1. 1 CARDIOVASCULAR EMERGENCIES

2. 2 Cardiovascular Disease 63,400,000 North Americans have one or more forms of heart or blood vessel disease 50% of all deaths are cardiovascular disease

3. 3 Cardiovascular Disease A cute M yocardial I nfarction (Heart Attack) - leading cause of death in U.S. 1.5 million North Americans will have AMI’s this year –Of these.5 million will die! –350,000 will die in first two hours!

4. 4 Cardiovascular Disease Risk Factors Major Uncontrollable –Age –Sex –Race –Heredity

5. 5 Cardiovascular Disease Risk Factors Major Controllable –Smoking –High BP –High blood cholesterol –Diabetes

6. 6 Cardiovascular Disease Risk Factors Minor Controllable –Obesity –Lack of exercise –Stress –Personality

7. 7 Cardiovascular Disease Control risk factors - decrease Coronary Artery Disease and Acute Myocardial Infarction

8. 8 Coronary Artery Disease Myocardium (heart muscle) requires continuous oxygen and nutrient supply Myocardial blood supply passes through coronary arteries

9. 9 Coronary Artery Disease Atherosclerosis –Narrowing of lumen plaque formation - related to Risk Factors results in decreased myocardial perfusion –Poor tissue perfusion causes: –tissue damage (ischemia) –tissue death (infarction)

10. 10 Atherosclerotic Plaque Formation

11. 11 Angina Pectoris “A choking in the chest” Angere - to choke Myocardial oxygen demand exceeds supply during periods of increased activity, exercise, or stressful event

12. 12 Angina Pectoris During stress the myocardium demands more O 2 Coronary arteries would normally dilate to supply more blood and O 2 In Angina Pectoris, the coronary arteries are unable to dilate sufficiently to increase perfusion

13. 13 Symptoms -Angina Pectoris Pain –Substernal –Squeezing/Crushing/Heaviness –May radiate to arms, shoulders, jaw, upper back, upper abdomen back –May be associated with shortness of breath, nausea, sweating

14. 14 Symptoms -Angina Pectoris Pain usually associated with 3E’s –Exercise –Eating –Emotion

15. 15 Symptoms -Angina Pectoris Pain seldom lasts > 30 minutes Pain relieved by –Rest –Nitroglycerin

16. 16 Symptoms -Angina Pectoris Great anxiety/Fear Fixation of the body Pale, ashen, or livid face Dyspnea (SOB) may be associated

17. 17 Symptoms -Angina Pectoris Nausea Diaphoresis BP usually up during attack Dysrhythmia may be present

18. 18 Angina Pectoris Following an angina attack there is no residual damage to the myocardium

19. 19 Forms of Angina Pectoris Stable Angina –Occurs with exercise –Predictable –Relieved by rest or Nitroglycerin

20. 20 Forms of Angina Pectoris Unstable Angina –More frequent/severe –Can occur during rest –May indicate impending MI –Requires immediate treatment and transport to appropriate facility

21. 21 Acute Myocardial Infarction “Heart Attack” Inadequate perfusion of myocardium –Death of myocardium Infarct –Damage to myocardium Ischemia

22. 22 Symptoms - AMI Chest Pain - cardinal sign of myocardial infarction –Occurs in 85% of MI’s –Substernal –“Crushing,” “squeezing,” “tight,” “heavy”

23. 23 Symptoms - AMI Chest Pain –May radiate to arms, shoulders, jaw, upper back, upper abdomen back –May vary in intensity –Unaffected by: swallowing coughing deep breathing movement

24. 24 Symptoms - AMI Chest Pain –Unrelieved by rest/nitroglycerin –Pain lasts longer than angina pain (up to 12 hours) –“Silent’ MI 15% of patients with MI, particularly common in elderly and diabetics

25. 25 Symptoms - AMI Shortness of breath Weakness, dizziness, fainting Nausea, vomiting Pallor and diaphoresis (heavy sweating)

26. 26 Symptoms - AMI Sense of impending doom Denial –50% of deaths occur in first two hours –Average patient waits 3 hours before seeking help

27. 27 Symptoms - AMI Changes in pulse, BP, respiration are not diagnostic of AMI

28. 28 Acute Myocardial Infarction Early recognition of MI is critical

29. 29 Management of Cardiac Chest Pain When in doubt, manage all chest pain as MI

30. 30 Management of Cardiac Chest Pain Begin management immediately if angina or MI are suspected. Complete the history and physical exam as you treat.

31. 31 Management of Cardiac Chest Pain Position of Comfort Patent Airway High concentration O 2 –non-rebreather mask 10-15 lpm

32. 32 Management of Cardiac Chest Pain Reassure the patient Obtain a brief history and physical exam Aspirin 325mg p.o.

33. 33 Management of Cardiac Chest Pain Nitroglycerin 0.4mg tablet sublingual –Patient should be sitting or lying down –Has Pt. Taken nitroglycerin in last 10 minutes? Is pain relieved? Headache? –Is BP > 90 systolic? –q 5 minutes until pain relieved or three tablets administered

34. 34 Management of Cardiac Chest Pain If pain is unrelieved by rest, oxygen, nitroglycerin or if a change has occurred in pattern of angina, transport immediately Transport in semi-sitting position if BP normal or elevated; flat if BP low

35. 35 Management of Cardiac Chest Pain Do not walk patient to the ambulance Do not use lights/siren if patient is awake, alert, breathing without distress Monitor vital signs every 5-10 minutes

36. 36 Management of Cardiac Chest Pain Request early ALS back-up –Deaths in MI result from arrhythmia's –Arrhythmia's can be prevented with early drug therapy

37. 37 Congestive Heart Failure CHF = Inability of heart to pump blood out as fast as it enters. May be left-sided, right-sided, or both.

38. 38 Congestive Heart Failure Usually begins with left-sided failure. –Left ventricle fails –Blood “stacks up” in lungs –High pressure in capillary beds –Fluid forced out of capillaries into alveoli

39. 39 Congestive Heart Failure Right-sided failure most commonly caused by Left-sided failure. Blood “backs up” into systemic circulation –Distended neck veins –Fluid in abdominal cavity –Pedal edema

40. 40 Causes of CHF Coronary Artery Disease Chronic hypertension (high blood pressure) AMI Valvular heart disease

41. 41 Symptoms of CHF Weakness Dyspnea Dyspnea on exertion Paroxysmal nocturnal dyspnea –Attacks of SOB that usually occur at night that awakens the patient

42. 42 Symptoms of CHF Orthopnea –Difficulty breathing in any position other than standing or sitting Abdominal discomfort Jugular Vein Distention (JVD) Pedal “Pitting” edema in lower extremities

43. 43 Symptoms of CHF Tachycardia Pulmonary Edema –Noisy, labored breathing –Coughing –Rales, wheezing –Pink, frothy sputum

44. 44 Management of CHF Sit patient up, let feet dangle Administer high concentration O 2 Assist ventilation as needed Monitor vital signs q 5-10 minutes Request early ALS back-up

45. 45 Pacemaker Failure Position of comfort Patent airway High Concentration O 2 Assist ventilations as needed ALS Intercept CPR as needed –DO NOT worry about damage to pacemaker

46. 46 Coronary Artery Bypass Position of comfort Patent airway High Concentration O 2 Assist ventilations as needed ALS Intercept CPR as needed –DO NOT worry about damage to sutures/staples or by-passed arteries

47. 47 Implanted Defibrillator If performing CPR on a patient: –Implanted defibrillator may “fire” –May feel slight “tingle”