1. Cardiovascular Emergencies CHAPTER 17

2. Review Circulatory System ◦Three major components Conduction System ◦Specialized cells ◦Three pacemaker sites ◦Sympathetic nervous system Heart ◦Right Ventricular Failure ◦Usually caused by COPD ◦Left Ventricular Failure ◦High Blood Pressure or damage The Vessels The Blood ◦Formed elements

7.  Thrombus  Platelets  Thrombin  Fibrin

8. Electrocardiogram Graphic representation of the heart’s electrical activity Human body acts as a conductor If conduction is damaged or disturbed causes PVC’s ◦Too many PVC’s can result in V-Tach

9.  Depolarization  Repolarization  P wave  QRS complex  T wave

10. Blood Pressure Amount of pressure exerted on the arterial wall during circulation ◦Systolic ◦Diastolic

11. Inadequate Circulation Perfusion- Hypoperfusion ◦What are the causes?

12. Cardiac Compromise & ACS AHA reports 7-8 million seek treatment for chest discomfort 2 million will actually have a cardiac related event 1.5 million will have MI 500,000 will die from MI 250,000 will die within 1 hour of onset of signs & symptoms

13. Cardiac Compromise & ACS Key treatment ◦Early recognition Time is critical-time is muscle Death of muscle is permanent

14. Atherosclerosis Smallest arterial structures to become stiff & less elastic Inflammatory disease Starts at innermost lining of vessels Common Risks Smoking Diabetes Hypertension High LDL’s Low HDL’s

15. Acute Coronary Syndrome Unstable Angina ◦Discomfort that is prolonged or worsening, or occurs without exertion Myocardial Infarction ◦Muscle death

16. Angina Pectoris PATHOPHYSIOLOGY Inadequate O2 supply to heart muscle Lack of O2 causes the discomfort Usually occurs during time of stress Usually will go away within 2-15 minutes SIGNS/SYMPTOMS Steady discomfort Cool, clammy skin Anxiety Dyspnea Diaphoresis Nausea &/or vomiting Indigestion

17. Assessment Women, elderly & diabetics may not experience these symptoms Pain usually goes away with Nitro If pain does not go away then question MI

18. Treatment Maintain airway O2 NRB @ 15 L Assist with Nitro with medical direction permission Administer ASA 160-325 mg per protocol

19. Acute MI PATHOPHYSIOLOGY Causes severe narrowing or complete blockage to coronary arteries After 20-30 minutes without O2, cells begin to die Ischemic heart tissue will become irritable Goal-reestablish blood flow ◦Catheterization ◦medications SIGNS & SYMPTOMS Chest discomfort Symptoms last longer Nitro does not relieve Anxiety Dyspnea Sense of impending doom Diaphoresis Nausea &/or vomiting Light-headed/dizzy Weakness Feel like need to have BM

20. Assessment Diabetics, elderly, & women usually do not experience these symptoms Reassessing constantly due to risk for cardiac arrest Never leave alone AED must be close Airway O2 Position of comfort Assist with Nitro per medical control 160-325 mg ASA per protocol

21. ACS in Female patients “CLASSICAL” FINDINGS Dull substernal chest pain Respiratory distress Nausea, vomiting Diaphoresis “ATYPICAL” FINDINGS Neck ache Pressure in the chest Pains in the back, breast, or upper abdomen Tingling in fingers Unexplained fatigue or weight gain Insomnia

24. Aortic Aneurysm or Dissection Pain may be confused with MI Aortic Aneurysm ◦Weakened wall of vessel ◦Occur most often in abdominal region ◦Aorta usually not felt, but will feel pulsating mass when in final stage Aortic Dissection ◦Tear in lining ◦Occur in thorax ◦Pain described as sharp or tearing ◦Syncope may be only sign ◦Sometimes can mimic stroke or MI ◦Systolic BP difference of 20 mmHg between upper arms ◦Severe pulse amplitude difference from upper & lower extremities

25. Aortic Aneurysm or Dissection

26. Treatment O2 Do not administer ASA Rapid transport

27. Heart Failure Inability for heart to blood out of ventricle ◦Causes ◦Heart damage ◦Valve disorder ◦Hypertension ◦Pulmonary edema ◦Cardiac rhythm disturbance ◦Certain drugs

28. Need figure 17-12

29. Heart Failure LEFT SIDE Left ventricle unable to pump effectively Reduces blood flow to the body Creates a traffic jam Can lead to pulmonary edema RIGHT SIDE Blood backs up venous system Causes ◦Hypertension ◦COPD

30. Cardiogenic Shock Can occur in either right or left failure Fail to pump enough blood to meet body needs Common cause MI ◦Sustained hypertension ◦Valve damage ◦Extremes in heart rate ◦Other cardiac muscle diseases

31. What’s the difference? LEFT FAILURE Cardiac output drops Drop in systolic BP Diminished or absent peripheral pulses Altered mental status Changes in heart rate Poor urinary output Respiratory distress Inspiratory crackles (rales) Possible pulmonary edema RIGHT FAILURE Hypoxia Respiratory distress Jugular vein distention Peripheral edema

33. Congestive heart Failure Buildup of fluid Commonly leads to pulmonary & perpheral edema Fluid accumulates in liver causing it to enlarge May also collect in abdomen

36. Treatment These patients will commonly tell you “I’m on a water pill” Airway Oxygen Nitroglycerin for chest discomfort per protocol Continually assess

37. Hypertensive emergencies PATHOPHYSIOLOGY Primary hypertension-most common Secondary hypertension-caused by underlying disease process SIGNS AND SYMPTOMS Strong bounding pulse Skin warm, dry, or moist Severe headache Ringing in the ears Nausea/vomiting Elevated BP Respiratory distress Chest pain Seizures Focal neural deficits Possible nosebleed Indications of organ dysfunction

38. Treatment Airway Oxygen Position of comfort-preferred semi fowlers

39. nitroglycerin Potent vasodilator Works quickly Can be sublingual or a spray Indications ◦Signs & symptoms of chest pain ◦Physician prescribed medication (POM) ◦EMT received approval from medical control Contraindications ◦Baseline SBP <90 mmHg ◦HR less than 50 or greater than 100 ◦Suspected head injury ◦Infant or child ◦3 doses have been given ◦Patient has taken Cialis, Levitra, or Viagra within last 24 hours

40. Nitro continued Administration ◦Complete history ◦Assess baseline vital signs ◦Obtain approval from medical control ◦6 rights ◦Wear gloves when giving medication ◦Place under the tongue ◦Reassess after 2 minutes ◦Document Dosing ◦0.4 mg(SL) or 0.3 mg (spray) every 3-5 minutes X 3 doses ◦If Nitro is still active-will create tingling sensation under tongue

41. Nitro ACTIONS Dilates blood vessels Decreases workload of heart Decreases cardiac oxygen demand SIDE EFFECTS Headache Drop in BP Change in pulse rate

43. Assessment & care guidelines Scene Size up Primary assessment Secondary assessment ◦SAMPLE history ◦OPQRST ◦Physical exam/baseline vital signs ◦Signs & symptoms