12: Cardiovascular Emergencies

1. 12: Cardiovascular Emergencies

2. 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.

3. 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.

4. 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.

5. 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.

6. 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.

7. 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.

8. 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.

9. 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.

10. 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.

11. 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.

12. 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.

13. 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.

14. 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.

15. 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.

16. 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

17. Blood Flow Through the Heart

18. Electrical System of the Heart

19. Coronary Arteries

20. Blood Flow

21. Blood

22. 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.

23. Materials build up inside blood vessels. This decreases or obstructs blood flow. Risk factors place a person at risk. Atherosclerosis

24. 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

25. 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.

26. 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

27. 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

28. Sudden Death • 40% of AMI patients do not reach the hospital. • Heart may be twitching.

29. Arrhythmias Bradycardia Ventricular Tachycardia

30. Cardiogenic Shock • Heart lacks power to force blood through the circulatory system. • Onset may be immediate or not apparent for 24 hours after AMI.

31. 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.

32. 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.

33. 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?

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

35. 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

36. 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

37. 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?

38. Focused History and Physical Exam • SAMPLE • OPQRST • Medications are important! • Medications often prescribed for CHF: • Furosemide • Digoxin • Amiodarone

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

40. Communication Relay history, vital signs, changes, medications, and treatments.

41. Aspirin • Administer according to local protocol. • Prevents clots from becoming bigger • Normal dosage is from 162 to 324 mg.

42. Nitroglycerin • Forms • Pill, spray, skin patch • Effects • Relaxes blood vessel walls • Dilates coronary arteries • Reduces workload of heart

43. Nitroglycerin Contraindications • Systolic blood pressure of less than 100 mm Hg • Head injury • Maximum dose taken in past hour

44. 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.

45. Assisting With Nitroglycerin (1 of 4) • Obtain order from medical direction. • Take patient’s blood pressure.

46. 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.

47. Assisting With Nitroglycerin (3 of 4) • Administer tablet or spray under tongue. • Have patient keep mouth closed until tablet dissolves or is absorbed.

48. 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.

49. Detailed Physical Exam • Perform if time allows. • Do not gather information unless: • Patient’s condition is stable • Everything else is done

50. 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.