Chapter 12

Cardiovascular Emergencies

12: Cardiovascular Emergencies

Objectives (1 of 6)
Describe the structure and function of the heart. Describe the care for patients experiencing chest pain. Identify the indications for using an AED. Define the role of the EMT-B in the emergency cardiac care system.
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Objectives (2 of 6)
Discuss the position of comfort for patients with cardiac compromise. Establish the relationship between airway management and cardiac compromise. Discuss fundamentals of early defibrillation.
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Objectives (3 of 6)
Explain importance of ACLS intervention. Discuss various types of AEDs.

State the need for assuring no pulse prior to attaching an AED.

Discuss circumstances resulting in inappropriate shocks.
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Objectives (4 of 6)
Discuss advantages and disadvantages of AEDs.
List the steps for using an AED. Differentiate between single- and multirescuer care with an AED.

Explain why pulses are not checked between shocks when using an AED.
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Objectives (5 of 6)
Discuss the importance of postresuscitation care.

Discuss the importance of completing the AED checklist.

Discuss the role AHA plays in the use of AEDs.
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Objectives (6 of 6)
List the indications for the use of nitroglycerin.

State contraindications and side effects for the use of nitroglycerin.

Define the functions of all controls on an AED.
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Blood Flow Through the Heart

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Electrical System of the Heart

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Coronary Arteries

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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.

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

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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
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Acute Myocardial Infarction (AMI)

Pain signals death of cells. Opening the coronary artery within the first hour can prevent damage. Immediate transport is essential.
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Pain of AMI
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

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

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Arrhythmias

Bradycardia

Ventricular Tachycardia
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Cardiogenic Shock
Heart lacks power to force blood through the circulatory system.

Onset may be immediate or not apparent for 24 hours after AMI.

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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.

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Signs and Symptoms of AMI

Sudden onset of weakness, nausea, and sweating
Chest pain or discomfort Pain in lower jaw, arms, or back Sudden fainting

Pulmonary edema
Sudden death
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Physical Findings of Cardiac Compromise (1 of 2)

Pulse rate increases. Blood pressure may be normal or falling. Respirations are usually normal. General appearance

Frightened
Nausea, vomiting, cold sweat
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Physical Findings of Cardiac Compromise (2 of 2)

Ashen gray skin Swollen neck veins with acute CHF Feeling of impending doom

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Approach to the Patient with Chest Pain (1 of 2)

Reassure the patient and perform initial assessment. Administer oxygen. Measure and record vital signs. Place the patient in a position of comfort.
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Approach to the Patient with Chest Pain (2 of 2)

Obtain focused history and physical exam. Ask about the chest pain using OPQRST. Assist with administration of prescribed nitroglycerin. Transport promptly. Report to medical control en route.
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Nitroglycerin
Forms Pill, spray, skin patch Effects Relaxes blood vessel walls Dilates coronary arteries Reduces workload of heart
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Nitroglycerin Contraindications
Systolic blood pressure of less than 100 mm Hg Head injury Patient age less than 15 years Maximum dose taken in past hour

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Assisting with Nitroglycerin (1 of 2)

Obtain order from medical direction. Take patients blood pressure. 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.
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Assisting with Nitroglycerin (2 of 2)

Administer tablet or spray under tongue. Have patient keep mouth closed until tablet dissolves or is absorbed. Recheck blood pressure. Record each activity and time of application. Perform reassessment. May repeat dose in 3 to 5 minutes.
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Heart Operations
Coronary artery bypass graft (CABG) Angioplasty Cardiac pacemaker
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Automatic Implantable Cardiac Defibrillators (1 of 2)

Maintains a regular heart rhythm and rate Do not place AED patches over pacemaker.
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Automatic Implantable Cardiac Defibrillators (2 of 2)

Monitor heart rhythm and deliver shocks as needed. Low electricity will not affect rescuers.

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Automated External Defibrillation (AED)

AEDs come in two forms: Automated Semiautomated A specialized computer recognizes heart rhythms that require defibrillation.
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AED Use Problems

Battery is dead. Patient is moving.

Patient is responsive and has a rapid pulse.

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AED Advantages
ALS providers do not need to be on scene. Remote, adhesive defibrillator pads are used. Efficient transmission of electricity

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Non-Shockable Rhythms
Asystole Pulseless electrical activity

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Rationale for Early Defibrillation

Early defibrillation is the third link in the chain of survival. A patient in ventricular fibrillation needs to be defibrillated within 2 minutes.

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Using an AED (1 of 3)
Assess responsiveness, pulse, and breathing. Deliver breaths and begin CPR. Turn on AED. Apply pads. Stop CPR.
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Using an AED (2 of 3)
Clear patient. Analyze rhythm. If no shock advised, continue CPR. If shock advised, deliver up to three shocks. Check pulse and breathing after shocks delivered.
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Using an AED (3 of 3)
If patient begins breathing, give oxygen, and transport. If patient is not breathing, ventilate and transport. If there is no pulse, continue CPR for 1 minute. Re-analyze. Deliver three more shocks if needed. Transport and call medical control.
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After AED Shocks

Check pulse. No pulse, no shock advised No pulse, shock advised If a patient is breathing independently: Administer oxygen. Check pulse. If a patient has a pulse but breathing is inadequate, assist ventilations.
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Transport Considerations
Keep AED attached. Check pulse frequently. Transport: When patient regains pulse After delivering six shocks After receiving three consecutive no shock advised messages Stop ambulance to use an AED.
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Cardiac Arrest During Transport

(1 of 2)

Check unconscious patients pulse every 30 seconds. If pulse is not present: Stop the vehicle. Perform CPR until AED is available. Analyze rhythm. Deliver shock(s). Continue resuscitation according to local protocol.
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Cardiac Arrest During Transport

(2 of 2)

If patient becomes unconscious during transport: Check pulse. Stop the vehicle. Perform CPR until AED is available. Analyze rhythm. Deliver up to three shocks. Continue resuscitation according to local protocol.
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Safety Considerations
Make sure the electricity injures no one. Do not defibrillate a patient lying in pooled water. Dry a soaking wet patients chest first. Do not defibrillate someone who is touching metal that others are also touching. Remove nitroglycerin patches.
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AED Maintenance
Read operators manual. Check AED and battery at beginning of each shift. Get a checklist from the manufacturer. Report any failures to the manufacturer and the FDA..
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Medical Direction
Should approve protocols Should review AED usage

Should review speed of defibrillation Should provide review of skills every 3 to 6 months

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Cardiovascular System Changes with Age

Decreased pumping of heart Electrical system changes Atherosclerosis Decreased peripheral circulation (diabetes) AMI without pain
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