ECG Webinar Series

Interactive CPD Series

Pathophysiology Part 2Presented by:

Mr Innes EatonParamedic Practitioner

24th May 2021

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Interactive CPD Series | Episode 5 | Pathophysiology Part 2

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Welcome to the Series!



• CPD Requirements• Anatomy & Physiology• Common Pathophysiology• Maternity Care• Patient Assessment• Paediatric Assessment• Sepsis• Oxygen & Entonox Guidelines• ECG Basics• Intermediate Life Support

Tonight’s Session



• Angina

• Acute Coronary Syndromes

• Heart Failure

• Q&A Session

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Interactive Quiz




Interactive Quiz



Cardiac Physiology

Right coronary artery

Left coronary artery

Left circumflex artery

Left anterior descending(or interventricular) artery

Diagonal branch

Right marginal artery

Left (or obtuse) marginal artery





Cardiac Physiology



Interactive Quiz




Interactive Quiz


Heart Disease

Angina



• Angina is insufficient blood flow to the heart muscle

• Caused by the progressive narrowing

• Referred to as ‘Ischaemia’

• Stable vs Unstable

• Stable = predictable

• Unstable = unpredictable


Recognition FeaturesPrimary Survey Expected Findings

Response Normal

Airway Normal

Breathing May have slight dyspnoea

Circulation Central chest pain – ask about onsetHR may be normal or bradycardic Blood pressure may be normal or lowCyanosis is possibleSweating++ECG may be normal or ST

Disability GCS may reduce if BP is very lowBM may increasePERRLA

Expose/Examine/Environment Normal temperatureNausea & vomiting common


THINK ONSET & RECOVERY!

Predicable onset with rapid & full

recovery suggests:

Stable Angina



Treatment



1. Calm and reassure2. Move to a quiet environment if possible3. Ask about the onset of the chest pain

• Following exertion/stress suggests stable• At random suggests unstable

4. Full set of observations including BP and ECG if able5. Aspirin 300mg tablet to chew (unless contraindicated)6. Entonox PRN for pain relief7. GTN 400mcg sub-lingual if BP stable

• Repeat every 5-10 minutes unless systolic drops <90mmHg• Anyone may assist the patient to take their own prescribed GTN

8. Monitor closely for deterioration – look for ECG changes9. Consider monitoring with the defib pads if unstable angina suspected10. Senior clinical support and/or transport to nearest A&E

Case Study



• Winston is 69 and overweight• He was walking up a steep hill in the park and now has central chest pain• When you arrive he is sitting on a bench looking pale, clammy and in obvious discomfort

• D: Safe to approach• R: Responds normally• A: No concerns• B: Slight dyspnoea, RR 24, SpO2 95%, ETCO2 not available• C: HR 90, BP 110/60, ECG does not show ST-elevation• D: GCS 15/15, BM 8.2, PERRLA 3+• E: Temp 36.7°C

• Winston has no cardiac history so has not been prescribed GTN• Since you have arrived, Winton’s symptoms have started to settle

Interactive Quiz




http://www.menti.com/



Acute Coronary Syndromes



• 3 conditions characterised by acute blockage of a coronary artery:

• Unstable angina• Non-ST-elevation myocardial infarction (NSTEMI)• ST-elevation myocardial infarction (STEMI)

• Angina is ischaemia, Infarct is death• The only difference between NSTEMI vs STEMI is whether

or not there is ST-Elevation present on the ECG• A normal ECG does NOT therefore rule out ACS• The only way to tell between unstable angina vs NSTEMI

is with a blood test

• One condition may lead to the next – repeat the ECG!



Response Normal

Airway Normal

Breathing May have slight dyspnoea

Circulation Central chest pain – ask about onsetHR may be normal or bradycardic Blood pressure may be normal or lowCyanosis is possibleSweating++ECG may be normal or ST or ST

Disability GCS may reduce if BP is very lowBM may increasePERRLA

Expose/Examine/Environment Normal temperatureNausea & vomiting common


THINK ONSET & RECOVERY!

Unpredictable onset without

recovery suggests:

ACS



Treatment



1. Calm and reassure2. Move to a quiet environment if possible3. Ask about the onset of the chest pain

• Following exertion/stress suggests stable• At random suggests unstable

4. Full set of observations including BP and ECG if able5. Aspirin 300mg tablet to chew6. Entonox PRN for pain relief7. GTN 400mcg sub-lingual if BP stable

• Repeat every 5-10 minutes until systolic drops <90mmHg• Anyone may assist the patient to take their own prescribed GTN

8. Clopidogrel 300-600mg orally, according to local guidelines• Only for confirmed STEMI

9. Monitor closely for deterioration – look for ECG changes10. Consider monitoring with the defib pads if unstable angina suspected11. Senior clinical support and/or transport to nearest A&E

Case Study



• Frank is 55 and has a long history of HTN and high cholesterol• Whilst sitting in the pub, Frank experienced sudden central chest pain and dyspnoea• When you arrive he is clutching at his chest, dripping in sweat and very pale

• D: Safe to approach• R: Can only say the odd word but alert• A: No concerns• B: Marked dyspnoea, RR 24, SpO2 89%, ETCO2 6.8kPa• C: HR 52, BP 89/40, ECG does not show ST-Elevation• D: GCS 15/15, BM 8.9, PERRLA 3+• E: Temp 36.9°C

• You are working with someone who has completed their SALM training• Frank’s symptoms seem to be getting worse rather than better

Interactive Quiz







Heart Failure



• Inability of the heart to beat efficiently due to structural damage

• 2 main causes are:• Following a myocardial infarction (MI)• Uncorrected high blood pressure

• Dead myocardium following an MI does not contract and becomes baggy

• Thickened myocardium resulting from long term high blood pressure becomes stiff


Heart Failure


Heart Failure



• When the ventricle cannot eject efficiently, pressure builds up in the vessels supplying that side of the heart

• Left side is supplied by the pulmonary vein• Right side is supplied by the vena cava

• When pressure in a vein builds up, fluid leaks out into the surrounding tissue

• Fluid in the lungs is pulmonary oedema• Fluid around the body is peripheral oedema



Response Normal – may struggle to speak

Airway Fine cracklesCoughing

Breathing Dyspnoea↑RRNormal or ↓SpO2

Circulation ↑HRBlood pressure unreliableCyanosis in severe casesECG may be normal

Disability GCS may reduce with hypoxiaBM unchangedPERRLA

Expose/Examine/Environment Temperature normalPitting oedema around the ankles




Treatment



1. Calm and reassure

2. Sit upright in a comfortable position – tripod

3. Move to a quiet environment if possible

4. Full set of observations including BP and ECG if able

5. Oxygen as required to maintain SpO2 >94%

6. GTN 400mcg sub-lingual if BP stable• Repeat every 5-10 minutes unless systolic drops <110mmHg• Maximum dose 2.4mg

7. Senior clinical support and/or transport to nearest A&E

Case Study



• Peter is 66 and had a large MI last year, although is recovering well• He calls 111 because he is more breathless than usual today• When you arrive he opens the door to greet you

• D: Safe to approach• R: Alert• A: Patent, coughing occasionally • B: Marked dyspnoea, RR 28, SpO2 94%, ETCO2 not available• C: HR 90, BP 120/50, ECG appears normal• D: GCS 15/15, BM 8.1, PERRLA 3+• E: Temp 36.3°C, bilateral pitting oedema to ankles

• Peter’s GP has recently changed his medication to help but it suddenly got worse today• When you listen to his chest there is clear fine crackles on both sides. You have completed SALM.

Interactive Quiz







Next Session



Interactive CPD Series | Episode 6 | Neurological Pathophysiology

Monday 31st May 202119:00 GMT

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