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Cardiac Emergencies

Cardiac Emergencies

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Cardiac Emergencies

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  1. Cardiac Emergencies Focused History, Physical Examination and Management of the Cardiac Patient

  2. Competency & Policy • Competency AHA/SHA BLS, CMC 03; 13; 14; 18; 19; 22; 23 • JHAH MSP RAC OM 1

  3. Objectives To provide staff working in remote area clinics with an overview and guidelines for assessing and managing patients with chest pain.

  4. Introduction • Chest pain is cardiac until otherwise determined • History is key • Physical examination • Diagnostic tools • Acute coronary syndrome • Efficient care = quick recognition • Focused history • Physical examination

  5. Focused History • Orderly and standard • Deductive (patient denial) • Observe clinical signs • History of present illness OPQRST & SAMPLE • Potential causes • Listen and note distress • Do not diagnose but differentiate • Physical examination in parallel with interview • Consider masking factors

  6. OPQRST & ILDCF Onset How did the symptoms begin? Provocation What were you doing? Quality Describe the pain Region/radiation Where is the pain? Severity 0 – 5 (Wong Baker or FRACC) Time/history How long and how frequent? Intensity, location, duration, characteristics and frequency

  7. SAMPLE • Signs and symptoms? • Pain, pressure, tightness, squeezing, heartburn, palpitations, radiating pain, shortness of breath, nausea, vomiting, dizziness, lightheadedness, anxiety, weakness, diaphoresis, numbness, tingling, peripheral oedema • Alergies? • Medications? OTC, herbal, homeopathic, recreational • Past history? Family or personal. Cardiac, pacemaker, CABG, stents, respiratory problems, last doctors visit and why • Last oral intake? • Exacerbation? Exercise? What were you doing?

  8. Physical Examination • Mental status • ABCs • Skin colour and temp • Abnormal pulse • Focus on cardiovascular and respiratory systems • Assess head-to-toe • JVD • Lung sounds, heart sounds, palpate chest and abdomen • Reassess respiration, rate and pattern

  9. ListenHeart Sounds, Apex Normal S1, S2 S3 S4

  10. Look & Feel • Surgical scars • Pacemakers, cardiac scars, abnormal surgery • Transdermal patches • Distension • Ascites, dependent oedema • Pain • Tenderness • Location • Oedema

  11. Assessment Diagnostic Tools • CC, PMH and 1o symptoms • EGC (within 10 mins) • SpO2 • Capnography • Baseline and serial vital signs • Postural hypotension • Blood tests • Troponin, serial CK-MB, U&Es

  12. Subjective Assessment Possible causes: Aortic dissection, pneumothroax, PE, pleurisy, infection, oesophagealvarices, CA, pericarditis, musculoskeletal, indigestion, … • Focus on OPQRST and abnormal findings • Classic pain • Heavy or squeezing and radiating • >20 mins • may include • Diaphoresis • Nausea& vomitting • Anxiety • No positional comfort • Levine’s sign

  13. Subjective Assessment • Positional pain suggests • Pleurisy, pericarditis, pneumonia, musculoskeletal • Tearing pain suggests • Aneurism • Silent MI • Elderly, diabetic, female, neuropathic co-morbid conditions • Atypical symptoms include • Syncope, altered mental status, weakness, fatigue, dyspnoea, epigastric pain, back pain, right side radiating pain

  14. Subjective Assessment • Elderly or diabetic patients • SoB indicative of MI • Exertional/paroxysmal nocturnal dyspnoea • Strong indication of MI • Chronic heart failure, acute COPD • SoB • Pink sputum • JVD • Peripheral oedema • Chest discomfort • Inspiratory rales • Diuretic medications • Recent medication changes

  15. Syncope Elderly may only present with CC of syncope • Cardiac causes • Heart blocks • Dysrythmias • Aortic stenosis • Unstable angina • Non-cardiac causes • Postural hypotension • Medications • Vasovagal reaction • Vasodepressor syncope

  16. Syncope Assessment • Where were you? • What were you doing? • Any pain or palpitations? • Dyspnoea? • Dizziness? • Weakness • Similar events? • How long were you out?

  17. Management • Assessment • SAMPLE • OPQRST (ILDCF) • Vital signs including apical and peripheral pulse • ESI triage • MONA protocol • Asprin 300 -325 mg (chewed) • O2 via NRB • Nitroglycerine 0.4-0.8 mg, every 5 mins, max 3 doses if SBP > 90 mmHg • IV cannulation, 18G ACF with 0.9% saline at 50 mLs/hr

  18. Ongoing Management Clinic level dependent Physician clinics: • Morphine • Thrombolysis • IV nitroglycerin • Troponin, CK-MB • ECG • Serial vital signs • Transfer and notify Nurse clinics: • ECG • Serial vital signs • Consult • Transfer and notify

  19. Ongoing Management • Door to ECG in under 10 mins (KPI) • Door to needle in under 30 mins • Comprehensive documentation • Pain relief • Dysrhythmias and their resolution • Respiratory distress or lack of • Anxiety or diminishing anxiety level

  20. Summary • Standard approach • Recognise • Focus history and physical examination • Understand different etiologies • Formulate a working hypothesis • Focused history, OPQRST and SAMPLE • Clinical signs, symptoms and subtlety • Stabilise and transfer

  21. References Elling, B., Elling, K. (2003). Principles of Patient Assessment in EMS. [Online]. Available at: http://www.delmarlearning.com/companions/content/0766838994/ppt/index.asp?isbn=0766838994. [Accessed on: 18 Jult 2015] RAC OM 1 Att H

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