CARDIAC EMERGENCIES

1. Given at the Cardiac Workshop at AIHC,
Detroit, Michigan, April 25, 1966
Cardiac Bmeltencies in Industry-
Nursing hnplications lor the
Occupational Health Nurse
BY MARY REYNOLDS, R.N., M.S.
I
WAS ASKED to discuss the role of the
occupational health nurse in cardiac emergen-
cies, and the early recognition of symptoms. It
is difficult to discuss these situations without
some review of background material, and so I have
attempted to combine it with heart conditions you
might see in industry. Interestingly enough, we see
exactly the same things in the hospital, need the
same background material and are faced with the
same decisions as are nurses outside the confines of
a medical institution.
Cardiac Pain
Cardiac pain is frequent, varied and alarming. It
may or may not be significant. We are conscious of
OUr hearts and how they are performing, and dis-
turbances which come to our attention can be
frightening. What causes this pain? There have been
many explanations over the years, and there are
still differences of opinion. One thing is apparent,
cardiac pain results from a decrease or cessation of
blood flow to the heart muscle, or myocardium. How
tnuch of a decrease of blood flow will cause pain is
not really known. There are a number of theories:
some feel that anoxia of the myocardium-s-even to
a small degree-causes pain, some that spasms of
the muscle account for it; others feel pain occurs
When, for some reason. the walls of the coronary
artery are distended.
A more recent theory explains pain on the basis
of an accumulation of metabolites. When there is
a decrease in the blood supply to the myocardium,
iSchemia results. During this period of ischemia,
tnuscle contractions are occcurring and produce a
substance, or substances (metabolites) which are
-Miss Reynolds is Associate Professor of Nursing, Univer-
Sity of Michigan School of Nursing, Ann Arbor, Michigan.
responsible for the often intolerable pain of heart
conditions. This is still a theory, but I thought it was
interesting. The same mechanism might very well
be the basis for angina pectoris, which I would like
to discuss now.
The Pain of Angina Pectoris
This condition is typically characterized by the
occurrence, on exertion, of substernal pain. It is de-
scribed as oppression, tightness or crowding in the
chest or substernal heaviness. Occasionally it is said
to be a vise-like gripping of the sternum and lateral
chest, and less frequently as burning. This pain is
rarely severe, more often it is of moderate intensity.
It is never stabbing and is not precipitated by cough-
ing or respiratory movements.
As it radiates to the upper extremities and else-
where the sensation is characterized by an ache, a
numbness, a tingling or other vague discomfort. The
location of the pain is usually under the upper part
of the sternum but is not necessarily felt along its
entire length. In fact, the pain is not always sub-
sternal. It may be projected over the left pectoral
region to the left shoulder and along the medial
aspect of the left arm to the elbow. It may further
be projected to the hand along the distribution of
the ulnar nerve. Less frequently, it is referred to the
right side or felt as constriction around the neck.
The attacks are often precipitated by excitement or
exertion, or they may occur at night or after meals.
The paroxysms usually last a few minutes to half an
hour and disappear quickly when the patient rests.
The administration of vasodilating drugs such as
nitroglycerine usually dispel the attacks. Frequently
patients carry these tablets with them. It is our re-
sponsibility to see that the patient puts the tablet
American Association of Industrial Nurses Journnl, February, 1967 11

2. Cardiac Emergencies
continued
L. to R. Miss Margaret Regan, R.N., Mrs. Beatrice Amos,
R.N., Mrs. Beryl Feldhouse, R.N., Mrs. Mary Benson, R.N.,
Miss Ru th Hellm an, R.N., Dr. J oseph Gaeta.
under his tongue, to provide quiet, lessen anxiety if
possible, and reassure him that the pain will subside.
The Pain of Acute Myocardial Infarction
The pain in this condition and its radiation distri-
bution is quite similar to that just described, but is
. more severe and prolonged. Various vivid descrip-
tions are given: intolerable crushing or clutching
substernally or over the precordium, vise-like sen-
sation around the chest, or the pain may defy de-
scription. The agony may be extreme and often
diffuses throughout the chest. You may see a strong
man pace the floor in agony, toss around and gen-
erally exhibit severe anguish. Unlike angina, this
may continue for hours and in some cases is relieved
only by morphine.
When the pain of a myocardial infarction is re-
ferred to the upper abdomen and is an explosive
kind of pain, it may resemble a perforating ulcer.
There may be muscle guarding and even abdominal
rigidity and fever. When the heart pain is referred
to the right upper quadrant it may be confused with
cholecystitis. In some patients the onset of myocar-
dial infarction may be signalized by a feeling of
distention in the epigastrium and the patient be-
12
lieves he has acute indigestion. The pain may rad iate
down the left arm to the fou rth an d fifth fingers of
the left hand.
A myocardial infarction is not infrequen tly fol-
lowed by a painful disability of the hands an d
shoulders, characterized by pain in one or both
sho ulders. It may occur week s or months afte r th e
infarc tion. The hand may be glossy, swollen, stiff
and painful on motion , and there may be stiffness
and limitation of motion of the sho ulde rs .
The etiology of the hand-shoulder syndrome is not
clear. It may come fro m a persistent stimulation of
th e sy mpathe tic nerves during the infarction. Chron-
ic sy mpathetic stimulation is thought to produce
chan ges in blood flow to these somatic areas and to
contribute to musculoskeletal changes in the ex-
tremity. The above symptoms serve to alert us to
the possibili ty th at the patient might have had a
coronary at some time. If he now comes with cardiac
pain, we have a better chance of determining what
our present actio n sho uld be .
The Acute Stage of Myocardial Infarction
This is a serious medical emerge ncy. It is fre-
que ntly the role of the nurse to observe accurately
and take emergency Jreasures in situations where
the physician is not immediately present. In cases of
myocardial infarcti on it is import an t for th e nurse
to do, or direct othe rs to do, the following:
1. Keep the patient at rest as near his basal rate of
activity as is possibl e.
2. Give nothing by mouth-there may be nau sea
and/or vomiting.
3. Give no nitroglycerine without the physician's
order- the vasodilating effect may cau se a fur-
ther lowered blood pressure with massive infarc-
tion and dea th.
4. Give oxygen-even in the absence of cyanosis
this will allow a given level of oxygen tension to
be achieved at a lower level of card iac output and
thus rest the heart.
5. Loosen clothing.
6. Give no medication (unless there is a standing
order in your organization).
We should remember that these patients may
appear to be in shock and are, but not the same
shock as seen in hemor rh age or accident situations.
The classic method of treating shock (Trendelen-
berg, fluids, lying flat) may produce se rious conse-

3. qu ences if this is shock from an infarction. High
venous pressure, bulging neck veins and th e defec-
tive action of a disabl ed heart are in sharp contrast
to the low venous pressure, collapsed veins and reg-
ular cardiac rhy thm of non-cardiac shock. It is
mandatory for the nurse to know the difference.
Thc Rolc of Potassium in Cardiac Emergencies
There seems to me to be a definite implication for
the nurses in industry, when it comes to heart condi-
tions and the role of potassium. This is the chief
cat ion of th e intercellular fluid. Any imbalan ce of
electrolytes or wa ter metabolism may produce alter-
ati ons in the potassium concentrati on of the extra-
cellular fluid. A deviation , even within very narrow
limits, is apt to be associated with disturbances in
conduction impulses throu gh muscle-both skeletal
and cardiac. Th e conduction system of the heart is
significantly affecte d by an abnormal rise or fall in
serum potassium levels. In a normal diet two to four
gra ms of potassium are ingested daily. Th e renal
excretion of potassium is so regulated th at the body
remains in potassium balance, provided that th ere is
no underlying pathology.
A low K level predisposes to cardiac arrhythmia.
A low K level also sensitizes th e heart to digitalis,
and pred isposes to digit alis intoxication. If an em-
ployee wh om yo u know is on digitalis complains of
vomiting to any great extent, you should investigate
to find out wh ether 0' not he should take his medi-
cine. The sa me principle applies in the use of di-
Uretics. Digitalis should be administered with
cau tion when there is vomiting or diuresis to any
great extent, because of th e possibility of low serum
1< and its consequences.
Clinical Signs of Potassium Deficiency
A pat ien t will complain of a gra dual decrease in
st re ngth. The mu scles are flaccid and some times
there are diminished or absent reflexes. He may
complain of weakness or a numb feeling and then
paralysis develops, extending from periphery to the
center. Respirat ory paralysis may also develop. It
is as important to know when not to do any thing as
to know when to do something. Withholding digi-
talis in the presence of severe vomiting, signs of
digitalis intoxication and a cardiac arrhythmia is
propel' emergency treatment.
Cardiac Asthma or Pulmonary Edema
Thi s is the most severe respiratory distress seen
Am erican Associat ion 0/ Ind ustrial Nurses Jou rnal, Februa ry, 196i
with congestive heart failure. It occurs when there
is a sudden intensification of pulmonary congestion
and can be precipitated by physical or emotional
exhaustion. This condition you might well see when
th e person is "on the job." The nam e "cardiac asth-
ma" is rarely heard today, but the condition gets its
name from th e asthmatic wheezes in persons in
he art failure with pulmonary congestion. The
wheezes are a result of the reduction in the lumen
of th e intrapulmonary airways by edema fluid , and
th ickening of the bronchiolar walls by edema. The
high intrathoracic pressure required to ove rcome
th e obstruc tion during expiration tends to narr0Y
th e bronchioles further and may even collapse them.
Th ere are seven major signs and symptoms we
should be on the alert for; dyspnea, ortho pnea,
cou gh, (all respiratory) ; extreme anxiety- feeling
of doom; audible gu rgling, bubbling sounds on ex-
piratory wheezing; frothy pink-tinged sputum; cya-
nosis , (due to excessive concentration of reduced
hemoglobin in the blood ) : cold sweat; pulse full at
first, then rapid and thready.
This is a real medical emergency. The patient
sho uld be placed in an upright position with opti-
mum chest expansion. Someone should stay with
him. Oxygen is usuall y effective and probably
sho uld be administe re d until the physician arrives
or th e patient has been transferred to the hospital.
Disorders of Cardiac Rhythm-Cardiac Arrhythmias
Disorders in cardiac rhythm can result from non-
serious cardiac infections and intoxications such as
pneumonia, hyperth yroidism , excessive use of alco-
hol, or from organic heart disease. They may de-
velop as complications related to either medical or
surg ical treatment of heart disease. For many dis-
orders of rhythm no cardiac reason can be found.
Arrhythmias may be of no consequen ce or may re-
quire immediate attention if th e patient is to survive.
T
HE RATE AND FORCE of the heart are under
the control of the autonomic nervous system
and the rate of the heart is slowed by para-
sympathetic (vagal) stimulation, (thus, "no
rectal temperatures in infarct") . The normal cardiac
cycle represents a balance between these two symp-
toms. The carotid sinus at the beginning of the in-
ternal carotid art ery responds to increased pressure
in the circulatory system and responds reflexively to
reduced pressure. The carotid body near the carotid
13

4. Cardiac Emergencies
continued
sinus is a chemo-receptor which responds to chem-
ical changes in the blood. The heart beat appears to
be initiated by the sinoatrial node and spreads
through the atrial muscle to the bundle of His. The
impulse is then carried rapidly to the ventricles via
the bundle branches so that the ventricular muscle
is activated almost simultaneously from various
points. In the normal cardiac cycle the atria contract
and then the ventricles. The latter contract from the
apex toward the base and this provides adequate
force to propel blood into the circulation. This brief
review should give us some clues to the symptoms
patients may have, and alert us to make significant
observations.
The nurse, whether in occupational health or the
hospital, is in a unique and vital position in the de-
tection of disorders of cardiac rhythm. If she can
give the physician an accurate and complete account
of the disorder, he will be able to render treatment
more rapidly. He might even be able to tell the
nurse over the phone what emergency measures to
take until he arrives. An accurate description of the
patient's condition will let him know what equip-
ment he will need.
When a change in rhythm of a patient's heart beat
is detected there are five things a nurse should re-
port to the physician.
1. Irregularities in rhythm
2. Irregularities in intensity of pulsation
3. Blood pressure
4. Heart rate
5. Symptoms.
We should remember that ear listening at the apex
of the heart is a far more precise method of detect-
ing irregularities than feeling the pulse.
We should take care that the patient is not made
aware of cardiac irregularities if he is not already
cognizant of them. It is conceivable that this might
start a serious anxiety cycle and could result in a
so-called "cardiac cripple." Patients attach great im-
portance to the heart and develop real fears if they
feel there is something wrong.
The nurse neither can, nor should, diagnose dis-
orders of rhythm or institute intensive therapy. This
is the prerogative of the physician. The nurse's re-
sponsibility is to have sufficient background to know
what she might expect, and how to observe and re -
14
port, precisely and completely, what she sees and
hears.
Excessively rapid heart rates are known as tachy-
cardia and excessively slow ones as brachycardia.
Tachycardias are also classified according to the site
of origin of impulse.
In Sinus Tachycardia the origin of the impulse is
normal, the heart beat is rapid. The rhythm is re-
regular, pulsations are of equal intensity and the
rate may be 130 or more. If shock for other reasons
is not present, the blood pressure will be normal,
circulation will be intact and palpitation may be the
only symptom. The patient ma y be anxious or
breathless or both. This condition is usually seen in
anxiety states, acute infections, intoxications, shock,
in injuries and in all types of heart disease. Unless
there is a persisting cause for this state, the pulse
will show a continuous slowing and the most im-
portant emergency measure is to reassure the
patient. Sedation may be ordered to lessen the
anxiety, and unless the pulse is excessively rapid
and shows no sign of slowing down, nothing further
need be done. The patient should be referred to his
physician for possible diagnosis of underlying dis-
ease. Pressure on the eyeballs or the carotid sinus
or forced vomiting may te rminate atrial tachycar-
dias because of the vagal stimulation from th ese
procedures.
Sinus Brachycardia This is a slow normal
rhythm, and if this is the only sign or symptom,
almost never requires treatment. The patient may
be upset if he thinks his heart is slowing to a stop.
It is true that a very slow rate might he indicative
of heart block, but it is unlikely in the absence of
any past history or present symptoms. A slow pulse
causes concern to nurses as well as patients, but is
rarely indicative of serious underlying pathology. It
might be a symptom of digitalis intoxication, but
even so, this is not a true cardiac emergency re-
quiring heroic measures.
Sinus Arrhythmia This is a normal condition
with variations in rate. There are alternate periods
of slow and rapid pulse, hut each phase is regular.
This condition has a relationship to respiration.
Deep breathing accentuates it and taking a deep
breath and holding it will induce a sinus arrhythmia.
It rarely produces symptoms, and indeed th e patient
rarely knows about it. We notice it when taking his
pulse.

5. Premature Contractions occur when an isolated
impulse activates the ventricle. Occasional contrac-
tions are not difficult to identify because the basic
rhythm is regular sinus rhythm. In themselves, pre-
mature beats are not cause for alarm, but our
awareness of these can alert the physician, since
they might be a precursor of the more serious ven-
tricular tachycardia or overdigitalization.
Atrial Fibrillation is perhaps one of the common
disturbances in cardiac rhythm. This means a total
disorganization of rhythm, identified by a com-
pletely irregular pulse, variations in intensity of the
heart beats and a rapid ventricular heartbeat.
Usually the apical rate (through the stethoscope) is
rapid and faster than the radial pulse rate. This
pulse deficit occurs because only the ventricles are
contracting effectively and not every beat is strong
enough to get through to the radial artery in the
wrist. This condition in and of itself is not serious
especially since it responds quickly and well to
treatment. In slow atrial fibrillation (90 or less) no
treatment may be required. In atrial fibrillation the
atria have been known to beat as much as 350 beats
a minute. Interestingly enough, the dynamics of cir-
culation are not disturbed in this condition. The con-
traction of the atria are not essential for good fillin g
of the ventricles, and so long as the ventricles have
time to fill and have nothing interfering with their
contractions the heart can function.
Ventricular Tachycardia
This is the most serious disorder of cardiac
rhythm. Here the impulses which initiate the ven-
tricular contractions all arise in the ventricle. The
rate is very rapid-I80 beats a minute. The rhythm
may or may not be irregular. The pulse may be of
fair quality or imperceptible. The blood pressure is
usually depressed , moderately in some cases, severe-
ly in other, more serious cases. This condition of
ventricular tachycardia should be suspected in a
patient who has an acute heart ailment or history of
one. Tachycardia may occur in any condition, such
as fever, which increases the metabolic rate, or after
a person, who has been ill, returns to work. The
change from relative rest to much activity can bring
on tachycardia. This again emphasizes the need to
know the past history of our patients, so we know
what action needs to be taken. In this situation, the
patient should be kept quiet and the physician noti-
fied immediately. Unless the rhythm is fairly slow
or the paroxysm of short duration, the patient's life
may be endangered.
Ventricular Fibrillation
This is the most serious of all disturbances in
cardiac rhythm. The rhythm may be so disturbed
and deficient that the patient cannot survive if it
persists. The contractions of the heart are disorgan-
ized and feeble, there may be no palpable pulse or
blood pressure and the circulation may be almost at
a standstill. Heart sounds may be inaudible and the
patient lapses quickly into shock and coma. Veins
may be collapsed, and even if one can be found
medications may not be circulated throughout th~
body due to the standstill circulation. This condition
may be seen in myocardial infarction and electric
shock. The patients collapse and need immediate and
vigorous treatment. The circulation may need to be
supported with mouth-to-mouth resuscitation.
Heart Block
In complete heart block no impulses pass from the
atrium to the ventricle and this condition may be
transient or permanent. The atria and ventricle beat
independently of each other and at an entirely dif-
ferent rate. We have mentioned that so long as the
ventricles are able to fill and contract adequately,
the contraction of the auricles is not such a serious
problem. The same applies here and there is no im-
mediate difficulty unless the heart rate is extremely
slow and circulation is in danger of being impaired.
Heart block should be suspected in a ventricular
rate of fifty or less. The blood pressure may be
normal, but the pulse pressure is likely to be large.
This condition can continue in a benign way for
years and produce no symptoms.
Problems arise when: 1) the ventricular rate is
too slow (30 or less); 2) when the heart develops
heart block and the ventricle delays taking up a
rhythm of its own, and 3) when there are periods
of ventricular fibrillation. Any of the above may
cause unconsciousness or convulsions (Adams-
Stokes Syndrome). When the ventricular rate is too
slow for circulation to be maintained and the output
of the heart is inadequate, the patient will show
signs of giddiness and weakness with developing
stupor, and this is as true in heart block as any other
cardiac condition.
Adams-Stokes Syndrome
Sometimes difficult problems arise in the Adams-
American Association 0/ Industrial Nurses Jourual , February, 1967 15

6. Stokes episodes in intermittent paroxysmal heart
block. When heart block develops, there may be an
appreciable delay between the time the last impulse
passes down the atrium and the time the ventricle
starts putting out its own impulses. During this time
there are no ventricular contractions, no heart beat,
no pulse, no blood pressure and no circulation. Gid-
diness will be slight and fleeting if this episode lasts
only a few seconds, as is often the case. If it lasts
longer than a few seconds unconsciousness and con-
vulsions will occur. A long delay would of course
be fatal. Fortunately, spontaneous recovery from
this Adams-Stokes episode is the rule. Once the
ventricles take up their own beat, and it is rapid
enough, symptoms disappear and are not likely to
recur unless the cycle repeats itself.
It is in situations such as heart block and the
above syndrome that we see internal pacemakers.
Persons who were not able to live, due to the failure
of the electrical impulse within the heart, are now
16
perfectly able to do so with this man-made electrical
impulse. The role of the nurse is again evident. She
is in a position to identify signs and symptoms
promptly since by the time the physician arrives the
episode is over. In prolonged attacks, prescribed
life-saving measures may be necessary, and the
nurse may find herself in the position of having to
make a judgment on the course of action. It be-
hooves us to know what we are looking for and at-
sometimes we cannot wait for the physician or
ambulance. Stokes-Adams is a distinct clinical en-
tity resulting from ventricular fibrillation or heart
block. Usually the patient recovers in about 60 sec-
onds, but the episode may repeat itself.
Cardiac Arrest
No emergency demands more immediate attention
than in a situation where the heart has stopped
beating. It does not matter what the cause. It may
be heart block or it may be electrocution. If more

7. than a few minutes elapse between the time th e
heart stops and heart beat is restored, one of three
things will happen: 1) the patient will die; 2) the
heart beat may be restored, but the patient will die
in a matter of hours or days, and 3) the most tragic
-the heart beat will be restored, but there has been
too long a delay and the patient survives with per-
manent damage to the brain, due to prolonged
anoxia. Cardiac arrest can happen to anyone any-
where, any time, and what to do when it does occur
should have been planned far ahead of time.
Teams have been set up in many areas inside the
hospital and out. Each member of the team should
know not only the theory behind what he is doing,
but know how to do it. This can be taught by film,
lecture or demonstration, and practice of mouth-to-
mouth resuscitation and external cardiac massage.
If you are the only nurse in the area and a patient
is not breathing, but there is a pulse, then mouth-to-
mouth resuscitation is in order. If, however, there
is no pulse, the pupils are fixed and dilated and the
patient is not breathing, then mouth-to-mouth resus-
citation must be combined with external cardiac
massage.
Summary
This has been an attempt to bring together what
seems to me to be those aspects of heart conditions
which you, as occupational health nurses, would be
most apt to see. There has been no detailed list of
things a nurse should do, because such a list would
be impossible to memorize. It seemed more appro-
priate to review some of the conditions you might
encounter, together with brief explanations of terms.
The treatment which we can render then becomes
clear, meaningful and appropriate.
Whatever you do in your home situation will be
governed by the philosophy of your organization,
and this is intended merely to state the facts and
hope you will find them useful.
Ameri can Association of Industrial Nurses Journal , February, 1967 17