1. Copyright 2009 Seattle/King County EMS Overview of CBT 434 Cardiovascular Emergencies Complete course available at www.emsonline.net

2. Copyright 2009 Seattle/King County EMS Introduction Cardiovascular 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

3. Copyright 2009 Seattle/King County EMS 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:

4. Copyright 2009 Seattle/King County EMS Terms acute 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

5. Copyright 2009 Seattle/King County EMS Terms, continued pulmonary 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

6. Copyright 2009 Seattle/King County EMS Anatomy Thoracic 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

7. Copyright 2009 Seattle/King County EMS 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

8. Copyright 2009 Seattle/King County EMS Arteries/Veins Anatomy, continued Purpose of CV system Provide cells with oxygen nutrients Remove waste Components Heart Arteries Arterioles Capillaries Veins Venules

9. Copyright 2009 Seattle/King County EMS Coronary Arteries Anatomy, continued 1. Right coronary artery 2. Left coronary artery 3. Atria 4. Ventricles 2 2 1 1 3 3 4 4

10. Copyright 2009 Seattle/King County EMS Myocardial Ischemia Myocardial 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

11. Copyright 2009 Seattle/King County EMS 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

12. Copyright 2009 Seattle/King County EMS Myocardial Ischemia, continued Reduced blood flow associated with conditions that cause: Hypotension (e.g. blood loss) Tachycardia Bradycardia

13. Copyright 2009 Seattle/King County EMS Coronary Thrombosis 1 1 Plaque forms on the inner wall of an artery

14. Copyright 2009 Seattle/King County EMS Coronary Thrombosis, continued 1 1 2 2 Hard surface of the plaque tears, exposing the soft under side

15. Copyright 2009 Seattle/King County EMS Coronary Thrombosis, continued 1 1 2 2 3 3 Platelets arrive to form a blood clot

16. Copyright 2009 Seattle/King County EMS Other Sources of Chest Pain Mediastinum Chest wall Lungs and pleura Abdomen Psychogenic Not all chest pain is cardiac related.

17. Copyright 2009 Seattle/King County EMS Conditions Angina 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 Onsetsudden Provocationphysical exertion, stress, cold weather, relieved by rest Qualitypressure or squeezing pain Radiatespain can radiate to jaw, arm or upper back Severitymild to moderate Timerelieved with rest and/or nitroglycerin within 3-5 min

18. Copyright 2009 Seattle/King County EMS Conditions, continued Acute 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

19. Copyright 2009 Seattle/King County EMS Conditions, continued Acute myocardial infarction (AMI) Chest discomfort Discomfort in other areas of the upper body Shortness of breath Diaphoresis, nausea or weakness

20. Copyright 2009 Seattle/King County EMS Conditions, continued Aortic 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

21. Copyright 2009 Seattle/King County EMS Conditions, continued Congestive 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

22. Copyright 2009 Seattle/King County EMS Conditions, continued Congestive heart failure signs Fatigue Cough, dyspnea Pulmonary edema (a severe form of CHF) Tachypnea Agitation and confusion Hypertension Swollen feet or lower legs

23. Copyright 2009 Seattle/King County EMS Initial Assessment Guides initial treatment Quickly assess a patient Make a decision SICK or NOT SICK SICK or NOT SICK

24. Copyright 2009 Seattle/King County EMS SICK/NOT SICK A 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.

25. Copyright 2009 Seattle/King County EMS Key Clinical Indicators Respirations (rate, character) Pulse (rate, character) Mental status Skin signs and color Body position SICK or NOT SICK SICK or NOT SICK

26. Copyright 2009 Seattle/King County EMS Patient History OPQRST OnsetWhat was patient doing when the pain started? ProvocationWhat makes it better or worse? Quality Can you describe it? What does it feel like? Radiates Where do you feel it? Where does it go? SeverityHow bad is it on a scale of 1 to 10 (ten being the worst)? TimeWhen did the pain begin?

27. Copyright 2009 Seattle/King County EMS 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

28. Copyright 2009 Seattle/King County EMS Physical Exam, continued Atypical presentations are common in elderly, diabetics and females. Classic SymptomsAtypical 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

29. Copyright 2009 Seattle/King County EMS Patient Care General steps Decide SICK or NOT SICK Ensure adequate airway and respirations Administer oxygen Position appropriately Assure ALS response

30. Copyright 2009 Seattle/King County EMS Patient Care, continued Other considerations Control airway secretions Assist ventilations with BVM Prepare for cardiac arrest and application of an AED

31. Copyright 2009 Seattle/King County EMS Nitroglycerin Used to treat angina Relaxes vascular muscles Increases blood flow & oxygen to myocardium

32. Copyright 2009 Seattle/King County EMS 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.

33. Copyright 2009 Seattle/King County EMS Nitroglycerin, continued “Assisting” a patient with nitroglycerin means you can: Locate the container Open it Offer a pill to the patient

34. Copyright 2009 Seattle/King County EMS Summary Thoracic 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

35. Copyright 2009 Seattle/King County EMS Summary, continued Myocardial 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.

36. Copyright 2009 Seattle/King County EMS Summary, continued OPQRST 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