Cardio 3

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McCann Paramedic Program: Cardiology Lecture 3-Treatment of Cardiovascular Emergencies

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Cardio 3

  1. 1. Cardiovascular Emergencies Part III Dale A. LeCrone Sr NRP Instructor
  2. 2. • Defibrillation • Surge of electric energy is delivered to the heart • Current depolarizes hearts muscle cells. • When cells repolarize after the shock, they should respond to an impulse from SA node. • Needs to be done as soon as possible for: • Ventricular fibrillation • Pulseless ventricular tachycardia • Not useful in asystole
  3. 3. • Manual defibrillation • Automated external defibrillator (AED): interprets cardiac rhythm • Manual defibrillation: paramedic interprets cardiac rhythm • Switch an AED to manual mode when: • All electrical therapy functions are needed. • Patient is in cardiac arrest.
  4. 4. • Manual defibrillation (cont’d) • Follow safety measures. • Make sure no one is touching the patient. • Do not defibrillate a patient in pooled water. • Do not defibrillate a patient who is touching metal. • If implanted pacemaker or internal defibrillator, place the pad below, or in anterior and posterior positions.
  5. 5. • To perform manual defibrillation: • Attach pads to the patient’s chest. • Dry the chest if necessary. • Check the instructions. • Set energy level to 200 J. • Charge the defibrillator. • Apply a conductive gel and apply pressure.
  6. 6. • To perform manual defibrillation (cont’d): • Follow recommended placement. • Position the negative pad right of the upper part of the sternum and the positive pad just below. • Clear the area. • Discharge the defibrillator.
  7. 7. • To perform manual defibrillation (cont’d): • Contraction of the chest will be evident. • Resume CPR immediately and continue for 2 minutes/5 cycles before checking pulse. • If the rhythm does not require a shock and there is a pulse, check the breathing.
  8. 8. • Inspect defibrillator, checking: • Defibrillation pads • Cables and connectors • Power supply • Monitor • ECG • Recorder • Ancillary supplies
  9. 9. • Patients who do not regain a pulse on the scene usually do not survive. • Transport when one of the following occurs: • The patient regains a pulse. • Six to nine shocks have been delivered. • Defibrillator gives three consecutive messages that no shock is advised.
  10. 10. • Automated external defibrillator (AED) • Charge pads and deliver countershocks. • Semiautomated AED prompts rescuer. • If you witness cardiac arrest, attach AED as soon as available. • If not witnessed, perform five cycles of CPR first.
  11. 11. • AED (cont’d) • After AED protocol: • Pulse is regained • No pulse regained and AED indicates no shock • No pulse regained and AED indicates shock is advised
  12. 12. • Cardiac arrest during transport • If pulse is not present: • Stop vehicle. • If defibrillator is not ready, perform CPR. • Analyze the rhythm. • Deliver one shock and resume CPR. • Continue resuscitation.
  13. 13. • Cardiac arrest during transport (cont’d) • If adult patient loses consciousness: • Check for a pulse. • Stop the vehicle. • If defibrillator is not ready, perform CPR. • Analyze the rhythm. • Deliver one shock and resume CPR. • Continue resuscitation.
  14. 14. • Synchronized cardioversion: use of the defibrillator to terminate hemodynamically unstable tachydysrhythmias. • Involves energy delivery at peak of R wave • Increases probability of depolarizing myocytes • Allows SA to resume pacemaker function
  15. 15. • Synchronized cardioversion (cont’d) • Performed just as defibrillation except the user selects the synchronize setting first. • Done only with severely impaired CO • When done on a conscious patient, he or she must be sedated.
  16. 16. • Artificial pacemakers deliver repetitive electric currents to the heart. • Passes through the skin across the heart • Pacer is set for a specific rate • Energy is increased until heart responds
  17. 17. • Several applications in prehospital care: • Interhospital transfer needing pacemaker implantation • Artificial pacemaker failure • Bradydysrhythmias or blocks associated with severely reduced CO
  18. 18. • Must increase heart rate and improve CO. • Support airway and breathing, then: • Establish IV line with normal saline. • Administer atropine. • If no response to atropine, begin TCP immediately. • If unsuccessful, consider a sympathomimetic drug. • Transport to a hospital.
  19. 19. • Decide on seriousness of symptoms. • Unstable tachycardia: • Chest pain • Dyspnea • Hypotension • Altered mental status
  20. 20. • Decide if signs and symptoms indicate tachycardia or another condition. • Rates of 150 beats/min rarely cause serious signs of tachycardia. • Slowing heart rate of patient compensating for a medical condition may be fatal.
  21. 21. • If unstable signs and symptoms result from tachycardia, cardioversion is needed. • If signs and symptoms are mild, slower but safer treatment is recommended. • Determine origin or pacemaker site of rhythm.
  22. 22. • In SVTs, attempt to stimulate vagus nerve. • Carotid sinus massage • Have patient bear down against a closed glottis. © Jones & Bartlett Learning. Courtesy of MIEMSS. © Jones & Bartlett Learning. Courtesy of MIEMSS.
  23. 23. • Never massage both carotid arteries simultaneously. • May cause significant bradycardia or asystole
  24. 24. • Consider patient’s history. • Patients at risk of thromboembolism include: • Advanced age • Coronary artery disease • High cholesterol • If successful, transport anyway.
  25. 25. • Administer adenosine. • 6 mg, by rapid IV push • Insert syringe of adenosine and syringe of at least 20 mL of normal saline solution. • Be prepared for a short run of asystole.
  26. 26. • Administer adenosine (cont’d). • If first dose is unsuccessful, administer again. • If still unsuccessful, transport immediately. • If patient becomes unstable, move to cardioversion algorithm. • If the rhythm is ventricular and patient is stable, transport to the hospital.
  27. 27. • Warnings of cardiac arrest: • Atherosclerosis • Underlying cardiac disease • Electrocution, drowning, or other trauma • Cardiac arrest management requires a systematic approach that is rehearsed.
  28. 28. • CPR should now be initiated prior to airway and breathing assessment. • Concentrate on high-quality compressions. • Avoid excessive volume and inflation pressure. • Keep compressions smooth, regular, and uninterrupted.
  29. 29. • Maintain compression for at least half the compression-release cycle. • Avoid jerky compressions. • Keep shoulders over patient’s sternum, keep elbows straight. • Maintain proper hand position. • Rotate compressors every 2 minutes.
  30. 30. • Single rescuer: give 30 compressions and 2 ventilations at rate of at least 100 per minute. • Do not interrupt CPR compressions except for: • Advanced airway placement • Defibrillation • Moving the patient • Do not stop for more than 10 seconds.
  31. 31. • Minimally interrupted chest compression • Use of adjunctive equipment • Cardiac monitoring for dysrhythmia • Establishment and maintenance of IV • Use of definitive therapy to: • Prevent cardiac arrest • Establish an effective cardiac rhythm and circulation. • Stabilize patient’s condition.
  32. 32. • Administer hypothermia therapy for patients in a coma after return of spontaneous circulation. • Transport to an appropriate facility. • Monitor closely.
  33. 33. • As you approach the scene, bring: • Defibrillator • Portable oxygen cylinder • Jump kit with airway management equipment • Intubation kit • IV equipment • Drug box • If alone, do not take time to carry everything.
  34. 34. • Assess circulation. • If no pulse, start CPR. • Second paramedic should attach defibrillator. • After 2 minutes, proceed. • Assess responsiveness. • If not responsive: • Open airway and assess breathing. • If not breathing: • Give two slow breaths using a bag-mask or barrier device.
  35. 35. • Check pulse and rhythm on monitor. • If ventricular fibrillation or tachycardia is present: • Follow algorithm. • If not present, resume CPR. • If still in cardiac arrest, may be: • Ventricular fibrillation or tachycardia • PEA • Asystole
  36. 36. • Address CAB issues. • Begin CPR and attach defibrillator. • Confirm ventricular fibrillation or tachycardia. • Confirm absence of pulse. • Resume CPR. • Clear patient and then defibrillate. • Biphasic: 120 to 200 J • Monophasic: 360 J • Resume CPR after discharge.
  37. 37. • On monitor: • Identify rhythm. • No pulse: move to asystole- PEA pathway. • Pulse: move to appropriate algorithm. • If ventricular fibrillation or tachycardia: resume CPR. • Clear the patient, then defibrillate. • Resume CPR. • Insert advanced airway if airway is not adequate.
  38. 38. • Start IV line. • If unable, establish IO access until IV is established. • Administer a vasopressor drug. • Epinephrine • Vasopressin • At end of 2 minutes of CPR, check for circulation and rhythm. • If ventricular fibrillation or tachycardia, resume CPR. • Clear the patient, then defibrillate.
  39. 39. • Resume CPR for 2 minutes. • Consider an antidysrhythmic medication. • After CPR, check for circulation and rhythm on monitor. • If ventricular fibrillation or tachycardia: • Resume CPR. • Clear patient and defibrillate. • Resume CPR for 2 minutes. • If still present, consider transport.
  40. 40. • If spontaneous circulation returns: • Assess vital signs. • Support airway and breathing, as necessary. • Provide medications as indicated. • Consider hypothermia protocol and transport to appropriate center.
  41. 41. • Organized cardiac rhythm not accompanied by a detectable pulse • Heart beat so weak from: • Cardiogenic or hypovolemic shock • Cardiac tamponade • Massive pulmonary embolism • Electrolyte imbalance disturbances • Drug overdose
  42. 42. • Resume CPR. • Insert an advanced airway if airway is not adequate. • Start an IV line. • If access cannot be established, consider IO access. • Administer a vasopressor drug. • At end of CPR, check circulation and rhythm. • If PEA still present: • Continue CPR. • Search for causes.
  43. 43. • Flat line may or may not be asystole. • Rule out other causes: • Leads not attached to patient or monitor • Incorrect monitor setting • Very-low-voltage ventricular fibrillation • True asystole
  44. 44. • Resume CPR. • Check for other causes of flat line. • Switch to another lead to detect low-voltage fibrillation. • Insert an advanced airway if airway is not adequate. • Start an IV line. • If unable to establish, consider IO access. • Administer a vasopressor drug. • Epinephrine • Vasopressin
  45. 45. • At end of 2 minutes of CPR, check for circulation and rhythm. • If asystole is still present: • Resume CPR. • Search for/treat possible causes. • Consider termination of resuscitation.
  46. 46. • Heart rate should be stabilized. • Stabilize cardiac rhythm. • If ventricular fibrillation or ventricular tachycardia, consider antidysrhythmic drug. • If severe bradycardia, atropine or TCP may be necessary.
  47. 47. • Lessen effects on the brain: • Correct marked hypotension. • Avoid tracheal suctioning in an intubated patient. • Consider elevating the patient’s head. • If effective rhythm is restored, transport. • If comatose, begin hypothermia treatment.
  48. 48. • In the past, once CPR was started, it had to continue until a physician pronounced death. • In some jurisdictions, pronouncement of death may be permitted by a paramedic.
  49. 49. • Coronary artery disease (CAD) is the most common form of heart disease. • If coronary arteries are blocked, cardiac muscle will be deprived of oxygen (ischemia). • If not restored, area will die (undergo infarction).
  50. 50. • Atherosclerosis • Affects inner lining of aorta and cerebral and coronary blood vessels • Leads to narrowing and blood flow reduction • Area provides a locus for the formation of a fixed blood clot (thrombus) • May cause arteriorsclerosis

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