Cardiovascular Emergencies

• Heart Disease


  • Cardiovascular disease is the number one cause of death in the U.S. for patients over 45, and many times the first indication of this disease is an acute coronary event

  
• Circulatory system components


  • The heart
  • The blood vessels
  • The blood volume
• The 4 Chambers of the Heart


  • Right Atrium
  • Right Ventricle
  • Left Atrium
  • Left Ventricle
• Heart's job


  To pump blood to supply oxygen-enriched red blood cells to tissues

  
• The Coronary Arteries
• Capillary Oxygen Exchange
• Blood


  • Volume within vascular system
  • Transport medium for the formed elements (RBC, WBC, platelets, electrolytes, glucose, protein, etc.)
  • Adult 6 liters or 12 pints
  • Teen 4.5 to 5.5 liters
  • Child 1.5 to 2 liters
  • Infant 300 ml
• Cardiac Conduction System


  In order for there to be organized & sequential contraction, there must first be organized & sequential electrical impulse that travels through the heart
• Pulse locations


  • Left Ventricle
  • Peripheral (Radial, Brachial, Posterior Tibial, Dorsalis Pedis)
  • Central (Carotid, Femoral)
• Blood Pressure


  • Systolic: The pressure exerted against the wall of the arteries when the heart contracts (left ventricle)
  • Diastolic: The pressure exerted against the walls of the arteries when the heart is at rest (left ventricle)
• Shock (Hypoperfusion)


  • Inadequate circulation - Cardiac compromise, as well as other medical or traumatic ailments can cause cardiovascular system to fail
  • Inadequate tissue perfusion
  • SHOCK IS INADEQUATE TISSUE PERFUSION
  • HYPOPERFUSION IS SHOCK
  • A state of profound depression of the vital processes of the body
• Signs and Symptoms of Early Shock


  • Restlessness
  • Anxiety or mental dullness
  • Pale, cyanotic, cool, clammy skin
  • Rapid weak pulse
  • Rapid and shallow breathing
  • Nausea and vomiting
• Reasons for Inadequate Circulation


  • Pump failure (Cardiogenic Shock)
  • Vascular changes (Distributive Shock)
  • Blood volume (Hypovolemic Shock)
• Acute Coronary Syndrome (ACS)


  • Coronary artery disease (CAD) is the diagnosis applied when the arteries become diseased and damaged by plaque
  • Two common vascular conditions that affect the heart are atherosclerosis and arteriosclerosis
  • Controllable Risk factors: smoking, diet, obesity, sedentary lifestyle, diabetes, hypertension
  • Uncontrollable risk factors: age, race, gender, heredity, type A personality

  
• Emergencies that can result from damage to the coronary arteries


  • Angina pectoris
  • Unstable angina
  • Myocardial infarction (MI)

  
• Pathophysiology of Angina Pectoris


  • Occurs when the heart's need for oxygen exceeds supply
  • Crushing or squeezing pain
  • Does not usually lead to death or permanent heart damage
  • Should be taken as a serious warning sign

  
• Pathophysiology of Unstable Angina


  In response to fewer stimuli than normal

  
• Pathophysiology of Stable Angina


  • Is relieved by rest or nitroglycerin
  • Treat angina patients like AMI patients

  
• Pathophysiology of AMI


  • Once dead, cells cannot be revived
  • "Clot-busting" (thrombolytic) drugs or angioplasty within 1 hour prevent damage
  • Immediate transport is essential
• Signs and Symptoms of AMI


  • Weakness, nausea, sweating
  • Chest pain that does not change
  • Lower jaw, arm, back, abdomen, neck pain
  • Irregular heartbeat and syncope (fainting)
  • Shortness of breath (dyspnea)
  • Pink, frothy sputum
  • Sudden death

  
• AMI pain vs Angina pain


  • Not always due to exertion
  • Lasts 30 minutes to several hours
  • Not always relieved by rest or nitroglycerin

  
• Pain Locations


  • Chest
  • Arm
  • Back
  • Abdomen
  • Neck
• Cardiac Syndrome Care


  1. Initiate Patient Assessment Plan

  2. ABC's & follow NYS protocol

  3. Make transport decision

  4. If authorized acquire 12 lead ECG

  5. If the patient is stable: Gather the SAMPLE and OPQRST history, Perform a focused physical exam, Assess baseline vitals

  6. If the patient is unstable: Perform a rapid physical exam, Gather above info in route to hospital
• OPQRST History


  • Onset—What were you doing when the pain started?
  • Provocation or palliation—Do you know of anything that makes the chest pain better or worse?
  • Quality—Describe the chest discomfort, what is it like?
  • Radiation—Does the discomfort radiate anywhere?
  • Severity—How intense is the pain on a 1–10 scale?
  • Time—When did the discomfort first start, and is it constant?
  • Interventions-What did you do for yourself before I arrived?

  
• Women and Heart Disease


  • The findings consistent with ACS may not present the same in females, as males
  • "Classical," but not necessarily common findings
  • "Non-classical - atypical", but not necessarily uncommon findings

  
• Signs and Symptoms in Females


  • Pressure in the chest
  • Pains in the back or breast
  • Tingling of the fingers
  • Unexplained fatigue or weight gain (water weight gain)
  • Insomnia
• Cardiac Syndrome Care


  1. Administer oxygen

  2. Titrate O2 to 92% via nasal cannula or NRB, or by PPV if the breathing is found to be inadequate

  3. Administer Aspirin
• Aspirin Administration Indications


  • Acute Cardiac Syndrome
  • Anginal chest pain
  • Ischemic chest pain

  
• Aspirin Pharmacokinetics


  • Blocks pain in CNS
  • Fever Reducer
  • Decreases platelet aggregation
  • Atheromatous patches inside vessels allow platelets to aggregate
  • Aspirin decreases the "stickiness" of platelets which constricts arteries
• Aspirin Dosage for ACS


  • 324mg PO (chewed)
  • (4) 81mg Baby aspirin
  • Avoid coated, enteric or time release preparations
• Aspirin Contraindications


  • Trauma
  • Aspirin Allergy
  • Upper GI bleeding
  • Active ulcer disease
  • Hemorrhagic stroke/aneurism
  • Bleeding disorders
  • Children with flu-like symptoms
• Aspirin Side Effects


  • ALLERGIC REACTION (Erythema/redness, Urticaria/hives, Airway swelling, Hypotension, tachypnea, tachycardia, Bronchospasm/wheezing)
  • Stomach irritation (Heart burn or indigestion, Nausea and vomiting)
  • Salicylism (Aspirin OD)
• Emergency Medical Care


  1. Constantly provide reassurance to decrease the patient's anxiety

  2. Assist the patient who has prescribed nitroglycerin with the medication

  3. Consider calling ALS backup, and initiate early transport

  4. DO NOT APPLY the AED, but be sure the equipment is available should the patient arrest
• Nitroglycerin


  • Nitroglycerin is a potent vasodilator
  • May come as a tablet or spray that is administered under the tongue
  • Usual dose is one spray (or tablet) under the tongue, which is commonly 0.4mg per dose
  • Can be repeated every 3-5 minutes, up to a total of 3 doses
  • Do not administer it if the systolic pressure is less than 120 mmHg
  • If a dose drops the blood pressure to (or below) 120 mmHg systolic, do not administer any more doses
• Nitroglycerin


  • Nitroglycerin (Generic name)
  • Common Brands: Nitrobid and Nitrostat
  • Other Forms: Transdermal patch, SL spray, Paste
• Nitroglycerin Actions


  • Dilates blood vessels
  • Decreases the workload of the heart
• Nitroglycerin Contraindications


  • Systolic blood pressure less than 120 mm/Hg
  • Head injury
  • Pediatric emergencies
  • Already taken maximum prescribed dose
• Nitroglycerin Dosage


  • 1 tablet or spray, under tongue
  • REPEAT Every 5 minutes IF No relief in pain and Blood pressure remains above 120 mg/Hg Systolic
  • Maximum 3 doses
  • EMT's only ASSIST. You DO NOT ADMINISTER
• Nitroglycerin Side Effects


  • Hypotension
  • Headache
  • Pulse rate changes
  • Tingling sensation under tongue
• Nitroglycerin Reassessment Strategies


  1. Monitor Blood Pressure

  2. Ask the patient the effect of pain relief

  3. Seek Medical direction before re-administering

  4. Record Reassessments