1. 14
Caring for Cardiac Emergencies

2. Objectives Review cardiovascular anatomy and physiology.
Define the following terms:
Angina
Cardiac compromise
Conduction pathway
Heart failure
Myocardial infarction
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3. Objectives Describe the normal flow of blood through the heart.
Explain common causes of cardiac compromise.
Describe the signs and symptoms of a patient experiencing cardiac compromise.
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4. Objectives
Differentiate and explain the pathophysiology of angina, myocardial infarction, and heart failure.
Explain the appropriate assessment and care for a patient experiencing cardiac compromise.
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5. Objectives
Demonstrate the ability to appropriately assess and care for a patient experiencing cardiac compromise.
Value the importance of caring for all patients with chest pain as though it were cardiac compromise.

6. Media Directory
Slide 18 Heart Attack Video Slide 21 Angina Video Slide 30 Congestive Heart Failure Video

7. Topics
Normal Heart Function Cardiac Compromise Emergency Care for Cardiac Compromise

8. NORMAL HEART FUNCTION

9. State Standards
21) Identify and perform skills to manage life threatening illnesses based on assessment findings of a pediatric, adult, and geriatric patient with medical emergencies, utilizing rubrics from textbooks, National HOSA guidelines, or clinical standards of practice in the following areas:
a. Altered mental status
b. Seizures
c. Stroke
d. Gastrointestinal bleeding
e. Anaphylaxis
. Infectious diseases
g. Diabetes
h. Psychological emergencies
i. Chest pain
j. Poisoning
k. Respiratory distress/Asthma
l. Vaginal bleeding
m. Nosebleeds

10. Objectives Students will be able to…
Identify signs and symptoms of common Cardiac Emergency conditions
Determine assessments needed for Cardiac Emergencies
Identify treatments for cardiac emergencies within the scope of practice for a first responder

11. Normal Heart Function The heart beats 100,000 times per day.
6,000 to 7,500 liters of blood circulates through the body each day.
The heart muscle receives its blood supply from the coronary arteries.
Blockage in an artery results in decreased blood flow to the heart.
Talking Point: 6,000 to 7,500 liters of blood is roughly equivalent to 2000 gallons; as much as many fire tanker trucks hold!
Talking Point: Blocking part of a garden hose increases water pressure. In a similar way, blocked blood vessels contribute to high blood pressure; a risk factor for heart attack and stroke.

12. Figure 14.3 The coronary arteries supply blood to the heart muscle (myocardium).

13. Normal Heart Function Cardiac cycle
Blood flows from the body, into the right atrium, down into the right ventricle and then into the lungs.
Blood exits the lungs and enters the left atrium then flows into the left ventricle.
Once the blood exits the left ventricle, it flows out to the body and the cycle begins again.

14. Figure 14.1 Major anatomy of the heart including blood flow through the chambers.

15. Normal Heart Function
The conduction pathway is the core of the electrical system that keeps the heart beating and the cardiac cycle going.
Damage to the conduction pathway can lead to an abnormal heart rhythm and is a common cause of poor circulation and perfusion.
Discussion Question: EKGs measure the heart's electrical signals. Has anyone seen an EKG completed?
Thinking Point: When electrical messages are interrupted, performance is affected; similar to when the digital picture on a TV is distorted when a storm causes signal interference.

16. Figure 14.2 The heart’s conduction pathway, highlighted in green.

17. Think About It The heart is a muscle with a big job to do.
Problems can arise that affect the heart tissue and/or the electrical system.
Thinking Point: Ask the students to name some problems that can affect the heart negatively.

18. CARDIAC COMPROMISE

19. Cardiac Compromise Cardiac Compromise Symptoms Chest discomfort
Diaphoresis
Dyspnea
Nausea/vomiting
Anxiety/irritability
Abnormal pulse
Abnormal blood pressure
Feeling of impending doom
Thinking Point: First ask the students to define cardiac compromise.

20. Angina Pectoris Angina pectoris (angina) is pain in the chest.
Decreased oxygenated blood supply in the coronary arteries leads to an increased oxygenated blood demand in the heart muscle.
Exertion
Partial blockage
Spasm
Critical Thinking: How can you tell when a patient is experiencing acute angina versus a heart attack? (A: A diagnosis can not be made in the prehospital setting; patients should be transported to a hospital for definitive diagnosis and treatment.)
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21. Angina Pectoris
Signs and symptoms of angina are nearly identical to a heart attack.
No actual damage to the heart muscle
Patients with angina history typically carry nitro.
Treatment for angina and myocardial infarction (heart attack) is the same.
Talking Point: Angina triggered by exertion is often resolved with rest whereas myocardial infarction symptoms will not resolve with rest. EMRs should never cancel responding EMS even if the patient claims relief.

22. Myocardial Infarction
Myocardial infarction (MI)
Myo, muscle
Cardial, heart
Infarction, tissue death
Blockage or narrowing of the coronary arteries leads to a permanent decrease in oxygenated blood supply.
Without oxygenated blood, the tissue of the heart begins to die.
Critical Thinking: How effective will the heart muscle be if any of the tissue begins to die? (A: The heart's overall effectiveness will be diminished.)

23. Myocardial Infarction
Typical signs and symptoms
Pain, pressure, tightness, or heaviness to the chest/upper abdomen
Pain or discomfort behind the sternum
Pain radiating to the shoulders or arms
Pain to the back, neck, jaw or upper abdomen
Critical Thinking: What should immediately be done for victims of cardiac arrest? (A: CPR & AED)

24. Myocardial Infarction
Atypical signs and symptoms
"Flu-like" signs and symptoms such as nausea and vomiting
Indigestion
Feeling of general weakness
Talking Point: Elderly people, diabetics and women are the most likely candidates for atypical symptoms.

25. Myocardial Infarction
Large amounts of tissue death or damage over an important electrical pathway may lead to cardiac arrest.
Patients in cardiac arrest are unresponsive, not breathing, and have no pulse.

26. Figure Both myocardial infarction and angina can present with symptoms of chest pain. Treat all cases of chest pain as a true cardiac emergency.

27. Heart Failure Congestive heart failure (CHF)
Weakened heart muscle is unable to pump blood efficiently and manage normal blood volume.
Chronic due to cardiac diseases
Sudden after a myocardial infarction
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28. Heart Failure Congestive heart failure (CHF)
Fluid backs up within the circulatory system.
Lungs
Lower extremities

29. Heart Failure Signs and Symptoms of Heart Failure Shortness of breath
Chest pain/discomfort
Rapid pulse rate
Pedal edema (swollen ankles)
Jugular Vein Distention (JVD)
Pale, moist skin
Altered mental status
Talking Point: Patients with shortness of breath may have difficulty speaking and answering questions.
Critical Thinking: Why do people experiencing shortness of breath usually prefer an upright position? (A: It is easier to breathe sitting up.)

30. Figure 14.5a Signs of heart failure include bulging neck veins.
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31. Figure 14.5b Signs of heart failure include swollen ankles (pedal edema).

32. Think About It Cardiac compromise is a life threatening condition.
Why is it important to rapidly identify cardiac compromise?
Describe the difference between angina and MI.
(A: Rapid identification and subsequent treatment will help minimize heart damage.)
(A: The signs and symptoms may not differ greatly. Transport to a hospital for definitive diagnosis and treatment.)

33. Emergency Care for Cardiac Compromise
Take appropriate Standard Precautions.
Perform a primary assessment and support the ABCs as necessary.
If allowed, provide oxygen per local protocols.
SpO2 should read between 95–100%.
Critical Thinking: Why might it be beneficial to obtain medical history from a family member on scene rather than asking a patient with shortness of breath to respond? (A: Patients with shortness of breath often have difficulty speaking in full sentences and talking can cause unnecessary exertion, further taxing their system.)
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34. Emergency Care for Cardiac Compromise
Determine chief complaint.
Onset
Provocation
Quality
Region and radiate
Severity
Time
Class Activity: Using the index cards from the Take Action activity completed at the end of Chapter 13; direct students to select one cause of cardiac compromise (angina, heart attack (MI), or heart failure) and, working in pairs, allow one student to role-play symptoms while the other performs the OPQRST assessment. Be sure each student has an opportunity to perform the assessment. Also make sure they cover the three possibilities. Suggest to the students to role-play some vague, less common symptoms.

35. Figure Algorithm for the emergency care of a patient with signs and symptoms of cardiac compromise.

36. Emergency Care for Cardiac Compromise
Provide emotional support and reassure the patient.
Allow the patient to maintain a position of comfort, usually sitting up.
Obtain vital signs.
Critical Thinking: Why is it important to ensure the patient does not exert him/her self? (A: The heart tissue may be dying and exertion, such as walking, can compromise the heart's performance even further.)

37. Figure 14.7 Algorithm for assessment of patients with chest pain.

38. Emergency Care for Cardiac Compromise
Assist the patient with the prescribed dose of nitroglycerin, if your protocols permit. Consult medical direction.
Continue to monitor vital signs. 
Class Activity: Bring small candy mints to class. Referring to Chapter 13, have students work in pairs to follow the Nitroglycerin "Steps for Assisting the Patient." Be sure each student has an opportunity to perform the steps.

39. Emergency Care for Cardiac Compromise
Medications
Nitroglycerin
Tablets, spray, paste
Prescribed for angina or previous MI
Dilates blood vessels
Decreases blood pressure and reduces cardiac workload
Dizziness and feeling lightheaded are common side effects.
Assist patient according to protocols.
Talking Point: It is still helpful to ask if the patient has taken nitroglycerin or aspirin, even if your local protocol does not allow you to assist with administration of these drugs. The information gathered should be relayed to EMS responders when they arrive on scene.
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40. Nitroglycerin Medication Form – Tablet

41. Nitroglycerin Medication Form – Sublingual Spray

42. Emergency Care for Cardiac Compromise
Medications
Aspirin
Analgesic
Clot inhibitor
Prescribed daily for angina
Beneficial for patients exhibiting signs and symptoms of an MI
Assist patient according to protocol.

43. Think About It What does "Time is Muscle" mean?
Performing a thorough assessment and appropriate treatment can contribute to how well the patient recovers from cardiac compromise.
Emergency Medical Responders make a difference.
A: The faster you can treat a patient in cardiac compromise, the less any heart muscle is at risk of dying and/ or suffering permanent damage.

44. Activity
Choose a Cardiac Emergency that we have discussed to create a scenario.
Do not tell the name of your cardiac emergency, instead give a scenario that includes signs and symptoms that you would get from an assessment.
The class will try to diagnose what condition your patient is suffering from.
Exit Ticket: Complete sentences
3 things you learned
2 things you already knew
1 thing that was surprising

45. SUMMARY

46. Summary A healthy heart is the core of the cardiovascular system.
Blood flows through the heart in a precise way.
Electrical impulses flow along the conduction pathway.
There are key signs and symptoms of cardiac compromise.
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47. Summary
Angina results from a diminished supply of oxygenated blood to the heart.
Myocardial infarction occurs when a portion of the heart dies due to inadequate blood supply.
Congestive Heart failure (CHF) is caused by a weakened heart that can no longer pump blood efficiently.
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48. Summary Care for cardiac compromise includes:
The ABCs
Supplemental oxygen
Obtaining a thorough medical history
Keeping the patient at rest
Monitoring vital signs
Initiate ALS transport if available.

49. REVIEW QUESTIONS

50. Review Questions Describe the normal flow of blood through the heart.
What are some vague symptoms of MI that may be seen in women or the elderly?
What is the appropriate assessment and care for a patient experiencing cardiac compromise?
Blood flows through the heart beginning with the right atrium (Figure 13-1). It then flows down into the right ventricle. From there it flows into the lungs, where it drops off carbon dioxide and picks up oxygen. It returns from the lungs and enters the left atrium, and then flows down into the left ventricle. The left ventricle is the largest and strongest chamber of the heart and must force blood out to the entire body. The heart muscle itself receives its blood supply from tiny vessels called coronary arteries.
During a cardiac event, those populations may experience what appear as "flu-like" signs and symptoms, such as nausea and vomiting, indigestion, or a feeling of general weakness. The patient may simply tell you, "I don't feel right," or "Something is wrong with me, but I don't know what it is."
OPQRST; be sure to review with the students specific questions to be asked in their assessment of suspected cardiac compromise.

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