Cardiac Emergencies


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Cardiac Emergencies

  1. 1. Chapter Cardiac Emergencies Fourteen
  2. 2. Chapter <ul><li>How to assess, recognize, and manage cardiac emergencies </li></ul><ul><li>How to assist patients in taking their nitroglycerin </li></ul><ul><li>How to attempt resuscitation of a patient in cardiac arrest by administering CPR and an AED </li></ul>Fourteen CORE CONCEPTS
  3. 3. Heart
  4. 4. Right Atrium Right Ventricle Left Atrium Left Ventricle Receives blood from veins; pumps to right ventricle Receives blood from lungs; pumps to left ventricle Pumps blood to the lungs Pumps blood through the aorta to the body Four Chambers of the Heart
  5. 5. Cardiac Conduction System
  6. 6. Coronary Arteries
  7. 7. Vessels of Circulation C a p i l l a r y b e d V e i n A r t e r y A r t e r i o l e s V e n u l e s V a l v e
  9. 9. Cardiac Compromise Any kind of problem with the heart K EY TERM
  10. 10. <ul><li>Suspect and treat if: </li></ul><ul><li>Suspect and treat if: </li></ul><ul><li>Pain, pressure, or discomfort </li></ul>in chest or upper abdomen <ul><li>Difficulty breathing </li></ul><ul><li>Sudden onset of sweating, nausea, </li></ul>(Continued) Cardiac Compromise and vomiting <ul><li>Anxiety and irritability </li></ul>
  11. 11. <ul><li>Rapid or slow pulse with no </li></ul>apparent cause <ul><li>Palpitation or fluttering sensation </li></ul>in the chest <ul><li>Feeling of impending doom </li></ul><ul><li>Suspect and treat if: </li></ul>Cardiac Compromise
  12. 12. Causes of Cardiovascular Compromise Atherosclerosis
  13. 13. Coronary arteries Partial blockage producing chest pain Area of decreased blood supply Causes of Cardiac Compromise Angina Pectoris
  14. 14. Causes of Cardiac Compromise Acute Myocardial Infarction Area of Infarct
  15. 15. Causes of Cardiovascular Compromise Aneurysms
  16. 16. Mild to severe confusion Anxiety Increased respiratory rate Dyspnea (shortness of breath) Difficulty breathing while lying flat Cyanosis Distended neck veins Pink sputum Rapid heart rate Normal to high blood pressure Abdominal distention Edema of the lower extremities Causes of Cardiac Compromise Congestive Heart Failure
  17. 17. Perform initial assessment.
  18. 18. Perform focused history and physical exam; take baseline vital signs.
  19. 19. If patient meets nitroglycerin criteria, consult medical direction. Check the “rights” and the expiration date.
  20. 20. Place patient in position of comfort; give high-concentration oxygen by nonrebreather mask.
  21. 21. Patient CARE Cardiac Compromise Emergency Care Steps <ul><li>No history of cardiac problems, OR </li></ul><ul><li>History of cardiac problems but no nitroglycerin, OR </li></ul><ul><li>Systolic blood pressure is < 100 </li></ul>Transport promptly if:
  22. 22. <ul><li>Right patient? </li></ul><ul><li>Right drug? </li></ul><ul><li>Right dose? </li></ul><ul><li>Right route? </li></ul><ul><li>Right time? </li></ul><ul><li>Right documentation? </li></ul>The “Rights”
  23. 23. Remove oxygen mask and ask patient to open mouth and lift tongue.
  24. 24. Place tablet or spray medication under tongue.
  25. 25. Have patient close mouth. Replace oxygen mask. Reassess patient; document findings.
  26. 26. <ul><li>Patient gets no relief AND </li></ul><ul><li>Systolic blood pressure remains </li></ul><ul><li>Medical direction authorizes another dose. Maximum three doses. </li></ul>> 90–100 AND Repeat Nitroglycerin after 5 Minutes IF
  27. 27. <ul><ul><li>Patient must have: </li></ul></ul><ul><ul><ul><li>• Chest pain </li></ul></ul></ul><ul><ul><ul><li>• No allergies to aspirin </li></ul></ul></ul><ul><ul><ul><li>• No history of asthma </li></ul></ul></ul><ul><ul><ul><li>• Not taking any other clotting medications </li></ul></ul></ul><ul><ul><ul><li>• Ability to swallow </li></ul></ul></ul><ul><ul><li>Medical control authorizes administration. </li></ul></ul>To Administer Aspirin (if Local Protocols Allow)
  29. 29. You need to be able to do CPR alone while your partner is preparing equipment or you are transporting a patient in cardiac arrest. One-Rescuer CPR
  30. 30. You must also be able to: <ul><li>Use an AED. </li></ul><ul><li>Provide high quality compressions. </li></ul><ul><li>Request ALS backup when appropriate. </li></ul><ul><li>Use bag-mask device and FROPVD. </li></ul><ul><li>Lift and move patients. </li></ul>(Continued) Two-Rescuer CPR: Critical Skill for EMT-B
  31. 31. You must also be able to: <ul><li>Suction the airway. </li></ul><ul><li>Use airway adjuncts. </li></ul><ul><li>Employ BSI precautions. </li></ul><ul><li>Interview family/bystanders. </li></ul>Two-Rescuer CPR: Critical Skill for EMT-B
  32. 32. High Quality Compressions Research has shown that high quality CPR compressions can double, if not triple, survival if applied promptly. Always press hard, fast (at least 100/minute) and allow full chest recoil. K EY TERM
  33. 33. <ul><li>Many EMS systems have </li></ul>resuscitated patients with AEDs. <ul><li>The highest survival rates occur in </li></ul>systems with strong links in the chain of survival. Automated External Defibrillation
  34. 34. American Heart Association's Chain of Survival
  35. 35. <ul><li>Biphasic </li></ul><ul><li>Sends shock in both directions, measures resistance, and adjusts energy. </li></ul><ul><li>Causes less damage to heart muscle. </li></ul><ul><li>Monophasic </li></ul><ul><li>Sends shock (energy current) from one pad to the other </li></ul>Types of AEDs
  36. 36. AEDs are extremely accurate in distinguishing between shockable and nonshockable rhythms. AED Analysis of Cardiac Rhythm
  37. 37. <ul><li>Very rarely does AED computer make a mistake. </li></ul><ul><li>AED-related errors are almost always human: </li></ul><ul><li>Not clearing patient </li></ul><ul><li>Not stopping ambulance to analyze rhythm </li></ul>Inappropriate Shocks
  38. 38. <ul><li>Ventricular fibrillation </li></ul><ul><ul><li>• 50% of cardiac arrest patients </li></ul></ul><ul><li>Ventricular tachycardia over a certain rate </li></ul><ul><ul><li>• 10% of cardiac arrest patients </li></ul></ul>AEDs will shock two rhythms: Shockable Rythms
  39. 39. <ul><li>An AED is applied ONLY to a patient who is unresponsive and you believe is in cardiac arrest. </li></ul>Safety Considerations (Continued)
  40. 40. <ul><li>No one should do CPR or touch </li></ul>the patient when the AED is analyzing the rhythm or delivering a shock. Safety Considerations
  41. 41. <ul><li>You may stop CPR to allow AED analysis and a shock (if detected). </li></ul><ul><li>Resume CPR immediately after delivering a shock or after AED analysis if no shock detected. </li></ul><ul><li>Other than AED analysis, do not interrupt for more than 10 seconds. </li></ul>Interrupting CPR
  42. 42. Take BSI. Briefly question bystanders about pre-arrest events.
  43. 43. Perform initial assessment. Verify patient is pulseless and not breathing. Check for no longer than 10 seconds.
  44. 44. Note <ul><li>In a witnessed arrest, defibrillation should occur before CPR. </li></ul><ul><li>In an unwitnessed arrest, or prolonged downtime, 2 minutes of CPR should precede defibrillation attempts. </li></ul>
  45. 45. <ul><li>AED Indications: </li></ul><ul><ul><li>Adult patients (puberty or older) after 2 minutes of CPR. </li></ul></ul><ul><ul><li>Children (1 year old to puberty) after 2 minutes of CPR and the availability of an AED designed for children. </li></ul></ul><ul><ul><li>Do not use an AED on an infant (under 1 year of age) </li></ul></ul>Note
  46. 46. Set up AED as partner starts (or resumes) CPR. Unless the arrest was witnessed, administer 2 minutes (5 cycles) of CPR.
  47. 47. Turn on power and, if appropriate, begin verbal report.
  48. 48. Firmly attach one pad to right upper bare chest. Firmly place one pad over lower left bare ribs.
  49. 49. Proper Placement of AED Pads
  50. 50. Say &quot;Clear!&quot; Ensure no one is touching patient. Press analyze button.
  51. 51. If AED advises shock, say &quot;Clear,&quot; ensure no one touching patient, and press shock button.
  52. 52. After delivery of shock, immediately perform CPR for 2 minutes (5 cycles), unless the patient wakes up.
  53. 53. Check effectiveness of CPR by evaluating pulse.
  54. 54. Gather additional information on arrest events.
  55. 55. Insert an airway adjunct and ventilate with high-concentration oxygen.
  56. 56. After two minutes of CPR, have all individuals stand clear and reanalyze with the AED.
  57. 57. If no shock is advised, check carotid pulse, for a maximum of 10 seconds. If present, assess adequacy of breathing.
  58. 58. If breathing is adequate, give high- concentration oxygen by nonrebreather. If inadequate, ventilate with high-concentration oxygen.
  59. 59. If the AED gives 3 consecutive no- shock messages with no carotid pulse . . . . . . or a total of 3 shocks are delivered . . . then transport with CPR and oxygen.
  60. 60. If advanced life support is not available, transport when: <ul><li>Patient regains pulse, OR </li></ul><ul><li>You have delivered 3 shocks, OR </li></ul><ul><li>AED has given 3 consecutive no-shock messages (separated by 2 minutes of CPR), OR </li></ul><ul><li>Your local protocols indicate an earlier transport. </li></ul>
  61. 61. <ul><li>While one EMT – B operates the AED, the partner performs CPR. </li></ul><ul><li>CPR must include high-quality compressions. </li></ul><ul><li>Defibrillation is the first priority in witnessed arrest or short downtimes. </li></ul>General AED Procedures
  62. 62. <ul><li>Do not touch patient when analyzing rhythm and delivering shocks. </li></ul><ul><li>Do not analyze rhythm or defibrillate in a moving ambulance. Stop first. </li></ul>General AED Procedures
  63. 63. <ul><li>Be familiar with your model of AED. </li></ul><ul><li>Check batteries at beginning of shift. </li></ul><ul><li>Follow manufacturer's charging recommendations. </li></ul><ul><li>Carry an extra battery. </li></ul>General AED Procedures
  64. 64. Coordination of EMT – B and ALS <ul><li>Call for ALS as soon as possible. </li></ul><ul><li>Local protocols determine if you should wait for ALS or begin transport to rendezvous with ALS. </li></ul>
  65. 65. AED in Progress If AED is in use by a first responder when you arrive, ensure they are performing properly, and continue with shock analysis and 2 minutes of CPR sequence.
  66. 66. Post-Resuscitation Care <ul><li>Maintain airway. </li></ul><ul><li>Transfer to ambulance. </li></ul><ul><li>Coordinate rendezvous with ALS if appropriate. </li></ul>
  67. 67. Post-Resuscitation Care <ul><li>Leave AED attached to patient. </li></ul><ul><ul><li>Patient has a high risk of returning to cardiac arrest. </li></ul></ul><ul><li>Perform focused assessment and ongoing assessment en route. </li></ul>
  68. 68. Post-Resuscitation Care <ul><li>If patient is unconscious, check pulse at least every 30 seconds. </li></ul><ul><li>If no pulse: </li></ul><ul><ul><li>Stop ambulance. </li></ul></ul><ul><ul><li>Analyze rhythm/deliver shocks per local protocol. </li></ul></ul><ul><ul><li>If AED not available, perform CPR. </li></ul></ul>
  69. 69. Single Rescuer with AED <ul><li>Initial assessment reveals: </li></ul><ul><ul><li>Unresponsive </li></ul></ul><ul><ul><li>Apnea </li></ul></ul><ul><ul><li>No pulse </li></ul></ul><ul><li>Immediately attach AED and initiate analysis if the arrest was witnessed. </li></ul>
  70. 70. Single Rescuer with AED <ul><li>Activate EMS system and start CPR: </li></ul><ul><ul><li>Immediately, if prolonged downtime, OR </li></ul></ul><ul><ul><li>AED gives no-shock message if arrest was witnessed </li></ul></ul>
  71. 71. Pediatrics & AED <ul><li>Do not use on patients less than 1 year old. </li></ul><ul><li>Aggressive airway management and CPR are best methods. </li></ul><ul><li>AED may be beneficial if pediatric AED is available. </li></ul>
  72. 72. Additional Safety Considerations <ul><li>Water </li></ul><ul><ul><li>Dry patient’s chest; remove from wet environment. </li></ul></ul><ul><li>Metal </li></ul><ul><ul><li>Ensure no one in contact with the patient is touching any metal. </li></ul></ul>
  73. 73. Additional Safety Considerations <ul><li>Medication Patch </li></ul><ul><ul><li>If patch visible on chest, remove it with gloved hands before delivering shock. </li></ul></ul>
  74. 74. Advantages of AEDs <ul><li>Initial training and continuing education are simple. </li></ul><ul><li>AEDs are very fast. </li></ul>
  75. 75. Advantages of AEDs <ul><li>Use of adhesive pads instead of paddles is safer, provides better electrode placement, and lowers EMT – B's anxiety. </li></ul>
  76. 76. AED Maintenance <ul><li>AED failure typically results from inadequate maintenance. </li></ul><ul><ul><li>For example, failing to charge batteries on a regular basis </li></ul></ul><ul><li>Use daily checklist to maintain machine and supplies. </li></ul>
  77. 77. AED Quality Improvement <ul><li>Medical direction </li></ul><ul><ul><li>Review calls </li></ul></ul><ul><ul><li>Assist in training and skills </li></ul></ul><ul><li>Continuing education </li></ul><ul><li>Skill review every 3 months </li></ul><ul><li>Data collection </li></ul>
  78. 78. Mechanical CPR Devices <ul><li>Mechanical CPR compressor devices can assist with high quality compressions during CPR. </li></ul><ul><li>Begin use early in the arrest. </li></ul><ul><li>Do not interrupt CPR for more than 10 seconds to apply. </li></ul>
  79. 79. 1. What signs and symptoms should prompt you to treat a patient for cardiac compromise? 2. What are the indications, contra-indications, and dose for nitroglycerin? Review Questions
  80. 80. 3. How many shocks should you give to a patient with a shockable rhythm? 4. What should you do when you get a no-shock message? Review Questions
  81. 81. 5. Which patients in cardiac arrest should not have an AED applied? 6. When using an AED, what safety practices should you follow? 7. How can you be sure that your AED will work when you need it? Review Questions
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