ATS - Cardiovascular Emergencies

Emergency Medical Technician
11 - Cardiovascular Emergencies
© 2014

© 2014
• Cardiovascular
emergencies are a
common cause of 911
calls
• Even a seemingly minor
chest discomfort
complaint can have life-
threatening implications
• Your ability to quickly
recognize critical
symptoms and provide
immediate interventions
can have a tremendous
impact on patient
outcome and survival
3

© 2014
1. Emergency Medications
2. Cardiac Compromise
3. ALS Assist: EKG Monitoring
4. Heart Failure with Congestion

© 2014
• Nitroglycerin is a
medication commonly
prescribed to cardiac
patients
• It works immediately to
relax and dilate the blood
vessel walls:
– This helps to reduce
the workload of the
heart and its demand
for oxygen
– It also increases the
supply of oxygenated
blood to the heart
muscle by dilating the
coronary arteries
6

© 2014
• If your patient has been
prescribed nitroglycerin
by their physician, your
protocols may allow you
to assist or administer
this medication
7

© 2014
• Indications to administer nitroglycerin
include:
– The patient exhibits signs and symptoms of
chest discomfort
– The patient has physician-prescribed
nitroglycerin
– You have received approval from medical
direction, or protocols permit
8

© 2014
• Nitroglycerin is a
vasodilator:
– Lowers the blood
pressure
• It is important that you
measure the blood
pressure:
– Just prior to
administering
– After administering the
medication
9

© 2014
• Contraindications for nitroglycerin include:
– A baseline systolic bpm below 90 mmHg
– A decrease greater than 30 mmHg from
baseline
– A heart rate of less than 50 bpm greater than
100 bpm
– A suspected head injury
– The patient is an infant or child
– Three doses have already been taken by the
patient
– The patient has taken an erectile dysfunction
drug in the past 24 hours
10

© 2014
• “Five rights” of
medication
administration before
giving any patient a drug
• This checklist helps
assure that you have:
1. The right patient
2. The right medication in
the bottle
3. Confirmed the right
route of delivery
4. That you will give the
right dose
5. That you have checked
for the right date
11

© 2014
• In addition, ask if the
patient has taken a
dose of nitroglycerine
already, and if so, when
and what if any were
the effects
12

© 2014
• If the patient meets the
criteria for
administration of
nitroglycerine and he is
alert and responsive:
– Assist him
– Place the tablet or
spray under his tongue
– He can be seated or
supine
13

© 2014
• Remind the patient to:
– Keep his mouth closed
– Not to swallow for a
few moments
 Until the tablet has
dissolved
14

© 2014
• After administration,
side effects may
include:
– Headache
– A change in pulse rate
as the body
compensates for the
dilation of blood
vessels
15

© 2014
• Reassess the blood
pressure 2 minutes
after administration,
and before giving the
next dose
16

© 2014
• If the patient
experiences no relief,
another dose may be
administered 3-5
minutes later if:
– The patient is
hemodynamically
stable
– It is authorized by
medical direction
• Record your actions:
– The dosage
– Time
– Results
17

© 2014
• In this application,
aspirin is not intended
for pain relief
• Aspirin keeps platelets
in the blood from
sticking together:
– This helps reduce the
formation of clots in
the coronary artery at
the site of the blockage
18

© 2014
• Aspirin should be
delivered in a
nonenteric or uncoated
form
• Aspirin is
contraindicated for
patients who:
– Are allergic to it
– Have a history of
stomach ulcers and
bleeding
19

© 2014
• As soon as you determine
that the symptoms are
suggestive of a heart
attack:
– Obtain approval from
medical direction
– Follow your protocols
regarding administration of
aspirin
• Check the “5 rights” of
medication
administration
• Confirm that your patient
is not allergic to aspirin:
– The patient should be
alert and oriented
20

© 2014
• Administer the
recommended dose,
which is typically 160 to
325 mg
• Have the patient chew
and swallow the tablet
• Record the time of
administration
• Reassess vital signs and
prepare for transport or
ALS intercept
21

© 2014
• Cardiac compromise is a
general term that refers to a
wide variety of cardiac
conditions, such as:
– Acute coronary syndrome
– Angina pectoris
– Acute myocardial
infarction
– Heart failure
• There are many conditions
and different ways that
the heart can be affected
• It may not be possible for
you to identify exactly the
type of cardiac
compromise your patient
is experiencing
23

© 2014
• But the key to effective
treatment is quickly
identifying that it is a
cardiac event
• Time is a critical
element
• A rapid response can
improve the outcome
for many patients
24

© 2014
• The signs and symptoms
of cardiac compromise as
in the case of acute
coronary syndrome, may
vary widely depending on
the underlying condition,
but the most common
indicators include:
– Chest discomfort that
radiates to any of the
following areas:
 Other areas of the chest
 Neck
 Jaw
 Arm
 Back
 Epigastrium
25

© 2014
• Chest discomfort can range from:
– Pain to a dull aching pressure
– Tightness
– Squeezing sensation
• Some patients may report discomfort that
radiates into the:
– Arms
– Shoulders
– Back
– Neck
– Jaw
26

© 2014
• Other signs and
symptoms of cardiac
compromise include:
– Epigastric pain
– Diaphoresis
– Dyspnea
– Syncope
– Overwhelming fatigue
– Anxiety or a feeling of
impending doom
– An abnormal pulse
– Abnormal blood
pressure
27

© 2014
• A patient with cardiac
compromise could:
– Present with only
one symptom
– A combination of
these signs and
symptoms
28

© 2014
• Epigastric or upper
abdominal pain is often
described as:
– Indigestion
– May include nausea
and vomiting
29

© 2014
• A sudden onset of
sweating:
– May be mistaken as
the onset of an
illness or fever
– Skin may be cool and
pale
30

© 2014
• The patient may
complain of shortness
of breath:
– If not mentioned, ask
specifically about it
31

© 2014
• Patient may report
being dizzy or having
fainted:
– Syncope can be an
indicator of a heart
rhythm disturbance
• Ask if the patient
experienced a sudden
episode of
“overwhelming fatigue
32

© 2014
• Patient may report
anxiety:
– Could appear as
irritability, or
– Describe a feeling of
“impending doom”
33

© 2014
• Be aware of an
irregular pulse that is
either too fast or too
slow
• Abnormal blood
pressure can present as
either too high or too
low
34

© 2014
• If the situation allows:
– Give the patient plenty
of time to respond to
your questions
• Allow patient to use
their own words to
describe the pain
35

© 2014
• To evaluate the pain, use the
mnemonic OPQRST:
– Onset
– Provocation and palliation
– Quality
– Region and radiate
– Severity
– Time
36

© 2014
• When determining the
onset:
– Ask what the patient
was doing when the
pain or discomfort
began
– Ask if the patient was
at rest or engaged in
physical activity
37

© 2014
• Ask if a change in
movement or
positioning makes the
pain or discomfort
either better or worse
• Cardiac chest pain is
not always constant and
may not change when
the patient shifts
position
38

© 2014
• When assessing the
quality of the pain or
discomfort, have the
patient describe it in
her own words
39

© 2014
• Chest pain may be
described in a variety of
ways:
– Pressure
– Tightness
– Aching
– Oppressive
– Burning
• Note whether she
clenches her fist as she
describes the pain:
– This is an indicator of
severe discomfort
40

© 2014
• “Region and radiate”
refer to the location and
aspects of the pain
• Have the patient point
with one finger where
the pain or discomfort
is the most intense
• Ask if the pain radiates
to any other location or
if it changes with
movement or breathing
41

© 2014
• Sometimes the pain
refers out to other parts
of the body:
– The patient may feel
pain radiating to either
arm or shoulder
• She may be able to
pinpoint the area or
may simply motion with
an open hand,
suggesting that the pain
may be radiating
42

© 2014
• The patient may NOT
complain of pain or
discomfort in the chest,
but instead report it in:
– Arms
– Back
– Neck
– Jaw
– Stomach area
43

© 2014
• To determine the severity of the pain:
– Ask the patient to rate it on a scale of
1 to 10
• Ask this question 3 different times:
– To determine the level of pain or
discomfort at the early point in your
care
44

© 2014
• To find out what the level of pain or discomfort
was when it first began:
– This helps you determine whether it has
gotten better or worse
• Then, after providing medications or
treatment interventions:
– Ask the patient again what the level of
pain or discomfort is
45

© 2014
• In addition, ask if other
symptoms preceded the
onset of the pain or
discomfort such as:
– Nausea
– Shortness of breath
– Lightheadedness
• A patient may deny or
reject the seriousness of
her condition, or she may
disregard symptoms due
to age or gender bias
46

© 2014
• If signs and symptoms
indicate cardiac
compromise, be direct
and persuasive
• Encourage her to accept
your treatment and
transport
• Do not let a patient
dismiss your concerns
47

© 2014
• Ask the patient what
time or for how long
she has had the pain or
discomfort
• Find out if it was
constant from the onset
or became constant
later
48

© 2014
• Some patients may only feel:
– Weak
– Short of breath
– Lightheaded
• She might not present with any pain
or chest discomfort at all or may
report only flu-like symptoms
49

© 2014
• To manage cardiac
compromise:
– Assess and maintain
the ABCs
– Allow the patient to
remain in a position of
comfort during
assessment
– Obtain baseline vital
signs
– Ask about current
symptoms
– Obtain medical history
50

© 2014
• Apply a pulse oximeter
• Administer oxygen
according to your
protocols:
– Some protocols
suggest the use of
supplemental oxygen if
the SPO2 reading is at
or below 94 percent
51

© 2014
• If the patient has
nitroglycerin, and signs
and symptoms are
typical of cardiac-type
chest discomfort:
– Consult with medical
direction / protocols
• If approved, confirm the
five rights of medication
administration
52

© 2014
• Assist with the
nitroglycerin and
administer aspirin
• Record the time of
administration, and
reassess blood pressure
53

© 2014
• Prepare for transport or
consider ALS intercept
• Provide reassurance
• Reassess vital signs
every 5 minutes
• Not all patients with
chest pain or cardiac
compromise will go into
cardiac arrest:
– Always be ready for
this possibility
54

© 2014
• Closely monitor and
perform an ongoing
assessment en route
• Be prepared to perform
CPR or use an AED
when appropriate
55

© 2014
• The electrocardiogram,
referred to as:
– EKG
– ECG
• One of the oldest
diagnostic cardiac
devices
• Provides valuable
information
• Is an essential tool for
the assessment of
cardiac patients
57

© 2014
• The heart gives off
electrical currents when
it contracts
• The EKG provides a
measurement over time
in the form of a graphic
representation of this
electrical activity
58

© 2014
• The heart’s electrical
activity is measured in
several directions
simultaneously
• By interpreting the
electrical currents
throughout a series of
heartbeats and from
various directions,
determinations can be
made about its’
functioning
59

© 2014
• When coronary arteries
are:
– Occluded
– The heart muscle
becomes hypoxic
• The conduction system
may be become erratic and
create abnormal rhythms
• These can be identified
on the EKG tracing
60

© 2014
• Depending on protocols,
EMT’s may assist ALS
providers in setting up
monitoring equipment
• To better assist, it is
important that you:
– Understand how EKG
devices work
– How to set up the
equipment
– How to place the
leads
61

© 2014
• In the prehospital field
the EKG it is most often
an adjunct or addition
to a standard monitor
defibrillator
• Some devices have:
– 1 to 3 leads
– 4 to 12 leads
• Be familiar with the
equipment that is used
in your system
62

© 2014
• Skin should be clean
and dry before applying
electrodes
• Use alcohol or an
abrasive pad to remove
dirt, body oil or other
substances that could
interfere with the
conductivity
• It may be necessary to
shave chest hair if it is
significant
• Dry the skin if the
patient is sweaty
63

© 2014
• The leads, or “limb
leads” will be placed
either on the chest
area, or on the
extremities:
– Depends on what is
preferred in your
system
64

© 2014
• Each electrode is:
– Color coded
– Has placement
indication on the head
• When placed on the
chest area, limb leads
should be at least 4 in
(10 cm) from the heart
65

© 2014
• The right arm or “R-A”
electrode is:
– White
– Placed to the right
anterior side of the
chest, under the
clavicle near the
shoulder
66

© 2014
• The left arm or “L-A”
electrode is:
– Usually black, but
could be brown or
green
– Placed on the left
anterior chest, under
the left clavicle near
the shoulder
67

© 2014
• The left leg or “L-L”
electrode is:
– Red
– Applied to the left
lower lateral chest wall
– About the seventh
intercostal space on
the anterior axillary
line
68

© 2014
• The right leg or “R-L”
electrode is:
– Usually green
– Applied to the right
lower chest
– About the seventh
intercostal space on
the axillary line
69

© 2014
• 12 lead monitoring
provides a more detailed
picture of the electrical
actively of the heart
• The 12-lead requires
placing 6 more
electrodes on the patient:
– The same 4 limb leads
used in 4-lead
monitoring plus six
“precordial” leads
• These are designated as
V1 through V6 and are all
placed on the chest
70

© 2014
• V2 to the immediate left
of the sternum at the
4th intercostal space
• Next, place V4 to the
left midclavicular line at
the 5th intercostal
space
• V3 is placed midway
between the leads V2
and V4 on the left
anterior chest
71

© 2014
• V6 is placed to the left
midaxillary line at the
same level as V4 and V5
• V5 is placed to the left
anterior axillary line at
the same level as V4
• After all leads are
properly placed, confirm
that they are adhering
well and making good
contact with the skin
72

© 2014
• Heart failure is often
the result of:
– Chronic cardiac
problems
– Diseased heart
valves
– Hypertension
– Pulmonary edema
74

© 2014
• When there is
inadequate pumping of
the heart:
– A backup of fluid into
the lungs and other
parts of the body can
result
• This further impairs the
heart’s ability to function
effectively
75

© 2014
• Congestive heart failure
(CHF), is the medical
diagnosis for this
condition and refers to
this fluid buildup
• You will find that the
signs and symptoms of
heart failure depend on:
• The severity of the
condition
• If it is acute onset
• If it is a chronic
condition
76

© 2014
• CHF patients often
experience orthopnea:
– Severe respiratory
distress when lying
down
• For relief, patients will
prop up on pillows or
sleep upright in chairs:
– Patients often report
feeling worse and
worse over several
days
77

© 2014
• Patients also may
complain of waking
from a sudden onset of
respiratory distress:
– Paroxysmal nocturnal
dyspnea
78

© 2014
• Anxiety
• Pale and sweaty skin
• Tachypnea; or rapid respiratory rate
• Tachycardia; or rapid heart rate over 100 bpm
• Pedal edema (swelling in the lower legs)
• Jugular vein distention
• Cyanosis
• Coughing of pink, frothy sputum (late sign)
79

© 2014
• Assess and stabilize the
ABCs
• Administer oxygen
according to your
protocols
• Apply a pulse oximeter
• Perform the primary
assessment
• Obtain baseline vitals
• Gather patient history
using OPQRST to
determine your first
course of intervention
80

© 2014
• If the patient is
experiencing chest
discomfort along with
respiratory distress and
has been prescribed
nitroglycerin:
– Administer according
to protocols
– Typically this is one
tablet every 3 to 5
minutes for a total of
three tablets
81

© 2014
• CHF patient in severe
respiratory distress may
also benefit
significantly from:
– Positive-pressure
ventilation with
supplemental oxygen
– Continuous positive
airway pressure
82

© 2014
• If the patient will
tolerate the application
of CPAP and your
protocols allow,
consider the use of
CPAP as an early
intervention
• CPAP can be used on
patients who present
with signs and
symptoms consistent
with COPD or CHF
83

© 2014
• CPAP helps move fluid back into the vascular
system:
– Reduces the work of breathing
– Relieves some of the pulmonary congestion
• CPAP has been shown to rapidly improve:
– Vital signs
– Work of breathing
– Dyspnea
84

© 2014
• If using CPAP the
patient should be:
– Alert
– Able to follow
commands
– Have a systolic blood
pressure above 90
mmHg
• Follow your local
protocols for guidance
and use of CPAP
85

© 2014
• Cardiovascular emergencies present in
many different ways
• It’s important to quickly recognize these
events as cardiac and provide quick and
effective interventions
• You should know how to provide
emergency medications as well as be able
to assist ALS providers with critical
monitoring equipment
• Your ability to recognize a cardiovascular
emergency in progress is critical to patient
survival

ATS - Cardiovascular Emergencies

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