Chap 18 Flashcards
Defibrillation
delivery of an electrical shock to stop the fibrillation of heart muscles and restore a normal heart rhythm
CPR
CardioPulmonary Resuscitation
ACS
Acute coronary syndrome or Cardiac compromise
-Anytime the heart may not be getting enough oxygen
Examples of ACS
-A coronary artery is narrowed or blocked, a one-way valve may stop working properly, or the specialized tissue that carries electrical impulses may function abnormally
Most common symptom of heart problem is chest pain, described as crushing, dull, heavy or squeezing. Also complains of difficulty breathing (dyspnea). Shows signs of anxiousness, feeling of impending doom, irritability and short temper
Sometimes radiates to arms, down upper abdomen or up to jaw
Other signs
- Sudden onset of sweating and nausea or vomiting
- Pain, pressure, or discomfort in the chest or epigastrium
- abnormal pulse or blood pressure
- Unusual generalized weakness
- Palpitations
Bradycardia 60 less and Tachycardia 100 more
Hypotensive less than 90
Hypertensive more than 140
Transport immediately if
- No history of cardiac problems
- History of cardiac problems but doesn’t have nitro
- Systolic below 90-100
Administer oxygen usually under what %
94%
ECG
12-lead electrocardiogram
STEMI
ST-elevation myocardial infarction
When one of the major arteries to the heart is blocked
Two ways to unclog vessel
Clot buster
Catheter balloon into coronary artery
PCI
Percutaneous Coronary Intervention- Catheter balloon
Requirements for Nitro
- Patient complains of chest pain
- Patient has a history of cardiac problems
- Patient physician has prescribed Nitro
- Patient has Nitro with him
- Systolic blood greater than 90 -100
- Hasn’t taken ED medication in last 48-72hrs
- Medical direction authorization
Nitro doses
1 dose spray under tongue or tablet and repeat in 5 minutes if all conditions are met
- Patient experiences no relief or only partial relief
- SYS still greater than 90-100
- Medical direction authorizes another dose
Max 3 doses
Nitroglycerin
Generic- Nitroglycerin
Trade- Nitrostat, Nitrolingual
Contraindications
-Hypotension below 90
-Patient has head injury
-Patient is infant or child
-Patient has already taken 3 doses
-Patient has taken ED meds in last 48-72hr
Viagra, Cialis, Levitra
Aspirin
Generic- Aspirin
Actions
-Prevents blood from clotting as quickly, leading to increased survival of myocardial infarction
-When administered to cardiac patients, aspirin not
Indications
-Complains of chest pain
-Not allergic to aspirin
-No history of asthma
-Not taking meds to prevent clotting
-Able to swallow without endangering the airway
-Authorized medical direction
Contraindications
- Patient is unable to swallow
- Allergic to aspirin
- History of Asthma
- Gastrointestinal ulcer or recent bleeding
- Patient has known bleeding disorder
- Medical direction may decide of giving aspirin if it out weighs the risks
- Already taking meds to prevent clotting
- Pregnancy
- recent surgery
Side effects
- Nausea
- Vomiting
- Heartburn
- If patient is allergic, bronchospasm and wheezing
- Bleeding
Thrombus
Occlusion
Embolism
Thrombus- a clot formed of blood and plaque attached to the inner wall of artery or vein
Occlusion- blockage, as of an artery, by fatty deposits
Embolism- blockage of a vessel by a clot or foreign material brought to the site by the blood current
CAD
Coronary artery disease- Disease that affect the arteries of the heart
-CAD is often the result of the buildup of fatty deposits (plaque) on the inner vessel wall of the arteries. As time passes, calcium can be deposited at the site of the plaque, causing the area to harden
Thrombus a clot formed of blood and plaque attached to the inner wall of an artery or vein. 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
Partial or complete blockages cause tissue downstream to starve of oxygen and may die. Blockage’s to the heart (heart attack), and blockages to the brain (stroke)
Factors to CAD
- Heredity
- Age
- Hypertension
- Obesity
- lack of exercise
- elevated blood levels of cholesterol and triglycerides
- cigarette smoking
Aneurysm
The dilation, or ballooning of a weakened section of the wall of an artery
When a artery bursts, there can be rapid, life-threatening internal bleeding. tissues beyond the rupture can be damaged because loss of blood flow. Death from shock can occur.
Two most common sites of aneurysms
- Aorta
- Brain
Electrical malfunctions of the heart
A malfunction of the hearts electrical system will generally result in a dysrhythmia, an irregular, or absent, heart rhythm. Dysrhythmia includes bradycardia, tachycardia and rhythms that might be present with no pulse including ventricular fibrillation, ventricular tachycardia, pulseless electrical activity, and asystole
Dysrhythmia
a disturbance in the heart rate and rhythm
Mechanical malfunctions of the heart
Mechanical failure of the hearts pumps or valves
Angina Pectoris
Pain in the chest occurring when blood supply to the heart is reduced (exertion or stress) and a portion of the heart muscle is not receiving enough oxygen
- Pain diminished after exertion is done
- Seldom does the painful attack last longer than 5 minutes
- Nitro is used to dilate blood vessels. This results in more blood staying in the veins of the body, so there is less blood coming back to the heart. With less blood to pump out, the heart does not have to work as hard.
Sprays, pills and patches (slow release throughout day)
AMI
Acute myocardial infarction (heart attack)
Condition in which a portion of the myocardium (heart muscle) dies as a result of oxygen starvation
Brough on by the narrowing or occlusion of the coronary artery and rarely brought upon by a aneurysm of the coronary artery
Some factors often considered as harmless can lead to AMI such as chronic respiratory problem, unusual exertion, or severe emotional stress
Sudden death- a cardiac arrest that occurs within 2 hours of the onset of symptoms. The patient may have no prior symptoms of CAD, about 25%
Treatment- Clot buster, balloon, or aspirin everyday
Two ways to unblock an coronary artery
Treated with medication called fibrinolytics (clot buster)to dissolve the clot
Balloon angioplasty or balloon catheterization
Two ways to prevent further blockages
Aspirin- to prevent clotting
beta blockers- slows the heart and makes it beat less strongly (less work for heart)
CHF
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 build up causes edema or swelling. The disorder is traditionally termed congestive because the fluids congest, or clog, the organs. It is termed heart failure because the congestion both results from and also aggravates failure of the heart to function properly.
CHF is brought on by diseased heart valves, hypertension, or some form of obstructive pulmonary disease such as emphysema. CHF is often a complication of AMI
Signs and symptoms
- Tachycardia >100
- Dyspnea
- Normal or elevated blood pressure
- Cyanosis
- Diaphoresis
- Pulmonary edema
- Pedal edema
- Anxiety or confusion due to hypoxia
- Engorged, pulsating neck veins (late sign)
- Enlarged liver and spleen with abdominal distention (late sign)
Rales
crackles in lungs
Typical % of cardiac arrest calls
1-2%
American Heart Association
-Most important factors that affect survival of cardiac arrest patients in its chain of survival concept
- Recognition and activation of the emergency response system
- Immediate high quality CPR
- Rapid defibrillation
- Basic and advances EMS
- ALS and post-arrest care
High performance CPR
- Compressing the chest 2-2.4 inches adults 1/3 depth of the chest for infants and children
- full relaxation on the upstroke of compressions
- Spending half of each compression on the downstroke and half on the upstroke
- Using correct hand position
- Compressing the chest between 100 and 120 per min
- Spending no more than 1 second on each ventilation
- Minimizing interruptions of CPR to no more than 10 secs
- ventilation every 10 compressions or 10 per minute (6secs)
-Key to high performance is increasing cardiac output
Rapid defibrillation
-If the response time of the defibrillator is longer than 8 mins, virtually no patients survive cardiac arrest
Basic and advanced EMS
- ACLS- Advanced cardiac life support
- EMT’s, Paramedics, EMT-cardiac, EMT-critical care, AEMT
ALS and post-arrest care
- Maintaining adequate oxygenation, avoiding hyperventilation, performing a 12-lead ECG, finding and managing treatable causes of the arrest, determining the appropriate destination for the patient, possibly inducing hypothermia and several other advanced interventions
- Inducing hypothermia showed reduction of brain damage. Cool patients body to around 90-93F and maintain temp for 12-24 hours. Rapid administration of cold intravenous fluid is no longer beneficial. Cold packs to major arteries can help prevent fever
Two types of defibrillators
Manual-operator looks at patients heart rhythm on a screen and decides the rhythm is shockable, lubricate, and charge two paddles and deliver a shock to the patients chest
Automated - There are two types of automated external defibrillators
- Semi-automated- more common type, advises the operator to press a button to shock and are sometimes called "shock advisory defibrillators" - Fully-automated do not advise the operator to take action. Delivers the shock automatically.
Traditional monophasic defibrillator- sends shock in one direction (negative to positive). 360 joules
Biphasic defibrillator send the shock first in one direction then the other. It measures the impedance or resistance between the pads and adjusts the energy accordingly. Feature allows AED to use less energy and cause less damage to the heart. Batteries can be smaller with makes AED lighter. 120 and 200 joules
Two types conditions that result in cardiac arrest are shockable rhythms
- Ventricular fibrillation
- Ventricular tachycardia
Non-shockable rhythms
- Pulseless electrical activity (PEA)
- Asystole- Condition in which the heart has ceased to generate electrical impulses
Ventricular fibrillation (VF)
A condition in which the heart’s electrical impulses are disorganized preventing the heart muscle from contracting normally
Up to 50% of all cardiac-arrest victims if EMS arrives in the first 8 minutes
Shockable rhythm for which defibrillation is effective
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 beats to produce flow sufficient to meet the body’s needs
Seen in less than 10% of out of hospital cases.
The rhythm is organized but to rapid
Pulseless V-tach is a shockable rhythm
Two non-shockable rhythms
- Pulseless electrical activity (PEA)
- A condition in which the hearts electrical rhythm remains relatively normal, yet the mechanical pumping activity fails to follow the electrical activity, causing cardiac arrest
- Sometimes blood loss is to great and the heart works but has no blood to pump
- 15-20% of cardiac-arrest victims
-Asystole- Condition in which the heart has ceased to generate electrical impulses. Commonly called “flatline”
-20-50% of cardiac arrest victims
-
Minutes and cycles between analyzing on AED
2 mins (5cycles) -After 3 shocks, prepare for transport
CPR primary assessment
if a bystander is doing CPR when you arrive, have the bystander stop. Spend no more than 10 secs to verify pulselessness (no carotid pulse), apnea (no breathing) or agonal breathing (irregular, gasping breaths) and absence of other signs of life. Look for external blood loss
Post-resuscitation care
After you have run through the AED protocol, the patients will be in one of three conditions
-The patient has a pulse- Keep AED on in case cardiac arrest happens again
- Patient has no pulse- AED will give a No shock indication
- The AED may be prompting you to analyze the rhythm because it “thinks” there is a shockable rhythm- In this case resume CPR
-
How often to check pulse of resuscitated unconscious patient
Check pulse ever 30 secs
Single rescuer with an AED
If no one else is available to perform CPR
- Apply AED and defibrillate immediately
- Perform CPR
- Analyze after 2 mins
Contraindications of AED’s
- If pads wont fit on the patient without touching each other
- Patient went into cardiac arrest due to severe blood loss or damage to one or more vital organs
- Hypothermia- Attempt defib once in a hypothermic cardiac arrest patient then wait until the core temp is at least 86F before attempting again
Pediatric note
Infants have healthy hearts and go into shockable rhythms less often. Cardiac arrest in infants is more often caused by respiratory problems such as foreign body airway obstruction or drowning. For this reason, aggressive airway management and artificial ventilation with chest compressions are best way to resuscitate
-New AED’s have child pads and lower voltage shocks
Do not defibrillate if…
- Anyone is touching the patient
- patient is wearing a nitroglycerin patch (remove)
- patient is wet or laying in water (dry the patient)
- patient is touching metal
Cardiac pacemaker
helps the heart beat in a normal, coordinated fashion. often placed below one of the clavicle, is visible as a small lump, and can be palpated
Keep AED pad in general area but at least several inches away
A malfunctioning pace maker usually results in a slow or irregular pulse and might show signs of shock
Implanted defibrillators
Implanted for patients at risk for ventricular fibrillation
When a patient develops a lethal cardiac rhythm, the implanted defibrillator detects is and shocks the patient.
Cardioverter
A combination of pacemaker and defibrillator
VAD
Ventricular assist device
For patients with one or both ventricles of the heart are very weak. A mechanical device that pumps blood for the heart.
Contains a pump in the patients chest and a power source outside the body.
LVAD- Left ventricle assist device
- takes blood out of the left ventricle and pumps it to the aorta, for systemic circulation (continuous flow)
- More popular than RVAD
- Patient will have no pulse
- Do not perform CPR on a patient with a VAD unless directed to do so by medical direction
- patients with LVADs typically have severe heart disease and either is waiting for a heart transplant or has a weak heart
Cardiac bypass surgery
A blood vessel from another part of the body us surgically implanted to bypass an occluded coronary artery. This helps restore blood flow to a section of the myocardium
If you patient a tells you he has had a bypass surgery or if you observe a midline surgical scar on the chest, provide same emergency care, including CPR and defib
The defibrillation part of your QI program involves a number of things, including
Medical direction initial training, maintenance of skills, case review, trend analysis strengthening the links in the chain of survival
Lucas CPR device
- Take standard precautions
- Ensure CPR is in progress and effective
- Stop CPR just long enough to put the LUCAS base plate under the patient
- Attach the LUCAS upper part and restart CPR
- Position the suction cup so the lower edge is just above the lower end of the sternum
- With the machine in the “Adjust” mode, position the pressure pad so it touches the chest without putting any pressure on it
- Push the “ACTIVE (Continuous)” or “Active (30:2)” button to start compressions
- Apply the stabilization strap before moving the patient
- Upon termination of arrest or return of spontaneous circulation, power down the unit
Auto-Pulse
- Take standard precautions
- Ensure CPR is in progress and effective
- Align the patient on the Auto-Pulse platform
- Close the Lifeband chest band over the patients chest
- Press start
- Provide BVM at a rate of 2 ventilations for every 30 compressions
- If advanced airway is in place (ETT, LMA, or Combitube), change to high performance
Terminating resuscitation
- Spontaneous circulation occurs. Then provide rescue breathing as needed
- Spontaneous circulation and breathing occur
- Another trained rescuer can take over for you
- You turn care of the patient over to a person with a higher level of training
- You are too exhausted to continue
- You receive a “no resuscitation’ order from a physician or other authority per local protocols. All Three criteria must be met
- The arrest was not witnessed by EMS or first responders
- There has been no return of spontaneous circulation after 3 rounds of CPR and rhythm checks with an AED
- The AED did not detect a shockable rhythm and did not deliver any shocks
