Ch. 18: Cardiac Emergencies Flashcards
composition of the blood
white blood cells, platelets, and plasma
acute coronary syndrome (ACS)
A blanket term for anytime the heart is not getting enough oxygen
signs and symptoms vary greatly (most common: chest pain that is typically crushing, dull, heavy or squeezing)
it is much safer for the EMT to treat all patients with certain signs and symptoms as though they are having a heart problem—ACS—instead of trying to decide whether or not the patient has a particular type of heart problem.
Common complaints of ACS
§ Most common symptom: chest pain
□ Typically crushing, dull, heavy, or squeezing
§ Common complaint
□ commonly radiates along the arms, down to the upper abdomen, or up to the jaw
□ Difficulty breathing: dyspnea
® Specifically ask about
□ Often anxious
□ Nausea or vomit
□ Pain or discomfort in upper chest
□ Less common: loss of consciousness
® may result from the heart beating too fast or too slow to adequately supply the brain with oxygenated blood
® Usually regain consciousness quickly
□ Sweating
□ Abnormal pulse
□ Blood pressure (hypotensive or hypertensive)
□ Bradycardia
□ Tachycardia
□ Irregular heart beat
□ Palpitations: irregular or rapid heartbeats they feel as a fluttering sensation in the chest
□ one-quarter and one-third do not have the typical presentation of chest discomfort
® Especially older patients and woman
□ Pain, pressure, or discomfort in the chest or upper abdomen (epigastrium)
Management of ACS
Follow these steps for the emergency care of a patient with suspected ACS:
1. Place the patient in a position of comfort, typically sitting up. This is especially true of patients with difficulty breathing. Patients who are hypotensive (systolic blood pressure less than 90) will usually feel better lying down. This position allows more blood to flow to the brain. Occasionally, you will see a patient who has both difficulty breathing and hypotension. It may be very difficult to find a good position in this case. The best way to determine the proper position is to ask the patient what position will relieve his breathing difficulty without making him weak or light-headed.
2. Determine if oxygen should be administered to the patient. Oxygen should be administered to patients who are hypoxic (saturations less than 94 percent) and those who are in distress or exhibit signs of criticality (e.g., altered mental status, respiratory dis- tress, or pale skin). The goal is to get the patient’s oxygen saturation to 94 percent.
This is a dramatic shift in oxygen administration theory. In the past, everyone with chest pain or discomfort was given oxygen by nonrebreather mask. You may hear people talk about this or even see protocols that still mention high-concentration oxygen. Laboratory and animal studies suggest that administering more oxygen than necessary may
lead to the production of certain chemical entities that can be harmful, so current recommendations are to administer only enough oxygen to bring the patient’s oxygen saturation level up to 94 percent. See the table “Respiratory Conditions with Appropriate Interventions” in the chapter titled “Respiration and Artificial Ventilation” and consider the following as you decide on oxygen therapy for your ACS patient:
• Patients who are in respiratory failure, who are experiencing agonal breaths, and who are apneic will receive high-concentration oxygen via ventilations with a BVM or pocket face mask.
• Patients who have low oxygen saturations or otherwise appear critical should receive high-concentration oxygen with the intent to bring the oxygen saturation above 94 percent and relieve discomfort and anxiety. This may be done by a mask or nasal cannula.
• Patients who complain of chest pain or discomfort who are alert and otherwise not in significant distress and have an oxygen saturation of at least 94 percent should not receive oxygen. These patients should be monitored carefully in the event distress develops or oxygen saturation levels decline. In this case administer oxygen as described above.
3. Transport immediately if the patient has any one of the following:
• No history of cardiac problems
• History of cardiac problems but does not have nitroglycerin
• Systolic blood pressure below 90 to 100 (Use the minimum systolic number in this
range that is designated by your EMS system.)
4. If you are trained, equipped, and authorized to do so, obtain a 12-lead electrocardiogram (ECG). Follow local protocol with regard to whether you should transmit it to a hospital or physician for interpretation. Determining whether the patient has an ST-elevation myocardial infarction (STEMI) may be extremely important in determining the kind of treatment the patient may benefit from and where you will transport the patient. In areas with more than one hospital, there may be one or two facilities with special treatment available for cardiac patients. Almost all hospitals can administer an intravenous drug to dissolve the clot that is causing insufficient oxygenation of the heart. A more effective way to unclog the coronary artery is to insert a catheter with a balloon at the tip into the arterial system and thread it into the coronary arteries. When the balloon reaches the narrow section of the artery, it is inflated, compressing the obstructive material against the side of the blood vessel and opening up circulation to the heart muscle again. This is called percutaneous coronary intervention (PCI) and is often bet- ter than the “clotbuster drug” approach when it is done early (within a few hours of onset of symptoms). Only hospitals with special facilities and available staff can do this, however. If your EMS system has the ability to transport patients to a hospital with this capability, there will be a local protocol that you should follow describing when, where, and how you should transport patients with certain signs and symptoms.
5. Give the patient (or help the patient take) nitroglycerin (Scan 18-2) if all of the follow- ing conditions are met:
1) Patient complains of chest pain
2) Patient has a history of cardiac problems
3) Patient’s physician has prescribed nitroglycerin (NTG)
4) Patient has the nitroglycerin with him
5) Systolic blood pressure meets your protocol criteria (usually greater than 90 to 100
systolic)
6) Patient has not taken Viagra or a similar drug for erectile dysfunction within forty-
eight to seventy-two hours (Use the time within this range that is designated by your
EMS system.)
7) Medical direction authorizes administration of the medication
6. After giving one dose of the nitroglycerin, give a repeat dose in 5 minutes if all of the following conditions are met:
• Patient experiences no relief or only partial relief
• Systolic blood pressure remains greater than 90 to 100 systolic
• Medical direction authorizes another dose of the medication
Administer a maximum of three doses of nitroglycerin, reassessing vital signs and chest pain after each dose. If the blood pressure falls below 90 to 100 systolic, treat the patient for shock (hypoperfusion). Transport promptly.
7. Give the patient (or help the patient take) aspirin (Scan 18-3) if all of the following conditions are met:
• Patient complains of chest pain.
• Patient is not allergic to aspirin.
• Patient has no history of asthma.
• Patient is not already taking any medications to prevent clotting. (Since some of
these patients may still benefit from aspirin, consult your local protocol or medical
direction in this case.)
• Patient has no other contraindications to aspirin (Scan 18-3).
• Patient is able to swallow without endangering the airway.
Medical direction authorizes administration of the medication.
Coronary artery disease (CAD)
Conditions that narrow or block the arteries of the heart
§ clot and debris from the plaque form a thrombus. A thrombus can reach a size where it causes an occlusion (cutting off) of blood flow, or it may break loose to become an embolism and move to occlude the flow of blood somewhere downstream in a smaller artery
risk factors of CAD
hereditary, age, hypertension (high blood pressure), obesity, lack of exercise, elevated blood levels of cholesterol and triglycerides, and cigarette smoking
Aneurysm
- the dilation, or ballooning, of a weakened section of the wall of an artery.
* Tissues beyond the rupture can be damaged because the oxygenated blood they need is escaping and not reaching them
* Most common locations: aorta and the brain (causes a severe form of stroke)
Electrical Malfunctions of the Heart
• malfunction of the heart’s electrical system will generally result in a dysrhythmia, an irregular, or absent, heart rhythm
® Bradycardia, tachycardia, irregular rhythm
• Cardiac arrest (no pulse)
Mechanical Malfunction of the heart
• In this situation a lack of oxygen causes the death of a portion of the myocardium. The dead area can no longer contract and pump
• If a large enough area of the heart dies, the pumping action of the whole heart will be affected. This can lead to cardiac arrest, shock, pulmonary edema (fluids “backing up” in the lungs), or congestive heart failure
Deterioration or malfunction of the heart valves is also a common component of cardiovascular disorders such as congestive heart failure
Angina Pectoris
• portion of the myocardium (heart muscle) dies as a result of oxygen starvation
• often referred to as a heart attack
• brought on by the narrowing or occlusion of the coronary artery that supplies the region with blood. Rarely the interruption of blood flow to the myocardium may be due to the rupturing of a coronary artery (aneurysm).
• sudden death, a cardiac arrest that occurs within two hours of the onset of symptoms
• Factors: often coronary artery disease, chronic respiratory problems, unusual exertion, or severe emotional stress, may trigger an AMI.
must reach a hospital quickly
• Patients may be on
® Daily aspirin
® Beta blocker: slows the heart and makes it beat less strongly.
Congestive Heart Failure
• condition of excessive fluid buildup in the lungs and/or other organs and body parts because of the inadequate pumping of the heart. The fluid buildup causes edema, or swelling.
• Progresses as follows:
1. A patient sustains an AMI. Myocardium in the area of the left ventricle dies. (Recall the function of the heart: The left is the side of the heart that receives oxygenated blood from the lungs and pulmonary circulation and pumps it to the rest of the body.)
2. Because of the damage to the left ventricle, blood backs up into the pulmonary circulation then the lungs. Fluid accumulation in the lungs is called pulmonary edema. This edema causes a poor exchange of oxygen between the lungs and the bloodstream, and the patient experiences shortness of breath, or dyspnea. Listening to this patient’s lungs with a stethoscope may reveal crackling or bubbly lung sounds called crackles (rales). Some patients cough up blood-tinged sputum from their lungs.
3. Left heart failure, if untreated, commonly causes right heart failure. The right side of the heart (which receives blood from the body and pumps it to the lungs) becomes congested because the clogged lungs cannot receive more blood. In turn, fluids may accumulate in the dependent (lower) extremities, the liver, and the abdomen. Accumulation of fluid in the feet or ankles is known as pedal edema. The abdomen may become noticeably distended. In a bedridden patient, fluid collects in the sacral area of the spine.
Signs and symptoms of CHF
• Tachycardia (rapid pulse, 100 beats per minute or more)
• Dyspnea (shortness of breath)
• Normal or elevated blood pressure
• Cyanosis
• Diaphoresis (profuse sweating) or cool and clammy skin
• Pulmonary edema, sometimes coughing up of frothy white or pink sputum
• Anxiety or confusion due to hypoxia (inadequate supply of oxygen to the brain and
other tissues) caused by poor oxygen/carbon dioxide exchange
• Pedal edema
• Engorged, pulsating neck veins (late sign)
Enlarged liver and spleen with abdominal distention (late sign)
Generally on several medications including (water pill/ diuretic)
Chain of survival
five elements: (1) immediate recognition and activation, (2) early CPR, (3) rapid defibrillation, (4) effective advanced life support, and (5) integrated post–cardiac arrest care
CPR
-100 to 120 bpm
1/3 chest depth
2 breaths after 30 compressions
Temperature intervention for post-cardiac care
One intervention that appears to reduce brain damage in some resuscitated patients is controlled hypothermia. Cooling a patient’s body to around 90°F to 93°F (32°C to 34°C) and maintaining that temperature for twelve to twenty-four hours has led to more survivors and less brain damage than in patients who did not receive the treatment
