2/12/2011 Statistics Cardiovascular Emergencies time is myocardium! Cardiovascular disease (CVD) claimed over 1 million lives in CVD has been th

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Marianna Oliver
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CVD has been the leading cause of death for Americans since 1900.

The majority of our 911 responses are for chest pain.

cholesterol levels Elevated blood glucose levels Diet Lack of

1 Statistics Cardiovascular Emergencies time is myocardium! Cardiovascular disease (CVD) claimed over 1 million lives in CVD has been the leading cause of death for Americans since Sudden cardiac death accounts for over 40% of these deaths. The majority of our 911 responses are for chest pain. Controllable Risk Factors Smoking High blood pressure Elevated cholesterol levels Elevated blood glucose levels Diet Lack of exercise Stress Uncontrollable Risk Factors Age Family history Race Sex Anatomy Circulation 1

Blood Red blood cells: Carries oxygen to tissues and cells Removes CO2 and waste White blood cells:

pain results from ischemia. Ischemic heart disease involves decreased blood flow to the heart.

Injury leads to inadequate heart function and death.

2 Blood Red blood cells: Carries oxygen to tissues and cells Removes CO2 and waste White blood cells: Fight infection Platelets: Helps blood clot Electrical System Coronary Arteries Cardiac Compromise Chest pain results from ischemia. Ischemic heart disease involves decreased blood flow to the heart. If blood flow is not restored, the tissue dies (infarct). Injury leads to inadequate heart function and death. Atherosclerosis So you are dispatched to a 67 year- old male c/o 9/10 crushing chest pressure that radiates to his jaw. He is also complaining i of shortness of breath and nausea, with no previous cardiac history 2

3 Chest Pain Pathophysiology what are YOU thinking? Mediastinum: Angina: stable or unstable AMI Esophagitis, esophageal rupture Pericarditis Mediastinal air Thoracic dissection Mitral valve prolapse Chest Pain Pathophysiology Chest Wall: Traumatic contusion/tamponadetamponade Cysts and infections Rib cartilage inflammation Shingles (Herpes Zoster) Muscle strain, overuse syndromes Chest Pain Pathophysiology Lungs and pleura: Pleurisy Pneumonia Pneumothorax, hemothorax Pulmonary embolus Asthma, bronchitis, URI Chest Pain Pathophysiology Abdomen: Gallbladder (cholecystitis, stones) Stomach (gastritis, GERD, perforated peptic ulcer) Pancreas (pancreatitis) Esophagitis, perforation Chest Pain Psychogenic: Stress Hyperventilation Anxiety and panic attacks 3

Classic Symptoms Pressure, fullness, heaviness, squeezing pain in center of chest with radiation Diaphoresis Nausea Shortness of breath Weakness Frequency of Symptoms Diaphoresis 78% Chest pain 64%

shortness of breath Nausea, dizziness Belching, burping, indigestion Palpitations, new dysrhythmia Pain only in jaw, neck, back, arm All chest pain is considered to be an AMI until proven otherwise!

4 Classic Symptoms Pressure, fullness, heaviness, squeezing pain in center of chest with radiation Diaphoresis Nausea Shortness of breath Weakness Frequency of Symptoms Diaphoresis 78% Chest pain 64% Nausea 52% Shortness of breath 47% No signs/symptoms 25% N Engl J Med 1984;311: Atypical Presentations Common in the elderly, diabetics, and females: Unusual fatigue Sudden onset of unusual shortness of breath Nausea, dizziness Belching, burping, indigestion Palpitations, new dysrhythmia Pain only in jaw, neck, back, arm All chest pain is considered to be an AMI until proven otherwise! Angina Pectoris Angina Chest pain caused when heart tissues do not get enough oxygen for a brief period of time. Typically crushing or squeezing. Onset with the 3-E s. Usually resolves with rest or meds. May be difficult to diagnose from AMI 4

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

Dysrhythmias Acute Myocardial Infarct Usually caused by the same mechanism as angina only with resulting tissue death.

5 Acute Coronary Syndrome Used to describe the range of conditions from unstable angina to AMI. Signs and symptoms usually caused by acute myocardial ischemia. ACS Signs & Symptoms Shortness of breath Signs of inadequate perfusion Chest pain, pressure, or discomfort (with or without radiation to back, neck, jaw, arm, wrists) Nausea Weakness/syncope Dysrhythmias Acute Myocardial Infarct Usually caused by the same mechanism as angina only with resulting tissue death. AMI Time is myocardium: Consequences can be serious: Congestive heart failure Cardiogenic shock Sudden death Cardiogenic Shock Heart lacks power to force blood through the circulatory system. Brought on when 40% of left ventricle is infarcted. Onset may be immediate or not apparent for 24 hours. Signs & Symptoms Altered LOC Rapid, shallow breathing Restlessness and anxiousness Pale, cool skin Tachycardia/dysrhythmia Hypotension 5

6 Congestive Heart Failure Occurs when the ventricles are damaged. CHF Heart tries to compensate with increased heart rate. Enlarged, ineffective left ventricle Fluid builds up into lungs or body as pump fails. Signs & Symptoms Fatigue Cough with pink, frothy sputum Dypsnea, tachypnea Pulmonary edema Agitation and confusion Hypertension Pedal edema, ascities Signs & Symptoms Thoracic Dissection Aortic Aneurysm 6

Signs & Symptoms Sudden and severe chest or upper back discomfort. Pain shoots to the shoulder blades.

Signs of shock JVD Decrease pulse pressures Esophageal Rupture Usually underlying alcohol abuse. Shock signs.

Usually yp presents as sharp discomfort. Changes with breathing and movement.

Exam Assessment Treatment and Plan Initial Assessment 60second clinical picture to determine if Sick or Not

7 Signs & Symptoms Sudden and severe chest or upper back discomfort. Pain shoots to the shoulder blades. Anxiety Diaphoresis Nausea Cardiac Tamponade Trauma induced, filling of the pericardial sac with blood. Signs of shock JVD Decrease pulse pressures Esophageal Rupture Usually underlying alcohol abuse. Shock signs. Coughing up bright red blood. Inflammation of the pericardium caused by infection. Usually yp presents as sharp discomfort. Changes with breathing and movement. Pericarditis Chest Pain Assessment BSI/Scene Safety Initial Assessment (Sick/Not Sick) Focused Exam Detailed Exam Assessment Treatment and Plan Initial Assessment 60second clinical picture to determine if Sick or Not Sick (Oxygen) Based upon your initial impression: Body position skin signs and color respiratory rate and effort mental status pulse rate and character Correct immediate life threats! 7

Your subjective findings are based upon what the patient or historian tells you: Patient Age Sex Chief Complaint SAMPLE History Signs/ igns/symptoms (associated with cardiac chest pain): Diaphoresis

8 Your subjective findings are based upon what the patient or historian tells you: Patient Age Sex Chief Complaint SAMPLE History Signs/ igns/symptoms (associated with cardiac chest pain): Diaphoresis (78%) Shortness of Breath (47%) Pain/discomfort (64%) Nausea/vomiting (52%) No signs or symptoms (25%) N Eng Journal Med 1984;311: Onset When and at what time did it start Provocation Does anything make it better or worse? Does it change with position, palpitation, inspiration? Quality Describe the pain/discomfort in your own words Region/ egion/radiation Where does it start? Does it radiate anywhere? Severity On a scale of 1 to 10, what was the pain/discomfort at onset? What is the pain/discomfort at now? Time When did this episode start? How long has it been going on? Allergies Medications Cardiac meds = cardiac problems. Ask about OTC meds, natural supplements, vitamins? Past Medical History Do you have any cardiac history? Risk factors such as smoking, diabetes, HTN, weight/diet? Last Oral Intake Events Leading to Call What were you doing when this event started? Think activity induce vs. non activity 8

9 Focused Exam (O) Listen to the patient they will tell you exactly what is wrong! Objective findings from your physical exam of the patient. Look for evidence of trauma/injury Evaluate: Level of consciousness Skin color and temperature Respiratory rate and effort Pupillary reaction Pulse rate Blood pressure (bilateral for chest pain!) Focused Exam (O) Listen to breath sounds Palpate chest Palpate abdomen Check pedal pulses BGL if diabetic with DLOC SpO2 after BP, confirm with pulses, RA & after administration of O2 Rhythm strip? Focused Exam (O) Based upon your clinical findings Observe the patient while they are talking with you, note any distress/discomfort (Levine sign) Watch for acute clinical signs: jugular vein distension, tracheal deviation, paradoxial chest movement. Detailed Exam (O) Complete and thorough neck, head to toe examination with non-critical patients if needed or time permits. Elicit further information and necessary interventions. Key in on critical findings! Assessment (A) This is your best guess (or rule out) as to what is going on with the patient. It is based upon YOUR Subjective and Objective findings and should help you develop and implement your Plan for patient care. 9

10 Plan (P) Medics? ABC s/monitor vitals Patient in position of comfort. Oxygen via? Assist with medications. Maintain body temperature. Calm and reassure. Minimize patient movement. Rapid transport! Other Stuff Coronary artery bypass graft (CABG) and other open heart surgeries Percutaneous transluminal coronary angioplasty (PTCA) Automatic implantable cardiac defibrillators (ACID) Pacemakers 10

Chapter 14 Cardiovascular Emergencies Cardiovascular Emergencies Cardiovascular disease has been leading killer of Americans since.

1 2 3 4 5 Chapter 14 Cardiovascular Emergencies Cardiovascular Emergencies Cardiovascular disease has been leading killer of Americans since. Accounts for 1 of every 2.8 deaths Cardiovascular disease (CVD)