Cardiovascular Emergencies


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  • Aorta: upper branch supplies both arms, descending aorta branches in to the right and left iliac arteries which in turn become the femoral arteries. Aorta to arteries to arterioles to capillaries. Vena cava: Returns blood from the veins, organs back through the heart to the lungs for oxygenation. Capillaries to venules to veins to vena cava.
  • Coronary arteries deliver oxygen to the heart. -Right coronary artery supplies right side and inferior wall of heart. -Left coronary divides into two branches and supplies the left ventricle
  • Atherosclerosis: disorder in which calcium and cholesterol build up and form plaque inside the walls of blood vessels. This can cause complete obstruction or blockage of blood flow through the coronary artery which can lead to ischemia and infarct. As a person ages, fatty material accumulates resulting in the narrowing of the lumen. Fact: In the United States, coronary artery disease is the leading cause of death for both men and women.
  • Angina occurs when a person with atherosclerosis exerts or is stressed. The heart muscle does not receive adequate blood flow and thus it becomes ischemic. Anaerobic metabolism begins and produces lactic acid and CO2 which accumulates in the myocardium causing pain. This process usually does not happen when the patient is at rest. 3-E’s: Exercise, eating, and emotion. Anginal pain that is not typical of normal angina or relieved by rest and meds indicates possible unstable angina.
  • Cardiogenic shock is due to the impaired ability of the heart to pump. It can be caused by disorders of the heart muscle, the valves, or the heart’s electrical conduction system with AMI being the most common cause. Dead myocardium does not contract, therefore, a weakened heart cannot pump enough blood throughout the body. There is an adequate blood volume but failure to blood in circulation. Hypoxia results due to inadequate perfusion.
  • AMI damages left ventricle. A weakened left ventricle is unable to pump blood effectively throughout the body. The blood and fluid backs up into the pulmonary veins and lungs. This fluid in the lungs reduces gaseous exchange in the alveoli (pulmonary edema). Hypoxia results due to inadequate oxygenation of the blood.
  • Pedal edema and ascities
  • A life-threatening condition in which blood gets behind the inner layer of the aorta, filling in the space between the layers of the arterial wall. The aorta widens and significantly disrupts blood flow.
  • Cardiovascular Emergencies

    1. 1. Cardiovascular Emergencies … time is myocardium!
    2. 2. Statistics <ul><li>Cardiovascular disease (CVD) claimed over 1 million lives in 2004. </li></ul><ul><li>CVD has been the leading cause of death for Americans since 1900. </li></ul><ul><li>Sudden cardiac death accounts for over 40% of these deaths. </li></ul><ul><li>The majority of our 911 responses are for chest pain. </li></ul>
    3. 3. Controllable Risk Factors <ul><li>Smoking </li></ul><ul><li>High blood pressure </li></ul><ul><li>Elevated cholesterol levels </li></ul><ul><li>Elevated blood glucose levels </li></ul><ul><li>Diet </li></ul><ul><li>Lack of exercise </li></ul><ul><li>Stress </li></ul>
    4. 4. Uncontrollable Risk Factors <ul><li>Age </li></ul><ul><li>Family history </li></ul><ul><li>Race </li></ul><ul><li>Sex </li></ul>
    5. 5. Anatomy
    6. 6. Circulation
    7. 7. Blood <ul><li>Red blood cells: </li></ul><ul><ul><li>Carries oxygen to tissues and cells </li></ul></ul><ul><ul><li>Removes CO2 and waste </li></ul></ul><ul><li>White blood cells: </li></ul><ul><ul><li>Fight infection </li></ul></ul><ul><li>Platelets: </li></ul><ul><ul><li>Helps blood clot </li></ul></ul>
    8. 8. Electrical System
    9. 9. Coronary Arteries
    10. 10. Cardiac Compromise <ul><li>Chest pain results from ischemia. </li></ul><ul><li>Ischemic heart disease involves decreased blood flow to the heart. </li></ul><ul><li>If blood flow is not restored, the tissue dies (infarct). </li></ul><ul><li>Injury leads to inadequate heart function and death. </li></ul>
    11. 11. Atherosclerosis
    12. 12. So… <ul><li>… you are dispatched to a 67 year- old male c/o 9/10 “crushing” chest pressure that radiates to his jaw. He is also complaining of shortness of breath and nausea, with no previous cardiac history… </li></ul>
    13. 13. … w hat are YOU thinking?
    14. 14. Chest Pain Pathophysiology <ul><li>Mediastinum: </li></ul><ul><ul><li>Angina: stable or unstable </li></ul></ul><ul><ul><li>AMI </li></ul></ul><ul><ul><li>Esophagitis, esophageal rupture </li></ul></ul><ul><ul><li>Pericarditis </li></ul></ul><ul><ul><li>Mediastinal air </li></ul></ul><ul><ul><li>Thoracic dissection </li></ul></ul><ul><ul><li>Mitral valve prolapse </li></ul></ul>
    15. 15. Chest Pain Pathophysiology <ul><li>Chest Wall: </li></ul><ul><ul><li>Traumatic contusion/ tamponade </li></ul></ul><ul><ul><li>Cysts and infections </li></ul></ul><ul><ul><li>Rib cartilage inflammation </li></ul></ul><ul><ul><li>Shingles (Herpes Zoster) </li></ul></ul><ul><ul><li>Muscle strain, overuse syndromes </li></ul></ul>
    16. 16. Chest Pain Pathophysiology <ul><li>Lungs and pleura: </li></ul><ul><ul><li>Pleurisy </li></ul></ul><ul><ul><li>Pneumonia </li></ul></ul><ul><ul><li>Pneumothorax, hemothorax </li></ul></ul><ul><ul><li>Pulmonary embolus </li></ul></ul><ul><ul><li>Asthma, bronchitis, URI </li></ul></ul>
    17. 17. Chest Pain Pathophysiology <ul><li>Abdomen: </li></ul><ul><ul><li>Gallbladder (cholecystitis, stones) </li></ul></ul><ul><ul><li>Stomach (gastritis, GERD, perforated peptic ulcer) </li></ul></ul><ul><ul><li>Pancreas (pancreatitis) </li></ul></ul><ul><ul><li>Esophagitis, perforation </li></ul></ul>
    18. 18. Chest Pain <ul><li>Psychogenic: </li></ul><ul><ul><li>Stress </li></ul></ul><ul><ul><li>Hyperventilation </li></ul></ul><ul><ul><li>Anxiety and panic attacks </li></ul></ul>
    19. 19. Classic Symptoms <ul><li>Pressure, fullness, heaviness, squeezing pain in center of chest with radiation </li></ul><ul><li>Diaphoresis </li></ul><ul><li>Nausea </li></ul><ul><li>Shortness of breath </li></ul><ul><li>Weakness </li></ul>
    20. 20. Frequency of Symptoms <ul><li>Diaphoresis 78% </li></ul><ul><li>Chest pain 64% </li></ul><ul><li>Nausea 52% </li></ul><ul><li>Shortness of breath 47% </li></ul><ul><li>No signs/symptoms 25% </li></ul><ul><li>N Engl J Med 1984;311:1144-7 </li></ul>
    21. 21. Atypical Presentations <ul><li>Common in the elderly, diabetics, and females: </li></ul><ul><ul><li>Unusual fatigue </li></ul></ul><ul><ul><li>Sudden onset of unusual shortness of breath </li></ul></ul><ul><ul><li>Nausea, dizziness </li></ul></ul><ul><ul><li>Belching, burping, indigestion </li></ul></ul><ul><ul><li>Palpitations, new dysrhythmia </li></ul></ul><ul><ul><li>Pain only in jaw, neck, back, arm </li></ul></ul>
    22. 22. All chest pain is considered to be an AMI until proven otherwise!
    23. 23. Angina Pectoris <ul><li>Chest pain caused when heart tissues do not get enough oxygen for a brief period of time. </li></ul><ul><li>Typically crushing or squeezing. </li></ul><ul><li>Onset with the 3-E’s. </li></ul><ul><li>Usually resolves with rest or meds. </li></ul><ul><li>May be difficult to diagnose from AMI </li></ul>
    24. 24. Angina
    25. 25. Acute Coronary Syndrome <ul><li>Used to describe the range of conditions from unstable angina to AMI. </li></ul><ul><li>Signs and symptoms usually caused by acute myocardial ischemia. </li></ul>
    26. 26. ACS Signs & Symptoms <ul><li>Shortness of breath </li></ul><ul><li>Signs of inadequate perfusion </li></ul><ul><li>Chest pain, pressure, or discomfort (with or without radiation to back, neck, jaw, arm, wrists) </li></ul><ul><li>Nausea </li></ul><ul><li>Weakness/syncope </li></ul><ul><li>Dysrhythmias </li></ul>
    27. 27. Acute Myocardial Infarct <ul><li>Usually caused by the same mechanism as angina only with resulting tissue death. </li></ul><ul><li>Time is myocardium: </li></ul><ul><li>Consequences can be serious: </li></ul><ul><ul><li>Congestive heart failure </li></ul></ul><ul><ul><li>Cardiogenic shock </li></ul></ul><ul><ul><li>Sudden death </li></ul></ul>
    28. 28. AMI
    29. 29. Cardiogenic Shock <ul><li>Heart lacks power to force blood through the circulatory system. </li></ul><ul><li>Brought on when 40% of left ventricle is infarcted. </li></ul><ul><li>Onset may be immediate or not apparent for 24 hours. </li></ul>
    30. 30. Signs & Symptoms <ul><li>Altered LOC </li></ul><ul><li>Rapid, shallow breathing </li></ul><ul><li>Restlessness and anxiousness </li></ul><ul><li>Pale, cool skin </li></ul><ul><li>Tachycardia/dysrhythmia </li></ul><ul><li>Hypotension </li></ul>
    31. 31. Congestive Heart Failure <ul><li>Occurs when the ventricles are damaged. </li></ul><ul><li>Heart tries to compensate with increased heart rate. </li></ul><ul><li>Enlarged, ineffective left ventricle </li></ul><ul><li>Fluid builds up into lungs or body as “pump” fails. </li></ul>
    32. 32. CHF
    33. 33. Signs & Symptoms <ul><li>Fatigue </li></ul><ul><li>Cough with pink, frothy sputum </li></ul><ul><li>Dypsnea, tachypnea </li></ul><ul><li>Pulmonary edema </li></ul><ul><li>Agitation and confusion </li></ul><ul><li>Hypertension </li></ul><ul><li>Pedal edema, ascities </li></ul>
    34. 34. Signs & Symptoms
    35. 35. Thoracic Dissection
    36. 36. Aortic Aneurysm
    37. 37. Signs & Symptoms <ul><li>Sudden and severe chest or upper back discomfort. “Pain shoots to the shoulder blades.” </li></ul><ul><li>Anxiety </li></ul><ul><li>Diaphoresis </li></ul><ul><li>Nausea </li></ul>
    38. 38. Cardiac Tamponade <ul><li>Trauma induced, filling of the pericardial sac with blood. </li></ul><ul><li>Signs of shock </li></ul><ul><li>JVD </li></ul><ul><li>Decrease pulse pressures </li></ul>
    39. 39. Esophageal Rupture <ul><li>Usually underlying alcohol abuse. </li></ul><ul><li>Shock signs. </li></ul><ul><li>Coughing up bright red blood. </li></ul>
    40. 40. Pericarditis <ul><li>Inflammation of the pericardium caused by infection. </li></ul><ul><li>Usually presents as sharp discomfort. </li></ul><ul><li>Changes with breathing and movement. </li></ul>
    41. 41. Chest Pain Assessment <ul><li>BSI/Scene Safety </li></ul><ul><li>Initial Assessment (Sick/Not Sick) </li></ul><ul><li>Focused Exam </li></ul><ul><li>Detailed Exam </li></ul><ul><li>Assessment </li></ul><ul><li>Treatment and Plan </li></ul>
    42. 42. Initial Assessment <ul><li>60second clinical picture to determine if Sick or Not Sick (Oxygen) </li></ul><ul><li>Based upon your initial impression: </li></ul><ul><ul><li>Body position </li></ul></ul><ul><ul><li>skin signs and color </li></ul></ul><ul><ul><li>respiratory rate and effort </li></ul></ul><ul><ul><li>mental status </li></ul></ul><ul><ul><li>pulse rate and character </li></ul></ul><ul><li>Correct immediate life threats! </li></ul>
    43. 43. Focused Exam (S) <ul><li>Your subjective findings are based upon what the patient or historian tells you: </li></ul><ul><li>Patient Age </li></ul><ul><li>Sex </li></ul><ul><li>Chief Complaint </li></ul>
    44. 44. Focused Exam (S) <ul><li>SAMPLE History </li></ul><ul><li>S igns/ S ymptoms (associated with cardiac chest pain): </li></ul><ul><ul><li>Diaphoresis (78%) </li></ul></ul><ul><ul><li>Shortness of Breath (47%) </li></ul></ul><ul><ul><li>Pain/discomfort (64%) </li></ul></ul><ul><ul><li>Nausea/vomiting (52%) </li></ul></ul><ul><ul><li>No signs or symptoms (25%) </li></ul></ul><ul><ul><ul><li>N Eng Journal Med 1984;311:11444-7 </li></ul></ul></ul>
    45. 45. Focused Exam (S) <ul><li>O nset – </li></ul><ul><ul><li>“ When and at what time did it start” </li></ul></ul><ul><li>P rovocation – </li></ul><ul><ul><li>“ Does anything make it better or worse?” </li></ul></ul><ul><ul><li>“ Does it change with position, palpitation, inspiration?” </li></ul></ul><ul><li>Q uality – </li></ul><ul><ul><li>“ Describe the pain/discomfort in your own words” </li></ul></ul>
    46. 46. Focused Exam (S) <ul><li>R egion/ R adiation – </li></ul><ul><ul><li>“ Where does it start?” </li></ul></ul><ul><ul><li>“ Does it radiate anywhere?” </li></ul></ul><ul><li>S everity – </li></ul><ul><ul><li>“ On a scale of 1 to 10, what was the pain/discomfort at onset?” </li></ul></ul><ul><ul><li>“ What is the pain/discomfort at now?’ </li></ul></ul><ul><li>T ime – </li></ul><ul><ul><li>“ When did this episode start?” </li></ul></ul><ul><ul><li>“ How long has it been going on?” </li></ul></ul>
    47. 47. Focused Exam (S) <ul><li>A llergies </li></ul><ul><li>M edications – </li></ul><ul><ul><li>Cardiac meds = cardiac problems. </li></ul></ul><ul><ul><li>Ask about OTC meds, natural supplements, vitamins? </li></ul></ul><ul><li>P ast Medical History – </li></ul><ul><ul><li>“ Do you have any cardiac history?” </li></ul></ul><ul><ul><li>“ Risk factors such as smoking, diabetes, HTN, weight/diet?”” </li></ul></ul>
    48. 48. Focused Exam (S) <ul><li>L ast Oral Intake </li></ul><ul><li>E vents Leading to Call – </li></ul><ul><ul><li>“ What were you doing when this event started?” </li></ul></ul><ul><ul><li>Think activity induce vs. non activity </li></ul></ul>
    49. 49. Listen to the patient… … they will tell you exactly what is wrong!
    50. 50. Focused Exam (O) <ul><li>Objective findings from your physical exam of the patient. </li></ul><ul><li>Look for evidence of trauma/injury </li></ul><ul><li>Evaluate: </li></ul><ul><ul><li>Level of consciousness </li></ul></ul><ul><ul><li>Skin color and temperature </li></ul></ul><ul><ul><li>Respiratory rate and effort </li></ul></ul><ul><ul><li>Pupillary reaction </li></ul></ul><ul><ul><li>Pulse rate </li></ul></ul><ul><ul><li>Blood pressure (bilateral for chest pain!) </li></ul></ul>
    51. 51. Focused Exam (O) <ul><li>Listen to breath sounds </li></ul><ul><li>Palpate chest </li></ul><ul><li>Palpate abdomen </li></ul><ul><li>Check pedal pulses </li></ul><ul><li>BGL if diabetic with DLOC </li></ul><ul><li>SpO2 after BP, confirm with pulses, RA & after administration of O2 </li></ul><ul><li>Rhythm strip? </li></ul>
    52. 52. Focused Exam (O) <ul><li>Based upon your clinical findings </li></ul><ul><li>Observe the patient while they are talking with you, note any distress/discomfort (Levine sign) </li></ul><ul><li>Watch for acute clinical signs: jugular vein distension, tracheal deviation, paradoxial chest movement. </li></ul>
    53. 53. Detailed Exam (O) <ul><li>Complete and thorough neck, head to toe examination with non-critical patients if needed or time permits. </li></ul><ul><li>Elicit further information and necessary interventions. </li></ul><ul><li>Key in on critical findings! </li></ul>
    54. 54. Assessment (A) <ul><li>This is your best guess (or rule out) as to what is going on with the patient. </li></ul><ul><li>It is based upon YOUR Subjective and Objective findings and should help you develop and implement your Plan for patient care. </li></ul>
    55. 55. Plan (P) <ul><li>Medics? </li></ul><ul><li>ABC’s/Monitor vitals </li></ul><ul><li>Patient in position of comfort. </li></ul><ul><li>Oxygen via? </li></ul><ul><li>Assist with medications. </li></ul><ul><li>Maintain body temperature. </li></ul><ul><li>Calm and reassure. </li></ul><ul><li>Minimize patient movement. </li></ul><ul><li>Rapid transport! </li></ul>
    56. 56. Other Stuff <ul><li>Coronary artery bypass graft (CABG) and other open heart surgeries </li></ul><ul><li>Percutaneous transluminal coronary angioplasty (PTCA) </li></ul><ul><li>Automatic implantable cardiac defibrillators (ACID) </li></ul><ul><li>Pacemakers </li></ul>