EMT

1. Copyright © 2023 by Jones & Bartlett Learning, LLC, an Ascend Learning Company and the American Academy of Orthopaedic Surgeons.
Cardiovascular
Emergencies
CHAPTER 18

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Introduction (1 of 3)
 CVD refers to a group of disorders of the heart and blood vessels
 Coronary heart disease (CHD)
 Disease of coronary arteries

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Introduction (2 of 3)
 AMI
 Narrowing/blockage of coronary artery
 Causes myocardial tissue death
 One person in the United States every 40 seconds

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Introduction (3 of 3)
 Cardiac arrest is the cessation of cardiac mechanic activity.
 In the United States, most out-of-hospital cardiac arrests (OHCAs) occur in a
home or residence

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Anatomy and Physiology Review (1 of 12)
 Structure and function
 Cardiovascular system
 Composed of heart and blood vessels
 Delivers oxygenated blood and nutrients to cells
 Delivers hormones
 Transports waste products to disposal sites

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Anatomy and Physiology Review (2 of 12)
 The heart has four chambers
 Right atrium
 Left atrium
 Right ventricle
 Left ventricle
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Anatomy and Physiology Review (3 of 12)
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Anatomy and Physiology Review (4 of 12)
 Right atrium
 Receives blood low in oxygen from the superior vena cava, inferior vena cava, and
the coronary sinus
 Left atrium
 Receives oxygenated blood from the lungs via the right and left pulmonary veins

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Anatomy and Physiology Review (5 of 12)
 Right ventricle
 Pumps deoxygenated blood to the lungs
 Left ventricle
 Pumps oxygenated blood throughout the body

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Anatomy and Physiology Review (6 of 12)
 The septa separate the heart into two functional pumps
 Right heart: the right atrium and right ventricle
 A low-pressure system (pulmonary circulation)
 Left heart: the left atrium and left ventricle
 A high-pressure system (systemic circulation)

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Anatomy and Physiology Review (7 of 12)
 Myocardium is the middle layer of the heart wall
 Composed of thick muscle tissue
 Responsible for:
 Cardiac contraction
 Efficient ejection of blood from the heart

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Anatomy and Physiology Review (8 of 12)
 Coronary arteries
 The left main coronary artery supplies:
 Left ventricle
 Interventricular septum
 The right coronary artery (RCA) supplies:
 Right atrium
 Right ventricle
 Part of the left ventricle
 Portions of the conduction system

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Anatomy and Physiology Review (9 of 12)
 Cardiac cells have four properties that help the heart function:
 Automaticity
 Excitability
 Conductivity
 Contractility

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Anatomy and Physiology Review (10 of 12)
 The cardiac conduction system comprises six parts:
 SA node
 AV node
 The bundle of His
 Right and left bundle branches
 The Purkinje fibers

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Anatomy and Physiology Review (11 of 12)
 Nerve stimulation
 Stimulation of sympathetic nerves
 Strengthens the force of contraction
 Increases the heart rate

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Anatomy and Physiology Review (12 of 12)
 Nerve stimulation
 Stimulation of parasympathetic nerves
 Slows the rate of discharge of the SA node
 Slows conduction through the AV node
 Weakens the strength of atrial contraction
 Can cause a small reduction in the force of ventricular contraction

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Patient Assessment

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Primary Survey
 Primary survey steps order varies
 Normally ABCDE (assess airway, breathing, and then circulation, disability, and
exposure)
 Order changes to CABDE if the patient is unresponsive and is suspected of
being in cardiac arrest

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History Taking (1 of 7)
 Acute coronary syndromes (ACSs): a series of cardiac conditions caused by an
abrupt reduction in blood flow through a coronary artery
 Unstable angina
 Non–ST segment elevation myocardial infarction (NSTEMI)
 ST segment elevation myocardial infarction (STEMI)

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History Taking (2 of 7)
 Common chief complaints
 Chest pain
 Dyspnea
 Fainting
 Palpitations
 Fatigue

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History Taking (3 of 7)
 If the patient faints:
 Determine between cardiac or noncardiac causes
 Cardiac causes:
 Dysrhythmias
 Increased vagal tone
 Heart lesions

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History Taking (4 of 7)
 Palpitations: sensation of abnormally fast or irregular heartbeat
 Inquire about:
 Onset, frequency, and duration
 Previous episodes

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History Taking (5 of 7)
 Patients may also report:
 Feelings of impending doom
 Nausea or vomiting
 Trauma involvement
 Hypoxia or poor perfusion
 Inquire about medical history

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History Taking (6 of 7)
 Ask about medications
 Prescription (particularly cardiac)
 Over-the-counter drugs
 Herbal supplements
 Recreational drugs

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History Taking (7 of 7)
 Determine if the patient has been diagnosed with the following:
 Aneurysm
 Atherosclerotic heart disease
 Congenital anomalies
 CAD
 Diabetes
 Inflammatory cardiac disease
 Previous cardiac surgery
 Pulmonary disease
 Renal disease
 Valvular disease
 Vascular disease

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Secondary Assessment (1 of 4)
 Physical exam should emphasize cardiac issues.
 Skin color and temperature may indicate circulation problems:
 Pale, mottled, or cyanotic skin
 Flushed, warm skin

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Secondary Assessment (2 of 4)
 Physical exam
 Inspect neck and tracheal position
 Inspect adjacent structures (neck veins, etc.)
 Estimate jugular pressure
 Inspect and palpate the chest
 Surgical scars
 Nitroglycerin (NTG) patch
 Pacemaker or defibrillator
 Chest enlargement
 Crepitus

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Secondary Assessment (3 of 4)
 Physical exam (cont’d)
 Listen with a stethoscope.
 Palpate the patient’s abdomen for distention and pulsations.
 Check for swelling.
 Bilateral pitting edema may be a sign of right ventricular failure (RVF).
 One-sided pitting edema suggests blockage.

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Secondary Assessment (4 of 4)
 Monitoring devices
 Cardiac monitor
 Waveform capnography
 Pulse oximeter

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Pulse Findings in Cardiac Patients
 Pulse deficit
 Apical pulse verses peripheral pulse
 Check blood pressure
 Pulsus paradoxus
 Check for beat-to-beat difference in the strength of a pulse
 Pulsus alternans

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Blood Pressure Findings in Cardiac Patients (1 of 2)
 Normal SBP: less than 120 mm Hg
 Normal DBP: less than 80 mm Hg
 Stage 2 hypertension
 SBP of 140 mm HG or higher
 DBP of 90 mm Hg

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Blood Pressure Findings in Cardiac Patients (2 of 2)
 In emergencies:
 Elevated blood pressure: anxiety or pain
 SBP lower than 90 mm Hg: hypotension or shock
 Widened pulse pressure: later stages of shock
 Narrowed pulse pressure: tachycardia or cardiac tamponade
 Obtain and compare BP in both arms.

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Assessment of Heart Sounds (1 of 4)
 S1: occurs when tricuspid and mitral valves close
 Decreased sounds can indicate:
 Fibrotic or calcified mitral valve
 Obesity
 Emphysema
 Cardiac tamponade

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Assessment of Heart Sounds (2 of 4)
 S2: occurs when pulmonary and aortic valves close
 Louder: chronic high blood pressure or pulmonary hypertension
 Decreased: hypotension
 Split: right bundle branch

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Assessment of Heart Sounds (3 of 4)
 S3: caused by ventricular wall vibrations
 Abnormal sound associated with heart failure
 S4: heard just before S1
 Turbulent filling of stiff ventricle in hypertrophy
 Possible myocardial infarction

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Assessment of Heart Sounds (4 of 4)
 Heart murmur:
 Sound from turbulent blood flow through the valves
 Causes:
 Increased blood flow across a normal valve
 Flow across an irregular or constricted valve
 Blood flow into an enlarged heart chamber
 Backward blood flow through a compromised valve

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Reassessment
 Reassessment should be done on the way to the hospital
 Prepare documentation of the call
 Notify the receiving facility of:
 History findings
 Physical exam findings
 Cardiac monitoring or ECG findings

38. Copyright © 2023 by Jones & Bartlett Learning, LLC, an Ascend Learning Company and the American Academy of Orthopaedic Surgeons.
Electrophysiology

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Depolarization (1 of 2)
 Muscle fibers stimulated to contract
 Occurs through changes in concentration of electrolytes across cell membranes

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Depolarization (2 of 2)
 Cell receives stimulus from conduction
 The permeability of the cell wall changes to allow Na+
in
 Ca+2
also enter
 Depolarization spreads, causing a mechanical contraction
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Repolarization
 Begins with the closing of sodium and calcium channels
 Sodium ions pumped out and potassium ions pumped in
 Maintains polarity of cell membrane
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Cardiac Action Potential
 Divided into five phases
 Phase 0: Cell depolarizes and
begins to contract
 Phase 1: Cell begins to repolarize
 Phase 2: Na+
and Ca++
enter the
cell; K+
flows out
 Phase 3: Final phase of
repolarization
 Phase 4: Resting phase
Reproduced from 12-Lead ECG: The Art of
Interpretation, courtesy of Tomas B. Garcia, MD.

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Refractory Periods
 Periods in which the cell is depolarized or in the process or repolarizing
 Absolute refractory period
 Relative refractory period

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The Conduction System (1 of 4)
 Specialized conduction tissue
propagates electrical impulses to
the muscular tissue.
 SA node
 Located in the right atrium
 Receives blood from the RCA
 Dominant pacemaker
 Impulses are spread through
internodal pathways, causing
contraction
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The Conduction System (2 of 4)
 AV node
 Electrical impulses move from the SA node to the AV node.
 Impulse conduction is delayed so the atria will empty into the ventricles.
 If the atrial rate becomes rapid, not all impulses go through the AV junction.
 Impulses normally pass into the:
 Bundle of His
 Right and left bundle branches
 Purkinje fibers

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The Conduction System (3 of 4)
 Secondary pacemakers
 Any conduction system component can act as a secondary pacemaker if the SA
node is damaged.

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The Conduction System (4 of 4)
 Accessory conduction pathways
 Extra heart muscle tissue connects the atria and ventricles
 James fibers
 In the internodal pathways
 Mahaim fibers
 Extend into the ventricles
 Bundle of Kent
 Enables early depolarization of ventricular tissue
 Can trigger tachydysrhythmias

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The Autonomic Nervous System and the Heart (1 of 6)
 Both the sympathetic and
parasympathetic divisions of the
autonomic nervous system affect
the heart.
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The Autonomic Nervous System and the Heart (2 of 6)
 Sympathetic (acceleratory) nerves
 Transmit commands by releasing norepinephrine
 Travels to SA and AV node and ventricles
 Heart speeds up to increase CO

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The Autonomic Nervous System and the Heart (3 of 6)
 Parasympathetic (inhibitory) nerves
 Sends messages through the vagus nerve
 Innervates functional areas
 Decreases heart rate
 Stimulated by:
 Increased pressure on carotid sinus
 Strained/forced exhalation against closed glottis
 Distention of hollow organ

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The Autonomic Nervous System and the Heart (4 of 6)
 If the brain senses that the heart
should slow its pace:
 Electrical impulse travels down
vagus nerve to SA node
 Stimulates release of ACh
 ACh signals SA node to decelerate
heart rate
 ACh molecule blocks additional
impulses from AV node
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The Autonomic Nervous System and the Heart (5 of 6)
 Baroreceptors
 Sensors composed of specialized nerve tissue
 Detect changes in blood pressure
 Generate reflex response
 In sympathetic or parasympathetic division of the ANS

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The Autonomic Nervous System and the Heart (6 of 6)
 Chemoreceptors
 Detect changes in the concentration in the blood
 Hydrogen ions (pH)
 Oxygen
 Carbon dioxide
 Sympathetic or parasympathetic response to changes

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Causes of Cardiac Dysrhythmia
 Evaluate in context with overall condition
 Treat the patient, not the monitor

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The Electrocardiogram (1 of 27)
 Three standard limb leads:
 Lead I
 Lead II
 Lead III
 Provides detailed information about
the heart’s conduction system
 Offer electrical snapshot of specific
part of the heart
Courtesy of Stryker Corporation/Physio-Control, Inc.

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The Electrocardiogram (2 of 27)
 Electrode placement
 Predetermined spots
 Usually adhesive with gel center
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The Electrocardiogram (3 of 27)
 Electrode placement basic principles:
 Shave body hair, if necessary
 Rub site with a dry gauze pad
 Attach electrodes to ECG cables before placement and confirm correct location
 Turn on the monitor and print sample strip
 Refer to Skill Drill 18-1: Performing Cardiac Monitoring

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The Electrocardiogram (4 of 27)
 Lead groups
 Limb leads
 I, II, III
 Precordial leads
 V1 to V6
 Augmented limb leads
 aVR, aVL, aVF

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The Electrocardiogram (5 of 27)
 Standard 12-lead ECG
 Three standard limb leads
 Three augmented limb leads
 Six precordial leads

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The Electrocardiogram (6 of 27)
 Limb leads
 Einthoven’s theory: Every time the
heart contracts, electrical energy is
emitted
 Lead I—attached to right and left
arms
 Lead II—runs between right arm
and left leg
 Lead III—runs between left arm
and left leg
Reproduced from 12-Lead ECG: The Art of Interpretation, courtesy
of Tomas B. Garcia, MD.

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The Electrocardiogram (7 of 27)
 Limb leads (cont’d)
 Leads I, II, and III are bipolar leads.
 Contain a positive and negative
pole
 Measure the difference in
electrical potential
Reproduced from 12-Lead ECG: The Art of Interpretation, courtesy
of Tomas B. Garcia, MD.

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The Electrocardiogram (8 of 27)
 Limb leads (cont’d)
 Augmented voltage (aV) leads are
created using four limb electrodes.
 Leads aVR, aVL, and aVF:
combine two limb leads and use
the other lead as the other pole © Jones & Bartlett Learning

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The Electrocardiogram (9 of 27)
 For continuous monitoring:
 White—right upper chest near shoulder
 Black—left upper chest near shoulder
 Red—left lower abdomen
 Green—right lower abdomen

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The Electrocardiogram (10 of 27)
 For 12-lead ECG:
 White—right wrist
 Black—left wrist
 Red—left ankle
 Green—right ankle

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The Electrocardiogram (11 of 27)
 Precordial leads
 V1 to V6
 Unipolar
 Referenced against a calculated
point: the Wilson central terminal
Reproduced from 12-Lead ECG: The Art of
Interpretation, courtesy of Tomas B. Garcia, MD.
Reproduced from 12-Lead ECG: The Art of
Interpretation, courtesy of Tomas B. Garcia, MD.
Reproduced from 12-Lead ECG: The Art of
Interpretation, courtesy of Tomas B. Garcia, MD.

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The Electrocardiogram (12 of 27)
© Jones & Bartlett Learning. © Jones & Bartlett Learning

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The Electrocardiogram (13 of 27)
 Contiguous leads
 Leads that view geographically
similar areas of the myocardium
 Right-sided leads
 Used to evaluate the electrical
activity of the right ventricle
 Precordial leads are placed on the
right anterior thorax
© Jones & Bartlett Learning

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The Electrocardiogram (14 of 27)
 Posterior leads
 Evaluate left ventricle posterior
wall electrical activity
 Three precordial leads placed on
left posterior thorax
© Jones & Bartlett Learning. Courtesy of MIEMSS.

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The Electrocardiogram (15 of 27)
 15-lead ECG
 Standard 12-lead ECG plus leads V4R, V7, and V8
 Standard 12-lead ECG followed by a second tracing with additional leads
 18-lead ECG
 12-lead tracing plus leads V4R through V6R and V7 through V9

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The Electrocardiogram (16 of 27)
 ECG concepts
 ECG baseline represents electrical
silence in the myocardium.
 Electric impulse moving toward a
negative electrode produces a
deflection below baseline.
 Electrical impulse moving toward a
positive electrode produces a
deflection above baseline.
Reproduced from 12-Lead ECG: The Art of Interpretation, courtesy of Tomas B.
Garcia, MD.

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The Electrocardiogram (17 of 27)
 ECG concepts (cont’d)
 Perpendicular movement toward a
positive electrode produces either:
 Perfectly flat line
 Biphasic waves
Reproduced from 12-Lead ECG: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

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The Electrocardiogram (18 of 27)
 ECG paper
 Graph paper moves past stylus at
25 mm/s
 One 1-mm box — 0.04 second
 One large box — 0.20 second
 Vertical axis — amplitude
 Standard amplitude calibration —
10 mm/mV Reproduced from 12-Lead ECG: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

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The Electrocardiogram (19 of 27)
 ECG paper (cont’d)
 A calibration box printed at the
beginning of all 12-lead ECGs
informs the paramedic about:
 Paper speed
 Amplitude
Reproduced from 12-Lead ECG: The Art of Interpretation,
courtesy of Tomas B. Garcia, MD.

74. Copyright
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The Electrocardiogram (20 of 27)
 ECG components
 Heart events can be recorded as
series of:
 Waves
 Segments
 Intervals
 Complexes
 P wave: represents atrial
depolarization
 Smooth, round, upright shape
 Normal duration of less than 0.11
second
 Amplitude less than 2.5 mm tall
Reproduced from 12-Lead ECG: The Art of Interpretation,
courtesy of Tomas B. Garcia, MD.

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The Electrocardiogram (21 of 27)
 ECG components (cont’d)
 PR interval (PRI):
 Represents the time required for
an impulse to traverse the atria
and AV junction
 Normal duration of 0.12 to 0.20
seconds
Reproduced from 12-Lead ECG: The Art of Interpretation,
courtesy of Tomas B. Garcia, MD.

76. Copyright
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The Electrocardiogram (22 of 27)
Reproduced from Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

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The Electrocardiogram (23 of 27)
 ECG components (cont’d)
 QRS complex: three waveforms
representing ventricular
depolarization
 From beginning of Q wave to end
of S wave
 Narrow in healthy people, less
than 0.11 second
 Indicates that impulse has
proceeded normally
 Q wave: First negative deflection
 R wave: First upward deflection
 S wave: Downward deflection after
the R wave © Jones & Bartlett Learning.

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The Electrocardiogram (24 of 27)
 ECG components (cont’d)
 J point: where QRS complex ends
and ST segment begins
 End of depolarization and
beginning of repolarization
 ST segment: begins at J point and
ends at T wave
Reproduced from Arrhythmia Recognition: The Art of Interpretation, courtesy of
Tomas B. Garcia, MD.

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The Electrocardiogram (25 of 27)
 ECG components (cont’d)
 T wave: represents ventricular
repolarization
 Should be asymmetric
 Less than half overall QRS
complex height
 Oriented in same direction as QRS
complex
 Very large: may indicate
myocardial ischemia, injury, and
infarction
 Tall, pointed (peaked): may
indicate hyperkalemia
 Deeply inverted: acute CNS
events
Reproduced from Arrhythmia Recognition: The Art of Interpretation, courtesy of
Tomas B. Garcia, MD.

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The Electrocardiogram (26 of 27)
 ECG components (cont’d)
 U wave: represents final stage of ventricular repolarization
 QT interval: represents all electrical activity of one completed ventricular cycle
 Begins at the onset of the Q wave
 Ends at the T wave
 Measures between 0.40 and 0.44 second
 Long QT intervals can lead to ventricular dysrhythmias and sudden cardiac arrest.

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The Electrocardiogram (27 of 27)
 ECG components (cont’d)
 TP segment
 Reference to compare with J point
 R-R interval: represents interval between two ventricular depolarizations

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Approach to Dysrhythmia Interpretation (1 of 7)
 Method to interpret dysrhythmias:
 Identify the waves (P-QRS-T)
 Measure PRI
 Measure QRS duration
 Determine rhythm regularity
 Measure heart rate

83. Copyright
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Approach to Dysrhythmia Interpretation (2 of 7)
 Rhythm regularity
 Measure the distance between R
waves
 Regular: the distance between R
waves is the same
Reproduced from Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

84. Copyright
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Approach to Dysrhythmia Interpretation (3 of 7)
 Rhythm regularity
 Irregularly irregular: no two R
waves are equidistant
Reproduced from Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

85. Copyright
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Approach to Dysrhythmia Interpretation (4 of 7)
 Rhythm regularity
 Regularly irregular: R waves
irregular but follow a pattern
Reproduced from Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

86. Copyright
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Approach to Dysrhythmia Interpretation (5 of 7)
 6-second method
 Fastest method for measuring
heart rate
 Count the number of QRS
complexes in a 6-second strip and
multiply by 10
© Jones & Bartlett Learning.

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Approach to Dysrhythmia Interpretation (6 of 7)
 Sequence method
 For regular rhythms
 Find R wave; count off above
sequence until next R wave
 Interval fewer than three boxes:
rate greater than 100
 Interval more than five boxes: rate
less than 60
Reproduced from 12-Lead ECG: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

88. Copyright
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Approach to Dysrhythmia Interpretation (7 of 7)
 1,500 method
 Count the number of small boxes
between any two QRS complexes
 Divide by 1,500
 Yields rate approximately 65
beats/min
Reproduced from 12-Lead ECG: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

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Specific Cardiac Dysrhythmias (1 of 13)
 Dysrhythmia classifications
 Disturbances of automaticity or conduction
 Tachydysrhythmias or bradydysrhythmias
 Life threatening or non–life threatening
 By site from which they arise

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Specific Cardiac Dysrhythmias (2 of 13)
 Normal sinus rhythm
 Intrinsic rate of 60 to 100 beats/min
 Upright P wave preceding each
QRS complex
Reproduced from 12-Lead ECG: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

91. Copyright
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Specific Cardiac Dysrhythmias (3 of 13)
 Sinus bradycardia
 Rate of less than 60 beats/min
 Upright P wave preceding every
QRS complex
 Can cause:
 Altered mental status
 Ischemic chest discomfort
 Acute heart failure
 Seizures/syncope
 Hypotension
 Treatment indicated when
signs/symptoms persist despite
adequate airway and breathing
Reproduced from Arrhythmia Recognition: The Art of Interpretation,
courtesy of Tomas B. Garcia, MD.

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Specific Cardiac Dysrhythmias (4 of 13)
 Administering emergency medical
care
 Maintain an open airway
 Apply a cardiac monitor, BP
monitor, and pulse oximeter
 Establish IV line with normal saline
 Administer atropine
Reprinted with permission Advanced Cardiovascular Life Support Provider Manual
©2020 American Heart Association, Inc.

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Specific Cardiac Dysrhythmias (5 of 13)
 Administering emergency medical care (cont’d)
 If there is no response to atropine, begin transcutaneous pacing (TCP)
immediately.
 If you are unsuccessful, consider administration of dopamine or epinephrine
infusion.
 Transport patient.

94. Copyright
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Specific Cardiac Dysrhythmias (6 of 13)
 TCPs
 Depolarize the myocardium by delivering electrical energy through the skin of the
chest
 Capture:
 Associated with ventricular depolarization
 Characterized by wide QRS complex

95. Copyright
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Specific Cardiac Dysrhythmias (7 of 13)
 TCPs (cont’d)
 Use in the following situations
 Patient with a bradydysrhythmia that severely reduces CO and does not respond to
atropine
 Patient who requires interhospital transfer for pacemaker implantation
 Symptomatic patient with artificial pacemaker failure
 Refer to Skill Drill 18-2: Performing TCP

96. Copyright
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Specific Cardiac Dysrhythmias (8 of 13)
 Sinus tachycardia
 The rate is more than 101 to 180
beats/min
 Upright P waves precede QRS
complexes
Reproduced from 12-Lead ECG: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

97. Copyright
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Specific Cardiac Dysrhythmias (9 of 13)
 Sinus tachycardia (cont’d)
 Can lead to electrical instability:
 Hypoxia
 Metabolic alkalosis
 Hypokalemia
 Hypocalcemia
 Treatment related to the underlying cause

98. Copyright
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Specific Cardiac Dysrhythmias (10 of 13)
 Sinus dysrhythmia
 Slight variation in sinus rhythm
cycling
 Increases during inspiration and
decreases during expiration
 Upright P waves precede the QRS
complexes
 Found in children and young adults
Reproduced from 12-Lead ECG: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

99. Copyright
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Specific Cardiac Dysrhythmias (11 of 13)
 Sinus arrest
 The SA node fails to initiate an
impulse
 Upright P waves precede QRS
complexes
Reproduced from 12-Lead ECG: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

100. Copyright
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Specific Cardiac Dysrhythmias (12 of 13)
 Sinus arrest (cont’d)
 Common causes:
 Ischemia of the SA node
 Increased vagal tone
 Carotid sinus massage
 Use of certain drugs
 Treatment may include a pacemaker

101. Copyright
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Specific Cardiac Dysrhythmias (13 of 13)
 Sick sinus syndrome
 A variety of rhythms involving a poorly functioning SA
 Common in older adults
 It shows on an ECG as:
 Sinus bradycardia
 Sinus arrest
 SA block
 Alternating patterns of bradycardia and tachycardia

102. Copyright
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Rhythms Originating in the Atria (1 of 23)
 Any atrial area may originate an impulse
 Rhythms have upright P waves preceding each QRS complex
 Not as well rounded

103. Copyright
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Rhythms Originating in the Atria (2 of 23)
 Premature atrial complex (PAC)
 Ectopic complex within another
rhythm
 An upright P wave precedes each
QRS complex
 Nonconducted PAC: P wave
occurs early on the ECG and is not
followed by a QRS complex
 Can result from stress, stimulants,
or conditions
 Treatment focused on underlying
cause
Reproduced from 12-Lead ECG: The Art of Interpretation,
courtesy of Tomas B. Garcia, MD.

104. Copyright
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by
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Surgeons.
Rhythms Originating in the Atria (3 of 23)
 Supraventricular tachycardia (SVT)
 Originates from a site above the ventricles
 Faster than 100 beats/min at rest
 QRS complexes measure 0.11 second or less
 At a rate of 150 to 180 beats/min, P waves are obscured by the T wave of the
preceding beat
Reproduced from 12-Lead ECG: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

105. Copyright
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Surgeons.
Rhythms Originating in the Atria (4 of 23)
 AV nodal reentrant tachycardia
 Most common type
 Treatment depends on the severity
of symptoms
 May include medication or
electrical therapy
Reproduced from 12-Lead ECG: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

106. Copyright
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Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Atria (5 of 23)
 Cannon “A” waves
 Dissociation between atria and ventricles
 Larger waves indicate:
 Deteriorating functionality of right ventricle
 Increasing right ventricular end-diastolic pressure

107. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Atria (6 of 23)
 Tachycardia management
 Decide on the seriousness of the symptoms
 Determine if QRS complex is narrow or wide
 Determine whether ventricular rhythm is regular or irregular

108. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Atria (7 of 23)
 Tachycardia management (cont’d)
 Stable tachycardia
 Vagal maneuvers and medications are recommended
 Unstable tachycardia
 Electrical therapy with synchronized cardioversion is recommended

109. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Atria (8 of 23)
 Tachycardia emergency care
 Maintain open airway
 SpO2 between 95% and 98%
 Apply cardiac monitor, BP monitor,
and pulse oximeter
 Establish IV infusion of normal
saline
Reprinted with permission. Advanced Cardiovascular Life Support Provider Manual
©2020 American Heart Association, Inc.

110. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Atria (9 of 23)
 Tachycardia emergency care (cont’d)
 QRS narrow and regular; stable; no contraindications: perform vagal maneuvers
 QRS narrow and regular; unstable: sedation before synchronized cardioversion
 Transport for definitive care

111. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Atria (10 of 23)
 Vagal maneuvers
 Stimulate baroreceptors
 Types:
 Carotid sinus massage
 Valsalva maneuver
© Jones & Bartlett Learning.

112. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Atria (11 of 23)
 Adenosine administration
 Administer at the IV site closest to the patient’s heart
 Follow with 20-mL flush of normal saline
 Be prepared for a short run of asystole

113. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Atria (12 of 23)
 Adenosine administration (cont’d)
 If the first dose is unsuccessful, administer again.
 If needed, repeat the dose again in 1 to 2 minutes.
 If adenosine does not convert the rhythm, rapidly transport the patient.

114. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Atria (13 of 23)
 If a patient with SVT becomes unstable, move to the unstable arm of the
tachycardia algorithm.
 Synchronized cardioversion
 Use of defibrillator to terminate hemodynamically unstable tachydysrhythmia

115. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Atria (14 of 23)
 Cardioversion
 Sedate patient
 Benzodiazepines
 Refer to Skill Drill 18-3: Performing Synchronized Cardioversion

116. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Atria (15 of 23)
 Preexcitation
 Early depolarization of ventricular
tissue by means of an accessory
pathway.
 Wolff-Parkinson-White syndrome
 Lown-Ganong-Levine syndrome
Reproduced from 12-Lead ECG: The Art of Interpretation,
courtesy of Tomas B. Garcia, MD.

117. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Atria (16 of 23)
 Preexcitation (cont’d)
 Seek advice of physician
 Base treatment on:
 Instability
 QRS complex width
 Ventricular rhythm regularity
 Do not administer medication that slows/blocks conduction through AV node.

118. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Atria (17 of 23)
 Atrial fibrillation (AF)
 Atria fibrillate or quiver
 Random depolarization from atria cells depolarizing independently
 Results in fibrillating or chaotic baseline
 Irregularly irregular appearance
 Common rhythm among older patients
 Tendency to cause clots
Reproduced from 12-Lead ECG: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

119. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Atria (18 of 23)
 Atrial flutter
 Atria contract too fast for the ventricles to match
 F waves resemble a sawtooth or picket fence
 F waves get blocked by the AV node, creating several F waves before each QRS
complex
© Jones & Bartlett Learning.

120. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Atria (19 of 23)
 Atrial flutter (cont’d)
 Can degenerate into AF
 Treatment is usually medication or electrical cardioversion
 Prehospital treatment uncommon in stable patients

121. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Atria (20 of 23)
 Wandering atrial pacemaker
 Pacemaker moves from SA node to other areas within the atria or AV junction
 P wave precedes each QRS (at least three shapes of P waves within a strip)
 At least three different shapes within one ECG strip
Reproduced from Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD

122. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Atria (21 of 23)
 Wandering atrial pacemaker (cont’d)
 Seen in children, older adults, and athletes
 Treatment in prehospital setting if:
 Dysrhythmia is associated with a slow rate
 Patient is symptomatic

123. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Atria (22 of 23)
 Multifocal atrial tachycardia (MAT)
 Multiple ectopic sites depolarize at different but rapid rates
 Characterized by a rate of more than 100 beats/min
 An upright P wave precedes each QRS complex
 Shape varies
Reproduced from Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

124. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Atria (23 of 23)
 Multifocal atrial tachycardia (cont’d)
 PRI: 0.12 to 0.20 second; varies slightly
 Most common in patients with:
 Significant lung disease
 Pulmonary hypertension
 Coronary disease
 Valvular heart disease
 Hypomagnesemia
 Generally ineffective therapies for SVT

125. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating at the AV Junction (1 of 7)
 Take over if the SA node fails
 Rate of 40 to 60 beats/min
 Impulse travels down into the ventricles and up toward the SA node

126. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating at the AV Junction (2 of 7)
 Three possibilities:
 Inverted P wave immediately followed by QRS complex
 Smaller inverted P wave hidden within QRS complex
 Inverted P wave after the QRS complex

127. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating at the AV Junction (3 of 7)
 Premature junctional complex
 Particular complex within another rhythm
 Inverted P wave that precedes or follows the QRS complex
 PR interval: less than 0.12 second
 QRS complex: 0.11 second or less
 Rarely treated in the prehospital setting
Reproduced from Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

128. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating at the AV Junction (4 of 7)
 Possible symptoms
 Perceived skipped beats
 Light-headedness
 Dizziness
 Other signs of decreased CO with frequent PJCs

129. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating at the AV Junction (5 of 7)
 Junctional escape rhythm
 Occurs when the SA node does not function
 The AV node becomes the pacemaker
 Most common with significant SA node problems
 Treatment usually an implanted pacemaker
Reproduced from Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

130. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating at the AV Junction (6 of 7)
 Accelerated junction rhythm
 Present with a rate exceeding 60 beats/min but less than 100 beats/min
 Regular rhythm, little variation between R-R intervals
 Seldom treated in the prehospital setting
Reproduced from Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

131. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating at the AV Junction (7 of 7)
 Junctional tachycardia
 Junctional rhythm rate higher than 100 beats/min
 Seldom requires prehospital treatment
 Hard to distinguish from other narrow-QRS tachycardias at a rapid ventricular rate
Reproduced from Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

132. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Ventricles (1 of 21)
 Ventricles may become the pacemaker if the AV junction does not take over
after the SA node fails.
 Wide QRS complexes and missing P waves

133. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Ventricles (2 of 21)
 Premature ventricular complex (PVC)
 Particular complex within another rhythm
 Occurs earlier than expected, causing an R-R interval between it and the previous
complex
Reproduced from Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

134. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Ventricles (3 of 21)
 Premature ventricular complex (cont’d)
 Unifocal: from the same spot within the ventricle
Reproduced from Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

135. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Ventricles (4 of 21)
 Premature ventricular complex (cont’d)
 Multifocal: two premature complexes with different appearances
Reproduced from Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD

136. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Ventricles (5 of 21)
 Premature ventricular complex (cont’d)
 Couplet: Two PVCs occur together
 Salvos: Three or more PVCs occur in a row
Reproduced from Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD

137. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Ventricles (6 of 21)
 Premature ventricular complex (cont’d)
 Bigeminy: PCVs alternate with normal complexes
 Trigeminy: The third beat is a PVC
Reproduced from Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

138. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Ventricles (7 of 21)
 Premature ventricular complex (cont’d)
 Most often originate from ischemia in ventricular tissue
 R-on-T phenomenon
 Do not require treatment in otherwise healthy patients

139. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Ventricles (8 of 21)
 Idioventricular rhythm
 Occurs when SA and AV nodes fail
 May or may not result in a palpable pulse
 Treatment: improving the CO
Reproduced from Arrhythmia Recognition: The Art of Interpretation,
courtesy of Tomas B. Garcia, MD.
Reproduced from Arrhythmia Recognition: The Art of Interpretation,
courtesy of Tomas B. Garcia, MD

140. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Ventricles (9 of 21)
 Accelerated idioventricular rhythm (IVR)
 Occurs when an IVR exceeds
40 beats/min but less than 100 beats/min
 Rarely requires intervention
Reproduced from Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

141. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Ventricles (10 of 21)
 Ventricular tachycardia (VT)
 Three or more sequential beats at a rate exceeding 100 beats/min
 Regular rhythm with only slight variation
 P waves absent
 Monomorphic QRS complexes
Reproduced from Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

142. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Ventricles (11 of 21)
 Ventricular tachycardia (cont’d)
 Occasionally the QRS complex will vary in height and width
 Torsades de pointes
 Requires treatment to maintain adequate CO
Reproduced from Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

143. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Ventricles (12 of 21)
 Ventricular fibrillation (VF)
 Rhythm in which the entire heart is fibrillating without a discernable pattern
 Occurs when many different heart cells become depolarized independently
Reproduced from Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

144. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Ventricles (13 of 21)
 Ventricular fibrillation (cont’d)
 Coarse: waves greater than 3 mm in amplitude
 Fine: waves less than 3 mm in amplitude
Reproduced from Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

145. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Ventricles (14 of 21)
 Defibrillation
 Surge of electrical energy delivered to the heart
 Effective for:
 VF
 Pulseless VT
 Types
 Automated external defibrillator (AED)
 Manual defibrillator

146. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Ventricles (15 of 21)
 Defibrillation (cont’d)
 CPR must be ongoing while
defibrillator is readied for use
 Adhesive pads maximize current
flow
 AEDs and manual defibrillators
deliver energy in waveforms
 Monophasic
 Biphasic
Reprinted with permission Circulation.2020;142:S366-S468
©2020 American Heart Association, Inc.

147. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Ventricles (16 of 21)
 Safety measures for defibrillation
 Ensure no one is touching the patient.
 Do not defibrillate if patient is lying in pooled water.
 Do not defibrillate someone touching metal that others are touching.
 Avoid placing pad over medication patch or metal objects.
 Place pad below any implanted device/battery or in anterior/posterior positions.

148. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Ventricles (17 of 21)
 Defibrillation gear
 Defibrillation pads
 Cables and connectors
 Power supply
 Monitor
 ECG recorder
 Any ancillary supplies (extra pads and spare batteries)
 Refer to Skill Drill 18-4: Performing Manual Defibrillation

149. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Ventricles (18 of 21)
 AED
 Manual mode
 Fully automated AED: no intervention required
 Semiautomated AED: uses visual and verbal prompts
 Refer to Skill Drill 18-5: Performing Defibrillation With an AED

150. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Ventricles (19 of 21)
 Wearable cardioverter-defibrillators
 For patients who:
 Are at risk of sudden cardiac death
 Are not immediate candidates for therapy with an implantable cardioverter-defibrillator

151. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Ventricles (20 of 21)
 Asystole (flat line)
 Entire heart no longer contracting
 There is a complete absence of electrical activity
 Generally considered a nonshockable cardiac arrest rhythm
Reproduced from Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

152. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Rhythms Originating in the Ventricles (21 of 21)
 Pulseless electrical activity (PEA)
 Organized cardiac rhythm not accompanied by a detectable pulse
 Heartbeat weak from:
 Cardiogenic or hypovolemic shock
 Cardiac tamponade
 Massive pulmonary embolism
 Electrolyte imbalance disturbances
 Drug overdose
 Key to treatment: identifying cause
 Nonshockable cardiac arrest rhythm

153. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Management of Adult Cardiac Arrest (1 of 16)
 Major risk factors:
 Prior hear disease (most common)
 Asthma, anaphylaxis
 Drug overdose
 Electrocution, drowning, or other trauma
 Cardiac arrest management requires a systematic approach that is rehearsed.

154. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Management of Adult Cardiac Arrest (2 of 16)
 Bring the following:
 Defibrillator
 Portable oxygen cylinder
 Airway management equipment
 Intubation kit
 IV equipment
 Drug box

155. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Management of Adult Cardiac Arrest (3 of 16)
 The goals of emergency medical care include:
 The return of spontaneous circulation (ROSC)
 The preservation of neurologic function
 Begin emergency care immediately upon discovering pulselessness.

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Management of Adult Cardiac Arrest (4 of 16)
 Withholding CPR is appropriate when:
 Attempts place rescuers at risk
 There are obvious clinical signs of irreversible death
 Physician order for life-sustaining treatment is not desired or DNAR order exists

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Management of Adult Cardiac Arrest (5 of 16)
 Proceeding with CPR:
 If chest compressions were provided before arrival: proceed with rhythm analysis.
 If chest compressions were not provided before arrival: begin chest compressions
while a second rescuer sets up the AED or defibrillator.

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Management of Adult Cardiac Arrest (6 of 16)
 Components of high-quality CPR include:
 Chest compressions at a rate of 100/min to 120/min
 Chest compression depth
 At least 2 inches (5 cm)
 Less than 2.4 inches (6 cm)
 Full chest recoil after each compression
 Minimal interruption of compressions
 Adequate ventilation
 Rotate patient every 2 minutes

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Management of Adult Cardiac Arrest (7 of 16)
 Four possible cardiac arrest rhythms
 Pulseless VT
 Pulseless VF
 Asystole
 PEA

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Management of Adult Cardiac Arrest (8 of 16)
 Key points to remember
 If defibrillation is indicated, the provider giving chest compressions should continue
while a second rescuer charges the defibrillator.
 Pause CPR, clear the patient, and deliver the shock.
 Resume chest compressions immediately, without pausing for a rhythm or pulse check.

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Management of Adult Cardiac Arrest (9 of 16)
 After 2 minutes or five cycles of CPR, pause efforts and check the rhythm on
the monitor.
 Rhythm other than VF or VT appears: identify the new rhythm and check for a pulse
 No pulse: move down the algorithm to the asystole-PEA pathway and immediately
resume CPR
 Pulse: move to the appropriate algorithm for the new rhythm

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Management of Adult Cardiac Arrest (10 of 16)
 Minimize rescuer fatigue by switching the CPR compressor and ventilator at the
end of each 2-minute session of CPR.
 To maximize the number of compressions delivered per minute, interruptions
should not exceed 10 seconds.

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Management of Adult Cardiac Arrest (11 of 16)
 Using normal saline, establish vascular access.
 Do not interrupt chest compressions.
 As soon as IV or intraosseous (IO) access is established, administer epinephrine.
 1 mg every 3 to 5 minutes until pulse returns
 Immediately follow administration of medication through an IV line during CPR
with a 20-mL flush of normal saline IV.

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Management of Adult Cardiac Arrest (12 of 16)
 Several options available for airway management
 Nonrebreathing mask used for three to four cycles of uninterrupted chest
compressions
 Bag-mask device
 For adults in cardiac arrest without an advanced airway, use a 30:2
compression/ventilation ratio.

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Management of Adult Cardiac Arrest (13 of 16)
 Several options available for airway management (cont’d)
 Ventilate until chest rise and deliver each breath over 1 second.
 When inserting an advanced airway, verify placement, secure the tube, and deliver
one breath every 6 seconds.

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Management of Adult Cardiac Arrest (14 of 16)
 VF or pulseless VT that persists or recurs after one or more shocks is called
refractory VF/VT.
 Consider amiodarone or lidocaine

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Management of Adult Cardiac Arrest (15 of 16)
 Consider the Hs and Ts to identify possible reversible causes
 If there is an ROSC, assess the vital signs, support the airway and breathing,
and give medications as indicated.

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Management of Adult Cardiac Arrest (16 of 16)
 Transportation of patients depends on the EMS system and is dictated by local
protocol.
 Safest to resuscitate at scene
 Unless location is unsafe
 Do not defibrillate in moving ambulance.

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Special Circumstances in Cardiac Arrest
 Cardiac arrests that require adjustments to procedures include those
associated with:
 Morbid obesity
 Anaphylaxis
 Opioids
 Acute asthma
 Electrolyte disturbances
 Drowning

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Post-Cardiac Arrest Care
 Begin by optimizing oxygenation
and ventilation
 Rapid correction of marked
hypotension
 Perform a neurologic assessment;
assess for signs of hypoperfusion
 Closely monitor the post–cardiac
patient
Reprinted with permission Circulation.2020;142:S366-S468 ©2020
American Heart Association, Inc.

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When To Stop CPR (1 of 2)
 Decisions regarding ongoing resuscitative efforts guided by local protocol or
direct communication with medical control
 Acceptable reasons to cease efforts:
 No additional benefits
 Less effective than CPR at scene
 Risk physical injury
 Futile cases
 EMS crew unavailable for other calls

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When To Stop CPR (2 of 2)
 BLS and ALS termination of resuscitation for adult out-of-hospital cardiac
arrests
 Gaining permission to stop CPR in the field involves:
 Expectations of patient’s family
 Disposition of body
 Pressure from bystanders
 Paramedics unaccustomed to telling family a patient is dead

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Atrioventricular (AV) Blocks (1 of 7)
 SA node initiates impulses resulting in heart contractions.
 Occasionally, impulses are delayed longer than usual, causing AV blocks.

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Atrioventricular (AV) Blocks (2 of 7)
 First-degree AV block
 Occurs when each impulse is delayed slightly longer than normal
 Least serious type of block
 Rarely treated in a prehospital setting
Reproduced from Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

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Atrioventricular (AV) Blocks (3 of 7)
 Second-degree AV block I: Mobitz
type I (Wenckebach)
 Occurs when an interruption in
impulse conduction occurs within
the AV node, bundle of His, or His-
Purkinje system
 Key to recognize:
 More P waves than QRS
complexes
 P waves occur at regular intervals
 PRI waves get longer
 Irregular ventricular rhythm
Reproduced from Arrhythmia Recognition: The Art of Interpretation,
courtesy of Tomas B. Garcia, MD.

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Atrioventricular (AV) Blocks (4 of 7)
 Second-degree AV block I: Mobitz type I (Wenckebach) (cont’d)
 Causes include:
 Ischemic heart disease
 Acute inferior wall or right ventricular MI
 Increased vagal tone
 Digoxin toxicity
 Certain electrolyte imbalances
 Administration of certain medicines
 Patient is usually symptomatic.
Reproduced from Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

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Atrioventricular (AV) Blocks (5 of 7)
 Second-degree AV block II (Mobitz type II)
 More serious than type I
 Occurs when several impulses cannot continue
 An intermittent block characterized by regularly occurring P waves and the abrupt
appearance of at least one P wave that is not followed by a QRS complex

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Atrioventricular (AV) Blocks (6 of 7)
 Second-degree AV block II (Mobitz type II) (cont’d)
 Causes include:
 Ischemic heart disease
 Acute anterior wall MI
 Infection heart diseases
 Cardiac surgery
 Emergency care may require TCP
 Can progress to third-degree without warning
 QRS duration is a clue

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Atrioventricular (AV) Blocks (7 of 7)
 Third-degree AV block
 Occurs when all impulses are prevented from reaching the ventricles and
generating a QRS complex
 The secondary pacemaker assumes responsibility
 Identified by nonconducted P waves
 Treated in the field only if it occurs with bradycardia
Reproduced from Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

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Artificial Pacemaker Rhythms (1 of 4)
 Artificial pacemakers
 Consist of:
 Pulse generator
 Wire electrodes
 Contain programmable hardware
 Implanted below right or left clavicle
 Generate unique vertical spike
Reproduced from Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

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Artificial Pacemaker Rhythms (2 of 4)
 Single-chamber pacemaker
 Dual-chamber (AV sequential) pacemaker
 Biventricular pacemaker
Reproduced from Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

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Artificial Pacemaker Rhythms (3 of 4)
 Fixed rate pacemaker
 Seldom used
 Demand pacemakers
 Generate impulses when patient’s heart rate has dropped below a predetermined
rate (60 beats/min)
Reproduced from Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

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Artificial Pacemaker Rhythms (4 of 4)
 If malfunction occurs, the patient’s heart will depend on its natural pacemaker,
greatly reducing CO.
 Failure to capture, pace, or sense
 Oversensing
 Runaway pacemaker

184. Copyright © 2023 by Jones & Bartlett Learning, LLC, an Ascend Learning Company and the American Academy of Orthopaedic Surgeons.
12-Lead ECGs

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12-Lead ECGs (1 of 2)
 Used to localize the cardiac muscle injury site and identify cardiac abnormalities
 Devices use interpretation software

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12-Lead ECGs (2 of 2)
 Indications
 Before and after electrical therapy
 Chest pain
 Electrical injury
 Electrolyte imbalance
 Medication overdose
 RVF/LVF
 Post-syncope
 Stroke
 Syncope or near-syncope
 Stroke
 Hemodynamic instability

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Acquisition Modes (1 of 2)
 Monitor mode is used for rhythm interpretation.
 Electronic filters to remove artifact
 Skews shape/location of ST segment and T wave
 Captures range of 1 to 30, 40, 100, or 150 Hz

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Acquisition Modes (2 of 2)
 Diagnostic mode filters out very little electrical information
 Electrical information within 0.05 to 150 Hz
 Records 12-lead ECG by default
 Possible for 3-lead ECG
 Frequency range near the bottom of tracing
© Jones & Bartlett Learning

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Lead Placement
 Practice with the equipment
 Make sure the patient does not get chilled
 Refer to Skill Drill 18-6: Acquiring a 12-lead ECG

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Approach to the 12-lead ECG Interpretation (1 of 33)
 Seven-step method
 Review the snapshot
 Interpret the dysrhythmia
 Determine the axis
 Identify conduction system disturbances
 Evaluate chamber size
 Review for zones of ischemia, injury, and infarction
 Identify noncardiac causes

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Approach to the 12-lead ECG Interpretation (2 of 33)
 Review the snapshot
 Look at tracing
 Did all the leads print?
 Is an artifact present?
 Is the rate at one of the extremes?

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Approach to the 12-lead ECG Interpretation (3 of 33)
 Dysrhythmia interpretation
 Identify waves (P-QRS-T)
 Measure PRI
 Measure QRS duration
 Determine rhythm regularity
 Measure heart rate

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Approach to the 12-lead ECG Interpretation (4 of 33)
 Determine the axis
 Vector: quantity with magnitude
and direction
 QRS axis: single vector that
represents the average of all
vectors created by the ventricles
during depolarization
Reproduced from Arrhythmia Recognition: The Art
of Interpretation, courtesy of Tomas B. Garcia, MD.

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Approach to the 12-lead ECG Interpretation (5 of 33)
 Determine the axis (cont’d)
 Viewed from lead I, QRS wave will
be:
 Positive if heading toward the left
arm
 Negative if heading toward the
right arm
© Jones & Bartlett Learning.

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Approach to the 12-lead ECG Interpretation (6 of 33)
 Determine the axis (cont’d)
 Viewed from lead aVF, QRS wave
will be:
 Positive if heading toward the feet
 Negative if heading toward the
head
 Quadrant system determines QRS
axis
 Intersection represents impulse
origin
© Jones & Bartlett Learning.

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Approach to the 12-lead ECG Interpretation (7 of 33)
 Determine the axis (cont’d)
 The QRS axis will always move
toward hypertrophy and away from
infarction.
 Enlarged ventricle: more electrical
energy
 Infarcted ventricle: no electrical
energy
© Jones & Bartlett Learning.

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Approach to the 12-lead ECG Interpretation (8 of 33)
 Conduction system disturbances
 Bundle branch blocks: QRS complex with a bizarre appearance and longer than
0.12 second
 Right bundle branch blocks (RBBB)
 Terminal R wave in lead V1
 Terminal S waves in leads I, aVL, and V6
Reproduced from 12-Lead ECG: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

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Approach to the 12-lead ECG Interpretation (9 of 33)
 Conduction system disturbances (cont’d)
 Left bundle branch blocks (LBBBs)
 Terminal S wave in lead V1
 Terminal R waves in leads I, aVL, and V6
Reproduced from 12-Lead ECG: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

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Approach to the 12-lead ECG Interpretation (10 of 33)
 Conduction system disturbances (cont’d)
 Anterior fascicular block
 rS complexes in leads II, III, aVF
 qR complexes in leads I and aVL
 Posterior fascicular block
 qR complexes in leads II, III, and aVF
 rS complexes in lead I

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Approach to the 12-lead ECG Interpretation (11 of 33)
 Conduction system disturbances (cont’d)
 Bifascicular block
 Two or more blocked fascicles or conduction pathways
 Trifascicular block
 All three components are blocked or impaired
 Concordant precordial pattern: QRS complexes in the precordial leads are all in the
same direction

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Approach to the 12-lead ECG Interpretation (12 of 33)
 Evaluate chamber size
 Right atrial abnormality
 Left atrial abnormality
 Right ventricular hypertrophy (RVH)
 Left ventricular hypertrophy (LVH)

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Approach to the 12-lead ECG Interpretation (13 of 33)
 Right atrial abnormality
 Results from chronic pulmonary disorders
 Characterized by P wave with an amplitude:
 Higher than 2.5 mm in lead II
 And/or higher than 1.5 mm in lead V1
 Normal P wave duration
Reproduced from 12-Lead ECG: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

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Approach to the 12-lead ECG Interpretation (14 of 33)
 Left atrial abnormality
 Characterized by:
 P wave longer than 0.12 second in
lead II
 P wave with a notched
appearance
 Biphasic P wave in lead V1
predominantly negative
 Caused by:
 Valvular heart disease
 Hypertensive heart disease
 Cardiomyopathy
 CAD
Reproduced from 12-Lead ECG: The Art of Interpretation,
courtesy of Tomas B. Garcia, MD.

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Approach to the 12-lead ECG Interpretation (15 of 33)
 Right ventricular hypertrophy
 Usually caused by pulmonary hypertension
 Diagnosed by R wave that exceeds the height of the S wave in V1
Reproduced from 12-Lead ECG: The Art of Interpretation,
courtesy of Tomas B. Garcia, MD.

205. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Approach to the 12-lead ECG Interpretation (16 of 33)
 Left ventricular hypertrophy
 From hypertension or cardiac
abnormalities
 Diagnosed by:
 Deepest S wave in V1 plus
 Tallest R wave in V5/V6, taller than
35 mm, and/or
 R wave in lead aVL taller than 11
mm
 Diagnosis made by
echocardiogram
Reproduced from 12-Lead ECG: The Art of Interpretation,
courtesy of Tomas B. Garcia, MD.

206. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Approach to the 12-lead ECG Interpretation (17 of 33)
 Review for zones of ischemia, injury, and infarction
 Early recognition limits tissue loss
 Characteristic changes on the ECG with coronary artery blockage
 ST-segment depression
 Ischemia
 ST-segment elevation
 Myocardial injury
 Pathologic Q waves
 Infarction

207. Copyright
©
2023
by
Jones
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Learning,
LLC,
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Ascend
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American
Academy
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Orthopaedic
Surgeons.
Approach to the 12-lead ECG Interpretation (18 of 33)
 Review for zones of ischemia,
injury, and infarction (cont’d)
 ST-segment depression greater
than 0.5 mm in two or more
contiguous leads in a patient with
chest pain or discomfort
 Unstable angina or NSTEMI
Reproduced from 12-Lead ECG: The Art of Interpretation,
courtesy of Tomas B. Garcia, MD

208. Copyright
©
2023
by
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Learning,
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an
Ascend
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American
Academy
of
Orthopaedic
Surgeons.
Approach to the 12-lead ECG Interpretation (19 of 33)
 Review for zones of ischemia, injury, and infarction (cont’d)
 Suspect STEMI if:
 For leads V2 and V3, the ST-segment elevation is 2 mm or more in men older than 40
years or 1.5 mm or more in women, or
 Elevated 1 mm or more at the J point in the other leads

209. Copyright
©
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Learning,
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Ascend
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Orthopaedic
Surgeons.
Approach to the 12-lead ECG Interpretation (20 of 33)
 Review for zones of ischemia, injury, and infarction (cont’d)
 Treatment decisions are made on the basis of:
 Patient presentation and history
 12-lead ECG findings
 Laboratory test results

210. Copyright
©
2023
by
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Learning,
LLC,
an
Ascend
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Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Approach to the 12-lead ECG Interpretation (21 of 33)
 Review for zones of ischemia,
injury, and infarction (cont’d)
 Correlate vascular anatomy with
the heart surface viewed by each
ECG lead
 Reciprocal changes help identify
MI
 Mirror image
 J-point
 ST-segment
 T-wave
© Jones & Bartlett Learning.

211. Copyright
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Learning,
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Surgeons.
Approach to the 12-lead ECG Interpretation (22 of 33)
 Benign early repolarization
 Coincidental finding
 Characterized by:
 ST-segment elevation
 J or fishhook appearance at the J
point
 Concave ST-segment morphology
 Changes in left precordial leads
and/or inferior leads
Reproduced from 12-Lead ECG: The Art of Interpretation,
courtesy of Tomas B. Garcia, MD.

212. Copyright
©
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by
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Learning,
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American
Academy
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Orthopaedic
Surgeons.
Approach to the 12-lead ECG Interpretation (23 of 33)
 Pericarditis
 Patients present with:
 Positional chest pain
 Shortness of breath
 History of recent infection or fever
 It is characterized by diffuse ST-
segment elevation and depressed
PR segment. © Jones & Bartlett Learning.

213. Copyright
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Learning,
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American
Academy
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Orthopaedic
Surgeons.
Approach to the 12-lead ECG Interpretation (24 of 33)
 Noncardiac causes
 Pulmonary embolism
 Acute intracranial hemorrhage
 Electrolyte abnormalities
 Genetic disorders that affect the heart

214. Copyright
©
2023
by
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Learning,
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American
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Orthopaedic
Surgeons.
Approach to the 12-lead ECG Interpretation (25 of 33)
 Pulmonary embolism
 Identified on a 12-lead ECG by:
 An S1Q3T3 pattern
 New RBBB
 ST-segment depression in leads V1 to V3
© Jones & Bartlett Learning.

215. Copyright
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Learning,
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Company
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American
Academy
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Orthopaedic
Surgeons.
Approach to the 12-lead ECG Interpretation (26 of 33)
 Hypothermia
 May develop J waves
 Reveals a bradycardic rhythm and
baseline containing artifact
 May be accompanied by:
 ST-segment depression
 T-wave inversion
Reproduced from 12-Lead ECG: The Art of Interpretation,
courtesy of Tomas B. Garcia, MD.

216. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Approach to the 12-lead ECG Interpretation (27 of 33)
 Electrolyte imbalances
 Hyperkalemia
 Tall, peaked, asymmetric T waves with flattened P wave
 Wide QRS complexes in severe cases
 Hypokalemia
 Flat or seemingly absent T and U waves
Reproduced from 12-Lead ECG: The Art of Interpretation,
courtesy of Tomas B. Garcia, MD.
Reproduced from 12-Lead ECG: The Art of Interpretation,
courtesy of Tomas B. Garcia, MD

217. Copyright
©
2023
by
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Learning,
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an
Ascend
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the
American
Academy
of
Orthopaedic
Surgeons.
Approach to the 12-lead ECG Interpretation (28 of 33)
 Hypercalcemia: shortened QT interval
 Hypocalcemia: lengthened QT interval
 Both due to length change in ST segment
 T wave unaffected

218. Copyright
©
2023
by
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Learning,
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Surgeons.
Approach to the 12-lead ECG Interpretation (29 of 33)
 Cardiomyopathy
 Dilated, weakens muscle and its
ability to pump blood
 Heart enlarges and stretched
 Hypertrophic
 Myocardial walls thicken
 Genetic
 Patients experience shortness of
breath, chest pain, and syncope
© Jones & Bartlett Learning.

219. Copyright
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Surgeons.
Approach to the 12-lead ECG Interpretation (30 of 33)
 Cardiomyopathy
 Restrictive cardiomyopathy
 Ventricular walls stiffen due to abnormal substances

220. Copyright
©
2023
by
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Learning,
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Ascend
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Orthopaedic
Surgeons.
Approach to the 12-lead ECG Interpretation (31 of 33)
 Brugada syndrome
 Disorder involving sodium
channels in the heart
 Characterized by:
 Incomplete RBBB
 ST-segment elevation that returns
to baseline
 Changes seen in leads V1 to V2
(possibly V3)
© Jones & Bartlett Learning.

221. Copyright
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Learning,
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Academy
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Surgeons.
Approach to the 12-lead ECG Interpretation (32 of 33)
 Long QT syndrome (LQTS)
 QT interval exceeding 0.44 second
 Result of:
 Genetic mutation of several genes
 Administration of certain drugs
 Conditions such as hypocalcemia, AMI, or pericarditis
Reproduced from Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD

222. Copyright
©
2023
by
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Learning,
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American
Academy
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Orthopaedic
Surgeons.
Approach to the 12-lead ECG Interpretation (33 of 33)
 Intracranial hemorrhage
 Inverted, symmetric T waves in
precordial leads
 Prolonged QT intervals
 Patient will have neurologic
symptoms or be unresponsive
© Jones & Bartlett Learning.

223. Copyright © 2023 by Jones & Bartlett Learning, LLC, an Ascend Learning Company and the American Academy of Orthopaedic Surgeons.
Pathophysiology, Assessment, and Management
of Specific Cardiovascular Conditions

224. Copyright
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2023
by
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Learning,
LLC,
an
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Academy
of
Orthopaedic
Surgeons.
Epidemiology of CVD
 Leading global cause of death in the United States
 Examples:
 Angina pectoris
 AMI
 Heart failure
 Hypertension
 Stroke
 Diseases of the arteries

225. Copyright
©
2023
by
Jones
&
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Learning,
LLC,
an
Ascend
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and
the
American
Academy
of
Orthopaedic
Surgeons.
Acute Coronary Syndromes (1 of 16)
 Characterized by:
 Abrupt reduction in blood flow through one or more coronary arteries
 Blood vessel blockage
 Ischemia: oxygen deprivation
 Infarction: tissue death
 Usually caused by rupture of atherosclerotic plaque

226. Copyright
©
2023
by
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Learning,
LLC,
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Ascend
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and
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American
Academy
of
Orthopaedic
Surgeons.
Acute Coronary Syndromes (2 of 16)
 Atherosclerosis
 Affects the inner lining of blood vessels
 Narrowing and blood flow reduction
 Area provides a locus for the formation of a fixed thrombus
 May cause arteriosclerosis

227. Copyright
©
2023
by
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Learning,
LLC,
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Ascend
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and
the
American
Academy
of
Orthopaedic
Surgeons.
Acute Coronary Syndromes (3 of 16)
 Nonmodifiable risk factors cannot be changed.
 Modifiable risk factors can be controlled, modified, or treated.
 Risk factors for CHD
 Health conditions
 Lifestyle habits
 Nonmodifiable factors
 Contribution factors

228. Copyright
©
2023
by
Jones
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Learning,
LLC,
an
Ascend
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Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Acute Coronary Syndromes (4 of 16)
 Angina pectoris
 Principal symptom of CAD
 Occurs when oxygen supply cannot meet demand
 A switch to anaerobic metabolism leads to CO2 and lactic acid accumulation
 If occurring at rest, CAD is more severe.

229. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
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Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Acute Coronary Syndromes (5 of 16)
 Angina pectoris (cont’d)
 Stable angina
 Follows a predictable, recurrent pattern
 Unstable angina
 More serious, higher level of obstruction
 Changes in frequency, severity, and duration
 May begin during sleep or at rest
 Warning of impending MI

230. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
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Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Acute Coronary Syndromes (6 of 16)
 Angina pectoris (cont’d)
 Variant angina
 Caused by coronary artery vasospasm
 Creates chest pain at rest
 Can occur in patients with normal coronary arteries or with CAD
 Resolution of symptoms on their own or with NTG

231. Copyright
©
2023
by
Jones
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Learning,
LLC,
an
Ascend
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Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Acute Coronary Syndromes (7 of 16)
 Angina pectoris (cont’d)
 Microvascular angina (MVA)
 Caused by constriction or spasm within smallest coronary artery wall
 Underrecognized and untreated
 More common in women and people with diabetes or hypertension
 Intense and prolonged chest discomfort

232. Copyright
©
2023
by
Jones
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Learning,
LLC,
an
Ascend
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the
American
Academy
of
Orthopaedic
Surgeons.
Acute Coronary Syndromes (8 of 16)
 Acute myocardial infarction (AMI)
 Deprivation of blood flow long enough for portion of cardiac muscle to die
 Location and size depends on which artery is blocked and where
 Subendocardial myocardial infarction
 Transmural myocardial infarction

233. Copyright
©
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by
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Learning,
LLC,
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Ascend
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Academy
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Orthopaedic
Surgeons.
Acute Coronary Syndromes (9 of 16)
 AMI (cont’d)
 Infarcted tissue is surrounded by a ring of ischemic tissue.
 Deprived of oxygen but still viable
 Electrically unstable
 Signs and symptoms of patients with unstable angina and AMI may be identical.

234. Copyright
©
2023
by
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Learning,
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Ascend
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American
Academy
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Orthopaedic
Surgeons.
Acute Coronary Syndromes (10 of 16)
 Assessment
 Identify whether STEMI is present; if so, notify the medical facility.
 Determine the time of onset.
 Monitor cardiac rhythm and vital signs.
 Administer appropriate medications.
 Transport to an appropriate facility.

235. Copyright
©
2023
by
Jones
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Bartlett
Learning,
LLC,
an
Ascend
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Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Acute Coronary Syndromes (11 of 16)
 Symptoms
 Chest pain (most common)
 Patient often clenches his or her fist when describing it
 May radiate to the arms, fingers, neck, jaw, upper back, or epigastrium
 Sometimes mistaken for indigestion
 Not influenced by body movements

236. Copyright
©
2023
by
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Learning,
LLC,
an
Ascend
Learning
Company
and
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American
Academy
of
Orthopaedic
Surgeons.
Acute Coronary Syndromes (12 of 16)
 Symptoms (cont’d)
 Not every ACS patient has chest discomfort (a silent MI)
 Anginal equivalents

237. Copyright
©
2023
by
Jones
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Learning,
LLC,
an
Ascend
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American
Academy
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Orthopaedic
Surgeons.
Acute Coronary Syndromes (13 of 16)
 Symptoms (cont’d)
 Women
 Discomfort in the back, shoulder, or neck that may come and go
 Shortness of breath
 Weakness
 Nausea and vomiting

238. Copyright
©
2023
by
Jones
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Bartlett
Learning,
LLC,
an
Ascend
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the
American
Academy
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Orthopaedic
Surgeons.
Acute Coronary Syndromes (14 of 16)
 Symptoms (cont’d)
 Older adults
 Compromised mental status
 Generalized weakness
 Syncope
 Shortness of breath
 Abdominal or epigastric discomfort
 Patients with diabetes
 Generalized weakness
 Syncope
 Light-headedness
 Diminished mental status

239. Copyright
©
2023
by
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Learning,
LLC,
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Ascend
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the
American
Academy
of
Orthopaedic
Surgeons.
Acute Coronary Syndromes (15 of 16)
 Obtain history.
 SAMPLE and OPQRST questions
 Ask patient about pain medication and its effectiveness
 Use pain rating scale.
 As soon as a cardiac condition is established, start treatment.

240. Copyright
©
2023
by
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Learning,
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Academy
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Orthopaedic
Surgeons.
Acute Coronary Syndromes (16 of 16)
 Signs
 Patient’s general appearance
 Patient’s level of responsiveness
 Skin
 Vital signs
 Signs of LVF
 Signs of RVF

241. Copyright
©
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by
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Learning,
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Academy
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Orthopaedic
Surgeons.
Management of Acute Coronary Syndromes (1 of 14)
 ACS patients with STEMI are most
likely to benefit from reperfusion
therapy.
 Start treatment at once on arrival
 Even before completing history or
secondary assessment
Reprinted with permission Advanced Cardiovascular Life Support Provider Manual
©2020 American Heart Association, Inc.

242. Copyright
©
2023
by
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Learning,
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American
Academy
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Orthopaedic
Surgeons.
Management of Acute Coronary Syndromes (2 of 14)
 Place the patient at physical and emotional rest.
 Stress response can make a damaged heart race.
 The heart is pushed faster but also works harder from afterload.
 Increased need for oxygen

243. Copyright
©
2023
by
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Learning,
LLC,
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Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Management of Acute Coronary Syndromes (3 of 14)
 To begin treatment, place the patient in a semi-Fowler position.
 Do not allow the patient to walk to the stretcher.
 Record vital signs.

244. Copyright
©
2023
by
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Learning,
LLC,
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American
Academy
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Orthopaedic
Surgeons.
Management of Acute Coronary Syndromes (4 of 14)
 Perform cardiac monitoring.
 Listen for rhythm irregularities.
 Keep cardiac drugs close at hand.
 Treat pulseless rhythms in accordance with the algorithm for each respective
dysrhythmia.
 Initiate CPR, defibrillation, or cardioversion, if indicated.

245. Copyright
©
2023
by
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Learning,
LLC,
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Ascend
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American
Academy
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Orthopaedic
Surgeons.
Management of Acute Coronary Syndromes (5 of 14)
 Administer aspirin and oxygen.
 If the patient is dyspneic, hypoxemic, or has obvious signs of heart failure:
 Maintain the SpO2 level at 94% or higher.

246. Copyright
©
2023
by
Jones
&
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Learning,
LLC,
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Ascend
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Company
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the
American
Academy
of
Orthopaedic
Surgeons.
Management of Acute Coronary Syndromes (6 of 14)
 Obtain a 12-lead ECG
 Do so within 10 minutes of patient
contact
 Perform before administration of
any medication (except aspirin and
oxygen)
 Repeat
 With each set of vital signs
 When symptoms change
 As often as necessary
Reproduced from Arrhythmia Recognition: The Art of Interpretation,
courtesy of Tomas B. Garcia, MD

247. Copyright
©
2023
by
Jones
&
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Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Management of Acute Coronary Syndromes (7 of 14)
 If symptoms suggest ischemia or infarction, the 12-lead ECG allows for rapid
placement into 1 of 3 categories:
 STEMI
 NSTEMI
 Normal (nondiagnostic)

248. Copyright
©
2023
by
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Learning,
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Academy
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Orthopaedic
Surgeons.
Management of Acute Coronary Syndromes (8 of 14)
 STEMI treatment requires
reperfusion therapy by:
 Percutaneous coronary
intervention (PCI)
 Fibrinolytic medication
 Converts body’s clot-dissolving
enzyme into active form
 Can cause uncontrolled bleeding
 Know which facilities are equipped
to administer each treatment.
© Jones & Bartlett Learning.

249. Copyright
©
2023
by
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Learning,
LLC,
an
Ascend
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and
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American
Academy
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Orthopaedic
Surgeons.
Management of Acute Coronary Syndromes (9 of 14)
 Ideal STEMI system
 Trained EMS dispatchers
 EMS triage and destination protocols
 12-lead ECG acquisition and interpretation capabilities
 ED protocols
 Staff experienced in ACLS

250. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
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Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Management of Acute Coronary Syndromes (10 of 14)
 Ideal STEMI system (cont’d)
 Communication with receiving institution
 Medical direction
 Interfacility transfer protocols
 Post–acute care capabilities
 Quality assurance/improvement

251. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Management of Acute Coronary Syndromes (11 of 14)
 For patients with STEMI, it is critical to minimize time to treatment:
 EMS-to-balloon time
 Door-to-balloon time
 Door-to-needle time
 Transport and destination decisions based on:
 Local resources
 Systems of care

252. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Management of Acute Coronary Syndromes (12 of 14)
 Provide pain relief.
 Administer NTG if there are no contraindications.
 Administer NTG sublingually as a 0.4-mg tablet or metered-dose spray.
 Follow local protocols.

253. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Management of Acute Coronary Syndromes (13 of 14)
 Transport the patient.
 Once the patient is stable, transport in semi-Fowler position.
 Ensure patient comfort.
 Additional treatment is advisable for long transports.

254. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Management of Acute Coronary Syndromes (14 of 14)
 A person with chest discomfort who refuses care is a high-risk refusal patient.
 Calmly try to persuade the patient.
 Suspected MI:
 Use nonmedical language
 Explain the risks of not accepting care
 Contact medical direction if necessary
 Document refusal

255. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Acute Coronary Syndromes
 Patient and family education
 Teach how to recognize signs and symptoms of a heart attack
 Call 9-1-1 within 5 minutes of symptom onset

256. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Heart Failure (1 of 6)
 Occurs when the heart cannot pump fast or powerfully enough to empty its
chambers
 Blood backs up into systemic or pulmonary circuit, or both
 Volume overload and inadequate tissue perfusion

257. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Heart Failure (2 of 6)
 Common features
 Fatigue
 Dyspnea
 Edema
 Exercise intolerance

258. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Heart Failure (3 of 6)
 Causes
 CAD (most common)
 Long-standing high BP
 Diabetes
 Dysrhythmias
 Cardiomyopathy
 Valvular heart disease
 Genetic conditions

259. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Heart Failure (4 of 6)
 Contributing factors
 Thyroid disorders
 Alcohol or illegal substance abuse
 Cancer treatments that damage myocardium
 Infectious agents that cause inflammation

260. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Heart Failure (5 of 6)
 Identify based on:
 Symptom onset
 Acute verses chronic
 Ventricle initially involved
 Left verses right

261. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Heart Failure (6 of 6)
 Heart failure can be caused by any condition that affects:
 Preload
 Afterload
 Contractility
 Heart rate

262. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Left Ventricular Failure (1 of 2)
 Blood backs up, causing a chain reaction.
 Right side continues to pump normally.
 Left side cannot keep up, and pressure increases.
 Fluid is forced into alveoli and forms a pulmonary edema.
 Buildup of fluid widens the gap between the alveoli/capillary membrane.

263. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Left Ventricular Failure (2 of 2)
 Two types of LVF
 Systolic failure
 Diastolic failure
 Common causes
 Poorly controlled hypertension
 Tachydysrhythmias
 Permanent damage to myocardium
due to CAD
 Increased demands on heart
© Jones & Bartlett Learning.

264. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Right Ventricular Failure (1 of 3)
 To eject the blood, the right
ventricle must overcome high
pressure and congestion within the
pulmonary vessels.
© Jones & Bartlett Learning.

265. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Right Ventricular Failure (2 of 3)
 Right ventricle fails when it cannot keep up.
 Blood backs up behind right ventricle.
 Pressure rises in right atrium.
 Veins and organs become congested with blood.
 Edema occurs.
 Fluid builds up in the abdomen, pleural cavity, and/or pericardial cavity.
 Generalized edema may occur.

266. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Right Ventricular Failure (3 of 3)
 Cor pulmonale
 RVF may occur by itself (without LVF) in conditions such as:
 RVI
 Pulmonary embolism
 Pulmonary hypertension
 RVF caused by pulmonary disease
 Result of COPD

267. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Compensatory Mechanisms (1 of 4)
 Attempt to improve CO
 May worsen heart failure
 Sympathetic nervous system
 Boosts heart rate
 Increases force of contraction
 Constricts blood vessels

268. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Compensatory Mechanisms (2 of 4)
 Accelerated heart rate and stronger force of contraction
 Increase the heart’s oxygen demand
 Reduce ventricle filling time
 Decrease time for coronary artery perfusion

269. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Compensatory Mechanisms (3 of 4)
 Decreased blood flow to the kidneys stimulates the renin-angiotensin-
aldosterone system.
 Angiotensin I promotes vasoconstriction
 Heart works harder to pump against high pressure
 Aldosterone II encourages sodium and water retention and increased blood volume
 Increased preload

270. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Compensatory Mechanisms (4 of 4)
 Increase CO for a time, but eventually heart failure advances
 Sodium and water enlarge the heart chambers.
 Ventricle walls thicken, weakening the force of contraction.
 Force of contraction decreases.
 The heart is unable to handle the increased volume of fluid, and CO decreases.

271. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Heart Failure (1 of 8)
 Assessment
 Symptoms
 Sudden shortness of breath (even during rest)
 Trouble sleeping, concentrating
 Feeling tired or weak
 Nausea
 Loss of appetite
 Restlessness
 Jugular venous distension (JVD) if RVF accompanies LVF

272. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Heart Failure (2 of 8)
 Assessment (cont’d)
 Signs and symptoms present with heart failure may be present with other
conditions.

273. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Heart Failure (3 of 8)
 Management
 Offer reassurance.
 Place patient in a position of comfort.
 Sitting position with feet dangling
 Decrease work of breathing
 Apply pulse oximeter.
 Provide supplemental oxygen as needed.
 SpO2 between 95% and 98%
 Monitor respiratory status.

274. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Heart Failure (4 of 8)
 Management (cont’d)
 Limit patient’s physical activity.
 Place the patient on a cardiac monitor and obtain a 12-lead ECG.
 Establish IV access.
 Administer pharmacologic therapy according to local protocol.
 Transport the patient without lights and siren.

275. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Heart Failure (5 of 8)
 Management (cont’d)
 Surgically implanted ventricular assist devices (VADs) act as an artificial ventricle.

276. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Heart Failure (6 of 8)
 Management (cont’d)
 VADs consist of:
 Blood pump
 Tubing
 External power source
 Alarms
 VADs categorized according to:
 Type of blood flow
 Length of time used for circulatory support
 Source of driving power
 Device location

277. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Heart Failure (7 of 8)
 VAD types
 Transcutaneous VADS
 Implantable VADs
 LVADs (most common)
 RVADs
 Complications with VADs include:
 Device malfunction or failure
 Thromboembolism
 Bleeding
 Heart failure
 Infection
 Dysrhythmias
 Cardiac tamponade
 Aortic insufficiency
 Sepsis

278. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Heart Failure (8 of 8)
 Management (cont’d)
 In VAD pump malfunction:
 Assess for alarms
 Auscultate for “hum” from pump
 Assess for signs of hypoperfusion
 A VAD coordinator can assist in making treatment and transport destination
decisions.

279. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Cardiac Tamponade (1 of 2)
 Pathophysiology
 Occurs when the buildup of pericardial fluid compresses the heart
 Impairs contraction and restricts ventricular filling

280. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Cardiac Tamponade (2 of 2)
 Signs and symptoms include:
 Beck triad
 Cold, pale, mottled, cyanotic skin
 Tachycardia
 Weak or absent peripheral pulses
 Pulsus paradoxus
 ECG is of limited value
 May show electrical alternans

281. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Cardiac Shock (1 of 13)
 Severe impairment of heart muscle function
 Decreases CO and tissue perfusion
 Most common causes:
 LVF
 AMI

282. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Cardiac Shock (2 of 13)
 Pathophysiology
 Occurs if myocardial contractility has diminished
 May occur after prolonged surgery or cardiac arrest

283. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Cardiac Shock (3 of 13)
 Pathophysiology (cont’d)
 Risk factors
 Older age
 Anterior MI
 Diabetes
 Hypertension
 Multivessel CAD
 Previous MI
 Peripheral vascular or cerebrovascular disease

284. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Cardiac Shock (4 of 13)
 Assessment
 Warm and dry
 Warm and wet
 Cool and dry
 Cold and wet (most common)

285. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Cardiac Shock (5 of 13)
 Warm and dry
 Signs of heart failure
 No pulmonary congestion
 Tachycardia
 Warm and wet
 Vasodilation
 Pulmonary congestion
 Tachycardia and fever

286. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Cardiac Shock (6 of 13)
 Cool and dry
 Peripheral vasoconstriction
 No pulmonary congestion
 Tachycardia
 Narrowed pulse pressure
 Acute mental status change
 Dizziness

287. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Cardiac Shock (7 of 13)
 Cold and wet
 Cold skin
 Pulmonary crackles on auscultation
 Ashen or cyanotic with mottled extremities
 Altered mental status
 Dyspnea, orthopnea, JVD
 Peripheral edema
 Third and fourth heart sounds may be heard
 Decrease in SBP

288. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Cardiac Shock (8 of 13)
 Ask patient/family members about:
 History of heart disease
 Prescribed medications

289. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Cardiac Shock (9 of 13)
 Management
 Ensure adequate oxygenation and ventilation.
 Establish vascular access.
 Continuously monitor ECG.
 Transport for definitive care.

290. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Cardiac Shock (10 of 13)
 Management (cont’d)
 In hospital: strengthen contractility without increasing the heart rate, alter
preload/afterload, and control any dysrhythmias
 Position patient
 Supine position: hypotension
 Sitting position with feet dangling: pulmonary congestion

291. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Cardiac Shock (11 of 13)
 Management (cont’d)
 Obtain vital signs.
 Place the patient on a cardiac monitor.
 Obtain a 12-lead ECG within 10 minutes of contact.
 Administer IV fluids/medications.
 Consult medical direction.

292. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Cardiac Shock (12 of 13)
 Management (cont’d)
 Vasoactive IV medications to treat cardiogenic shock include:
 Dopamine
 Norepinephrine
 Epinephrine
 If instructed to give a vasoactive medication, check:
 IV site often
 Patient’s response

293. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Cardiac Shock (13 of 13)
 Management (cont’d)
 Refusal of care
 Urge patient to accept assistance
 Contact medical direction for advice
 Document refusal

294. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Hypertensive Emergencies (1 of 8)
 Acute elevation of blood pressure to 180/120 mm Hg or higher
 Evidence of end-organ damage
 Silent killer
 Hypertensive urgency
 BP of 180/120 mm Hg or higher without symptoms of end-organ damage

295. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Hypertensive Emergencies (2 of 8)
 Pathophysiology
 Most cases result from advances atherosclerosis or arteriosclerosis.
 Anxiety or pain can briefly elevate BP.

296. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Hypertensive Emergencies (3 of 8)
 Pathophysiology (cont’d)
 Persistent elevation of diastolic pressure is indicative of hypertensive disease,
which can:
 Significantly shorten life span
 Predispose to other medical conditions

297. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Hypertensive Emergencies (4 of 8)
 Assessment
 Neurologic signs and symptoms
 Cardiovascular signs and symptoms
 Additional signs and symptoms
 Decrease/absence of urine output
 Nausea/vomiting
 Ringing in the ears (tinnitus)
 Nosebleed
 Muscle cramps

298. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Hypertensive Emergencies (5 of 8)
 Assessment (cont’d)
 Peripheral pulses may feel strong or bounding.
 Check BP in both arms.
 Ask patient about medications:
 Prescribed and over-the-counter
 Recreational drug use

299. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Hypertensive Emergencies (6 of 8)
 Management
 Provide supportive care.
 Administer oxygen.
 Establish an IV line.
 Apply the cardiac monitor and pulse oximeter.
 Maintain the SpO2 at 94% or higher
 Do not delay transport.
 Reassure patient and family.

300. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Hypertensive Emergencies (7 of 8)
 Management (cont’d)
 If a long transport time is unavoidable, paramedics may need to initiate drug
therapy in the field.
 Labetalol: decreases overall peripheral vascular resistance and prevents reflex
tachycardia
 Keep patient supine.
 Check blood pressure every 2 to 3 minutes.
 Stop infusion when BP falls to target level.

301. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Hypertensive Emergencies (8 of 8)
 Management (cont’d)
 Refusal of care
 Urge patient to accept assistance
 Contact medical direction for advice
 Document refusal

302. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Infectious Diseases of the Heart (1 of 10)
 Endocarditis
 Infection of the inner lining of the heart
 Characterized by endocardium inflammation
 Occurs when bacteria in the bloodstream colonize a heart valve or other damaged heart
tissue

303. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Infectious Diseases of the Heart (2 of 10)
 Endocarditis (cont’d)
 Highest risks
 Patients with mitral or aortic valve disease
 Patients with prosthetic heart valves
 Congenital heart disease
 Right-sided endocarditis

304. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Infectious Diseases of the Heart (3 of 10)
 Endocarditis (cont’d)
 Assessment
 Symptoms
 Fever
 Chills
 Headache
 Loss of appetite
 Weight loss
 Muscle and joint aches and pains
 ECG changes may be seen, including a prolonged PRI, third-degree AV block, or
LBBB.
 Night sweats
 Shortness of
breath
 Cough
 Heart failure
 Janeway lesions
 Osler nodes

305. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Infectious Diseases of the Heart (4 of 10)
 Endocarditis (cont’d)
 Management
 Supportive prehospital care:
 Patient comfort
 Establish IV line
 Apply cardiac monitor
 Apply pulse oximeter and administer oxygen

306. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Infectious Diseases of the Heart (5 of 10)
 Endocarditis (cont’d)
 Treatment:
 Antibiotics
 Surgery in severe cases
 Refusal of care
 Urge patient to accept assistance
 Contact medical direction for advice
 Document refusal

307. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Infectious Diseases of the Heart (6 of 10)
 Pericarditis
 An inflammation of the pericardium
 Caused by viral (most common), bacterial, or fungal infection
 Assessment
 Recent flulike signs and symptoms
 Chest discomfort/pain
 Pain decreases when sitting up and forward
 Pericardial friction rub

308. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Infectious Diseases of the Heart (7 of 10)
 Pericarditis (cont’d)
 Management
 Supportive care
 Treatment: nonsteroidal anti-inflammatory drugs
 Refusal of care

309. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Infectious Diseases of the Heart (8 of 10)
 Myocarditis
 Inflammation of myocardium
 Usually benign and self-limiting
 Signs and symptoms:
 Flulike
 Chest discomfort
 Decreased appetite
 Palpitations
 Dysrhythmia
 Supportive prehospital care

310. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Infectious Diseases of the Heart (9 of 10)
 Rheumatic fever
 Inflammatory disease caused by streptococcal bacteria
 Causes aortic or mitral valve stenosis, leading to heart complications
 Supportive prehospital care

311. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Infectious Diseases of the Heart (10 of 10)
 Scarlet fever
 Caused by Streptococcus pyogenes
 Signs and symptoms:
 Sore throat
 Fever
 Rash
 “Strawberry tongue”
 Patients younger than 1 year are at greater risk
 Treated with antibiotics
 Supportive prehospital care

312. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Aortic Aneurysm (1 of 9)
 Dilation or outpouching of a blood vessel or wall of a heart chamber
 Dissection
 Tear in the vessel wall separates into layers
 Blood fills the space between layers, causing them to separate.

313. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Aortic Aneurysm (2 of 9)
 A false channel is formed between intimal and medial layers.
 If dissection goes back to aortic valve:
 It may not be able to close
 Blood will regurgitate into left ventricle during systole
 Compromised coronary blood flow

314. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Aortic Aneurysm (3 of 9)
 Dissection may begin anywhere along the aorta, but most begin:
 In the ascending aorta within 2 inches of the aortic valve
 In the descending aorta at the site of the ligamentum arteriosum
 Aneurysms of the ascending thoracic aorta are usually caused by cystic
medical degeneration.

315. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Aortic Aneurysm (4 of 9)
 Assessment
 Signs and symptoms depend on location
 Chief complaint: sudden chest pain

316. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Aortic Aneurysm (5 of 9)
 Assessment (cont’d)
 Ascending aorta dissection: pain that is substernal or located in the neck, throat,
jaw, or face
 Descending aortic dissection: flank pain, pain between the shoulder blades, in the
back, abdomen, or lower extremities
 May be difficult to distinguish between AMI and dissecting aneurysm

317. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Aortic Aneurysm (6 of 9)
 Assessment (cont’d)
 Symptoms
 Feeling of impending doom
 Pain, weakness, numbness in extremities
 Signs of myocardial ischemia
 Heart failure
 Altered mental status
 Stroke

318. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Aortic Aneurysm (7 of 9)
 Assessment (cont’d)
 Ascending aorta dissections (younger patients)
 More severe
 Pressure differences greater than 20 mm Hg between the arms
 Accompanied by acute neurologic changes

319. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Aortic Aneurysm (8 of 9)
 Assessment (cont’d)
 Descending aorta dissections (older patients with history of hypertension)
 Less severe
 Distal pulses hard to feel
 Rupture of aneurysm may occur

320. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Aortic Aneurysm (9 of 9)
 Management
 Contact medical direction immediately.
 Avoid procedures that may delay transport.
 Establish IV line.
 Apply cardiac monitor.
 Apply pulse oximeter and oxygen, if indicated.
 Give IV fluids per protocol.
 Administer opioids if the patient can.
 Reassess every 5 minutes.

321. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Acute Arterial Occlusion and Acute Limb Ischemia (1 of 11)
 Occlusion: sudden disruption of arterial blood flow that occurs because of:
 Thrombus
 Embolus
 Tumor
 Direct trauma

322. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Acute Arterial Occlusion and Acute Limb Ischemia (2 of 11)
 Thrombus
 When blockage affects an extremity, muscle contraction may stop blood flow.
 Collateral circulation develops.
 If extensive collateral circulation develops, the patient may notice no change or only
a mild increase in symptoms.

323. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Acute Arterial Occlusion and Acute Limb Ischemia (3 of 11)
 Embolus
 Most common
 Begins in the heart and travels to the extremities
 Mostly occur in patients with significant underlying heart disease

324. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Acute Arterial Occlusion and Acute Limb Ischemia (4 of 11)
 Direct trauma can be caused by:
 Extremity injury
 Diagnostic procedure such as cardiac catheterization
 Dissecting aneurysm
 Vasospasm (usually attributable to IV drug use)
 Blockage of a vascular graft

325. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Acute Arterial Occlusion and Acute Limb Ischemia (5 of 11)
 Acute limb ischemia
 Results when an arterial occlusion suddenly reduces blood flow to an arm or leg
 10% of patients experience intermittent claudication
 40% of patients present with atypical symptoms
 Leg tiredness or fatigue
 Remaining 50% of patients are asymptomatic

326. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Acute Arterial Occlusion and Acute Limb Ischemia (6 of 11)
 Assessment
 Gather accurate history.
 If symptoms began suddenly, the probable cause is embolus.
 If symptoms occurred gradually, the probable cause is thrombus.
 Determine if the patient has had a previous episode.

327. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Acute Arterial Occlusion and Acute Limb Ischemia (7 of 11)
 Assessment (cont’d)
 Remember the five Ps:
 Pain
 Pulselessness
 Pallor
 Paresthesia
 Paralysis

328. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Acute Arterial Occlusion and Acute Limb Ischemia (8 of 11)
 Assessment (cont’d)
 Discover any risk factors for blood clot development.
 Review skin color of affected limb.
 Assess movement and sensation in all extremities.
 Check heart rate and rhythm.
 Check blood pressure in both arms.
 Listen for a bruit.
 Watch for signs of chronic limb ischemia.

329. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Acute Arterial Occlusion and Acute Limb Ischemia (9 of 11)
 Management
 If limb ischemia affects a lower extremity, sit the patient up, with feet lower than
chest.
 Establish an IV line.
 Apply cardiac monitor.
 Apply the pulse oximeter and administer oxygen.

330. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Acute Arterial Occlusion and Acute Limb Ischemia (10 of 11)
 Management (cont’d)
 Give medications as instructed by medical direction.
 Keep the ambulance warm to avoid vasoconstriction of the skin.
 Transport rapidly.
 Reassess patient’s condition frequently.

331. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Acute Arterial Occlusion and Acute Limb Ischemia (11 of 11)
 Management (cont’d)
 Monitor the five Ps.
 Refusal of care
 Urge to accept assistance
 Contact medical direction for advice
 Document refusal

332. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Acute Deep Vein Thrombosis (1 of 7)
 Thrombophlebitis: the development of a blood clot in an inflamed or damaged
vein
 Superficial thrombophlebitis
 Deep vein thrombosis (DVT)

333. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Acute Deep Vein Thrombosis (2 of 7)
 Three important factors:
 Venous stasis (sluggish blood flow)
 Damage to the inner lining of a vessel
 Blood clotting disorders

334. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Acute Deep Vein Thrombosis (3 of 7)
 Assessment
 Patient may seek care because of swelling, pain, or tenderness in a limb.
 Discover any risk factors for DVT.

335. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Acute Deep Vein Thrombosis (4 of 7)
 Assessment (cont’d)
 Carefully assess the patient’s upper and lower extremities.
 Compare extremities in pairs
 Look for signs of inflammation of the skin over the affected vein.
 Look for pain on dorsiflexion of the foot (Homan sign).
 Do not rub or massage limbs.

336. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Acute Deep Vein Thrombosis (5 of 7)
 DVT diagnoses
 Arthritis
 Cellulitis
 Muscle or soft-tissue injury
 Superficial thrombophlebitis

337. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Acute Deep Vein Thrombosis (6 of 7)
 Management
 Supportive prehospital care
 Establish an IV line and apply cardiac monitor.
 Apply a pulse oximeter and administer oxygen.
 Monitor for pulmonary embolism.

338. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Acute Deep Vein Thrombosis (7 of 7)
 Management (cont’d)
 Transport without lights or siren.
 Refusal of care
 Urge to accept assistance
 Contact medical direction for advice
 Document refusal