1. Cardiovascular Emergencies
Chapter 18
Cardiovascular Emergencies

2. Case History
You respond to a nursing home for a “heart attack.” On arrival, you find a 64-year-old female complaining of “crushing” chest pain and shortness of breath for the last 40 minutes. The patient tells you that she has had two heart attacks in the past and the pain is now similar.

3. Sudden Cardiac Death Heart disease is #1 cause of death in U.S.
340,000 prehospital deaths annually
EMS cannot save all victims.
The community is the “ultimate coronary care unit” for sudden death.

4. Ventricular Fibrillation
Most common rhythm of sudden death
Can only be treated with electric shock
Early defibrillation is critical

5. AED and the Chain of Survival
Early access
Early CPR
Early defibrillation
Early ACLS

6. Role of EMT-B in Cardiovascular Emergencies
Administer oxygen.
Assist with the administration of nitroglycerin.
Perform CPR.
Provide early defibrillation.
Request ALS assistance, as needed.
Provide prompt transportation.
Communicate assessment findings to hospital.

7. Review of Anatomy and Physiology

8. Chambers of the Heart and Conduction System

9. Systemic and Pulmonary Circulation

10. Cardiac Output Stroke volume  heart rate
Either parameter can increase or decrease cardiac output.
Varies with activity and other factors

11. Blood Pressure Measured in every patient > 3 years old
Pressure exerted on the walls of arteries
Cardiac output  resistance of vessels
Contributing factors
Force of contraction
Heart rate
Status of blood vessels (dilated vs. constricted)
Blood volume

12. Inadequate Circulation – Shock
Shock (hypoperfusion)
Signs and symptoms
Pale, cyanotic, cool clammy skin
Rapid, weak pulse
Rapid and shallow breathing
Restlessness, anxiety, or mental dullness
Nausea and vomiting

13. Arteriosclerosis Narrowing of the arteries Less blood can flow.
Caused by buildup of fatty deposits and plaque
Less blood can flow.
First signs of disease may occur with physical exertion or stress.

14. Myocardial Oxygen Supply and Demand
Normally oxygen supply via coronary arteries meets demand.
Mismatch occurs when increased demand is not met by an increase in blood supply.
May be due to narrowed coronary arteries
Angina pectoris
Problem can be addressed in two ways.
Decrease demand (rest, nitroglycerin)
Increase supply (oxygen, nitroglycerin)

15. Angina Pectoris Chest pain
Commonly caused by increased oxygen demands on the heart
Stress
Exertion
Exercise
Relieved by rest and nitroglycerin

16. Myocardial Ischemia and Infarction
State of decreased blood flow to tissues
Myocardial ischemia
Not enough blood flow to meet the oxygen needs of the myocardium
Myocardial infarction
Necrosis or death of heart cells

17. Ischemic Chest Pain Center of the chest
May radiate to the neck, jaw, or arms
Patients may complain of abdominal pain or indigestion.

18. Ischemic Heart Disease Signs and Symptoms
Sudden onset of sweating
Difficulty breathing (dyspnea)
Anxiety, irritability
Loss of consciousness

19. Cardiac Compromise Signs and Symptoms
Feeling of impending doom
Epigastric pain
Nausea/vomiting
Palpitations
Lightheadedness
Weakness
Dizziness

20. Initial Assessment Identify need for priority care.
Identify life-threatening conditions.
Chest pain patient with altered mental status
Consider impending cardiac arrest.
Have CPR equipment and AED available.
Patients with chest pain may prefer sitting position.
Patients with altered mental status should be placed in supine position.

21. Initial Assessment Consider need for oxygen, airway, and ventilation.
Nonrebreather
Positive-pressure ventilation
Check for signs of poor perfusion.

22. SAMPLE History Signs and symptoms Allergies Medications
Past medical history
Last oral intake
Events surrounding the chief complaint

23. Important Questions
Onset
Provocation
Quality
Radiation
Severity
Time

24. Focused Physical Exam Patient may deny symptoms.
Make every attempt to convince the patient to seek help.
Altered mental status may be caused by low cardiac output.
Examine neck veins and accessory muscles.
Check breath sounds.

25. Baseline Vital Signs A range of vital signs are possible
Normal vital signs
Abnormal pulses related to arrhythmias
Hypotension and other signs of hypoperfusion
Cardiac arrest
Preexisting medical conditions may alter vitals signs (e.g., hypertension)

26. Emergency Care of Responsive Cardiac Patient
Perform the initial assessment.
Ensure an open airway and consider the need for:
Manual maneuvers (head tilt/chin lift, jaw thrust)
An oropharyngeal or nasopharyngeal airway
Suction

27. Emergency Care of Responsive Cardiac Patient
Evaluate the adequacy of breathing and consider need for positive-pressure ventilation.
Administer supplemental oxygen.
Reduce activity and anxiety.

28. Emergency Care of Responsive Cardiac Patient
Carry the patient to the ambulance in a position of comfort.
Prioritize transport.
Consider administration of nitroglycerin.
Perform ongoing assessment en route to the hospital.

29. Nitroglycerin
Generic name
Nitroglycerin
Trade name
Nitrostat™

30. Indications and Contraindications
Patient exhibits signs and symptoms of chest pain.
Has physician prescribed sublingual tablets?
Specific authorization by medical direction
Contraindications
Blood pressure < 100 mm Hg systolic
Head injury
Infants and children
Patient has already met maximum prescribed dose.

31. Actions and Side Effects
Relaxes blood vessels
Decreases workload of heart
Side effects
Hypotension
Headache
Pulse rate changes

32. Nitroglycerin BP > 100 systolic BP < 100 systolic or no NTG
Administer one dose.
Repeat in 3-5 minutes, if no relief.
Give up to a maximum of three doses.
Reassess after each dose.
BP < 100 systolic or no NTG
Continue focused assessment.
Transport promptly.

33. Administering Nitroglycerin
Perform a focused assessment of the cardiac patient.
Take blood pressure (must be >100 mm Hg).
Question the patient regarding administration of the last dose.

34. Administering Nitroglycerin
Ensure that patient understands the route of administration.
Contact medical direction.
Ensure right patient, right medication, right dose, right route.
Ensure medication is not expired.

35. Administering Nitroglycerin
Place tablet or spray under the tongue.
Recheck blood pressure within 2 minutes.
Record activity and times.
Perform reassessment.

36. Reassessment Strategies
Monitor blood pressure.
Ask patient about effect on pain relief.
Seek medical direction before readministering.
Record reassessments.

37. Summary of Management of Patients with Chest Pain
Place in the position of comfort.
Administer oxygen.
Assist with prescribed nitroglycerin.
May be repeated every 3-5 minutes up to a total of three doses.
If the systolic BP >100 mm Hg

38. Heart Failure Condition resulting from a damaged or weak heart muscle
Caused by severe myocardial infarctions, chronic hypertension, and/or other causes

39. Heart Failure Left-sided Backup in lungs Pulmonary edema Dyspnea
Accessory muscle use
Rales on auscultation

40. Heart Failure Right-sided Backup in systemic circulation
Swelling of body tissues
Ankles, sacrum, abdomen

41. Cardiac Arrest Management Skills of the EMT-Basic
One- and two-rescuer CPR
Use of AED
Request for ALS backup when appropriate
Use of BVM or mouth-to-mask with oxygen attached
Use of flow-restricted, oxygen-powered ventilatory devices

42. Cardiac Arrest Management Skills of the EMT-Basic
Lifting and moving patients
Suctioning airways
Use of airway adjuncts
Use of BSI
History and physical assessment

43. Rationale for Early Defibrillation
Ventricular fibrillation is the most common initial rhythm of cardiac arrest.
Defibrillation is the only effective treatment of ventricular fibrillation.
EMS systems have demonstrated increased survival through early defibrillation programs.
Survival is associated with implementation of the chain of survival.

44. Time and AEDs Survival rate is approximately 50% after 5 minutes.
Survival reduced by 7% to 10% each minute.
Rapid defibrillation is key.
CPR helps extend survival time.

45. Patient Age and Use of AED
Medical patient >8 years old
CPR
AED with adult pads
Medical patient 1-8 years old
AED with pediatric pads
Consider transport or ALS intercept

46. AED Analysis of Cardiac Rhythms
Microprocessor confirms rhythms for which a shock is indicated.
Accuracy is high.
Analysis is dependent on properly charged defibrillator batteries.
Inappropriate delivery of shocks
Human error, mechanical error
Ventricular tachycardia
Attach defibrillator only to unresponsive, pulseless, nonbreathing patients.

47. Interruption of CPR Do not touch patient during analysis and shocks.
Resume CPR immediately after every shock.

48. Advantages of AEDs Initial training and continuing education
Speed of operation
First shock can be delivered within 1 minute of arrival at the patient’s side.
Remote defibrillation through adhesive pads
Rhythm monitoring
Option on some defibrillator models

49. If AED Advises No Shock Perform CPR for 5 cycles.
If patient is awake and breathing adequately
Give high-concentration oxygen.
Transport.
If patient is awake and not breathing adequately
Artificially ventilate with high-concentration oxygen.

50. Standard Operational Procedures
Defibrillation comes first when a collapse occurs in your presence.
Do not do anything that delays analysis.
EMT must be familiar with device.

51. Standard Operational Procedures
Patient contact must be avoided during analysis.
State “Clear the patient” before delivering shocks.
Check batteries at beginning of shift.
Carry extra batteries.

52. Recurrent Ventricular Fibrillation
If patient wakes up after shocks:
Check pulse frequently.
If pulse is not present:
Stop vehicle.
Start CPR, if defibrillator is not immediately ready.
Analyze rhythm.
Deliver shock, if indicated.
Continue resuscitation per protocol.

53. Conscious Patient Becomes Pulseless and Apneic
Stop vehicle.
Start CPR if defibrillator is not immediately ready.
Attach AED, analyze rhythm.
Deliver shock.
Continue resuscitation per protocol.

54. No Shock Message Start or resume CPR. Analyze rhythm.
After 5 cycles of CPR

55. Coordination with ALS Personnel
EMS system design establishes protocols.
AED usage does not require ALS on scene.
ALS should be notified as soon as possible.
Transport vs. await ALS per local protocols.
Safety considerations
Water – rain
Metal

56. Postresuscitation Care
Manage airway.
Assess need for ventilation.
Consider ALS backup.
Keep AED attached to patient en route.
Perform focused assessment and reassessment en route.

57. Defibrillator Maintenance
Regular maintenance for defibrillators
Daily operators shift checklist
Defibrillator failure
Improper device maintenance
Battery failure
Ensure proper battery maintenance and battery replacement schedules.

58. Medical Direction Medical direction is essential part of AED program.
AED event must be reviewed by the medical director.
Reviews of events
Written report
Review of voice-ECG tape recorders
Solid-state memory modules
Magnetic tape recordings stored in device
Quality improvement

59. Cardiac Arrest Caused by heart rhythms that result in no blood flow
Asystole
Pulseless electrical activity
Ventricular fibrillation/ventricular tachycardia
Ventricular fibrillation is a useless quivering of the heart.
Results in no blood flow
Defibrillation is only effective treatment.

60. AED
Computerized device that can recognize shockable vs. nonshockable heart rhythms
Advises operator to deliver an electric shock when appropriate

61. AED Operation: 4 Steps
1. Turn on the device.

62. AED Operation: 4 Steps
2. Attach the electrode pads.

63. AED Operation: 4 Steps
3. Clear the patient and allow the device to analyze.

64. AED Operation: 4 Steps
4. When advised, clear the patient and push the shock button.

65. AED Electrode Pads Right pad Left pad Right upper chest
Below the clavicle
Right border of the sternum
Left pad
Left chest
2 to 3 inches below the armpit