EMT Refresher Cardiology

1. EMT Refresher Cardiology Christina Moore Halifax EMS NREMT-P / CCEMT-P

2. Objectives • Identify Causes of Chest Pain • Anatomy • Physiology • Pathophysiology • Assessment • Treatment Options • Differentiate key origins of C Px

3. Why? • Frequency EMS Calls for Chest Pain? • In Halifax, ~ 40% • You?

4. A Bit of History • 1960s 30-40% chance of death days after heart attack • Today 6%

5. Chest Pain • List Types, sources, etc

6. Chest Pain - Summary • Heart Attack (ACS / AMI) • Cardiac Tamponade • Ischemia • Pericarditis • Pulmonary Embolism • Angina (Stable/Unstable) • Tension Pneumothorax • Myocarditis • Shingles • Muscular-skeletal problems • Aortic Dissection • Aortic Aneurysm • Pleurisy • CHF • Esophogeal Rupture • Aortic Stenosis • Mitral Valve Prolaps • Cardiomyopathy • Cholecystitis • Pancreatitis • Esophogeal tear • Cocaine-indused chest pain • Coronary Spasm (Prinzmetal’s Angina) • Cardiac Dysrhythmia Others?

7. Chest Pain Sorted • Heart Attack (ACS / AMI) • Cardiac Tamponade • Cardiac Dysrhythmia • Pulmonary Embolism • Tension Pneumothorax • Aortic Dissection • CHF • Esophogeal Rupture • Cholecystitis • Pancreatitis • Esophogeal tear • Aortic aneurysm • Cocaine-indused chest pain • Coronary Spasm (Prinzmetal’s Angina) • Angina (Stable/Unstable) • Ischemia • Pericarditis • Myocarditis • Shingles • Muscular-skeletal problems • Pleurisy • Aortic Stenosis • Mitral Valve Prolaps • Cardiomyopathy The Killers

8. What tools do we have • Eyes – inspect • Ears/Stethoscope - auscultate • Hands – palpate • History – personal and familial • Watch – time • EKG 4/12 lead • Phone-a-friend • Medication Administration • Knowledge/skills/experience • Capnography • Lab Tests (bio-markers, chem7, ABG, etc) • X-Ray • Ultrasound • Cardiac Cath • Cardiac Echo

9. Anatomy • Go to http://www.visiblebody.com/start Goals • cardiac circulatory system • cardiac conductive system • And the other fun stuff

10. Key Physiology Points • Cardiac Tissue • Automaticity • Conductivity • Contractility • Rhythmicity • Excitability

11. Physiology Continued • Gas of Life? • Nutrients: O2, Sugar • Waste: CO2, H2O • pH: 7.35 – 7.45 • Exhaled CO2: 35 – 45 mmHg What Happens to Tissue when WRONG

12. Pathophysiology • What happens when it goes wrong • No O2, dirty combustion & bad byproducts • No Sugar – see above • Too Many bad byproducts • Expanding field of injury • No O2 & No Sugar - dying

13. Pathophysiology Measured • Pain • Blood Sugars • Capnography • Blood pH • SpO2 • Troponin/bio-markers • Urine

14. Pathophysology Observed • SHOCK

15. Case Study • 63 yof, teeth/jaw pain and a “tight neck”, sweating • Initial Observations • From Across the Room

16. Case Study • Initial Life-Threatening Diagnoses/Interventions • Differentiate? • Cholecystitis • Pancreatitis • Esophogeal tear • Aortic aneurysm • Cocaine-indused chest pain • Coronary Spasm (Prinzmetal’s Angina) • Angina (Stable/Unstable) • Ischemia • Pericarditis • Myocarditis • Shingles • Muscular-skeletal problems • Pleurisy • Aortic Stenosis • Mitral Valve Prolaps • Cardiomyopathy • Heart Attack (ACS / AMI) • Cardiac Tamponade • Cardiac Dysrhythmia • Pulmonary Embolism • Tension Pneumothorax • Aortic Dissection • CHF • Esophogeal Rupture

17. Assessment • SAMPLER • OPQRST • Diagnostics • EKG 4 & 12 lead

18. EMS Treatment • Oxygen • Aspirin • Nitroglycerin (NTG) • IV – 2 lines preferred • STEMI Alert • Paramedic Request • Rapid Transport to Cath Lab

19. Oxygen • Per American Heart Assoc, 2010 Guidelines: • 2-6 lpm O2 via Nasal Cannula • Titrate to SpO2 approx 96% (not 100%) • Why?

20. Aspirin • Class of Medication • Mechanism of Action • Indications • Contra-Indications • Dosing? • Dude, Dose, Delivery, Date, Document

21. Nitroglycerin • Class of Medication • Mechanism of Action • Indications • Contra-Indications • Dosing? • Dude, Dose, Delivery, Date, Document

22. EKG • Mechanism of Action • Indications • Contra-Indications • Dude,Date, Document

23. Case Study

25. STEMI Alert • When 12-lead EKG prints * * * ACUTE MI * * * • When you have confirmation from medic • When you have transmitted & confirmed

26. STEMI Alert • DHMC Zone 2 • Valid reason to call DHART Helicopter • “Drip & Ship” via Critical Access Hospital • Timed process from: • 911 to “Balloon” • EMS to Balloon • Door to Balloon • Goals: 90 minutes

27. Next Steps • One link in a many link chain • Paramedic Interventions • Pain Control • IV Beta Blocker • ER Interventions • IV Heparin Bolus, Hep drip • IV Fibrinolytic • IV NTG • Cath Lab

28. Cardiac Circulation

29. Cardiac Cath • YouTube http://www.youtube.com/watch?v=3Z2DaU0GBAE&feature=feedf_more

30. Acute Coronary Syndrome • Questions/Discussion on ACS? • Let’s do the next one

31. Induced Hypothermia • What happens to pissed off tissue? • Sprained Ankle… • Swelling • Pain • Treatment • RICE: Rest, Ice, Compression, Elevation

32. Induced Hypothermia • Compartment Syndrome? • What is it? • Where can it happen?

33. Induced Hypothermia • CPR – with return of spontaneous circulation • Pt’s mental state deteriorated • Induce hypothermia with cold (4d C) IV fluids • Keep chilled and “medical coma” for 3 days

34. Future of Hypothermia • Trauma? • Strokes? • Kids? • Lots of potential… lots of unanswered questions

35. Other “Chest Pain” • Chest Pain with Respiratory Distress • Tension Pneumothorax • Pulmonary Embolism • Esophogeal Rupture • Acute Pulmonary Edema / CHF

36. Tension Pneumothorax • History? • Progressive deterioration • Pressure on the heart/great vessels • Disrupting blood flow

37. Tension Pneumothorax • Assessment • Chest Discomfort • Severe Respiratory Distress • Decreased or absent breath sounds on affected side • Obstructive Shock • Treatment?

38. Tension Pneumothorax • Decompression • Paramedic – large needle to chest • MD/PA – large tube in chest • Field Treatment: • Rapid transport, • high flow O2, • Intercept

39. Pulmonary Embolism (PE) • Cause? • Blood clot in an artery in the lungs • Often starts somewhere else, travels through heart to lungs and lodges in there • If <30% impact, few symptoms unless… • COPD, etc

40. PE • Assessment • Chest Pain • Tachypnea (96%) • SoB (82%) • Chest Pain (49%) • Cough (20%) • Hemoptysis (7%) • EKG – Sinus Tachycardia

41. PE • History / Risk Factors • Young women who smoke and use birth control • Deep Vein Thrombosis (DVT) • Traveller’s Syndrome • Leg Cramps

42. PE Diagnostic • In Field: History, Assessment • In ED: • CTA (CT-angiogram) • D-Dimer • X-Ray • Treatment • Thrombolytics \ anticoagulantion therapy

43. Esophogeal Rupture • Often iatrogenic • Post surgical, post procedural • Swallowed foreign object (caustic, sharp, etc) • BFT , Penetrating Trauma • Forceful vomitting

44. Esophogeal Rupture • Assessment: History • Treatment: Supportive

45. CHF • Pump Failure • Brian Richard’s Drawing

46. CHF • Assessment • Management • V.S., EKG, Lung Sounds • CPAP • Treat shock/symptoms

47. Other Chest Pain • Chest Discomfort with Altered Vital Signs • Cardiac Dysrhythmia • Aortic Aneurysm \ Dissection • Pericardial Tamponade • Acute Coronary Syndrom (covered)

48. Other Chest Pain • Unstable Angina • Coronary Spasm / Prinzmetal Angina • Cocaine-Induced Chest Pain

49. Other Chest Pain • Chest Pain due to Infection • Pericaditis • Myocarditis • Simple Pneumothorax

50. Other Chest Pain • Intra-abdominal Causes of Chest Discomfort • Cholecystitis • Pancreatitis • Esophogeal Tear • Neurological Causes of Chest Pain • Thoracic Outlet Syndrome (pg 205) • Herpes Zoster (Shingles)