1 2 3 4 5 6 Chapter 16 Cardiovascular Emergencies Cardiovascular Emergencies Cardiovascular disease has been leading killer of Americans since 1900. Accounts for of every 3 deaths Cardiovascular disease (CVD) claimed 931,108 lives in the US during 2001. 2,551 per day Almost two people per minute! Prevention EMS can help reduce deaths by: Encouraging healthy life-style Early access to medical care More training of laypeople Public access to defibrillation devices Recognizing need for advanced life support (ALS) Use of cardiac centers when they are available Physiology of the Circulatory System (1 of 2) Pulse: The wave of blood through the arteries formed when the ventricle contracts Can be felt where an artery passes near the skin surface and over a bone Physiology of the Circulatory System (2 of 2) Blood pressure: Amount of force exerted against walls of arteries Systole: Left ventricle Diastole: Left ventricle relaxes Perfusion: of blood within an organ or tissue If inadequate, the patient goes into shock Pulse Points 1
7 8 9 10 11 Components 1. Heart (pump) 2. Vessels (pipes) 3. Blood (fluid) The Heart Muscular organ Myocardium--the heart Lies directly behind the sternum Has 4 chambers -Left and right (upper chambers) -Left and right ventricles (lower chambers) Septum--divides left and right sides The Heart Has it s own supply Has it s own electrical system The heart is divided into 2 types of circulation: 1. Circulation 2. Systemic Circulation Pulmonary Circulation Circulation to and from lungs Right side of heart blood enters the right atrium from the superior vena cava Enters the right ventricle through a valve Pumped through pulmonary arteries to lungs Receives oxygen from alveoli and leaves waste products and carbon dioxide Systemic Circulation Circulation to and from body side of heart blood enters left atria through pulmonary vein 2
12 13 14 15 16 17 18 19 20 1 2 blood enters left atria through pulmonary vein Enters left ventricle through a valve Pumped to aorta and the body Delivers oxygen to cells and removes waste Cardiovascular Structure and Function Blood Flow Through the Heart 1. Vena Cava 2. Right 3. Tricuspid valve 4. Right Ventricle 5. Pulmonic Valve 6. Pulmonary 7. Lungs 8. Pulmonary Vein 9. Left Atrium 10. Mitral Valve 11. Left Ventricle 12. Aortic Valve 13. Aorta 14. Body Blood Flow Through the Heart Blood Flow Through the Heart Electrical System of the Heart The Heart The Heart Coronary Arteries Blood Vessels Arteries--Carries blood from the heart (usually oxygenated) Arteries branch into arterioles and then into capillaries Veins--Carries blood the heart (usually unoxygenated) 3
21 22 23 24 25 Veins--Carries blood the heart (usually unoxygenated) Veins branch into venules and then into capillaries Blood Vessels Capillaries--Very thin vessels where the actual gas exchanges occurs -Oxygen and nutrients delivered to cells -Carbon dioxide and picked up Forms capillary beds Blood Components Plasma -Sticky yellowish -Carries cells and nutrients -The fluid cells float in Erythrocytes (red blood cells) -Contain iron -Gives blood it s color -Carries Blood Components Leukocytes (white blood cells) -Fights infection Platelets -Clot formation -Usually clots in 4 to 6 minutes Pulses A pulse is felt when blood passes through an artery during. Peripheral pulses felt in the extremities Central pulses felt near the body s trunk Blood Pressure Blood pressure is the force of circulating blood against artery walls. Systolic blood pressure The maximum pressure generated by ventricle Diastolic blood pressure 4
26 27 28 29 30 ventricle Diastolic blood pressure The pressure against artery walls while the left ventricle is at rest Cardiac Perfusion Cardiac output is the volume of blood that passes through the t in 1 minute. Heart rate volume of blood ejected with each contraction (stroke volume) Perfusion is the constant flow of oxygenated blood to tissues Requirements of good perfusion If perfusion fails, cellular, and eventually patient, death occur. Cardiac Compromise Chest pain results from, which is decreased blood flow Ischemic heart disease involves decreased blood flow to the heart. If blood flow is not restored, the tissue. Coronary Artery Disease (CAD) Atherosclerosis Arteriosclerosis Atherosclerosis Calcium and build up inside blood vessels. This decreases or obstructs blood flow. Risk factors place a person at risk. Fatty material accumulates with Arteriosclerosis Coronary artery wall becomes and stiff due to calcium deposits Hardening of the Arteries Causes coronary arteries to loose their nature Decreases blood flow Causes hypertension 5
31 32 33 34 35 36 37 1 2 Causes hypertension Major Risk Factors of Coronary Artery Disease Uncontrollable Age Sex Heredity Controllable High Blood Pressure High Cholesterol Diabetes Minor Risk Factors of Coronary Artery Disease Obesity Inactivity Stress Personality Coronary Artery Disease Coronary Artery Disease Acute Coronary Syndrome Angina Pectoris Pain in chest that occurs when the heart does not receive enough Typically crushing or squeezing pain Rarely lasts longer than 10-15 minutes Can be to differentiate from heart attack Should be taken as a serious warning sign Angina Pectoris Signs/Symptoms 1. Squeezing/crushing chest pain 2. Pain may radiate to, arms, neck, jaw, upper back, or upper abdomen 3. Pain may be in area of radiation only 6
upper back, or upper abdomen 3. Pain may be in area of radiation only 4. Possible shortness of breath (SOB) 38 39 40 41 42 Angina Pectoris 5. Pain associated with the 3 E s -Exercise - -Emotion 6. Pain seldom lasts for more than 10-15 minutes 7. Pain normally relieved by: -Rest - Angina Pectoris Following an angina attack, there is residual damage to the myocardium Angina Pectoris Two Forms of Angina 1. Stable Angina -Pain in duration and frequency -Pain relieved by predictable amounts of rest and nitroglycerin 2. Unstable Angina -Change occurs in patterns -30% go on to infarct within 3 months Treatment of Angina Pectoris Treat all first time angina and unstable angina as a myocardial. When in doubt, manage all chest pain as a myocardial infarction Acute Myocardial Infarction Acute Myocardial Infarction (AMI)--Heart Attack Death of the due to inability of diseased coronary arteries to allow adequate perfusion 7
43 Death of the due to inability of diseased coronary arteries to allow adequate perfusion Once myocardium tissue dies, it will not regenerate Myocardial Infarction Incidence MI is the cause of death in the US 1 to 1.5 million Americans will have a MI this year. Of these, about 600,000 will die. 350,000 will die in the first hours after symptoms begin, without ever reaching the hospital!! 44 45 46 47 Acute Myocardial Infarction (AMI) Pain signals death of cells. Clot-busting drugs or within the first few hours can prevent damage. Immediate transport is essential. Pain of AMI Chest Pain is cardinal sign of an AMI Occurs in of AMIs May or may not be caused by exertion Does not resolve in a few minutes Can last from 30 minutes to several hours May not be relieved by rest or Pain of AMI May be crushing, squeezing, tight, heavy May radiate to neck, jaw, shoulders, arm, upper back, or even abdomen May occur in areas of only May vary in intensity, unaffected by swallowing, coughing, deep breathing, or movement 15% have Signs/Symptoms of AMI Chest pain Shortness of breath (SOB) Weakness, dizziness, fainting 8
48 49 50 51 52 53 Shortness of breath (SOB) Weakness, dizziness, fainting Nausea, Pallor, diaphoresis (sweating) Feeling of doom Pulmonary edema Signs/Symptoms of AMI Changes is pulse, BP, or respirations are not of an AMI Early recognition is critical 50% of deaths occur in first 2 hours, but the average person waits hours before seeking help Serious Consequences of AMI Sudden Death Cardiogenic Congestive heart failure Sudden Death 40% of AMI patients do not reach the hospital. Death is due to (irregular heart rhythm) Heart may be twitching. Arrhythmias (1 of 2) Arrhythmias (2 of 2) Treatment of Cardiac Chest Pain (1 of 3) 1. Reassure patient 2. High concentration of 2. Give 3. Reassure/calm patient 4. Obtain brief history and perform physical exam 5. Give 54 Treatment of Cardiac Chest Pain (2 of 3) 6. If patient has history of angina with changes in pattern, transport 9
55 56 57 58 6. If patient has history of angina with changes in pattern, transport immediately. 7. Transport in semi-sitting position if BP is normal if BP is low. 8. Do NOT allow patient to walk to ambulance. 9. Don t use lights and sirens if patient is awake, alert, and breathing without distress. Treatment of Cardiac Chest Pain (3 of 3) 10. Monitor vital signs every 10 minutes 11. Request ALS Backup - of deaths occur from arrhythmias. -Arrhythmias can be treated with early drug therapy. 12. ALWAYS examine for edema and listen to lung sounds Cardiogenic Shock Heart lacks to force blood through the circulatory system. Onset may be immediate or not apparent for 24 hours after AMI. Inadequate to body tissues causes organs to malfunction Low BP Arrhythmias: Irregular heart beats Congestive Heart Failure Congestive Heart Failure (CHF)--Inability of the heart to blood out as fast as it enters. Can be left-sided or right-sided Usually begins with left-sided failure. Congestive Heart Failure Causes of CHF Coronary Artery Disease (CAD) Chronic hypertension Valvular heart disease 10
Valvular heart disease 59 60 61 62 63 Congestive Heart Failure Pathophysiology Left fails Blood backs up into lungs Pressure increases in capillary beds Fluids forced out of beds into the alveoli causing pulmonary edema; fluid in the lungs Congestive Heart Failure Signs/Symptoms Dyspnea on exertion nocturnal dyspnea Orthopnea-dyspnea lying down Tachycardia-rapid pulse rate (>100 bpm) Congestive Heart Failure Signs/Symptoms (Cont.) Tachypnea- breathing Noisy, labored breathing Rales, wheezing Pink, frothy Congestive Heart Failure Right sided failure most commonly caused by sided failure. Blood backs up into systemic circulation -distended neck veins -fluid in abdominal cavity -pedal edema-fluid in feet and ankles Congestive Heart Failure Treatment Sit patient up with feet down High concentration of oxygen Assist as needed Monitor vital signs every 5 to 10 minutes 11
64 65 66 67 Assist as needed Monitor vital signs every 5 to 10 minutes Request ALS backup Hypertensive Emergencies (1 of 2) Systolic pressure greater than mm Hg Common symptoms include altered mental status and pulmonary edema. If untreated, can lead to stroke or dissecting aortic aneurysm. Common symptoms Sudden, severe Strong, bounding pulse Ringing in the ears Hypertensive Emergencies (2 of 2) Common symptoms Nausea and vomiting Warm skin (dry or moist) Nosebleed Normally, there is no pre-hospital care for hypertension at the EMT-B level Rapid transport, contact Paramedic backup Aortic Aneurysm Aortic aneurysm is weakness in the of the aorta. Susceptible to rupture aneurysm occurs when inner layers of aorta become separated Primary cause: uncontrolled hypertension S/S of Aortic Aneurysm Very sudden chest pain Comes on full force blood pressures between extremities May complain of flank pain 12
68 69 70 71 72 73 74 blood pressures between extremities May complain of flank pain Transport patients quickly and safely. AMI vs Aortic Aneurysm Physical Findings of Cardiac Compromise Pulse rate and may be irregular. Blood pressure may be normal or falling. Respirations are usually normal. General appearance Frightened Nausea, vomiting, sweat Approach to the Patient with Chest Pain (1 of 2) Reassure the patient and perform initial assessment. Administer Measure and record vital signs. Place the patient in a position of comfort. Approach to the Patient with Chest Pain (2 of 2) Obtain history and physical exam. Ask about the chest pain Assist with administration of prescribed. Transport promptly. Report to medical control en route. Heart Surgeries Coronary artery graft (CABG) Angioplasty Cardiac pacemaker Internal Cardiac Pacemakers Maintains a regular heart and rate Do not place AED patches over pacemaker. Implanted under a heavy muscle or fold of skin in the upper left portion of the chest Automatic Implantable Cardiac Defibrillators Monitor heart rhythm and deliver as 13
75 76 77 78 79 Monitor heart rhythm and deliver as needed. Low electricity will not affect rescuers. External Defibrillator Vest A vest with built-in monitoring electrodes and defibrillation pads worn by the patient. Attached to a monitor Uses high-energy shocks Do not the patient if devices warns it is about to deliver a shock. Vest should remain in place while CPR is being performed unless it interferes with LVADs Left assist devices (LVADs) Used to enhance the pumping of the left ventricle. May be pulsatile or continuous The patient or family can tell you more about the device. Cardiac Arrest The complete of cardiac activity Absence of a carotid pulse Was terminal before CPR and external defibrillation were developed in the 1960s Automated External Defibrillation Analyzes signals from heart Identifies ventricular fibrillation Administers shock to heart when needed Management of Return of Spontaneous Circulation (ROSC) Monitor for respirations. Provide oxygen via BVM at to breaths/min. Maintain oxygen saturation between 95% and 99%. Assess blood pressure. 14
Maintain oxygen saturation between 95% and 99%. Assess blood pressure. See if patient can follow simple commands. Immediately begin transport if ALS is not en route per local protocol. 15