Overview of CBT 434 Cardiovascular Emergencies

Copyright 2009 Seattle/King County EMS

Overview of CBT 434 Cardiovascular Emergencies

Complete course available at www.emsonline.net


IntroductionCardiovascular Emergencies • Leading cause of death in the US

• Hundreds of thousands of Americans die from cardiac arrest each year

• 9 out of 10 cardiac arrest victims die before they get to the hospital


Practical Skills

• Focused history using SAMPLE/OPQRST • Assisting with nitroglycerin• Auscultation and assessing breath sounds• Assisting ventilations with BVM• Care for ACS, CHF, aortic dissection, shock• Use of AED

To receive CBT or OTEP credit, you must perform the following practical skills:


Termsacute coronary syndrome (ACS) - A term used to describe a range of symptoms and conditions from acute myocardial infarction to unstable angina

aortic dissection - A tear in the lining of the aorta

infarction - Death of tissue due to loss of blood flow

ischemia - Poor oxygen supply to tissue

myocardium - Another term for heart muscle


Terms, continuedpulmonary edema - Abnormal accumulation of fluid in the tissues and air spaces of the lungs

sustained tachycardia - Persistent heart rate of 100 or greater caused by a clinical condition such as hypoxia or impending shock

thrombus - A clot formed in a blood vessel or in a chamber of the heart


AnatomyThoracic Cavity • Neck to lower ribs

• Divided into mediastinum and pleural cavities

• Diaphragm at its base

• Contains trachea, esophagus, heart, aorta, vena cava and the pulmonary artery

• Pleural cavities


Structures

Anatomy, continued• 12 pairs of ribs

• Connect to sternum through a bridge of cartilage

• Lower 5 ribs connect to sternum through the costal arch

• Intercostal muscles between ribs


Arteries/Veins

Anatomy, continued

Purpose of CV system• Provide cells with oxygen

nutrients• Remove waste

Components • Heart • Arteries• Arterioles• Capillaries • Veins• Venules


Coronary Arteries

Anatomy, continued

1. Right coronary artery

2. Left coronary artery

3. Atria

4. Ventricles

21

3

4


Myocardial IschemiaMyocardial ischemia is the lack of blood flow and oxygen to the myocardium (heart muscle).

•Inadequate blood flow to a part of the body

•Caused by constriction or blockage of the blood vessels

•Cells do not receive adequate supply of O2

Coronary Artery 75% occluded occluded


Myocardial Ischemia, continued

Obstruction

• Inadequate blood flow to a part of the body

• Caused by constriction or blockage of the blood vessels

• Cells do not receive an adequate supply of oxygen


Myocardial Ischemia, continued

Reduced blood flow associated with conditions that cause:

• Hypotension (e.g. blood loss)

• Tachycardia

• Bradycardia


Coronary Thrombosis1

Plaque forms on thePlaque forms on theinner wall of an arteryinner wall of an artery


Coronary Thrombosis, continued1

2

Hard surface of the Hard surface of the plaque tears, exposing plaque tears, exposing

the soft under sidethe soft under side


Coronary Thrombosis, continued1

2

3

Platelets arrive to Platelets arrive to form a blood clotform a blood clot


Other Sources of Chest Pain• Mediastinum

• Chest wall

• Lungs and pleura

• Abdomen

• Psychogenic

Not all chest pain is cardiac related. Not all chest pain is cardiac related.


ConditionsAngina pectoris is chest pain due to myocardial ischemia.

• Brought on by exercise, stress or cold weather • Possible radiation of pain to jaw, arm or upper back • Sudden onset • Usually relieved with rest within 3-5 minutes and/or

nitro Assessment of Angina

Onset suddenProvocation physical exertion, stress, cold weather, relieved by restQuality pressure or squeezing pain Radiates pain can radiate to jaw, arm or upper backSeverity mild to moderateTime relieved with rest and/or nitroglycerin within 3-5 min


Conditions, continuedAcute coronary syndrome (ACS) describes a range of clinical conditions.

The symptoms, which vary from patient to patient, are caused by acute myocardial ischemia:

• Shortness of breath • Discomfort • Chest pain • Pressure • Nausea • Weakness • Dysrhythmia • Syncope


Conditions, continuedAcute myocardial infarction (AMI)

• Chest discomfort

• Discomfort in other areas of the upper body

• Shortness of breath

• Diaphoresis, nausea or weakness


Conditions, continuedAortic dissection

• Blood gets behind inner layer of the aorta• Blood starts to fill space between layers of

arterial wall• Aorta widens and significantly disrupts blood flow

Symptoms

• Sudden and severe chest or upper back pain

• Anxiety • Diaphoresis • Nausea


Conditions, continuedCongestive heart failure (CHF)

• Occurs when heart is too weak to adequately circulate blood

• In left-sided heart failure, pulmonary edema occurs as blood backs up into lungs

• Increases fluid in alveoli - results in SOB


Conditions, continuedCongestive heart failure signs

• Fatigue • Cough, dyspnea • Pulmonary edema (a severe form of CHF) • Tachypnea • Agitation and confusion • Hypertension • Swollen feet or lower legs


Initial Assessment

• Guides initial treatment

• Quickly assess a patient

• Make a decision

SICK or

NOT SICK


SICK/NOT SICKA SICK patient is one who can die quickly unless you initiate aggressive BLS and ALS treatment and rapid transport.

A NOT SICK patient is one who can be ill or injured, but not severely enough to be life threatening.


Key Clinical Indicators• Respirations (rate, character)

• Pulse (rate, character)

• Mental status

• Skin signs and color

• Body position

SICK or

NOT SICK


Patient HistoryOPQRST

Onset What was patient doing when the pain started?

Provocation What makes it better or worse?

QualityCan you describe it?What does it feel like?

RadiatesWhere do you feel it? Where does it go?

Severity How bad is it on a scale of 1 to 10 (ten being the worst)?

Time When did the pain begin?


Physical Exam• Auscultate breath sounds starting at the

bases

• BP in both arms (note difference of 10 mm Hg or more)

• Skin color, moisture and temperature

• Pulse oximetry

• Blood glucometry

• Head, neck-to-toe exam


Physical Exam, continuedAtypical presentations are common in elderly, diabetics and females.

Classic Symptoms Atypical Symptoms

• Pressure, fullness, heaviness, squeezing pain in center of chest that can radiate to neck, shoulder, jaw or back

• Sweating • Nausea • Weakness • Shortness of breath

• Unusual fatigue • Sudden onset of unusual SOB

during usual activities or at rest • Nausea, dizziness • Belching, burping, indigestion • Palpitations, new dysrhythmia,

esp. atrial fibrillation • Pain experienced only in jaw,

neck, back, arm or wrist


Patient CareGeneral steps

• Decide SICK or NOT SICK • Ensure adequate airway and

respirations• Administer oxygen• Position appropriately• Assure ALS response


Patient Care, continued

Other considerations

• Control airway secretions• Assist ventilations with BVM• Prepare for cardiac arrest and

application of an AED


Nitroglycerin• Used to treat angina• Relaxes vascular muscles • Increases blood flow & oxygen to

myocardium


Nitroglycerin, continued

You may assist a patient in taking prescribed nitroglycerin if:

1. Pain is the same for which nitroglycerin is normally taken

2. Patient’s BP is greater than 100 mmHg

systolic*Follow your local protocol if different.


Nitroglycerin, continued

“Assisting” a patient with nitroglycerin means you can:

• Locate the container • Open it• Offer a pill to the patient


SummaryThoracic cavity is divided into mediastinum and pleural cavities.

Structures within the thoracic cavity include:

• Intercostal muscles • Ribs • Sternum• Costal arch • Diaphragm • Heart• Lungs• Trachea • Aorta • Pulmonary arteries


Summary, continuedMyocardial ischemia is the lack of blood flow and oxygen to the heart muscle.

Acute coronary syndrome (ACS) is the term used to describe clinical conditions ranging from unstable angina to acute myocardial infarction.

Sources of chest pain include the mediastinum, chest wall, lungs/pleura and abdomen. It can also be due to psychogenic sources.

Common cardiovascular emergencies are angina, AMI, aortic dissection, CHF and cardiogenic shock.


Summary, continuedOPQRST is a mnemonic that helps assess the character of a complaint.

Principles of care for a cardiovascular emergency include:

• Decision of SICK or NOT SICK• Ensure an adequate airway and respirations • Administer oxygen• Position the patient appropriately• Assure an ALS response

Overview of CBT 434 Cardiovascular Emergencies

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