Cardiac Emergencies Flashcards
Right Atrium
Receives blood from veins; pumps to right ventricle.
Right Ventricle
Pumps blood to the lungs.
Left Atrium
Receives blood from lungs; pumps to left ventricle.
Left Ventricle
Pumps blood through the aorta to the body.
How does the normal function of the heart and blood vessels relate to blood pressure and distal pulses?
.
How is shock related to the function of the heart and blood vessels?
.
Acute Coronary Syndrome (ACS)
• Sometimes called cardiac compromise
• Refers to any time the heart may not be
getting enough oxygen
• Many different kinds of problems under the ACS heading
• Symptoms often mimic non-cardiac conditions
• Treat all patients with ACS-like signs and symptoms as though they are having a heart problem
Symptoms Acute Coronary Syndrome (ACS)
- Chest pain is best-known symptom
- Can be described as “crushing, dull, heavy, or squeezing”
- Sometimes described only as pressure or discomfort - feels like indigestion
- Radiates to arms, upper abdomen, jaw
- Dyspnea also found in ACS
- May be the only finding in some patients
- Anxiety, feeling of impending doom
- Nausea and pain or discomfort in upper abdomen (epigastric pain)
- Sweating
- Abnormal pulse (tachycardia/bradycardia)
- Abnormal blood pressure
- Women will tell you they just don’t feel like themselves
Symptoms of Acute Coronary Syndrome (ACS)
- Perform primary assessment
- Obtain history and physical exam
- Use OPQRST to get history of present illness
- Obtain SAMPLE history
- Take baseline vital signs
Treatment for Acute Coronary Syndrome (ACS)
• Place patient in position of comfort (typically sitting up)
• Apply high-concentration oxygen - if O2 Sats are good a nasal cannula’s fine
• Transport
• If trained, equipped, and authorized to do so, obtain a 12-lead electrocardiogram (ECG) - can pinpoint where the MI is occurring
• Give the patient nitro if conditions are met (makes the fuel line bigger)
• Give the patient aspirin if conditions are met
• Follow local protocol as to whether to transmit it to hospital for interpretation
Indications for administering nitroglycerin
ACS
– Chest pain
– History of cardiac problems and prescribed nitroglycerin
– Patient has nitroglycerin
– Medical direction authorizes administration
Contraindications for administering nitroglycerin
– Systolic blood pressure less than 90–100 (consult local protocol)
– Patient has taken Viagra or similar drug for erectile dysfunction within 48–72 hours
Indications for administering aspirin
– Chest pain
– Ability to safely swallow
– Medical control authorization
Contraindications for administering aspirin
– Inability to swallow
– Allergy to aspirin
– History of asthma
– Patient already taking other anti-clotting medications
Causes of Coronary Artery Disease
• Conditions that narrow or block arteries of heart
• Often result from fatty deposit build-up on inner
walls of arteries
• Build-up narrows inner vessel diameter, restricts flow of blood
• Thrombus—occlusion of blood flow caused by formation of a clot on rough inner surface of diseased artery
• Thrombus can break loose and form an embolism
• Emboli can move to occlude flow of blood downstream in a smaller artery
• Reduced blood supply to myocardium causes emergency in majority of cardiac- related medical emergencies
• Chest pain is most common symptom of reduced blood supply
What is an Aneurysm
- Weakened sections of blood vessels begin to dilate (balloon)
- Bursting can cause rapid, life- threatening internal bleeding
Dysrhtmias
Electrical Malfunctions of the Heart
• Malfunction of heart’s electrical system generally results in dysrhythmia
• Dysrhythmias include bradycardia, tachycardia, and rhythms that may be present when there is no pulse
Mechanical Malfunctions of the Heart
- Angina pectoris
* Acute myocardial infarction (AMI) • Congestive Heart Failure (CHF)
Angina Pectoris
• Chest pain caused by insufficient blood
flow to the myocardium
• Typically due to narrowed arteries secondary to coronary artery disease
• Pain usually during times of increased myocardial oxygen demand, such as exertion or stress
Acute Myocardial Infarction (AMI)
- Death of a portion of the myocardium due to lack of oxygen
* Coronary artery disease is usually the underlying reason
Congestive Heart Failure (CHF)
- Inadequate pumping of the heart
- Often leads to excessive fluid build-up in lungs and/or body
- May be brought on by diseased heart valves, hypertension, obstructive pulmonary disease
- Often a complication of AMI
Progression of CHF
- Patient sustains AMI
- Myocardium of left ventricle dies
- Because of damage to left ventricle, blood backs up into pulmonary circulation and lungs
- If untreated, left heart failure commonly causes right heart failure
Signs and Symptoms of CHF (right sided heart failure)
- Tachycardia (>100 bpm)
- Dyspnea and cyanosis
- Normal or elevated blood pressure
- Diaphoresis
- Pulmonary edema
- Anxiety or confusion due to hypoxia
- Pedal edema (sacral in a bedridden pt)
- Engorged, pulsating neck veins (late sign)
- Enlarged liver and spleen
patient will tell you they are taking a water pill
Cardiac Arrest Chain of Survival
• Five elements
- Immediate recognition and activation
- Early CPR
- Rapid defibrillation
- Effective advanced life support
- Integrated post-cardiac arrest care
Early CPR
• Increases survival chances significantly
• Three ways CPR can be delivered earlier
– Get CPR-trained professionals to patient
faster
– Train laypeople in CPR
– Train dispatchers to instruct callers how to perform CPR
Why is Rapid Defibrilation Important
• Sooner defibrillator arrives, more likely patient will survive cardiac arrest
Why is Integrated Post-Cardiac Arrest Care important
• Coordinating numerous means of assessment and interventions that together maximize the chance of neurologically intact survival
Elements of Integrated Post-Cardia Arrest Care
- Maintaining adequate oxygenation
- Avoiding hyperventilation
- Performing 12-lead ECG
- Managing treatable causes of arrest
- Appropriate destination for patient
- Possibly inducing hypothermia
Management of Cardiac Arrest
• EMT provides two links in chain of survival
– Early CPR
– Rapid defibrillation
Treatment of Cardiac Arrest
• Standard Precautions • ALS (when available) • One- and two-rescuer CPR • Using an automated external defibrillator • Artificial ventilations and airway management • Interviewing bystanders and family members • Lifting and moving patients
Two types of Automated External Defribrilator (AED)
• Semiautomatic
– Advises EMT to press button that causes
machine to deliver shock through pads • Fully automatic
– Does not advise EMT to take any action; delivers shock automatically
Classification of AED
• Classified by type of shock delivered
– Monophasic: sends single shock from
negative pad to positive pad
– Biphasic: sends shock in one direction and then the other
What are the most common condition resulting in cardiac arrest - shockable rhythms
– Ventricular fibrillation
– Ventricular tachycardia
AED Safety Measures
• Do not defibrillate soaking-wet patient
• Do not defibrillate if patient is touching anything metallic that other people are touching
• Remove nitroglycerin patches before defibrillating
• Defibrillation can be performed on patient
with an implanted device
• Position defibrillation pads on patient’s chest to avoid contact with the device
AED Maintenance
- Use checklist at beginning of every shift to ensure you have all supplies and AED is functioning properly
- Make sure battery is charged and you have a spare with defibrillator
What functions does AED Quality Improvement involve?
• Involves multiple functions – Medical direction – Initial training – Maintenance of skills – Case review – Trend analysis – Strengthening links in chain of survival
What do you need to keep in mind when Coordinating CPR and AED
- Interrupt CPR only when absolutely necessary and for as short a period as possible
- CPR must be paused for rhythm analysis and defibrillation
Describe the primary assessment for a non-repsonsive patient
• Perform primary assessment
– If bystanders are doing CPR when
you arrive, have them stop
– Verify pulselessness, apnea, absence of other signs of life no longer than 10 seconds
• Apply AED
– Bare patient’s chest; quickly shave area where pads will be placed if necessary
– If available, use pediatric AED pads
– If using adult pads, do not overlap
• Use AED – Turn on AED – Attach pads to cables and then to patient – Stop CPR and analyze – Clear patient and shock if indicated
• Immediately begin CPR after delivering a shock
• Reassess patient after providing 2 minutes or 5 cycles of CPR
• If AED finds no shockable ECG rhythm, will advise that no shock is indicated
– Pulseless electrical activity – Asystole
• Resume CPR immediately
• If patient wakes or begins to move
– Obtain baseline vital signs
– Administer high-concentration oxygen
– Transport
Things to keep in mind when providing CPR
• When providing CPR
– Compressions must not be interrupted for any longer than 10 seconds
– Compressions at least 2 inches deep for adult and at least one-third depth of chest for infants and children with full chest recoil
– Rate should be at least 100 per minute
– Rotate personnel through compressor position to prevent fatigue
What is done during Post-Resuciatiion Care
• Patient has a pulse – Manage airway; avoid hyperventilation – Keep defibrillator on patient during transport in case patient goes back into arrest – Reassess frequently (every 5 minutes) – Consider hypothermia protocols
• Patient goes back into cardiac arrest – Stop vehicle, resume CPR – Analyze rhythm as soon as possible – Deliver shock if indicated – Continue with 2 shocks separated by 2 minutes (5 cycles)
Chapter Review
• Patients with cardiac compromise or ACS
can have many different presentations.
• Some complain of pressure or pain in the chest with difficulty breathing. Others may have just mild discomfort that they ignore or that goes away and returns.
Chapter Review
• Between 10%–20% of heart attack
patients have no chest discomfort.
• Because of these possibilities and the severe complications of heart problems, have a high suspicion and treat patients with these symptoms for cardiac compromise.
Chapter Review
- ACS patients need high-concentration oxygen and prompt, safe transportation to definitive care.
- You may be able to assist patients who have their own nitroglycerin.
Chapter Review
• To provide maximum chance of survival for patients in cardiac arrest, EMS agencies must strengthen their performance of the chain of survival: immediate recognition and activation, early CPR, rapid defibrillation, effective ALS, and integrated post-cardiac arrest care.
Remember
• The heart is a simple pump that moves deoxygenated blood to the lungs and oxygenated blood to the body. Pressure within the cardiovascular system is critical to the moving of blood.
Remember
- Acute coronary syndrome (ACS) is a blanket term that refers to a number of situations in which perfusion of the heart is inadequate.
- Although there are common symptoms of ACS, EMTs must recognize atypical findings and err on the side of caution.
Remember
• Oxygen, nitroglycerine, and aspirin are key medications indicated to treat ACS. However, the definitive treatment is transportation of the patient to a facility that can open the blocked artery.
Remember
- Most cardiac conditions are caused by arterial problems. Angina pectoris and acute myocardial infarction are caused by inadequate perfusion of the heart.
- Heart failure can be caused by either electrical or mechanical problems.
Remember
- The most important element of cardiac arrest care is the administration of high- quality chest compressions.
- The American Heart Association’s chain of survival describes the key elements necessary to maximize the cardiac arrest patient’s chance of survival.
Remember
- AED provides early defibrillation in cardiac arrest patients with ventricular tachycardia and ventricular fibrillation.
- Post-cardiac arrest care is an essential element of cardiac arrest care.
- Mechanical CPR devices provide automated chest compressions in cardiac arrest settings.
Questions to Consider
• What position is best for a patient with:
– Difficulty breathing and a blood pressure of 100/70?
– Chest pain and a blood pressure of 180/90?
• Describe how to “clear” a patient before administering a shock.
Questions to Consider
• List three safety measures to keep in mind
when using an AED.
• List the steps in the application of an AED.
Critical Thinking
• A 78-year-old male has been complaining of severe shortness of breath for 20 minutes prior to your arrival. When you arrive, you find the patient unconscious and not moving. What are your immediate priorities?
cardiopulmonary resuscitation (CPR)
actions taken to revive a person by keeping the patients heart and lungs working
defibrillation
delivery of an electrical shock to stop the fibrillation of heart muscles and restore a normal heart rhythm
acute coronary syndrome (ACS)
cardiac compromise
a blanket term used to represent any symptoms related to lack of oxygen (ischemia) in the heart muscle. Also called cardiac compromise.
acute myocardial infarction (AMI)
the condition in which a portion of the myocardium dies as a result of oxygen starvation; often called a heart attack by laypersons.
agonal breathing
irregular, gasping breaths that precede apnea and death
angina pectoris
pain in the chest, occurring when blood supply to the heart is reduced and a portion of the heart muscle is not receiving enough oxygen
aneurysm
the dilation, or ballooning, of a weakened section of the wall of the artery
apnea
no breathing
asystole
when the hear has ceased generating electrical impulses
bradycadia
when the heart rate is slow, usually below 60 beats per minute.
cardiovascular system
the heart and the blood vessels
congestive heart failure (CHF)
the failure of the heart to pump efficiently, leading to excessive blood or funds in the lungs, the body, or both
coronary artery disease (CAD)
diseases that affect the arteries of the heart
dyspnea
shortness of heath; labored or difficult breathing
dysrhythmia
a disturbance in heart rate and rhythm
edema
swelling resulting from a build up of fluid in the tissues
embolism
blockage of a vessel by a coo or foreign material brought to the site by the current of the blood
nitroglycerin
a medicate that dilates the blood vessels
occlusion
blockage. as of an artery by fatty deposits
pedal edema
accumulation of fluid int he feet or ankles
pulmonary edema
accumulation of th fluid in the lungs
pulseless electrical activity (PEA)
a condition in which the hearts electoral rhythm remains relatively normal, yet the mechanical pumping activity fails to follow the electrical activity, causing cardiac arrest
sudden death
a cardiac arrest that occurs within 2 hours of the onset of symptoms. The patient may have no prior symptoms of coronary artery disease.
tachycardia
when the heart rate is fast, above 100 beats per minute
thrombus
a clot formed of bloom and plaque attached to the inner wall of an artery of vein
ventricular fibrillation (VF)
a condition in which the hearts electrical impulses are disorganized, preventing the heart muscle from contracting normally
ventricular tachycardia (V-tach)
a condition in which the heartbeat is quite rapid; if rapid enough, ventricular tachycardia will not allow the hearts chambers to fill with enough blood between betas to produce blood flow sufficient to meet the body’s needs
symptoms of a heart problem
• chest pain - crushing, dull, heavy squeezing
• pressure
• discomfort
• difficulty breathing
• sudden onset of sweating, nausea and vomiting
pain or pressure radiating down the arm, upper abdomen (epigastric) or jaw
• anxious or feeling if impending doom
• irritability or short temper
• loss of consciousness
• abnormal pulse or blood pressure
• bradycardia or tachycardia
• palpitation or irregular heartbeat
• hypotensive (systolic 150 or diastolic >90)
• unusual feeling of fatigue
Symptoms of Acute Coronary Syndrome
- Pain, pressure or discomfort in the chest or upper abdomen
- Difficulty breathing
- Palpitations
- Sudden onset of sweating & nausea or vomiting
- Anxiety (feeling of impending doom or vomiting)
- Unusual generalized weakness
- Abnormal pulse (rapid, slow or irregular)
- Abnormal blood pressure
Patient Care for Acute Coronary Syndrome
• Place in position of comfort, usually sitting up
• Pt who are hypotensive BP 94
• Continue to check for altered mental status and airway
• Transport immediately if the pt has any one of:
-No history of cardiac problems
- History of cardiac problem, but no nitroglycerin
-
When does clinical and biological death occur
biological death heart not beating
4-6 minutes before clinical death
.
Excellent CPR only provides 30% of blood flow to the brain
Tricuspid valve Bicuspid valves Inferior and Superior vena cava pulmonary artery aorta
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SA Node
AV Node
Bundle branch
all the cardiac conduction system begins with the sa node 60-100 impulses per minute, but the back up is the av node at it fires at 40-60, it takes over but a slower
What is going on in the body
when born the arteries are nice and round can carry a lot of blood, over the years fatty deposits build up and the arteries can’t feed the heart blood as well (arteriosclerosis, atherosclerosis)
What is the dosage for nitro is
dosage for nitro is 0.4 mg - based on medical direction every 5 minutes until pain is 0 or the blood pressure is under 100
lowest blood pressure to administer nitro
systolic of 100 (not 90-100 is the book)
contraindication for nitro
male sexual enhancement drugs
(original indication for reducing pulmonary hypertension - excessive pressure in the pulmonary side - when being invented - reduces systolic blood pressure in cardiac pt’s increases coronary perfusion)
if given when also taking male enhancement crash blood pressure
have you taken viagra, cialis, or levitra
thrombus
a clot form of blood and plaque attached to the inner wall of an artery
occlusion
blockage as of an artery by fatty deposits
embolism
blockage of vessel by a clot of foreign material brought to the site by the blood current
aneurysm
the dilation, or ballooning , of a weaker section of the wall of an artery
angina
pain that goes away with rest (have something wrong with my gas line)- pain with infarction does no go away
MI
death of tissue in the heart - heart muscle does not regenerate
dysrhythmia
a disturbance in the heart rate and rhythm
angina pectoris
pain in the chest occurring when blood supply to the heart is reduced and a portion of the heart muscle is not receiving enough oxygen
CHF
right side pumping well and the left side is not so the fluid is backing up in the lungs - can hear the bubbling when the try and talk to you
CPAP pushes the air in and that pushes the fluid back where it needs to be - a BVM may help to do this
left side is failing - CHF
right side is failing you see back up in the body - JVD distention in vascular organs of the body - edema
nitroglycerin
a medication that dilates the blood vessels
Differences between right sided and left sided heart failure
Left-sided heart failure: (PULMONARY) When the left ventricle can’t pump out enough blood, it gets backed-up in the lungs (behind the left ventricle), causing pulmonary edema, a build-up of fluid in the lungs. Among other things, this brings about shortness of breath. Left-sided heart failure often leads to right-sided heart failure.
Right-sided heart failure: (SYSTEMIC) The right ventricle cannot pump out enough blood, causing fluid to back up in the veins and then in capillaries of the body (behind the right ventricle). Because of the back-up, fluid leaks out of the capillaries and builds up in the tissues, a condition called systemic edema. Edema is especially noticeable in the legs because the lower half of the body drains into the right side of the heart .
What does a defibrillator do
SA node -
coronary artery gets blocked, becomes ischemic, throws beats on its own
relative refractory period - very fragile part of the rhythm - if an extra beat occurs here - can go into v-Fib
stop the uncoordinated activity with defibrillation
AED - 2500V at 66 amp - stop what you are doing - the chaotic area - hope the normal activity picks back up
Do 2 minutes of compression before to increase perfusion of the heart - give the heart oxygen, glucose and remove lactic acid - increases chance of returning to a normal rhythm
shocking someone stops the abnormal rhythm
v fib
does not generate a pulse and will eventually turn into asytole
v tach
in va tach one area of the heart has taken over 100 bpm or even faster 150 bpm - v tach can generate a pulse
can have v-tach with a pule and v-tach without a pulse
the AED is only placed on a pt with a pulse - if you put the AED on a pt in V-tach with a pulse you should not shock
all it knows is that the electrical rhythm is shockable
test question where do the patches go
below the collar bone on the right side
left side on the ribs
final exam has 15 CPR questions
.
your pt has an internal cardiac defib
yes hook it up and continue with AED and CPR
if the AED keeps telling you no shock advised the pt is probably in asystole
.
Most common site of aneurysm
aorta and brain
sudden death
a cardiac arrest that occurs within 2 hours of the onset of symptoms. The patient may have no prior symptoms of coronary artery disease (25%).
In most cases, sudden death occurs outside of hospitals.
typical cardiac arrest patient and witness
a male in his 60’s, a women in her 60’s
Is the quality of CPR done by a person instructed by dispatch effective
Yes - as effective as a layperson trained in CPR
What is the single most important factor in determining survival from cardiac arrest
early defibriliation
If the time of defibrillation is greater than …X… minutes virtually no patient survives cardiac arrest
8 In these instance it is true that eery minute counts
add management of cardiac arrest to this (pg 485)
.
what is the primary electrical disturbance resulting in cardiac arrest
ventricular fibrillation (up to 50%) - chaotic rhythm present in 50% of cardiac arrest victims if EMS personnel arrive in the first 8 minutes
how often is v tach observed
less than 10% of out of hospital cases - heart rhythm very fast but organized
Is it appropriate to shock a person in v-tach who is awake
no - but an AED would indicate shock advised
how often is PEA pulseless electrical activity observed
15 to 20% - heart muscle fails even though there is electrical activity
how often is asystole observed
remaining 20 to 50% of victims present with asystole
Out of 10 how many victims will an AED shock
6 or 7 of 10 cardiac arrest patients
add figure 20-6 to this
..
what is the dose of a biphasic AED
120-200 joules
the heart rhythm starts with P
P, Q, R, S, T - add what is going on at these steps
