1. Chapter 17 Cardiovascular Emergencies Copyright ©2010 by Pearson Education, Inc. All rights reserved. Prehospital Emergency Care, Ninth Edition Joseph J. Mistovich Keith J. Karren

2. Objectives 1.Define key terms introduced in this chapter. 2.Describe the relationship between chest pain or discomfort, heart disease, and cardiac arrest (slide 44).slide 44

3. Objectives 3.Describe the structure and function of the circulatory system, including (slides 14-27):slides 14-27 a.The cardiac conduction system b.Conductive tissue and conductivity c.Contractile tissue and contractility d.Automaticity e.Effects of the autonomic nervous system (sympathetic and parasympathetic) on the heart f.Gross anatomy of the heart g.Systemic and pulmonary circulation h.Coronary arteries i.Plasma and formed elements of the blood 4.Explain the relationship between electrical and mechanical events in the heart (slides 28-30).slides 28-30

4. Objectives 5.Describe the processes of depolarization and repolarization, and relate the waves and intervals of a normal electrocardiogram (ECG) to the physiological events they represent (slide 29).slide 29 6.Discuss the relationship between hypoxia, damage to the cardiac conduction system, premature ventricular contractions, ventricular tachycardia, and ventricular fibrillation (slide 30).slide 30 7.Describe the roles of the heart and blood vessels in maintaining normal blood pressure (slides 31-34).slides 31-34 8.Explain the importance of early recognition of signs and symptoms and the early treatment of patients with cardiac emergencies (slides 35-36).slides 35-36

5. Objectives 9.Explain the pathophysiology and the appropriate assessment and management of the following conditions that may be classified as cardiac compromise or acute coronary syndrome (slides 40- 63):40- 63 a.Angina pectoris b.Myocardial infarction c.Aortic aneurysm or dissection d.Congestive heart failure e.Cardiogenic shock f.Hypertensive emergencies g.Cardiac arrest 10.Explain the typical presentation of myocardial ischemia or infarction in females (slide 49).slide 49

6. Objectives 11.Explain the indications, contraindications, forms, dosage, administration, actions, side effects, and reassessment for nitroglycerin (slides 65-66).slides 65-66 12.Explain the special considerations in assessing and managing pediatric and geriatric patients with cardiac emergencies (slides 67-72).slides 67-72 13.Explain the assessment-based approach to assessment and emergency medical care for cardiac compromise and acute coronary syndrome (slides 74- 83).74- 83 14.Discuss the indications and contraindications for fibrinolytic therapy in patients with cardiac emergencies (slides 78-79).slides 78-79

7. Objectives 15.Given a series of scenarios, demonstrate the assessment-based management of a variety of patients with cardiovascular emergencies, including: Explain the indications, contraindications, forms, dosage, administration, actions, side effects, and reassessment for aspirin (slides 80-83).slides 80-83

8. Multimedia Directory Slide 30Explanation of Some Cardiac Rhythms Animation Slide 39Coronary Artery Disease Video Slide 42Understanding Coronary Heart Disease Video Slide 45Angina Pectoris and Nitroglycerin Video Slide 48Understanding Myocardial Infarctions Video Slide 64Understanding Dysrhythmias Video Slide 70Understanding Congenital Heart Defects Animation Slide 84Information about AEDS Video Slide 85Understanding Ventricular Fibrillation Video

9. Topics Review of the Circulatory System Anatomy and Physiology Cardiac Compromise and Acute Coronary Syndrome (ACS) Nitroglycerin Age-Related Variations: Pediatrics and Geriatrics Assessment and Care: General Guidelines

10. CASE STUDY Dispatch

11. Respond to 321 Congress Street, Reali’s Restaurant for a 49-year-old male with chest discomfort. EMS Unit 23 Time out 1735

12. Patient found seated at a table, clutching his chest Patient’s name is Paul Antak “I feel like someone is standing on my chest” Upon Arrival

13. How would you proceed to assess and care for this patient?

14. Back to Topics Review of the Circulatory System Anatomy and Physiology

15. The Circulatory System The Conduction System Back to Objectives

16. The Conduction System

17. The Circulatory System The Heart

19. The Circulatory System The Vessels

20. Major Arteries and Veins

21. Coronary Arteries

22. The Circulatory System The Blood

23. Components of Blood

24. Clot Formation Thrombus Platelets Thrombin Fibrin

25. Coronary Artery Thrombus

26. The Circulatory System Cardiac Contraction

27. To Lungs From Lungs To the Body

28. The Electrocardiogram Back to Objectives

29. Depolarization Repolarization P wave QRS complex T wave Back to Objectives

30. Return to Directory Click here to view an animation and explanation of some cardiac rhythms.here Explanation of Some Cardiac Rhythms

31. Blood Pressure Back to Objectives

32. Systolic blood pressure Diastolic blood pressure

33. Inadequate Circulation

34. Perfusion Hypoperfusion

35. Cardiac Compromise and Acute Coronary Syndrome (ACS) Back to Topics

36. Cardiac compromise Back to Objectives

37. Atherosclerosis

38. Arteriosclerosis Artherosclerosis Coronary artery disease (CAD)

39. Return to Directory Click here to view a video on the topic of coronary artery disease.here Coronary Artery Disease

40. Acute Coronary Syndrome Back to Objectives

41. Unstable angina Myocardial infarction Myocardial ischemia

42. Understanding Coronary Heart Disease Return to Directory Click here to view a video on the topic of understanding coronary heart disease.here

43. Acute Coronary Syndrome Angina Pectoris

44. Pathophysiology Assessment Back to Objectives

45. Return to Directory Click here to view a video on the topic angina pectoris and nitroglycerin.here Angina Pectoris and Nitroglycerin

46. Emergency Medical Care ABCs O 2 Pulse oximeter Nitroglycerin (if prescribed) Aspirin ALS

47. Acute Coronary Syndrome Acute Myocardial Infarction

48. Return to Directory Click here to view a video on the topic of understanding myocardial infarctions.here Understanding Myocardial Infarctions This video link wasn’t in the supplied documentation To be supplied later - wds

49. Acute Myocardial Infarction Pathophysiology Assessment Back to Objectives

50. Emergency Medical Care ABCs O 2 Pulse oximeter Nitroglycerin (if prescribed) Aspirin ALS Reassess

51. Acute Coronary Syndrome Aortic Aneurysm or Dissection

52. Aortic Aneurysm Causes Signs Symptoms

53. Aortic Dissection Causes Signs Symptoms

54. Other Causes of Cardiac Compromise Heart Failure

55. Pathophysiology Cardiogenic shock Signs and symptoms Need figure 17-12 Don’t have art yet - wds

56. Congestive Heart Failure Cause Acute versus chronic Edema

57. Assessment of Heart Failure

58. Emergency Medical Care ABCs O 2 Nitroglycerin (if prescribed) Reassess

59. Other Causes of Cardiac Compromise Hypertensive Emergencies

60. Hypertensive Emergency Pathophysiology Assessment

61. Emergency Medical Care ABCs O 2 Pulse oximeter Semi-Fowler’s ALS

62. Other Causes of Cardiac Compromise Cardiac Arrest

64. Understanding Dysrhythmias Return to Directory Click here to view a video on the topic of understanding dysrhythmias.here

65. Back to Topics Nitroglycerin

66. Indications Contraindications Forms Administration Side effects Back to Objectives

67. Age-Related Variations: Pediatrics and Geriatrics Back to Topics

68. Pediatric Considerations Back to Objectives

69. Congenital condition Typically respiratory in nature

70. Understanding Congenital Heart Defects Return to Directory Click here to view a video on the topic of congenital heart defects.here

71. Geriatric Considerations

72. Watch for deterioration Past medical history significant

73. Assessment and Care: General Guidelines Back to Topics

74. Assessment-Based Approach: Cardiac Compromise and Acute Coronary Syndrome Scene Size-Up and Primary Assessment Back to Objectives

75. Dispatch Scene size-up Primary assessment

76. Secondary Assessment Assessment-Based Approach: Cardiac Compromise and Acute Coronary Syndrome

77. Secondary Assessment History Onset Provocation Quality Radiation Severity Time

78. Fibrinolytics Purpose Indications Contraindications Back to Objectives

79. Physical exam Baseline vital signs Signs and symptoms

80. Emergency Medical Care Assessment-Based Approach: Cardiac Compromise and Acute Coronary Syndrome Back to Objectives

81. Emergency Medical Care O 2 Position of comfort Nitroglycerin (if prescribed) Aspirin ALS

82. Reassessment Assessment-Based Approach: Cardiac Compromise and Acute Coronary Syndrome

83. Reassessment Continually reassess for changes.

84. Return to Directory Click here to view a video on the topic of AEDS.here Information about AEDS

85. Understanding Ventricular Fibrillation Return to Directory Click here to view an animation about understanding ventricular fibrillation.here

86. CASE STUDY Follow-Up

87. Primary Assessment “I feel like someone is standing on my chest.” Alert and oriented Rapid, adequate breathing O 2 started at 15 lpm via nonrebreather mask Skin pale, cool, and slightly moist No sign of other injuries CASE STUDY

88. Secondary Assessment O: sudden onset P: nothing makes it better or worse Q: dull, squeezing pain; radiating to left arm S: 8/10 T: 20 minutes ago CASE STUDY

89. Secondary Assessment S: chest discomfort, irregular pulse, sweaty and pale skin A: none M: medication for HTN and nitroglycerin P: HTN L: in the middle of a meal E: started while eating his meal CASE STUDY

90. Physical Exam Pupils equal and responsive No JVD Clear, equal bilateral breath sounds BP: 180/110 mmHg; P: 98 irregular; RR: 28; SpO 2 : 98 percent on O 2 Medical direction gives permission to assist in administration of nitroglycerin and aspirin CASE STUDY

91. Physical Exam Patient becomes unresponsive, pulseless, and apneic CASE STUDY

92. Treatment and Reassessment Move patient to floor; apply AED, indicates a shockable rhythm ALS called Patient defibrillated; CPR started, five cycles of 30:2 After two minutes a palpable carotid and radial pulse; patient still unresponsive CASE STUDY

93. Treatment and Reassessment ALS arrives: “Where are you with your cardiac arrest management?” ALS performs – Advanced airway management – IV access – Medication administration CASE STUDY

94. Treatment and Reassessment CASE STUDY BP: 102/84mmHg, P: 102 irregular, RR: 10 assisted Arrive at hospital ED continues post-resuscitation care

95. 46-year-old female reported to have anxiety and tingling in her fingers Arrive on scene at an office building The woman’s supervisor greets you first and tells you the patient was at her desk, began feeling nauseated and short of breath, and then broke out in a sweat and became pale Her coworkers became concerned and called 911 Critical Thinking Scenario

96. The patient appears nervous She states she’s been under tremendous stress lately. She is extremely tired and woke up last night with a dull aching pain in her back and chest She has no known medical history and is taking no medications Critical Thinking Scenario

97. Vital signs: BP: 102/70 mmHg HR: 110 bpm RR: 28 times per minute SpO 2 : 94 percent Skin is pale, cool, and clammy Critical Thinking Scenario

98. 1.Do her vital signs concern you? 2.Would you consider withholding oxygen delivery with this patient? 3.Explain how this patient may be having non-classical signs of myocardial ischemia. 4.What is your treatment plan for this patient? Critical Thinking Questions

99. Reinforce and Review Please visit www.bradybooks.com www.bradybooks.com and follow the myBradykit links to access content for the text.