Self Explanatory

1. Barry Kidd 2010 1
Basic Cardiology
For EMR’s

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Objectives
Describe the structure and function of the
cardiovascular system
Describe EMS care for chest pain patients,
including oxygen, aspirin and nitroglycerin
Identify some causes of cardiac
emergencies

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Quick facts
The heart beats on average 70 times per
minute, 4200 times per hour, 100,000
beats per day, 365 Million beats per year,
and about 30 Billion beats in an average
lifetime of 80 years.
The adult heart pumps 7,500 liters of
blood daily.
It takes 20 seconds to pump blood to
every cell in your body.

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Cardiovascular disease is the number one cause of
death in the U.S. and Canada, and many times the
first indication of this disease is an acute coronary
event
Cardiac arrest is the most severe manifestation of
an acute coronary syndrome, and with rapid
intervention the EMR can make the difference
between life and death

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Basic Anatomy and Physiology
The cardiovascular system consists of:
– Heart (The pump)
– Major blood vessels (The hoses)
Arteries: Aorta, arteries, arterioles
Veins: Vena Cava, veins, venules
Capillaries: Nutrient, gas and waste product
exchange
– Blood (The fluid)
– Cardiac Conduction System (The power)

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The Heart
The heart is simply just a muscle.
It has four chambers:
– Left and Right Atrium
– Left and Right Ventricles
Valves:
– Tricuspid and Bicuspid
– Pulmonic and Aortic

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Chambers of the heart
Atria:
– Right atrium receives deoxygenated blood from the
body
– Left atrium receives oxygenated blood from the lungs
Ventricles
– Right ventricle sends deoxygenated blood to the
lungs
– Left ventricle sends oxygenated blood to the body
The left and right sides of the heart are divided
by the septum.

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Major Vessels of the Heart
Vena Cava: Superior and inferior carry
blood from body to the right atrium
Pulmonary Artery: Carries blood from right
ventricle to the lungs for gas exchange
Pulmonary Vein: Carries freshly
oxygenated blood back to the left atrium
Aorta: Carries blood from left ventricle out
to the body

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Valves
Valves prevent the backflow of blood through the
system
Tricuspid and Bicuspid valves on the right and
left between the atria and ventricles
Pulmonic valve between the right ventricle and
pulmonary artery
Aortic (Mitral) valve between the left ventricle
and the aorta
Veins also have valves to prevent backflow of
blood. Arteries do not.

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A picture is worth a thousand words

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Cardiac conduction system
Each beat of the heart is actually just muscular
contraction in reaction to an electrical impulse
created by the heart itself. (Automaticity)
The impulse starts at the Sinoatrial (SA) node
located in the right atrium and travels through
the atria, causing them to contract and squeeze
the blood into the ventricles. (Atrial Kick)
The impulse then is held at the Atrioventricular
(AV) node, located between the atria and
ventricles

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Cardiac conduction
The impulse is held for a fraction of a second at
the AV node to allow the ventricles to fill
The impulse then travels through the Bundle of
His to the bundle branches and eventually to the
Purkinjie fibers in the ventricles.
The ventricles respond to the impulse by
contracting, causing ventricular systole, and
forcing the blood out of the ventricles through
the arteries

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Blood flows through the system
Deoxygenated blood enters the right atrium from
the inferior and superior vena cava
Passes through the tricuspid valve to the right
ventricle
Is squeezed through the pulmonic valve and into
the pulmonary artery to the lungs
Gas exchange takes place, becomes
oxygenated
From the lungs into the pulmonary vein and into
the left atrium

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Blood flow
From the left atrium, through the bicuspid valve
into the left ventricle
Through the aortic valve and into the aorta
The coronary artery, the first small vessel off the
aorta, feeds blood to the heart itself
Oxygenated blood travels through the aorta to
all the arteries in the body (except the pulmonic
artery)
Arteries become smaller and smaller until they
become arterioles, the smallest arteries

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Blood flow
Arterioles connect to capillaries, which are one
cell thick.
Cells take oxygen from the blood and rid
themselves of waste products at the capillary
level
Capillaries connect to venules, the smallest of
the veins
Deoxygenated blood travels through larger and
larger veins until they reach the vena cava and it
starts all over again

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Any Questions So Far?
Good, now the hard part is
over

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Angina Pectoris
Angina Pectoris: Chest pain, usually brought on
by exertion.
Indicates area of the heart is not perfusing
adequately, causing ischemia.
Usually lasts 2-15 minutes and may be relieved
with rest.
Can radiate to neck, arms, jaw, back or
shoulders.
May have cool, clammy skin, diaphoresis,
dyspnea, anxiety, N/V
Women, elderly and diabetics may show atypical
signs.

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Ventricular Fibrillation
Ventricular Fibrillation-
Ventricles simply
quivering.
Ventricles not squeezing,
no pulse, no blood flow
Total disorganized
electrical activity in the
heart
Early defibrillation is the
key!!!

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Ventricular Tachycardia
Ventricular Tachycardia-
Ventricles beating so fast
as to not pump blood
adequately
Limited diastolic period,
not allowing ventricles to
fill enough to provide
adequate cardiac output
Can progress to VF if not
treated early
May or may not have a
pulse, pulse may be
rapid, weak and thready
Defibrillation if pulseless

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Asystole
Asystole- Total
absence of electrical
activity in the heart.
Very low chance of
recovery
AED will not allow
defibrillation
Perform CPR until
advanced care arrives

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Pulseless Electrical Activity
PEA- The heart’s electrical system is firing
in an organized rhythm, but the
myocardium is not responding
No response by the muscle means no
pulse, therefore, no circulation
Any rhythm seen on monitor that has no
pulse is PEA
No defibrillation in cases of PEA

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Signs and Symptoms of cardiac
compromise
Squeezing, dull pressure, feeling of heaviness on chest,
or sharp, stabbing pain in chest radiating to arm or jaw
Sudden onset of perfuse sweating
Pale skin
Dyspnea
Anxiety, irritability
Feeling of impending doom
Abnormal pulse or BP
Epigastric pain
Nausea or vomiting

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Case Study
You are an EMR working in your community.
You and your partner are enjoying a relaxing
afternoon on a warm fall day. The radio
screams to life “Unit 91-XYZ, you are needed to
respond to 321 Elm St. for a 58 year old male
with chest pain and shortness of breath”. You
scramble to the rig and tear down the road with
lights and sirens blaring. As you arrive at the
address, a woman rushes out to meet your
ambulance, “Please, please, you have to help
him. Come on, hurry, I think he is having
another heart attack”.

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Now What?
Scene safe, BSI…..Don’t Forget!!!
Scene size up: Number of patients, need for additional
resources, get ALS rolling if they haven’t been already
General impression of patient:
– 58 y.o. male, average build, sitting, clutching his chest, breathing
labored and slightly fast
– ABC’s
– Seems alert, answers your questions
– Skin pale and diaphoretic
History of present illness
– SAMPLE history with OPQRST

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SAMPLE
Signs and Symptoms: Chest pain, trouble breathing. Pt
clutching chest and labored breathing
Allergies: Codeine and amoxicillin
Medications: ASA, NTG, Lasix, Toprol, Glucophage
Past medical history: DM, HTN, AMI x 3, cardiac stinting
Last oral intake: Ate lunch about 3 hours ago
Events: Was cutting firewood for about an hour and
developed the pain, came into the house to rest.

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OPQRST
Onset- While cutting firewood
Provokes/ Palliative- Rest improves pain,
exertion worsens it
Quality- Sharp, stabbing pain in middle of chest
on left side, feels like my last heart attack
Radiation- Radiates to left shoulder and jaw
Severity- 9/10
Time- 15 minutes ago, hasn’t stopped

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What do we do?
While you were asking questions, your partner was getting vitals for
you:
– BP 164/96, P 104, R 22 and labored
You place him on oxygen, NRB @ 12-15LPM
ASSIST him with his Nitroglycerin, but be sure you follow the 5
rights
– Right Patient
– Right Route
– Right Med
– Right Dosage
– Right time
If protocols permit, give aspirin, 325mg total. Have patient chew and
swallow.
LOAD AND GO!!!

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Ongoing Assessment
Monitor vital signs, to include a pain scale every 5
minutes. Transport to your intercept or the hospital.
How many times can you assist him with his NTG? And
how often?
What do you need before he takes any nitro?
What if he doesn’t tolerate the NRB?
In what position would you transport him?
Would you transport code 1 or code 3?
What if he passes out?
What if he stops breathing?
What if his heart stops?

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Oxygen Therapy
Who gets oxygen?
How are we going to give it?
How much are we going to give?
Who doesn’t get oxygen?
Remember, technically oxygen is a drug,
always chart the response to
administration.

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Nitroglycerin
As EMR we can ASSIST patients take their
Nitroglycerin tablets or sprays.
Dosage is 0.3-0.4mg per tab or spray
Make sure you follow the 5 rights.
Make sure the medication isn’t expired.
Must have systolic BP over 100 prior to
administration.
Can be given every 3-5 minutes, up to 3 times
provided systolic BP is over 100 and patient is
not pain free.

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Nitroglycerin
Nitroglycerin is a vasodilator, it works by opening
up the vessels to the heart, allowing more
oxygen to get to the ischemic areas that are
causing the pain.
Pt will most likely develop a headache, possibly
some dizziness.
Contraindicated if BP below 90 systolic, HR
below 50 or above100, suspected head injury, or
if pt has taken “daddy’s little helpers”

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Aspirin
Aspirin has a rapid acting antiplatelet
effect, which helps prevent clot formation.
Usual dosage for Cardiac patient is 160-
325mg.
Chewable “baby” aspirin 81 mg each.
Give 81mg X 4, chew and swallow.
Contraindications: Already taken ASA or
hypersensitivity to ASA.

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On our way …..

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Questions