Cardiovascular disease is the leading cause of death in the United States. The document discusses signs and symptoms of various cardiovascular emergencies like myocardial infarction, angina, cardiogenic shock, and congestive heart failure. It also covers assessment of chest pain, including gathering a history and performing a physical exam to determine the likely cause and guide treatment and transport. The goal is to identify life threats and provide care to stabilize the patient while expediting transport to a hospital.

1. Cardiovascular
Emergencies
…time is myocardium!

2. Statistics
• Cardiovascular disease (CVD)
claimed over 1 million lives in 2004.
• CVD has been the leading cause of
death for Americans since 1900.
• Sudden cardiac death accounts for
over 40% of these deaths.
• The majority of our 911 responses
are for chest pain.

3. Controllable Risk Factors
Smoking
High blood pressure
Elevated cholesterol levels
Elevated blood glucose levels
Diet
Lack of exercise
Stress

4. Uncontrollable Risk Factors
Age
Family history
Race
Sex

5. Anatomy

6. Circulation

7. Blood
• Red blood cells:
• Carries oxygen to tissues and cells
• Removes CO2 and waste
• White blood cells:
• Fight infection
• Platelets:
• Helps blood clot

8. Electrical System

9. Coronary Arteries

10. Cardiac Compromise
• Chest pain results from ischemia.
• Ischemic heart disease involves
decreased blood flow to the heart.
• If blood flow is not restored, the
tissue dies (infarct).
• Injury leads to inadequate heart
function and death.

11. Atherosclerosis

12. So…
…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…

13. …what are YOU thinking?

14. Chest Pain Pathophysiology
• Mediastinum:
• Angina: stable or unstable
• AMI
• Esophagitis, esophageal rupture
• Pericarditis
• Mediastinal air
• Thoracic dissection
• Mitral valve prolapse

15. Chest Pain Pathophysiology
• Chest Wall:
• Traumatic contusion/tamponade
• Cysts and infections
• Rib cartilage inflammation
• Shingles (Herpes Zoster)
• Muscle strain, overuse syndromes

16. Chest Pain Pathophysiology
• Lungs and pleura:
• Pleurisy
• Pneumonia
• Pneumothorax, hemothorax
• Pulmonary embolus
• Asthma, bronchitis, URI

17. Chest Pain Pathophysiology
• Abdomen:
• Gallbladder (cholecystitis, stones)
• Stomach (gastritis, GERD,
perforated peptic ulcer)
• Pancreas (pancreatitis)
• Esophagitis, perforation

18. Chest Pain
• Psychogenic:
• Stress
• Hyperventilation
• Anxiety and panic attacks

19. Classic Symptoms
• Pressure, fullness, heaviness,
squeezing pain in center of chest
with radiation
• Diaphoresis
• Nausea
• Shortness of breath
• Weakness

20. Frequency of Symptoms
• Diaphoresis 78%
• Chest pain 64%
• Nausea 52%
• Shortness of breath 47%
• No signs/symptoms 25%
N Engl J Med 1984;311:1144-7

21. Atypical Presentations
• Common in the elderly, diabetics, and
females:
• Unusual fatigue
• Sudden onset of unusual shortness of
breath
• Nausea, dizziness
• Belching, burping, indigestion
• Palpitations, new dysrhythmia
• Pain only in jaw, neck, back, arm

22. All chest pain is
considered to be an
AMI until proven
otherwise!

23. Angina Pectoris
• Chest pain caused when heart
tissues do not get enough oxygen for
a brief period of time.
• Typically crushing or squeezing.
• Onset with the 3-E’s.
• Usually resolves with rest or meds.
• May be difficult to diagnose from AMI

24. Angina

25. Acute Coronary Syndrome
Used to describe the range of
conditions from unstable angina
to AMI.
Signs and symptoms usually
caused by acute myocardial
ischemia.

26. ACS Signs & Symptoms
• Shortness of breath
• Signs of inadequate perfusion
• Chest pain, pressure, or discomfort
(with or without radiation to back,
neck, jaw, arm, wrists)
• Nausea
• Weakness/syncope
• Dysrhythmias

27. Acute Myocardial Infarct
Usually caused by the same mechanism as
angina only with resulting tissue death.
Time is myocardium:
Consequences can be serious:
Congestive heart failure
Cardiogenic shock
Sudden death

28. AMI

29. Cardiogenic Shock
Heart lacks power to force blood
through the circulatory system.
Brought on when 40% of left ventricle is
infarcted.
Onset may be immediate or not
apparent for 24 hours.

30. Signs & Symptoms
• Altered LOC
• Rapid, shallow breathing
• Restlessness and anxiousness
• Pale, cool skin
• Tachycardia/dysrhythmia
• Hypotension

31. Congestive Heart Failure
Occurs when the ventricles are
damaged.
Heart tries to compensate with
increased heart rate.
Enlarged, ineffective left ventricle
Fluid builds up into lungs or body as
“pump” fails.

32. CHF

33. Signs & Symptoms
• Fatigue
• Cough with pink, frothy sputum
• Dypsnea, tachypnea
• Pulmonary edema
• Agitation and confusion
• Hypertension
• Pedal edema, ascities

34. Signs & Symptoms

35. Thoracic Dissection

36. Aortic Aneurysm

37. Signs & Symptoms
• Sudden and severe chest or
upper back discomfort. “Pain
shoots to the shoulder blades.”
• Anxiety
• Diaphoresis
• Nausea

38. Cardiac Tamponade
• Trauma induced,
filling of the
pericardial sac with
blood.
• Signs of shock
• JVD
• Decrease pulse
pressures

39. Esophageal Rupture
• Usually
underlying
alcohol abuse.
• Shock signs.
• Coughing up
bright red blood.

40. Pericarditis
• Inflammation of the
pericardium caused
by infection.
• Usually presents as
sharp discomfort.
• Changes with
breathing and
movement.

41. Chest Pain Assessment
BSI/Scene Safety
Initial Assessment (Sick/Not Sick)
Focused Exam
Detailed Exam
Assessment
Treatment and Plan

42. Initial Assessment
60second clinical picture to determine if
Sick or Not Sick (Oxygen)
Based upon your initial impression:
– Body position
– skin signs and color
– respiratory rate and effort
– mental status
– pulse rate and character
Correct immediate life threats!

43. Focused Exam (S)
Your subjective findings are based
upon what the patient or historian
tells you:
Patient Age
Sex
Chief Complaint

44. Focused Exam (S)
SAMPLE History
Signs/Symptoms (associated with cardiac
chest pain):
– Diaphoresis (78%)
– Shortness of Breath (47%)
– Pain/discomfort (64%)
– Nausea/vomiting (52%)
– No signs or symptoms (25%)
N Eng Journal Med 1984;311:11444-7

45. Focused Exam (S)
Onset –
“When and at what time did it start”
Provocation –
“Does anything make it better or worse?”
“Does it change with position, palpitation,
inspiration?”
Quality –
“Describe the pain/discomfort in your own
words”

46. Focused Exam (S)
Region/Radiation –
“Where does it start?”
“Does it radiate anywhere?”
Severity –
“On a scale of 1 to 10, what was the
pain/discomfort at onset?”
“What is the pain/discomfort at now?’
Time –
“When did this episode start?”
“How long has it been going on?”

47. Focused Exam (S)
Allergies
Medications –
Cardiac meds = cardiac problems.
Ask about OTC meds, natural supplements,
vitamins?
Past Medical History –
“Do you have any cardiac history?”
“Risk factors such as smoking, diabetes, HTN,
weight/diet?””

48. Focused Exam (S)
Last Oral Intake
Events Leading to Call –
“What were you doing when this event started?”
Think activity induce vs. non activity

49. Listen to the patient…
…they will tell you exactly
what is wrong!

50. Focused Exam (O)
Objective findings from your physical exam
of the patient.
Look for evidence of trauma/injury
Evaluate:
– Level of consciousness
– Skin color and temperature
– Respiratory rate and effort
– Pupillary reaction
– Pulse rate
– Blood pressure (bilateral for chest pain!)

51. Focused Exam (O)
Listen to breath sounds
Palpate chest
Palpate abdomen
Check pedal pulses
BGL if diabetic with DLOC
SpO2 after BP, confirm with pulses, RA &
after administration of O2
Rhythm strip?

52. Focused Exam (O)
Based upon your clinical findings
Observe the patient while they are
talking with you, note any
distress/discomfort (Levine sign)
Watch for acute clinical signs: jugular
vein distension, tracheal deviation,
paradoxial chest movement.

53. Detailed Exam (O)
Complete and thorough neck, head to
toe examination with non-critical
patients if needed or time permits.
Elicit further information and
necessary interventions.
Key in on critical findings!

54. Assessment (A)
This is your best guess (or rule out) as
to what is going on with the patient.
It is based upon YOUR Subjective and
Objective findings and should help you
develop and implement your Plan for
patient care.

55. Plan (P)
Medics?
ABC’s/Monitor vitals
Patient in position of comfort.
Oxygen via?
Assist with medications.
Maintain body temperature.
Calm and reassure.
Minimize patient movement.
Rapid transport!

56. Other Stuff
• Coronary artery bypass graft (CABG)
and other open heart surgeries
• Percutaneous transluminal coronary
angioplasty (PTCA)
• Automatic implantable cardiac
defibrillators (ACID)
• Pacemakers