1. Copyright 2006 Seattle/King County EMS Overview of CBT 434 Cardiovascular Emergencies Complete Course Available at: www.emsonline.net

2. © 2006 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. © 2006 Seattle/King County EMS Practical Skills focused history using SAMPLE/OPQRST technique assisting with nitroglycerin auscultation technique and assessing breath sounds assisting ventilations with BVM care for acute coronary syndrome, CHF, aortic dissection, shock use of AED Practical Skills Checklist Practical Skills Checklist available at EMS Online. To receive CBT or OTEP credit, you must perform the following practical skills: EMS Online

4. © 2006 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 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

5. © 2006 Seattle/King County EMS Anatomy, continued Thoracic Cavity extends from neck to lower reaches of ribs divided into mediastinum and pleural cavities lies in the center with diaphragm at its base contains the trachea, esophagus, heart, aorta, vena cava and the pulmonary artery pleural cavities lie on each side of mediastinum

6. © 2006 Seattle/King County EMS Structures Anatomy, continued Thoracic Cavity 12 pairs of ribs surrounding thoracic cavity connect to sternum through a bridge of cartilage lower 5 ribs connect to sternum through a long cartilage bridge called the costal arch the intercostal are muscles between the ribs

7. © 2006 Seattle/King County EMS Arteries and Veins Anatomy, continued Thoracic Cavity Structures The purpose of the cardiovascular system is to: 1. provide cells with oxygen nutrients 2. remove waste Its components are: heart arteries arterioles capillaries veins venules

8. © 2006 Seattle/King County EMS Coronary Arteries Thoracic Cavity Structures Arteries and Veins Anatomy, continued There are two main arteries that nourish the heart with blood: 1. right coronary artery 2. left coronary artery The heart has four chambers that contract in coordination to pump blood: 3. top two chambers are the atria 4. bottom chambers are called ventricles 2 2 1 1 3 3 4 4

9. © 2006 Seattle/King County EMS Myocardial Ischemia 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 Myocardial ischemia is the lack of blood flow and oxygen to the myocardium (heart muscle). Coronary Artery 75% occluded occluded

10. © 2006 Seattle/King County EMS Myocardial Ischemia, continued What Causes Myocardial Ischemia? 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 Reduced blood flow associated with conditions that cause: hypotension (e.g. blood loss) tachycardia bradycardia

11. © 2006 Seattle/King County EMS Coronary Thrombosis, continued 1 1 Plaque forms on the inner wall of an artery

12. © 2006 Seattle/King County EMS Coronary Thrombosis, continued 1 1 2 2 Hard surface of the plaque tears, exposing the soft under side

13. © 2006 Seattle/King County EMS Coronary Thrombosis, continued 1 1 2 2 3 3 Platelets arrive to form a blood clot

14. © 2006 Seattle/King County EMS Other Sources of Chest Pain Chest pain can arise in the: mediastinum chest wall lungs and pleura abdomen psychogenic Not all chest pain is cardiac related.

15. © 2006 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 nitroglycerin 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

16. © 2006 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. The range of symptoms can include: shortness of breath discomfort chest pain pressure nausea weakness dysrhythmia syncope

17. © 2006 Seattle/King County EMS Conditions, continued Acute myocardial infarction (AMI) occurs when oxygenated blood cannot reach the myocardium and muscle tissue dies caused when a coronary artery is completely blocked or occluded same mechanism as angina except that AMI results in tissue death and is not reversible Patients with AMI can experience: chest discomfort discomfort in other areas of the upper body shortness of breath diaphoresis, nausea or weakness

18. © 2006 Seattle/King County EMS Conditions, continued Aortic dissection a condition in which blood gets behind the inner layer of the aorta blood starts to fill the space between the layers of the arterial wall aorta widens and significantly disrupts blood flow. This patient can experience: sudden and severe chest or upper back pain anxiety diaphoresis nausea

19. © 2006 Seattle/King County EMS Conditions, continued Congestive heart failure (CHF) occurs when the heart is too weak to adequately circulate blood in left-sided heart failure, pulmonary edema occurs as blood backs up into the lungs increases the amount of fluid in the alveoli of the lung and results in shortness of breath Signs of left-sided CHF include: fatigue cough dyspnea pulmonary edema (a severe form of CHF) tachypnea agitation and confusion hypertension swollen feet or lower legs

20. © 2006 Seattle/King County EMS Patient Care Initial Assessment guides the initial path of treatment quickly assess a patient make a decision 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. SICK or NOT SICK

21. © 2006 Seattle/King County EMS Patient Care, continued Key clinical indicators respirations (rate and character) pulse (rate and character) mental status skin signs and color body position The SICK/NOT SICK choice is a very important medical decision. SICK or NOT SICK

22. © 2006 Seattle/King County EMS Patient Care, continued OPQRST is an excellent tool for assuring a thorough medical history. OPQRST OnsetWhat was patient doing when the pain started? ProvocationWhat makes it better or worse? QualityCan you describe it? What does it feel like? RadiatesWhere 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?

23. © 2006 Seattle/King County EMS Patient Care, continued Physical Exam auscultate breath sounds starting at the bases blood pressure 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 See demonstration of proper auscultation of breath sounds at www.emsonline.net/cardiac/physical.asp.

24. © 2006 Seattle/King County EMS Patient Care, continued Physical Exam Atypical presentations are common in the 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 shortness of breath 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

25. © 2006 Seattle/King County EMS Patient Care, continued SICK or NOT SICK Management General Steps include: decision of SICK or NOT SICK ensuring an adequate airway and respirations administering oxygen positioning the patient appropriately assuring an ALS response Other considerations include: controlling airway secretions assisting ventilations with a BVM. preparing for cardiac arrest and application of an AED

26. © 2006 Seattle/King County EMS Patient Care, continued Nitroglycerin a medication used to treat angina relaxes vascular muscles increases blood flow and oxygen to the myocardium EMS providers may assist a patient in taking prescribed nitroglycerin IF: 1.pain is the same for which nitroglycerin is normally taken AND 2.patient’s blood pressure is greater than 100 mmHg systolic. Make sure the expiration date of the medication has not passed.

27. © 2006 Seattle/King County EMS Patient Care, continued Assisting a patient with nitroglycerin means you can: locate the container open it offer a pill to the patient Do NOT administer the drug by placing a pill in the patient’s mouth. You may assist in the same way with nitroglycerin spray. If you have any doubts about the circumstances, consult with the responding paramedic unit or with medical control before assisting with nitroglycerin.

28. © 2006 Seattle/King County EMS Summary The thoracic cavity is divided into the: mediastinum pleural cavities. The structures within the thoracic cavity include: intercostal muscles ribs sternum costal arch diaphragm heart lungs trachea aorta pulmonary arteries

29. © 2006 Seattle/King County EMS Summary 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. 5 common cardiovascular emergencies are angina, AMI, aortic dissection, CHF and cardiogenic shock.

30. © 2006 Seattle/King County EMS Summary 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

31. © 2006 Seattle/King County EMS Questions What questions do you have about cardiovascular emergencies? Three options: 1.Ask the Doc: http://www.emsonline.net/doc.asphttp://www.emsonline.net/doc.asp 2.Check Guidelines/Standing orders at EMS Online: http://www.emsonline.net/downloads.asp http://www.emsonline.net/downloads.asp 3.Email support: help@emsonline.nethelp@emsonline.net Dr. Mickey Eisenberg Medical Director EMS Online Guidelines and Standing Orders Mike Helbock Training Division Manager