2. Core concept
• Aspects of acute coronary syndrome (ACS)
• Conditions that may lead to a cardiac emergency
• Other cardiovascular emergencies
3. Topics
•Cardiac Anatomy and Physiology
•Acute Coronary Syndrome
•Causes of Cardiac Conditions
•Other Cardiovascular Emergencies
4. Cardiovascular system
•The cardiovascular system delivers oxygen
and nutrients to tissue and removes by-
products of metabolism and cellular waste
from tissue throughout the body.
•Consist mainly of the heart, blood vessels
and blood.
6. Four Chambers of the Heart
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.
11. Think About It
•How does the normal function of the heart
and blood vessels relate to blood pressure
and distal pulses?
•How is shock related to the function of the
heart and blood vessels?
12. Angina pectoris
•Refers to any time the heart may not be getting
enough oxygen
•Angina pectoris is chest pain caused by a temporary
imbalance between the coronary arteries' ability to
supply oxygen and the cardiac muscle's demand for
oxygen
continued
13. Angina
Conditions that present with Angina are:
1. Stable Angina
2. Unstable Angina
3. Myocardial Infarction
a. ST-segment elevation myocardial infarction (STEMI)
b. Non-ST-segment elevation myocardial infarction (NSTEMI
14. Angina Pectoris
•Typical STABLE ANGINA is exertional, and is relieved
promptly by rest or nitroglycerin.
•Unstable Angina consists of ischemic coronary artery
symptoms which are more frequent, severe, or prolonged
than stable angina,
• The angina
a. Occur at rest or with minimal exertion
b. Is more difficult to control with drugs
15. Acute Coronary Syndrome (ACS)
•Symptoms often mimic non-cardiac
conditions
•Treat all patients with ACS-like signs and
symptoms as though they are having a heart
problem
16. Symptoms of ACS
• Chest pain is best-known symptom
• Can be described as “crushing, dull, heavy, or
squeezing”
• Sometimes described only as pressure or discomfort
• Radiates to arms, upper abdomen, jaw
continued
20. Treatment
• Place patient in position of comfort
(typically sitting up)
• Apply high-concentration oxygen
• Transport
21. Treatment
•If trained, equipped, and authorized to do so,
obtain a 12-lead electrocardiogram (ECG)
•Follow local protocol as to whether to
transmit it to hospital for interpretation
•Employ O . N. A of MONA.
continued
22. Treatment
• Indications for administering nitroglycerin
•Chest pain
•History of cardiac problems and prescribed
nitroglycerin
•Patient has nitroglycerin
•Medical direction
authorizes administration
continued
23. Treatment
• Contraindications for administering nitroglycerin
•Systolic blood pressure less than 90–100
(consult local protocol)
•Patient has taken Viagra or similar drug for
erectile dysfunction within 48–72 hours
continued
26. Causes of Cardiac Conditions
• Heart problems are caused by a number of disorders
affecting condition and function of blood vessels and heart
Risk factors
• Age high cholesterol
• Gender diabetes
• Family history
• Smoking
• Poor diet
• High blood pressure
27. Coronary Artery Disease
• Conditions that narrow or block arteries of heart
• Often result from fatty deposit build-up on inner
walls of arteries
• Build-up narrows inner vessel diameter, restricts
flow of blood
28. Coronary Artery Disease
• Thrombus—occlusion of blood flow caused by
formation of a clot on rough inner surface of
diseased artery
• Thrombus can break loose and form an embolism
• Emboli can move to occlude flow of blood
downstream in a smaller artery
continued
29. Coronary Artery Disease
•Reduced blood supply to myocardium
causes emergency in majority of cardiac-
related medical emergencies
•Chest pain is most common symptom of
reduced blood supply
31. Aortic dissection
• A serious condition in which a tear occurs in the inner layer of the
aorta
• Blood rushes through the tear, causing the inner and middle
layers to split.
• There are 2 types: type A and type B
• Type A- most common and dangerous type, occurs at the area
where the aorta exits the heart,
• Type B- occurs at the descending aorta and may extend to the
abdomen
32. Signs and symptoms
• Sudden severe chest pain or upper back pain which is
described as tearing.
• Sudden severe abdominal pain
• Loss of consciousness
• Shortness of breath
• Symptoms of stroke
• Weak pulse in one arm or thigh
33. Management of aortic dissection
• Assessment
• High concentration of oxygen
• Transport
• ACLS intercept
34. Electrical
Malfunction of the Heart
• Malfunction of heart’s electrical system generally
results in dysrhythmia
• Dysrhythmias include bradycardia, tachycardia,
and rhythms that may be present when there is
no pulse
35. Mechanical
Malfunctions of the Heart
•Angina pectoris
•Acute myocardial infarction (AMI)
•Congestive Heart Failure (CHF)
36. Angina Pectoris
•Chest pain caused by insufficient blood flow to the
myocardium
•Typically due to narrowed arteries secondary to
coronary artery disease
•Pain usually during times of increased myocardial
oxygen demand, such as exertion or stress
37. Acute Myocardial Infarction (AMI)
•Death of a portion of the myocardium due to lack
of oxygen
•Coronary artery disease is usually the underlying
reason
38. Congestive Heart Failure (CHF)
• Inadequate pumping of the heart
• Often leads to excessive fluid build-up in lungs and/or body
• May be brought on by diseased heart valves, hypertension,
obstructive pulmonary disease
• Often a complication of AMI
39. Progression of CHF
• Patient sustains AMI
• Myocardium of left ventricle dies
• Because of damage to left ventricle, blood backs
up into pulmonary circulation and lungs
• If untreated, left heart failure commonly causes
right heart failure
40. Signs and Symptoms of CHF
• Tachycardia
• Dyspnea and cyanosis
• Normal or elevated blood pressure
• Diaphoresis
• Pulmonary edema
continued
41. continued
Signs and Symptoms of CHF
• Anxiety or confusion due to hypoxia
• Pedal edema
• Engorged, pulsating neck veins (late sign)
• Enlarged liver and spleen
42. Hypertensive crisis
• Hypertension –blood pressure of 140/90mmHg and above.
Hypertensive crisis
• Blood pressure reading of 180/120mmHg or greater. Usually due
to uncontrolled blood pressure.
• Occurs in two forms: urgency and emergency.
• Hypertensive urgency- extremely high blood pressure without
suspected end organ damage.
43. Hypertensive crisis
• Hypertensive emergency- extremely high blood pressure
associated with life-threathening complications.
• Signs and symptoms include; severe chest pain,severe
headache, confusion, blurr vision, severe anxiety, shortness of
breath, seizures , unresponsive
44. Management of Hypertensive crisis
• Perform primary survey
-correct any ABCDE problems
-high concentration of oxygen
-transport promptly to appropriate facility
• History taking and physical examination.
• Baseline vital signs.
• Prompt transport.
45. Shock
4 main etiologies of shock include:
Hypovolemic: Low cardiac output due to low intravascular volume.
Cardiogenic: Low cardiac output despite adequate intravascular
volume.
Distributive: Low total peripheral or systemic vascular resistance,
usually septic.
Obstructive: Low cardiac output due to outflow obstruction.
46. Hypovolemic shock
1. Hemorrhage
a. Trauma
b. Gastrointestinal hemorrhage
c. Postsurgical, post procedural bleeding
d. Intra-abdominal (e.g., abdominal aortic
aneurysm, ruptured ectopic pregnancy)
2. Volume depletion
a. Vomiting
b. Diarrhea
c. Excessive diuresis (from diuretics or
uncontrolled diabetes). D: Burns
47. Classes of Hypovolemic Shock
Class I Class II Class III Class IV
Blood Loss < 750 750-1500 1500-2000 > 2000
% Blood Vol. < 15% 15 – 30% 30 – 40% > 40%
Pulse < 100 > 100 > 120 > 140
Blood Pressure Normal Normal Decreased Decreased
Pulse Pressure Normal Decreased Decreased Decreased
Resp. Rate 14 – 20 20 – 30 30 – 40 > 40
UOP > 30 20 – 30 5 – 15 negligible
Mental Status sl. Anxious mildly anx confused lethargic
Fluid crystalloid crystalloid blood blood
48. Clinical Presentation of Hypovolemic Shock
• Tachycardia and tachypnea
• Weak, thready pulses
• Hypotension
• Skin cool & clammy
• Mental status changes
• Decreased urine output: dark & concentrated
50. Obstructive shock
Outflow Obstruction:
a. Aortic stenosis
b. Hypertrophic cardiomyopathy
c. Pulmonary embolism (PE)
Reduced filling
a. Constrictive pericarditis
b. Tension pneumothorax
c. Mitral stenosis
51. Distributive shock
1. Septic shock; as a result of severe infection in the blood.
2. Anaphylactic shock; as a result of severe allergic reaction.
3. Neurogenic shock; as a result of injury to the spinal cord.
52. Cellular Response to Shock
Blood
Loss Inadequate
Perfusion
Cellular
Hypoxia
Aerobic
Metabolism
Anaerobic
Metabolism
Lactic
Acid
Cellular
Edema
Acidosis
53. Stages of shock
•Initial stage- tissues are under perfused, decreased cardiac
output without signs and symptoms.
•Compensatory/reversible stage- activation of sympathetic
nervous system and renin-angiotensin system.
54. Stages of shock
Progressive stage- if there is no interventions or if
interventions fails, compensatory mechanisms worsen cardiac
state leading to anerobic metabolic metabolism and acidosis.
Cardiologist care required for cardiogenic shock.
Refractory/irreversible stage- survival is extremely limited,
complications such as cardiopulmonary arrest, dysrhythmias,
multiple organ failure, stroke and death.
55. Sympatho-Adrenal Response to Shock
• Most immediate of compensatory mechanisms are those of
Sympathetic Nervous System and Renin Angiotensin Mechanism
•Sympathetic Nervous System
• Epinephrine, NE and Cortisol released
•Cause vasoconstriction, increase in HR, and increase of
Cardiac Contractility (Cardiac Output)
•Renin-Angiotensin Axis
• Water and Sodium Conservation and Vasoconstriction
• Increase in Blood Volume and Blood Pressure 55
56. Shock Index (SI)
• A bedside assessment defined as heart rate divided by systolic blood
pressure, with a normal range of 0.5 to 0.7 in healthy adults.
• Has been suggested as such a marker that can be used to predict severity of
hypovolemic shock.
• Classification of hypovolemic shock based on the SI enables a fast and
reliable assessment of hypovolemic shock in the emergency department.
• SI <0.6 (no shock), SI ≥0.6 to <1.0 (mild shock), SI ≥1.0 to <1.4 (moderate
shock) and SI ≥1.4 (severe shock).
57. Mgt of shock
• Assessment- ABCDE approach
• High concentration of oxygen
• Keep patient warm
• Specific treatment dependind on cause of shock.
• Transport
