1. Copyright © 2004, Mosby Inc. All rights reserved.

2. Cardiovascular Emergencies Slide 1 Copyright © 2004, Mosby Inc. All rights reserved. Chapter 18

3. 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. 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. Slide 2 Copyright © 2004, Mosby Inc. All rights reserved.

4. Sudden Cardiac Death Heart disease is #1 cause of death in U.S. Heart disease is #1 cause of death in U.S. 250,000 prehospital deaths annually 250,000 prehospital deaths annually  EMS cannot save all of victims.  The community is the “ultimate coronary care unit” for sudden death. Slide 3 Copyright © 2004, Mosby Inc. All rights reserved.

5. Ventricular Fibrillation Most common rhythm of sudden death Most common rhythm of sudden death Can only be treated with electric shock Can only be treated with electric shock Early defibrillation is critical Early defibrillation is critical Slide 4 Copyright © 2004, Mosby Inc. All rights reserved.

6. AED and the Chain of Survival Early access Early access Early CPR Early CPR Early defibrillation Early defibrillation Early ACLS Early ACLS Slide 5 Copyright © 2004, Mosby Inc. All rights reserved.

7. Role of EMT-B in Cardiovascular Emergencies Administer oxygen. Administer oxygen. Assist with the administration of nitroglycerin. Assist with the administration of nitroglycerin. Perform CPR. Perform CPR. Provide early defibrillation. Provide early defibrillation. Request ALS assistance, as needed. Request ALS assistance, as needed. Provide prompt transportation. Provide prompt transportation. Communicate assessment findings to hospital. Communicate assessment findings to hospital. Slide 6 Copyright © 2004, Mosby Inc. All rights reserved.

8. Review of Anatomy and Physiology Slide 7 Copyright © 2004, Mosby Inc. All rights reserved.

9. Chambers of the Heart and Conduction System Slide 8 Copyright © 2004, Mosby Inc. All rights reserved.

10. Systemic and Pulmonary Circulation Slide 9 Copyright © 2004, Mosby Inc. All rights reserved.

11. Cardiac Output Stroke volume  heart rate Stroke volume  heart rate Either parameter can increase or decrease cardiac output. Either parameter can increase or decrease cardiac output. Varies with activity and other factors Varies with activity and other factors Slide 10 Copyright © 2004, Mosby Inc. All rights reserved.

12. Blood Pressure Measured in every patient > 3 years old Measured in every patient > 3 years old Pressure exerted on the walls of arteries Pressure exerted on the walls of arteries Cardiac output  resistance of vessels Cardiac output  resistance of vessels Contributing factors Contributing factors  Force of contraction  Heart rate  Status of blood vessels (dilated vs. constricted)  Blood volume Slide 11 Copyright © 2004, Mosby Inc. All rights reserved.

13. 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 Slide 12 Copyright © 2004, Mosby Inc. All rights reserved.

14. Arteriosclerosis Narrowing of the arteries Narrowing of the arteries  Caused by buildup of fatty deposits and plaque Less blood can flow. Less blood can flow. First signs of disease may occur with physical exertion or stress. First signs of disease may occur with physical exertion or stress. Slide 13 Copyright © 2004, Mosby Inc. All rights reserved.

15. Myocardial Oxygen Supply and Demand Normally oxygen supply via coronary arteries meets demand. Normally oxygen supply via coronary arteries meets demand. Mismatch occurs when increased demand is not met by an increase in blood supply. 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. Problem can be addressed in two ways.  Decrease demand (rest, nitroglycerin)  Increase supply (oxygen, nitroglycerin) Slide 14 Copyright © 2004, Mosby Inc. All rights reserved.

16. Angina Pectoris Chest pain Chest pain Commonly caused by increased oxygen demands on the heart Commonly caused by increased oxygen demands on the heart  Stress  Exertion  Exercise Relieved by rest and nitroglycerin Relieved by rest and nitroglycerin Slide 15 Copyright © 2004, Mosby Inc. All rights reserved.

17. Myocardial Ischemia and Infarction Ischemia Ischemia  State of decreased blood flow to tissues Myocardial ischemia Myocardial ischemia  Not enough blood flow to meet the oxygen needs of the myocardium Myocardial infarction Myocardial infarction  Necrosis or death of heart cells Slide 16 Copyright © 2004, Mosby Inc. All rights reserved.

18. Ischemic Chest Pain Center of the chest Center of the chest May radiate to the neck, jaw, or arms May radiate to the neck, jaw, or arms Patients may complain of abdominal pain or indigestion. Patients may complain of abdominal pain or indigestion. Slide 17 Copyright © 2004, Mosby Inc. All rights reserved.

19. Ischemic Heart Disease Signs and Symptoms Sudden onset of sweating Sudden onset of sweating Difficulty breathing (dyspnea) Difficulty breathing (dyspnea) Anxiety, irritability Anxiety, irritability Loss of consciousness Loss of consciousness Slide 18 Copyright © 2004, Mosby Inc. All rights reserved.

20. Cardiac Compromise Signs and Symptoms Feeling of impending doom Feeling of impending doom Epigastric pain Epigastric pain Nausea/vomiting Nausea/vomiting Palpitations Lightheadedness Weakness Dizziness Slide 19 Copyright © 2004, Mosby Inc. All rights reserved.

21. Initial Assessment Identify need for priority care. Identify need for priority care. Identify life-threatening conditions. 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 chest pain may prefer sitting position. Patients with altered mental status should be placed in supine position. Patients with altered mental status should be placed in supine position. Slide 20 Copyright © 2004, Mosby Inc. All rights reserved.

22. Initial Assessment Consider need for oxygen, airway, and ventilation. Consider need for oxygen, airway, and ventilation.  Nonrebreather  Positive-pressure ventilation Check for signs of poor perfusion. Check for signs of poor perfusion. Slide 21 Copyright © 2004, Mosby Inc. All rights reserved.

23. SAMPLE History Signs and symptoms Signs and symptoms Allergies Allergies Medications Medications Past medical history Past medical history Last oral intake Last oral intake Events surrounding the chief complaint Events surrounding the chief complaint Slide 22 Copyright © 2004, Mosby Inc. All rights reserved.

24. Important Questions Onset Onset Provocation Provocation Quality Quality Radiation Radiation Severity Severity Time Time Slide 23 Copyright © 2004, Mosby Inc. All rights reserved.

25. Focused Physical Exam Patient may deny symptoms. Patient may deny symptoms.  Make every attempt to convince the patient to seek help. Altered mental status may be caused by low cardiac output. Altered mental status may be caused by low cardiac output. Examine neck veins and accessory muscles. Examine neck veins and accessory muscles. Check breath sounds. Check breath sounds. Slide 24 Copyright © 2004, Mosby Inc. All rights reserved.

26. Baseline Vital Signs A range of vital signs are possible 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) Preexisting medical conditions may alter vitals signs (e.g., hypertension) Slide 25 Copyright © 2004, Mosby Inc. All rights reserved.

27. Emergency Care of Responsive Cardiac Patient Perform the initial assessment. Perform the initial assessment. Ensure an open airway and consider the need for: Ensure an open airway and consider the need for:  Manual maneuvers (head tilt/chin lift, jaw thrust)  An oropharyngeal or nasopharyngeal airway  Suction Slide 26 Copyright © 2004, Mosby Inc. All rights reserved.

28. Emergency Care of Responsive Cardiac Patient Evaluate the adequacy of breathing and consider need for positive-pressure ventilation. Evaluate the adequacy of breathing and consider need for positive-pressure ventilation. Administer supplemental oxygen. Administer supplemental oxygen. Reduce activity and anxiety. Reduce activity and anxiety. Slide 27 Copyright © 2004, Mosby Inc. All rights reserved.

29. Emergency Care of Responsive Cardiac Patient Carry the patient to the ambulance in a position of comfort. Carry the patient to the ambulance in a position of comfort. Prioritize transport. Prioritize transport. Consider administration of nitroglycerin. Consider administration of nitroglycerin. Perform ongoing assessment en route to the hospital. Perform ongoing assessment en route to the hospital. Slide 28 Copyright © 2004, Mosby Inc. All rights reserved.

30. Nitroglycerin Generic name Generic name  Nitroglycerin Trade name Trade name  Nitrostat™ Slide 29 Copyright © 2004, Mosby Inc. All rights reserved.

31. Indications and Contraindications Indications Indications  Patient exhibits signs and symptoms of chest pain.  Has physician prescribed sublingual tablets? »Specific authorization by medical direction Contraindications Contraindications  Blood pressure < 100 mm Hg systolic  Head injury  Infants and children  Patient has already met maximum prescribed dose. Slide 30 Copyright © 2004, Mosby Inc. All rights reserved.

32. Actions and Side Effects Actions Actions  Relaxes blood vessels  Decreases workload of heart Side effects Side effects  Hypotension  Headache  Pulse rate changes Slide 31 Copyright © 2004, Mosby Inc. All rights reserved.

33. Nitroglycerin BP > 100 systolic BP > 100 systolic  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 BP < 100 systolic or no NTG  Continue focused assessment. Transport promptly. Transport promptly. Slide 32 Copyright © 2004, Mosby Inc. All rights reserved.

34. Administering Nitroglycerin Perform a focused assessment of the cardiac patient. Perform a focused assessment of the cardiac patient. Take blood pressure (must be >100 mm Hg). Take blood pressure (must be >100 mm Hg). Question the patient regarding administration of the last dose. Question the patient regarding administration of the last dose. Slide 33 Copyright © 2004, Mosby Inc. All rights reserved.

35. Administering Nitroglycerin Ensure that patient understands the route of administration. Ensure that patient understands the route of administration. Contact medical direction. Contact medical direction. Ensure right patient, right medication, right dose, right route. Ensure right patient, right medication, right dose, right route. Ensure medication is not expired. Ensure medication is not expired. Slide 34 Copyright © 2004, Mosby Inc. All rights reserved.

36. Administering Nitroglycerin Place tablet or spray under the tongue. Place tablet or spray under the tongue. Recheck blood pressure within 2 minutes. Recheck blood pressure within 2 minutes. Record activity and times. Record activity and times. Perform reassessment. Perform reassessment. Slide 35 Copyright © 2004, Mosby Inc. All rights reserved.

37. Reassessment Strategies Monitor blood pressure. Monitor blood pressure. Ask patient about effect on pain relief. Ask patient about effect on pain relief. Seek medical direction before readministering. Seek medical direction before readministering. Record reassessments. Record reassessments. Slide 36 Copyright © 2004, Mosby Inc. All rights reserved.

38. Summary of Management of Patients with Chest Pain Place in the position of comfort. Place in the position of comfort. Administer oxygen. Administer oxygen. Assist with prescribed nitroglycerin. Assist with prescribed nitroglycerin. May be repeated every 3-5 minutes up to a total of three doses. May be repeated every 3-5 minutes up to a total of three doses. If the systolic BP >100 mm Hg If the systolic BP >100 mm Hg Slide 37 Copyright © 2004, Mosby Inc. All rights reserved.

39. Heart Failure Condition resulting from a damaged or weak heart muscle Condition resulting from a damaged or weak heart muscle Caused by severe myocardial infarctions, chronic hypertension, and/or other causes Caused by severe myocardial infarctions, chronic hypertension, and/or other causes Slide 38 Copyright © 2004, Mosby Inc. All rights reserved.

40. Heart Failure Left-sided Left-sided  Backup in lungs  Pulmonary edema  Dyspnea  Accessory muscle use  Rales on auscultation Slide 39 Copyright © 2004, Mosby Inc. All rights reserved.

41. Heart Failure Right-sided Right-sided  Backup in systemic circulation  Swelling of body tissues »Ankles, sacrum, abdomen Slide 40 Copyright © 2004, Mosby Inc. All rights reserved.

42. Cardiac Arrest Management Skills of the EMT-Basic One- and two-rescuer CPR One- and two-rescuer CPR Use of AED Use of AED Request for ALS backup when appropriate Request for ALS backup when appropriate Use of BVM or mouth-to-mask with oxygen attached Use of BVM or mouth-to-mask with oxygen attached Use of flow-restricted, oxygen- powered ventilatory devices Use of flow-restricted, oxygen- powered ventilatory devices Slide 41 Copyright © 2004, Mosby Inc. All rights reserved.

43. Cardiac Arrest Management Skills of the EMT-Basic Lifting and moving patients Lifting and moving patients Suctioning airways Suctioning airways Use of airway adjuncts Use of airway adjuncts Use of BSI Use of BSI History and physical assessment History and physical assessment Slide 42 Copyright © 2004, Mosby Inc. All rights reserved.

44. Rationale for Early Defibrillation Ventricular fibrillation is the most common initial rhythm of cardiac arrest. Ventricular fibrillation is the most common initial rhythm of cardiac arrest. Defibrillation is the only effective treatment of ventricular fibrillation. Defibrillation is the only effective treatment of ventricular fibrillation. EMS systems have demonstrated increased survival through early defibrillation programs. EMS systems have demonstrated increased survival through early defibrillation programs. Survival is associated with implementation of the chain of survival. Survival is associated with implementation of the chain of survival. Slide 43 Copyright © 2004, Mosby Inc. All rights reserved.

45. Time and AEDs Survival rate is approximately 50% after 5 minutes. Survival rate is approximately 50% after 5 minutes. Survival reduced by 7% to 10% each minute. Survival reduced by 7% to 10% each minute. Rapid defibrillation is key. Rapid defibrillation is key. CPR helps extend survival time. CPR helps extend survival time. Slide 44 Copyright © 2004, Mosby Inc. All rights reserved.

46. Patient Age and Use of AED Medical patient >8 years old Medical patient >8 years old  CPR  AED with adult pads Medical patient 1-8 years old Medical patient 1-8 years old  CPR  AED with pediatric pads Consider transport or ALS intercept Consider transport or ALS intercept Slide 45 Copyright © 2004, Mosby Inc. All rights reserved.

47. AED Analysis of Cardiac Rhythms Microprocessor confirms rhythms for which a shock is indicated. Microprocessor confirms rhythms for which a shock is indicated.  Accuracy is high. Analysis is dependent on properly charged defibrillator batteries. Analysis is dependent on properly charged defibrillator batteries. Inappropriate delivery of shocks Inappropriate delivery of shocks  Human error, mechanical error  Ventricular tachycardia Attach defibrillator only to unresponsive, pulseless, nonbreathing patients. Attach defibrillator only to unresponsive, pulseless, nonbreathing patients. Slide 46 Copyright © 2004, Mosby Inc. All rights reserved.

48. Interruption of CPR Do not touch patient during analysis and shocks. Do not touch patient during analysis and shocks. CPR may be stopped up to 90 seconds for 3 shocks. CPR may be stopped up to 90 seconds for 3 shocks. Resume CPR after 3 shocks are delivered or heart converts to normal rhythm. Resume CPR after 3 shocks are delivered or heart converts to normal rhythm. Slide 47 Copyright © 2004, Mosby Inc. All rights reserved.

49. Advantages of AEDs Initial training and continuing education Initial training and continuing education Speed of operation Speed of operation  First shock can be delivered within 1 minute of arrival at the patient’s side. Remote defibrillation through adhesive pads Remote defibrillation through adhesive pads Rhythm monitoring Rhythm monitoring  Option on some defibrillator models Slide 48 Copyright © 2004, Mosby Inc. All rights reserved.

50. If AED Advises No Shock Check pulse. Check pulse. If patient is breathing adequately If patient is breathing adequately  Give high-concentration oxygen.  Transport. If not breathing adequately If not breathing adequately  Artificially ventilate with high- concentration oxygen.  Transport. Slide 49 Copyright © 2004, Mosby Inc. All rights reserved.

51. Standard Operational Procedures Assuming no on-scene ALS Assuming no on-scene ALS Patient should be transported when one of the following occurs: Patient should be transported when one of the following occurs:  The patient regains a pulse  Six shocks are delivered  AED gives three consecutive no shock messages Slide 50 Copyright © 2004, Mosby Inc. All rights reserved.

52. Standard Operational Procedures Defibrillation comes first. Defibrillation comes first. Do not do anything that delays analysis. Do not do anything that delays analysis. EMT must be familiar with device EMT must be familiar with device Slide 51 Copyright © 2004, Mosby Inc. All rights reserved.

53. Standard Operational Procedures Patient contact must be avoided during analysis. Patient contact must be avoided during analysis. State “Clear the patient” before delivering shocks. State “Clear the patient” before delivering shocks. Check batteries at beginning of shift. Check batteries at beginning of shift. Carry extra batteries. Carry extra batteries. Slide 52 Copyright © 2004, Mosby Inc. All rights reserved.

54. Recurrent Ventricular Fibrillation Check pulse every 30 seconds Check pulse every 30 seconds If pulse is not present: 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. Continue resuscitation per protocol. Slide 53 Copyright © 2004, Mosby Inc. All rights reserved.

55. Conscious Patient Becomes Pulseless and Apneic Stop vehicle. Stop vehicle. Start CPR if defibrillator is not immediately ready. Start CPR if defibrillator is not immediately ready. Attach AED, analyze rhythm. Attach AED, analyze rhythm. Deliver up to three shocks. Deliver up to three shocks. Continue resuscitation per protocol. Continue resuscitation per protocol. Slide 54 Copyright © 2004, Mosby Inc. All rights reserved.

56. No Shock Message, No Pulse Present Start or resume CPR. Start or resume CPR. Analyze rhythm. Analyze rhythm.  Until three consecutive “no shock” messages or patient regains pulse Continue transport. Continue transport. Slide 55 Copyright © 2004, Mosby Inc. All rights reserved.

57. Coordination with ALS Personnel EMS system design establishes protocols. EMS system design establishes protocols. AED usage does not require ALS on scene. AED usage does not require ALS on scene. ALS should be notified as soon as possible. ALS should be notified as soon as possible. Transport vs. await ALS per local protocols. Transport vs. await ALS per local protocols. Safety considerations Safety considerations  Water – rain  Metal Slide 56 Copyright © 2004, Mosby Inc. All rights reserved.

58. Postresuscitation Care Manage airway. Manage airway. Assess need for ventilation. Assess need for ventilation. Consider ALS backup. Consider ALS backup. Keep AED attached to patient en route. Keep AED attached to patient en route. Perform focused assessment and reassessment en route. Perform focused assessment and reassessment en route. Slide 57 Copyright © 2004, Mosby Inc. All rights reserved.

59. Defibrillator Maintenance Regular maintenance for defibrillators Regular maintenance for defibrillators Daily operators shift checklist Daily operators shift checklist Defibrillator failure Defibrillator failure  Improper device maintenance  Battery failure  Ensure proper battery maintenance and battery replacement schedules. Slide 58 Copyright © 2004, Mosby Inc. All rights reserved.

60. Medical Direction Medical direction is essential part of AED program. Medical direction is essential part of AED program. AED event must be reviewed by the medical director. AED event must be reviewed by the medical director. Reviews of events Reviews of events  Written report  Review of voice-ECG tape recorders  Solid-state memory modules  Magnetic tape recordings stored in device Quality improvement Quality improvement Slide 59 Copyright © 2004, Mosby Inc. All rights reserved.

61. Cardiac Arrest Caused by heart rhythms that result in no blood flow 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. Ventricular fibrillation is a useless quivering of the heart.  Results in no blood flow  Defibrillation is only effective treatment. Slide 60 Copyright © 2004, Mosby Inc. All rights reserved.

62. AED Computerized device that can recognize shockable vs. nonshockable heart rhythms Computerized device that can recognize shockable vs. nonshockable heart rhythms Advises operator to deliver an electric shock when appropriate Advises operator to deliver an electric shock when appropriate Slide 61 Copyright © 2004, Mosby Inc. All rights reserved.

63. AED Operation: 4 Steps 1. Turn on the device. Slide 62 Copyright © 2004, Mosby Inc. All rights reserved.

64. AED Operation: 4 Steps 2. Attach the electrode pads. Slide 63 Copyright © 2004, Mosby Inc. All rights reserved.

65. AED Operation: 4 Steps 3. Clear the patient and allow the device to analyze. Slide 64 Copyright © 2004, Mosby Inc. All rights reserved.

66. AED Operation: 4 Steps 4. When advised, clear the patient and push the shock button. Slide 65 Copyright © 2004, Mosby Inc. All rights reserved.

67. AED Electrode Pads Right pad Right pad  Right upper chest  Below the clavicle  Right border of the sternum Left pad Left pad  Left chest  2 to 3 inches below the armpit Slide 66 Copyright © 2004, Mosby Inc. All rights reserved.