AEDs Classified by type of shock delivered Monophasic Sends single shock from negative pad to positive pad Biphasic Sends shock in one direction and then the other Covers Objective: 18.10 continued on next slide

How AEDs Work Analyzes cardiac rhythm to determine whether shock is indicated Covers Objective: 18.10 Point to Emphasize: An automated external defibrillator (AED) contains a computer that analyzes the patient's heart rhythm and delivers a shock to eradicate ventricular fibrillation or ventricular tachycardia. continued

Covers Objective: 18.10 Point to Emphasize: An automated external defibrillator (AED) contains a computer that analyzes the patient's heart rhythm and delivers a shock to eradicate ventricular fibrillation or ventricular tachycardia. AED cardiac arrest treatment sequence. continued

How AEDs Work Most common conditions resulting in cardiac arrest are shockable rhythms. Ventricular fibrillation Ventricular tachycardia Covers Objective: 18.10

Coordinating CPR and AED for a Patient in Cardiac Arrest
Interrupt CPR only when absolutely necessary and for as short a period as possible. CPR must be paused for rhythm analysis and defibrillation. Covers Objective: 18.11

Patient Assessment Perform primary assessment.
If bystanders are doing CPR when you arrive, have them stop. Verify pulselessness, apnea, absence of other signs of life no longer than 10 seconds. Covers Objective: 18.9 Point to Emphasize: Depending on findings during the primary assessment, treatment of a cardiac arrest patient may be either A-B-C (airway, breathing, circulation) or C-A-B (circulation/compressions, airway, breathing). Discussion Topic: Discuss how the primary assessment of a patient in cardiac arrest differs from a non-cardiac arrest patient.

Patient Assessment Covers Objective: 18.9 Point to Emphasize: Depending on findings during the primary assessment, treatment of a cardiac arrest patient may be either A-B-C (airway, breathing, circulation) or C-A-B (circulation/compressions, airway, breathing). Discussion Topic: Discuss how the primary assessment of a patient in cardiac arrest differs from a non-cardiac arrest patient. 2. Verify the absence of a spontaneous pulse. Check for no longer than 10 seconds.

Patient Care Apply AED Bare patient's chest.
Quickly shave area where pads will be placed if necessary. If available, use pediatric AED pads. If using adult pads, do not overlap. Covers Objective: 18.9 Knowledge Application: Use manikins to simulate cardiac arrest scenarios. Have teams of students practice the sequence of cardiac arrest care.

3. Provide CPR while another EMT sets up the AED.
Patient Care Covers Objective: 18.9 Knowledge Application: Use manikins to simulate cardiac arrest scenarios. Have teams of students practice the sequence of cardiac arrest care. 3. Provide CPR while another EMT sets up the AED.

Patient Care Use AED. Turn on AED.
Attach pads to cables and then to patient. Stop CPR and analyze. Clear patient and shock if indicated. Covers Objective: 18.9

Patient Care Covers Objective: 18.9 If advised by the AED, press the button to deliver a shock. Immediately perform compressions.

Patient Care Immediately begin CPR after delivering a shock.
Reassess patient after providing 2 minutes or 5 cycles of CPR. Covers Objective: 18.9 Discussion Topics: Discuss the importance of quality chest compression and early defibrillation in cardiac arrest survival. Describe the sequence for using an AED to treat a patient in cardiac arrest.

Patient Care Covers Objective: 18.9 Discussion Topics: Discuss the importance of quality chest compression and early defibrillation in cardiac arrest survival. Describe the sequence for using an AED to treat a patient in cardiac arrest. 9. Perform CPR for 2 minutes (5 cycles), unless the patient wakes up, moves, or begins to breathe. Follow AED prompts.

Patient Care If AED finds no shockable ECG rhythm, will advise that no shock is indicated. Pulseless electrical activity Asystole Resume CPR immediately. Covers Objective: 18.9 continued on next slide

Patient Care When providing CPR
Compressions must not be interrupted for any longer than 10 seconds Compressions at least 2 inches deep for adult and at least one-third depth of chest for infants and children with full chest recoil Covers Objective: 18.9 Critical Thinking: Why are high-quality chest compressions important? Why must we limit interruptions of these compressions? continued on next slide

Patient Care When providing CPR Rate should be at least 100 per minute
Rotate personnel through compressor position to prevent fatigue Covers Objective: 18.9 Critical Thinking: Why are high-quality chest compressions important? Why must we limit interruptions of these compressions? continued on next slide

Patient Care If patient wakes or begins to move:
Obtain baseline vital signs. Administer high-concentration oxygen. Transport. Covers Objective: 18.12 continued

Patient Care continued
Covers Objective: 18.12 Check the patient's pulse during CPR to confirm the effectiveness of compressions. continued

Special Considerations for AED Use
General Principles One EMT operates the defibrillator while another does CPR. CPR must include high-quality compressions. Defibrillation comes first. You must be familiar with the model of AED used in your area. Covers Objective: 18.12 continued on next slide

General Principles All contact with the patient must be avoided during rhythm analysis. Pulse checks should not occur during rhythm analysis. State, "Clear!" and be sure everyone is clear of the patient before delivering every shock. Covers Objective: 18.12 continued on next slide

General Principles Check the batteries at the beginning of your shift, and carry a spare. If you have delivered three shocks and are without backup, prepare patient for transport. An AED is often not able to analyze a rhythm accurately in a moving emergency vehicle. Covers Objective: 18.12

Coordination with ALS Personnel Notify as soon as possible to greater the patient's chance of survival. If the team arrives before you have finished the first shock, they should allow you to complete the shock. Your actions may depend on location of the arrest and estimated time of arrival of the ALS team. Covers Objective: 18.12

Coordination with Others Who Defibrillate before You Arrive Let the operator of the AED complete the shock before you take over care of the patient. You may need to take the first AED to the hospital with the patient so data can be retrieved from the machine. Your protocols will dictate transfer of care. Covers Objective: 18.12

Post-Resuscitation Care
If patient has a pulse Manage airway. Avoid hyperventilation. Keep defibrillator on patient during transport in case patient goes back into arrest. Reassess frequently (every 5 minutes). Consider hypothermia protocols. Covers Objective: 18.12 continued on next slide

If patient has no pulse You will need to resume CPR. AED will have given you a "No shock indicated" message. AED may be prompting you to analyze the rhythm because it "thinks" there is a shockable rhythm. Covers Objective: 18.12 continued on next slide

Ensure adequate ventilation and oxygenation Adjust amount to no more than what is necessary to achieve oxygen saturation of 94 percent Protocol may require you to place the patient in therapeutic hypothermia. Use techniques of lifting and moving. Covers Objective: 18.12

Patients Who Go Back into Cardiac Arrest
Stop the vehicle and resume CPR. Have someone else start CPR if the AED is not immediately ready. Analyze rhythm as soon as possible. Deliver shock if indicated. Continue with 2 shocks separated by 2 minutes (5 cycles). Covers Objective: 18.12 Knowledge Application: Use a programmed patient to simulate a post-cardiac arrest patient. Have teams of students practice post-cardiac arrest care.

Witnessed Arrests in the Ambulance
No guarantees, but very good chance of reviving patient because you can defibrillate very shortly after patient goes into shockable rhythm Stop the vehicle and treat this patient like any other patient in cardiac arrest. Covers Objective: 18.12

Single Rescuer with an AED
Apply the AED and defibrillate immediately Once shock delivered or received "No shock indicated," begin chest compressions. After about 2 minutes, check rhythm again and shock as needed. Covers Objective: 18.12

Contraindications Pads won't fit on patient without touching each other. Trauma with severe blood loss or damage to one or more vital organs Hypothermia Covers Objective: 18.12 continued on next slide

Contraindications Do not defibrillate soaking-wet patient.
Do not defibrillate if patient is touching anything metallic that other people are touching. Remove nitroglycerin patches before defibrillating. Verbally and visually "CLEAR!" patient before defibrillating. Covers Objective: 18.12

Say, "Clear!" Ensure that all individuals are clear of the patient.
AED Safety Covers Objective: 18.12 Say, "Clear!" Ensure that all individuals are clear of the patient.

Implants and Surgeries
Defibrillation can be performed on patient with an implanted device. Position defibrillation pads on patient's chest to avoid contact with the device. Covers Objective: 18.12 continued on next slide

Implants and Surgeries
Some devices and surgeries you may observe in the field include: Cardiac pacemaker Implanted defibrillator Ventricular assist device Cardiac bypass surgery Covers Objective: 18.12

Quality Improvement Involves multiple functions Medical direction
Initial training Maintenance of skills Case review Trend analysis Strengthening links in chain of survival Covers Objective: 18.12 continued on next slide

Quality Improvement Maintenance
Use checklist at beginning of every shift to ensure you have all supplies and AED is functioning properly. Make sure battery is charged and you have a spare with defibrillator. Covers Objective: 18.12

Mechanical CPR Devices
Mechanical devices assist EMTs to provide high-quality compressions. Using the LUCAS CPR device Stop CPR just long enough to put the LUCAS base plate under the patient. Apply stabilization strap before moving the patient. Upon termination of arrest or return of spontaneous circulation, power down. Covers Objective: 18.13 Point to Emphasize: Mechanical CPR devices provide automated chest compressions to cardiac arrest patients. You still need to remember to take Standard Precautions when using mechanical CPR compressor devices. Discussion Topic: Describe the function and application of mechanical CPR devices. Knowledge Application: Demonstrate the use of a mechanical CPR device. continued on next slide

Mechanical CPR Devices
Using the Auto-Pulse Align the patient on the Auto-Pulse platform. Provide bag-mask ventilation at a rate of two ventilations for every 30 compressions. After 2 minutes of CPR, reassess for pulse and/or shockable rhythm. Covers Objective: 18.13 Point to Emphasize: Mechanical CPR devices provide automated chest compressions to cardiac arrest patients. You still need to remember to take Standard Precautions when using mechanical CPR compressor devices. Discussion Topic: Describe the function and application of mechanical CPR devices. Knowledge Application: Demonstrate the use of a mechanical CPR device.

Terminating Resuscitation
Once you start resuscitation, you must continue until: Spontaneous circulation occurs. Then provide rescue breathing as needed. Spontaneous circulation and breathing occur. Another trained rescuer can take over for you. Covers Objective: 18.12 Point to Emphasize: Note that all three of these criteria must be met before resuscitation is terminated: The arrest was not witnessed by EMS personnel or first responders. There has been no return of spontaneous circulation after three rounds of CPR and rhythm checks with an automated external defibrillator (AED). The AED did not detect a shockable rhythm and did not deliver any shocks. continued on next slide

Once you start resuscitation, you must continue until: You turn care of patient over to a person with higher level of training. You are too exhausted to continue. You receive a "no resuscitation" order from a physician or other authority per local protocols. Covers Objective: 18.12 continued on next slide

Once you start resuscitation, you must continue until: Criteria to determine when it is reasonable to stop without missing anyone who has a chance of survival Arrest not witnessed by EMS personnel or first responders No return of spontaneous circulation after three rounds of CPR and rhythm checks with an AED Covers Objective: 18.12 continued on next slide

Once you start resuscitation, you must continue until: Criteria to determine when it is reasonable to stop without missing anyone who has a chance of survival AED did not detect a shockable rhythm and did not deliver any shocks. Covers Objective: 18.12

Ventricular Fibrillation and AED Video
Covers Objective: 18.11 Video Clip Ventricular Fibrillation and AED What is ventricular fibrillation? How does an AED work? Click on the screenshot to view a video on the subject of ventricular fibrillation. Back to Directory

Cardiac Arrest Animation
Covers Objective: 18.9 Video Clip Cardiac Arrest What can cause cardiac arrest? What components influence stroke volume? Discuss the appropriate emergency care that an EMT should provide if he witnesses a patient in cardiac arrest. Describe how the heart behaves when in ventricular fibrillation. Click on the screenshot to view an animation on the topic of cardiac arrest. Back to Directory

Click on the screenshot to view a video on the topic of AEDs.
AED Video Covers Objective: 18.12 Video Clip AEDs Why is time an important factor when using an AED? What is the goal of defibrillation? What rhythms does the AED recognize as shockable? Discuss the benefits of an AED. Discuss the different types of AEDs available for use. Click on the screenshot to view a video on the topic of AEDs. Back to Directory

Coronary Heart Disease Video
Covers Objective: 18.7f Video Clip Understanding Myocardial Infarctions What is the most common symptom of a myocardial infarction? Discuss how most myocardial infarctions begin. What are some treatments for myocardial infarctions? Click on the screenshot to view a video on the topic of coronary heart disease. Back to Directory

Chapter Review

Chapter Review Patients with cardiac compromise or ACS can have many different presentations. Some complain of pressure or pain in the chest with difficulty breathing. Others may have just mild discomfort that they ignore or that goes away and returns. Between 10 and 20 percent of heart attack patients have no chest discomfort. continued on next slide

Chapter Review Because of these possibilities and the severe complications of heart problems, it is important to have a high suspicion and treat patients with these symptoms for ACS. The treatment will not hurt them and may help them. continued on next slide

Chapter Review Patients with suspected ACS who are hypoxic or short of breath need oxygen and prompt, safe transportation to definitive care. You may be able to assist patients who have their own nitroglycerin in taking it, thereby relieving pain and anxiety. continued on next slide

Chapter Review To provide maximum chance of survival for patients in cardiac arrest, EMS agencies must strengthen their performance of the chain of survival: Immediate recognition and activation Early CPR Rapid defibrillation Effective ALS Integrated post-cardiac arrest care

Remember The heart is a simple pump that moves deoxygenated blood to the lungs and oxygenated blood to the body. Pressure within the cardiovascular system is critical to the moving of blood. continued on next slide

Remember Acute coronary syndrome (ACS) is a blanket term that refers to a number of situations in which perfusion of the heart is inadequate. Although there are common symptoms of ACS, EMTs must recognize atypical findings and err on the side of caution. continued on next slide

Remember Oxygen, nitroglycerine, and aspirin are key medications indicated to treat ACS. However, the definitive treatment is transportation of the patient to a facility that can open the blocked artery. continued on next slide

Remember Most cardiac conditions are caused by arterial problems. Angina pectoris and acute myocardial infarction are caused by inadequate perfusion of the heart. Heart failure can be caused by either electrical or mechanical problems. continued on next slide

Remember The most important element of cardiac arrest care is the administration of high-quality chest compressions. The American Heart Association's chain of survival describes the key elements necessary to maximize the cardiac arrest patient's chance of survival. continued on next slide

Remember AED provides early defibrillation in cardiac arrest patients with ventricular tachycardia and ventricular fibrillation. Post-cardiac arrest care is an essential element of cardiac arrest care. Mechanical CPR devices provide automated chest compressions in cardiac arrest settings.

Questions to Consider What position is best for a patient with:
Difficulty breathing and a blood pressure of 100/70? Chest pain and a blood pressure of 180/90? Describe how to "clear" a patient before administering a shock. Talking Points: Most patients with difficulty breathing prefer an upright position although low blood pressure can sometimes make sitting up difficult. Often semi-Fowlers is appropriate. Before defibrillating you should verbally announce the procedure by yelling "clear." You should also visually inspect yourself, your team, and your patient to be sure no one is in contact prior to the shock. continued on next slide

Questions to Consider List three safety measures to keep in mind when using an AED. List the steps in the application of an AED. Talking Points: To defibrillate safely, you should dry your patient, remove the patient from wet environments, remove metal jewelry, and assure no one is in contact. Remove medication patches and offset pad placement to avoid implanted devices. When applying the AED, you should bare the chest, turn on the device, attach the pads, stop CPR and analyze, and then clear and shock if advised. CPR should be immediately resumed.

Critical Thinking A 78-year-old male has been complaining of severe shortness of breath for 20 minutes prior to your arrival. When you arrive, you find the patient unconscious and not moving. What are your immediate priorities? Talking Points: Unconscious and not moving likely indicates cardiac arrest. You should immediately perform a primary survey and check for a pulse. If there is no pulse, begin CPR and attach an AED. Analyze the rhythm and shock if indicated.

18 Cardiac Emergencies.

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18 Cardiac Emergencies.

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Presentation on theme: "18 Cardiac Emergencies."— Presentation transcript:

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