Ch. 15: Cardiovascular Emergencies

The Heart Enclosed in pericardial sac Myocardium = heart muscle Four chambers: two atria, two ventricles Sides divided by septum Atrioventricular valves: tricuspid and mitral Semilunar valves: pulmonic and aortic Electrical pathways cause contractions

Blood Vessels Carry blood to and from the heart Arteries: transport blood away from the heart Aorta: largest artery in the body Veins: bring blood to the heart Super and inferior venae cavae Capillaries: connect arteries and veins Aorta – Arteries – Arterioles – Capillaries – Venules – Veins – Venae Cavae

Major Arteries Major Veins

Blood Transports materials from one area of the body to another Oxygen, CO2, protein building blocks, sugars, fats, hormones, waste products, etc When engaging in physical activity, body needs more oxygen and nutrients than when at rest – heart must pump blood faster

© Catherine R. Gordon

Cardiovascular Emergencies Most causes of CV system failure traced back to cardiovascular disease (CVD) CVD leading cause of death worldwide More than 1/3 of adult population in US has CVD. Most cases of CVD attributed to coronary artery disease or atherosclerosis

Atherosclerosis “Hardening of the arteries” Plaques form and build up along the inner lining of the arteries. Heart doesn’t receive the oxygen and nutrients it needs, which causes the heart muscle to die End result of plaque build up is coronary artery disease. Angina pectoris Leads to hypertension, heart failure, AMI, and sudden cardiac death.

Figure 15-8 The progression of artery occlusion in atherosclerosis: (a) the patient's risk factors and other factors cause the inner wall to be damaged; (b) fatty deposits develop, which lead to (c) fibrous plaque, which further occludes the vessel's internal diameter; (d) platelets aggregate in these areas, forming blood clots that nearly or completely occlude the artery.

Hypertension Abnormally elevated blood pressure, over 140/90 Internal diameters of small arterioles narrow due to atherosclerosis or other cause that restricts blood flow through arteries Vessel narrowing causes pressure to build Damages blood vessels over time Affects nearly 1B people worldwide; 1/3 in the US If untreated, it can lead to stroke and kidney failure, and more

Pulmonary Edema Accumulation of fluid in the lungs Caused by severe left-sided congestive heart failure, which in turn results from acute MI, direct trauma to the lungs, certain medical conditions, and certain drugs As the condition worsens, the patient goes into cardiogenic shock from profound hypoxia

Congestive Heart Failure Occurs when the heart can’t adequately pump blood to the body Blood backs up into major blood vessels leading to heart, and subsequently into organs Right-sided heart failure results in back-up into the systemic circulation, and then the dependent tissues, esp. the ankles and feet Left-sided heart failure causes back-up into the lungs, resulting in pulmonary edema

S/S: Congestive Heart Failure S/S depend on the side affected. Right heart failure: swollen ankles that can progress up the leg, often with “pitting edema.” Left heart failure: Shortness of breath is common. If onset is rapid, it can be life-threatening. Patients can have right and left CHF simultaneously.

Angina Pectoris Chest pain/discomfort caused by ischemia of the myocardium Occurs when the oxygen demands of the heart exceed the available supply Common occurrence in people with CAD due to narrowing of the arteries Can also be caused by vasoconstriction or spasm of the coronary arterie

Acute Myocardial Infarction (AMI) Mostly (90%) caused by blood clots that in turn cause blockage of the coronary arteries. The result is ischemia and death of heart muscle served by the affected coronary artery(ies). If enough tissue dies, life is threatened because the heart can’t pump

S/S: AMI Chest pain can be crushing or heavy, stationary or radiating. Women have painless MI more often than men. S/S can include anxiety, dizziness, nausea, diaphoresis, feeling of impending doom

Aortic Aneurysm A ballooning outwards of the aorta S/S: Two types: abdominal and thoracic S/S: Abdominal pain radiating to the groin/back Dizziness Abdomen may be tender, with a pulsatile mass Ruptured? Profound shock with hypotension and diaphoresis

Cardiogenic Shock Caused by damage to myocardium Heart’s output of blood reduced Blood pressure cannot be maintained

S/S: Cardiogenic Shock Patients appear deathly ill and in shock: pale skin, diaphoresis, anxiety, respiratory distress. If caused by AMI, the patient will be tachycardic and hypotensive If caused by abnormal heart rhythm, the patient might be bradycardic, or tachycardic and hypotensive.

Pericardial Tamponade Occurs when excess fluid builds up in the pericardial space Compresses heart, can’t pump adequately PT is life-threatening, requires emergency fluid removal

S/S: Pericardial Tamponade Shortness of breath, anxiety or restlessness, and pale, cool, diaphoretic skin Chest pain is common Hypotension, distended neck veins, and muffled/distant heart tones Patient might present with only fatigue and tachycardia.

Pulmonary Embolism One of the most lethal forms of thromboembolism Passage of a blood clot (thrombus) formed in a vein through right side of heart and into pulmonary artery where it lodges Deep venous thrombosis Decreases or blocks blood flow—no exchange of oxygen or CO2 Arterial carbon dioxide increases, oxygen decreases Inhibits circulation

S/S: Pulmonary Embolism Sudden onset of chest pain Shortness of breath Tachycardia Sharp pain that increases with deep breaths Cyanosis and hypoxia S/S DVT: Severe pain, tenderness to touch, swelling in one leg

Sudden Cardiac Arrest (SCA) Abrupt cessation of effective pumping of blood from heart to coronary arteries, brain, and other vital organs Caused by AMI, ventricular fibrillation, pulseless ventricular tachycardia, asystole.

Arrhythmias Irregular heart beat or heart rhythm, which can compromise normal heart function Primary cause of life-threatening arrhythmia is ischemia of myocardium Life-threatening arrhythmias (can lead to SCA): Ventricular fibrillation: chaotic and ineffective contraction of that ventricles that leads to cardiac arrest Ventricular tachycardia: rapid contraction of the ventricles that can lead to ineffective blood flow to body tissues, cardiac arrest Asystole: complete absence of a heartbeat due to lack of electrical activity within the heart

Assessment Scene safety Primary assessment: ABCDs Patients in SCA will be unresponsive, apneic, pulseless – immediately begin CPR Secondary assessment: SAMPLE history, pay close attention to complaints of chest pain and any medications (esp. nitroglycerin or aspirin) Patient may have difficulty communicating, talk to relative Assess chest pain using OPQRST (cardiac pain usually described as either “heavy,” “crushing,” or “tight.” If pain radiates into jaw or down arm, may indicate AMI Detailed secondary physical exam Check pulse, blood pressure, skin condition, capillary refill, level of responsiveness – evidence as to whether not tissue perfusion is effective Assess skin for color, temperature, diaphoresis (with chest pain may indicate that heart is ischemic. Listen to breath sounds Reassess patient and vital signs Every 3-5 mins if patient is unstable Every 10-15 mins if patient is stable

Management Evaluate ABCs and treat problems as they are found If patient is in cardiac arrest: Time is of the essence – Golden Hour Request ALS immediately, and call for oxygen and an AED. Begin CPR.

Management Chain of Survival Immediate recognition of cardiac arrest, activation of EMS Early CPR emphasizing chest compressions Rapid defibrillation if indicated Early, effective ALS Integrated post-cardiac arrest care

Management CVD Patient NOT in Cardiac Arrest Call for immediate assistance, oxygen, AED, and ALS. Keep patient calm, put in position of comfort. If hypotensive, keep supine and warm, and elevate legs If CHF, sit patient up and put legs in dependent position

Other Considerations Medications: Implantable devices may be in place Plavix: anti-platelet to prevent formation of clots Nitroglycerin: vasodilator Coumadin: blood thinner Lipitor: lowers harmful cholesterol levels Cordarone: diuretic that removes excess fluid from the body Implantable devices may be in place High flow oxygen therapy is crucial Nitroglycerin -- assist patient if they have their prescription with them and conditions/protocols allow Aspirin -- assist patient if they have aspirin and protocols allow for it