12: Cardiovascular Emergencies

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.
 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.
 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.
 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.
 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.
 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.
 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.
 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.
 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.
 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.
 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.
 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.
 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.
 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.
 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
Blood Flow Through the Heart
Electrical System of the Heart
Coronary Arteries
Blood Flow
Blood
 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.
 Atherosclerosis
• Materials build up inside
blood vessels.
• This decreases or
obstructs blood flow.
• Risk factors place a
person at risk.
 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
 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.
 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
 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
 Sudden Death
• 40% of AMI patients do not reach the hospital.
• Heart may be twitching.
 Arrhythmias

Bradycardia

Ventricular Tachycardia
 Cardiogenic Shock
• Heart lacks power to force blood through the
circulatory system.
• Onset may be immediate or not apparent for 24
hours after AMI.
 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.
 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.
• What is wrong with this patient?
You are the Provider (continued)

• What must you know before administering any

medication?
• What must you specifically know before assisting a
patient with nitroglycerin?
 Scene Size-up

• Scene size-up
• General impression
– Is the patient responsive?
 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
 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
• You obtain a brief history while taking the patient’s
blood pressure. (continued)
You are the Provider

• Your partner retrieves the nitroglycerin and obtains

permission from medical control.
• Your partner administers the nitroglycerin.
• What else can you do at this time?
 Focused History and Physical Exam

• SAMPLE
• OPQRST
• Medications are important!
• Medications often prescribed for CHF:
– Furosemide
– Digoxin
– Amiodarone
 Focused Physical Exam
• Cardiac and respiratory systems
• Look for skin changes.
• Lung sounds
• Baseline vital signs
– BOTH systolic and diastolic BP readings
 Communication

Relay history, vital signs, changes, medications,

and treatments.
 Aspirin
• Administer according to local protocol.
• Prevents clots from becoming bigger
• Normal dosage is from 162 to 324 mg.
 Nitroglycerin
• Forms
– Pill, spray, skin patch
• Effects
– Relaxes blood vessel
walls
– Dilates coronary arteries
– Reduces workload of
heart
Nitroglycerin Contraindications
• Systolic blood pressure of less than
100 mm Hg
• Head injury
• Maximum dose taken in past hour
 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.
Assisting With Nitroglycerin (1 of 4)
• Obtain order from medical direction.
• Take patient’s blood pressure.
 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.
Assisting With Nitroglycerin (3 of 4)
• Administer tablet or spray under tongue.
• Have patient keep mouth closed until tablet
dissolves or is absorbed.
 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.
 Detailed Physical Exam

• Perform if time allows.

• Do not gather information unless:
– Patient’s condition is stable
– Everything else is done
 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.
 You are the Provider
(continued)

• ALS arrives and you report your interventions and

vital signs.
• ALS performs cardiac monitoring and prepares for
morphine administration.
• The patient’s pain is gone by the time you reach
the hospital.
 Heart Surgeries and Pacemakers
• Coronary artery bypass graft (CABG)
• Angioplasty
• Cardiac pacemaker
 Automatic Implantable Cardiac
Defibrillators (1 of 2)
• Maintains a regular
heart rhythm and
rate
• Do not place AED
patches over
pacemaker.
 Automatic Implantable Cardiac
Defibrillators (2 of 2)
• Monitor heart rhythm
and deliver shocks as
needed.
• Low electricity will not
affect rescuers.
 Cardiac Arrest
• The complete cessation of cardiac activity, either
electrical, mechanical, or both.
 Automated External Defibrillator
(AED)
• AEDs come in various models.
• Some operator interaction
required.
• A specialized computer
recognizes heart rhythms that
require defibrillation.
Potential AED Problems
• Battery is dead.
• Patient is moving.
• Patient is responsive and
has a rapid pulse.
 AED Advantages

• ALS providers do not need to be on

scene.
• Remote, adhesive defibrillator pads
are used.
• Efficient transmission of electricity
 Non-Shockable Rhythms
• Asystole
• Pulseless electrical activity
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.
 AED Maintenance
• Read operator’s 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.
 Medical Direction
• Should approve protocols
• Should review AED usage
• Should review speed of defibrillation
• Should provide review of skills every 3 to 6 months
 Preparation
• Make sure the electricity injures no one.
• Do not defibrillate a patient lying in pooled water.
• Dry a soaking wet patient’s chest first.
• Do not defibrillate a patient who is touching metal.
• Remove nitroglycerin patches.
• Shave a hairy patient’s chest if needed.
 Using an AED (1 of 8)
• Assess responsiveness.
• Stop CPR if in progress.
• Check breathing and pulse.
• If patient is unresponsive
and not breathing
adequately, give two slow
ventilations.
 Using an AED (2 of 8)
• If there is a delay in
obtaining an AED, have
your partner start or
resume CPR.
• If an AED is close at
hand, prepare the AED
pads.
• Turn on the machine.
 Using an AED (3 of 8)
• Remove clothing from
the patient’s chest
area. Apply pads to the
chest.
• Stop CPR.
• State aloud, “Clear the
patient.”
 Using an AED (4 of 8)
• Push the analyze
button, if there is one.
• Wait for the computer.
• If shock is not needed,
start CPR.
• If shock is advised,
make sure that no one
is touching the patient.
• Push the shock button.
 Using an AED (5 of 8)
• After the shock is delivered, most AEDs will
automatically reanalyze the rhythm; if not, push the
analyze button again.
• If the machine advises a shock, deliver a second
shock.
• Reanalyze the rhythm.
• If the machine advises a shock, deliver a third
shock.
 Using an AED (6 of 8)
• Check for pulse.
• If the patient has a
pulse, check breathing.
• If the patient is
breathing adequately,
provide oxygen via
nonrebreathing mask
and transport.
 Using an AED (7 of 8)
• If the patient is not
breathing adequately,
use necessary airway
adjuncts and proper
positioning to open
airway.
• Provide artificial
ventilations with high-
concentration oxygen.
• Transport.
 Using an AED (8 of 8)
• If the patient has no pulse, perform 1 minute of CPR.
• Gather additional information on the arrest event.
• After 1 minute of CPR, make sure no one is touching
the patient.
• Push the analyze button again (as applicable).
• If necessary, repeat one cycle of up to three stacked
shocks.
• Transport and check with medical control.
• Continue to support the patient as needed.
 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.
 Transport Considerations
• Transport:
– When patient regains pulse
– After delivering six to nine shocks
– After receiving three consecutive “no
shock advised” messages
• Keep AED attached.
• Check pulse frequently.
• Stop ambulance to use an AED.
 Cardiac Arrest During Transport (1 of 2)
• Check unconscious patient’s 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.
 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.