Chapter 17 Cardiac Emergencies

1
Chapter 17Cardiac Emergencies
2
U.S. DOT Objectives Directory

• U.S. DOT Objectives are covered and/or supported
  by the PowerPoint Slide Program and Notes for
  Emergency Care, 11th Ed. Please see the Chapter
  17 correlation below.
• KNOWLEDGE AND ATTITUDE
• 4-3.1 Describe the structure and function of the
  cardiovascular system.
• Slides 10-16
• 4-3.2 Describe the emergency medical care of the
  patient experiencing chest pain or discomfort.
  Slides 30-41, 43
• 4-3.3 List the indications for automated external
  defibrillation (AED). Slides 55, 57, 59
• 4-3.4 List the contraindications for automated
  external defibrillation. Slides 56, 58, 65, 69
• 4-3.5 Define the role of EMT in the emergency
  cardiac care system. Slides 30-92
• 4-3.6 Explain the impact of age and weight on
  defibrillation. Slide 86
• 4-3.7 Discuss the position of comfort for
  patients with various cardiac emergencies. Slide
  31

(cont.)
3
U.S. DOT Objectives Directory

• KNOWLEDGE AND ATTITUDE
• 4-3.8 Establish the relationship between airway
  management and the patient with cardiovascular
  compromise. Slides 50, 73, 82, 86
• 4-3.9 Predict the relationship between the
  patient experiencing cardiovascular compromise
  and basic life support. Slides 41-50
• 4-3.10 Discuss the fundamentals of early
  defibrillation. Slides 44, 47
• 4-3.11 Explain the rationale for early
  defibrillation. Slides 44, 47
• 4-3.12 Explain that not all chest pain patients
  result in cardiac arrest and do not need to be
  attached to an automated external defibrillator.
  Slide 43
• 4-3.13 Explain the importance of prehospital ACLS
  intervention if it is available. Slide 48
• 4-3.14 Explain the importance of urgent transport
  to a facility with advanced cardiac life support
  if it is not available in the prehospital
  setting. Slides 33-34
• 4-3.15 Discuss the various types of automated
  external defibrillators. Slides 53-54

(cont.)
4
U.S. DOT Objectives Directory

• KNOWLEDGE AND ATTITUDE
• 4-3.16 Differentiate between the fully automated
  and the semiautomated defibrillator. Slide 53
• 4-3.17 Discuss the procedures that must be taken
  into consideration for standard operations of the
  various types of automated external
  defibrillators. Slides 55-79
• 4-3.18 State the reasons for assuring that the
  patient is pulseless and apneic when using the
  automated external defibrillator. Slide 59
• 4-3.19 Discuss the circumstances which may result
  in inappropriate shocks. Slide 56
• 4-3.20 Explain the considerations for
  interruption of CPR when using the automated
  external defibrillator. Slides 60-62, 77
• 4-3.21 Discuss the advantages and disadvantages
  of automated external defibrillators. Slide 53
• 4-3.22 Summarize the speed of operation of
  automated external defibrillation. Slide 53

(cont.)
5
U.S. DOT Objectives Directory

• KNOWLEDGE AND ATTITUDE
• 4-3.23 Discuss the use of remote defibrillation
  through adhesive pads. Slide 54
• 4-3.24 Discuss the special considerations for
  rhythm monitoring. Slides 57-58
• 4-3.25 List the steps in the operation of the
  automated external defibrillator. Slides 64-76
• 4-3.26 Discuss the standard of care that should
  be used to provide care to a patient with
  persistent ventricular fibrillation and no
  available ACLS. Slides 51-88
• 4-3.27 Discuss the standard of care that should
  be used to provide care to a patient with
  recurrent ventricular fibrillation and no
  available ACLS. Slides 51-88
• 4-3.28 Differentiate between single rescuer and
  multi-rescuer care with an automated external
  defibrillator. Slide 85
• 4-3.29 Explain the reason for pulses not being
  checked between shocks with an automated external
  defibrillator.

(cont.)
6
U.S. DOT Objectives Directory

• KNOWLEDGE AND ATTITUDE
• 4-3.30 Discuss the importance of coordinating
  ACLS trained providers with personnel using
  automated external defibrillators. Slides 80-81
• 4-3.31 Discuss the importance of
  post-resuscitation care. Slides 82-84
• 4-3.32 List the components of post-resuscitation
  care. Slides 82-84
• 4-3.33 Explain the importance of frequent
  practice with the automated external
  defibrillator. Slide 92
• 4-3.34 Discuss the need to complete the Automated
  Defibrillator Operators Shift Checklist. Slide
  91
• 4-3.35 Discuss the role of the American Heart
  Association (AHA) in the use of automated
  external defibrillation. Slide 44
• 4-3.36 Explain the role medical direction plays
  in the use of automated external defibrillation.
  Slide 92
• 4-3.37 State the reasons why a case review should
  be completed following the use of the automated
  external defibrillator. Slide 92
• 4-3.38 Discuss the components that should be
  included in a case review. Slide 92

(cont.)
7
U.S. DOT Objectives Directory

• KNOWLEDGE AND ATTITUDE
• 4-3.39 Discuss the goal of quality improvement in
  automated external defibrillation. Slide 92
• 4-3.40 Recognize the need for medical direction
  of protocols to assist in the emergency medical
  care of the patient with chest pain. Slides
  35-36, 38-40, 92
• 4-3.41 List the indications for the use of
  nitroglycerin. Slides 36-37
• 4-3.42 State the contraindications and side
  effects for the use of nitroglycerin. Slides
  36-37
• 4-3.43 Define the function of all controls on an
  automated external defibrillator, and describe
  event documentation and battery defibrillator
  maintenance. Slides 67, 70-71, 74
• 4-3.44 Defend the reasons for obtaining initial
  training in automated external defibrillation and
  the importance of continuing education. Slide 92
• 4-3.45 Defend the reason for maintenance of
  automated external defibrillators. Slide 91

(cont.)
8
U.S. DOT Objectives Directory

• KNOWLEDGE AND ATTITUDE
• 4-3.46 Explain the rationale for administering
  nitroglycerin to a patient with chest pain or
  discomfort. Slides 35-40

(cont.)
9
U.S. DOT Objectives Directory

• SKILLS
• 4-3.47 Demonstrate the assessment and emergency
  medical
• care of a patient experiencing chest pain or
  discomfort.
• 4-3.48 Demonstrate the application and operation
  of the automated external defibrillator.
• 4-3.49 Demonstrate the maintenance of an
  automated external defibrillator.
• 4-3.50 Demonstrate the assessment and
  documentation of patient response to the
  automated external defibrillator.
• 4-3.51 Demonstrate the skills necessary to
  complete the Automated Defibrillator Operators
  Shift Checklist.
• 4-3.52 Perform the steps in facilitating the use
  of nitroglycerin for chest pain or discomfort.
• 4-3.53 Demonstrate the assessment and
  documentation of patient response to
  nitroglycerin.
• 4-3.54 Practice completing a prehospital care
  report for patients with cardiac emergencies.

10
Virtual Tours and Animations

• Click here to view a virtual tour of the
  respiratory system.
• Click here to view a virtual tour of the heart.
• Click here to view a virtual tour of the head and
  neck.
• Click here to view a virtual tour of the trunk
  and abdomen.
• Click here to view an animation of the heart.
• Click here to view an animation of cardiovascular
  emergencies.

11
Review of Circulatory System
12
Cross-Section of the Heart
13
The Four Chambers of the Heart
Left Atrium
Right Atrium
Receives blood from veins pumps to right
ventricle.
Receives blood from lungs pumps to left
ventricle.
Right Ventricle
Left Ventricle
Pumps blood through the aorta to the body.
Pumps blood to the lungs.
14
Cardiac Conduction System
15
The Coronary Arteries
16
Vessels of Circulation
17
Cardiac Compromise
18
Causes of Cardiac Compromise
(cont.)
19
Aneurysms
Causes of Cardiac Compromise
(cont.)
20
Electrical Malfunctions of the Heart
Causes of Cardiac Compromise

• Bradycardia
• Less than 60 beats per minute
• Tachycardia
• Greater than 100 beats per minute
• No pulse
• Cardiac arrest

(cont.)
21
Mechanical Malfunctions of the Heart
Causes of Cardiac Compromise

• This can lead to cardiac arrest, shock, pulmonary
  edema (fluids backing up in the lungs), or
  congestive heart failure.

(cont.)
22
Causes of Cardiac Compromise
Angina Pectoris
Coronary arteries
Partial blockage producing chest pain
Area of decreased blood supply
(cont.)
23
Causes of Cardiac Compromise
Angina Pectoris
(cont.)
Click here to view an animation on angina
pectoris.
24
Causes of Cardiac Compromise
Acute Myocardial Infarction
Area of Infarct
(cont.)
25
Causes of Cardiac Compromise

• Myocardial infarction or ventricular weakening
  causes blood back-up to the lungs with fluid
  accumulation.

(cont.)
26
Congestive Heart Failure
Causes of Cardiac Compromise
27
Symptoms of Cardiac Compromise

• Chest Pain
• Discomfort in chest or upper abdomen
• Pain, pressure, crushing, squeezing, heaviness
• Palpitation/fluttering
• May radiate down one or both arms

28
Signs and Symptoms of Cardiac Compromise

• Difficulty breathing (dyspnea)
• Nausea, vomiting
• Anxiety/feeling of impending doom
• The elderly, diabetics, and female patients may
  not experience chest pain or discomfort in
  cardiac compromise. Weakness and difficulty
  breathing are more common symptoms.

(cont.)
29
Signs and Symptoms of Cardiac Compromise

• Cool, pale skin
• Dizziness
• Sweating
• Abnormal heart rates
• Tachycardiafaster than 100 bpm
• Bradycardiaslower than 60 bpm
• Abnormal blood pressures

30
Perform a Complete Initial Assessment
31
Place Patient in Position of Comfort Give
High-Concentration Oxygen by Nonrebreather Mask
32
Perform Focused History and Physical Exam Take
Baseline Vital Signs
33
Assessing Cardiac Compromise

• Transport immediately if
• No history of cardiac problems OR
• History of cardiac problems, but no
  nitroglycerin
• OR
• Systolic blood pressure is lt100

(cont.)
34
Assessing Cardiac Compromise

• Transport decision
• If available, transport patient to hospitals that
  have
• Clot-buster capabilities
• Ability to perform angioplasty
• Local protocols will provide guidance.

35
Nitroglycerin
36
To Administer Nitroglycerin

• Patients must have
• Chest pain
• History of cardiac problems
• Prescribed nitroglycerin with them
• BP meets or exceeds local protocol requirements
  (often 100 mmHg or greater)
• Not recently taken Viagra or similar drug for
  erectile dysfunction
• Medical direction authorizes administration.

37
The Five Rights
38
Nitroglycerin Administration
39
Repeat Nitroglycerin if

• Patient gets no or only partial relief
• AND
• Blood pressure remains acceptable per protocol
• Medical direction authorizes another dose
• Maximum three doses

40
Administration of Aspirin (if Local Protocols
Allow)

• Patient must have
• Chest pain
• No allergies to aspirin
• No history of asthma
• Not taken any other clotting medications
• Ability to swallow
• Medical direction authorizes administration.

41
Cardiac Compromise and BLS
42
Cardiac Compromise
Click here to view an animation on cardiac
compromise.
(cont.)
43
Cardiac Compromise

• Some patients with cardiac compromise go into
  cardiac arrest.
• You must be prepared for that, but fortunately,
  most patients with heart problems do not go into
  cardiac arrest.

44
American Heart AssociationChain of Survival
45
Early Access

• Public recognizes an emergency exists.
• Public knows emergency access phone number (911
  or other ).

46
Early CPR

• Train the public to perform CPR.
• Get CPR-trained professionals to the patient
  faster.
• Train dispatchers to instruct callers in CPR.

47
Early Defibrillation

• Single most important factor in survivability
  (time is critical!)
• Automated External Defibrillation (AED)
• Use of nontraditional responders (police, fire,
  security, for example)

48
Early Advanced Care

• Advanced Cardiac Life Support (ACLS)
• Typically provided by EMT-Paramedics (other EMT
  levels may have some options)
• Also provided by emergency department physicians

49
Management of Cardiac Arrest

• You must be able to
• Use an automated external defibrillator.
• Request ALS backup when appropriate.
• Use BVM and FROPVD.
• Lift and move patients.

(cont.)
50
Management Cardiac Arrest

• You must also be able to
• Suction the airway.
• Use airway adjuncts.
• Take Standard Precautions.
• Interview family/bystanders.

51
Automated External Defibrillation
52
Automated External Defibrillation

• Many EMS systems have resuscitated patients with
  AEDs (automated external defibrillators).
• The highest survival rates occur in systems with
  strong links in the chain of survival.

53
Types of AEDs

• Semi-automatic/shock advisory
• Computer in AED analyzes rhythm and advises EMT
  to deliver shock.
• Fully automatic
• EMT turns on power and attaches to patient
  shocks delivered automatically if needed.

(cont.)
54
Types of AEDs

• Monophasic
• Sends single shock (energy current) from one pad
  to the other
• Biphasic
• Sends shock in both directions, measures
  resistance, and adjusts energy
• Causes less damage to heart muscle

55
Analysis of Cardiac Rhythm
AEDs are extremely accurate in distinguishing
between shockable and nonshockable rhythms.
56
Inappropriate Shock

• Very rarely does the AED computer make a mistake.
  
• AED-related errors are almost always human error
  due to
• Touching the patient during analysis.
• Not stopping the ambulance to analyze rhythm.

57
Shockable Rhythm
AEDs will shock two rhythms

• Ventricular fibrillation
• Up to 50 of cardiac arrest patients
• Ventricular tachycardia over certain rates
• Up to 10 of cardiac arrest patients

58
Non-shockable Rhythm

• An AED will not shock
• Asystole (2050 of victims) OR
• Pulseless electrical activity (PEA) (1520 of
  victims)
• Typically, at most 6 to 7 out of 10 patients are
  in a shockable rhythm.

59
Safety Considerations
An AED must be applied ONLY to a patient who is
unresponsive, apneic, and pulseless.
(cont.)
60
Safety Considerations
No one should do CPR or touch the patient when
the AED is analyzing the rhythm or delivering a
shock.
61
Shock First or Compressions

• When the response time is greater than 4 to 5
  minutes, it is appropriate to do 2 minutes of CPR
  (about 5 cycles) prior to analyzing and
  administering the first shock.
• It is appropriate to re-prime the pump by doing
  CPR for 2 minutes. If you come on the scene and a
  citizen or other provider is already doing
  high-quality compressions, you can count that
  effort toward the first 2 minutes and proceed
  with applying the AED.

62
Note
63
Take Standard Precautions. Briefly question
bystanders about pre-arrest events.
64
Perform Initial Assessment Verify Patient Is
Pulseless and Not Breathing
65
AED Contraindications

• Is the patient younger than 1 year old?
• Is there any trauma?
• If yes to either, do not use the AED.

66
Set Up AED as Partner Starts (or Resumes) CPR
67
Turn on Power and, if Appropriate, Begin Verbal
Report
68
Firmly Attach One Pad to Right-Upper Bare Chest
Firmly Place One Pad over Lower-Left Bare Ribs
69
Proper Placement of AED Pads
70
Say Clear! Ensure No One Is Touching Patient
Press Analyze Button
71
If AED Advises Shock, Say Clear Ensure No One
Is Touching Patient Press Shock Button
72
If There Is No Pulse, Resume CPR for Two
Minutes Check Effectiveness of CPR by Evaluating
Pulse
73
Insert an Airway Adjunct, and Ventilate with
High-Concentration Oxygen
74
After Two Minutes of CPR, Clear Patient and
Repeat Sequence
75
If No Shock Is Advised, Check Carotid Pulse If
Present, Assess Adequacy of Breathing
76
If Breathing Is Adequate, Give High-Concentration
Oxygen by Nonrebreather

• If inadequate, ventilate with high-concentration
  oxygen.

77
General AED Procedures

• While one EMT operates the AED, the partner
  performs CPR.
• Defibrillation is first priority!

(cont.)
78
General AED Procedures

• Do not touch patient when analyzing rhythm and
  delivering shocks.
• Do not analyze rhythm or defibrillate in a moving
  ambulance. Stop first.

(cont.)
79
General AED Procedures

• Be familiar with your model of AED.
• Check batteries at beginning of shift.
• Follow manufacturers charging recommendations.
• Carry an extra battery.

80
Coordination of EMT and ALS

• Call for ALS as soon as possible.
• Local protocols determine if you should wait for
  ALS or begin transport to rendezvous with ALS.

81
AED in Progress
If AED is in use by a first responder when you
arrive, ensure that the AED is being used
properly, and continue with shocks.
82
Post-resuscitation Care

• Maintain airway.
• Transfer to ambulance.
• Coordinate rendezvous with ALS if appropriate.

(cont.)
83
Post-resuscitation Care

• Leave AED attached to patient.
• Patient has a high risk of returning to cardiac
  arrest.
• Perform focused assessment and ongoing assessment
  en route.

(cont.)
84
Post-resuscitation Care

• If patient is unconscious, check pulse at least
  every 30 seconds.
• If no pulse
• Stop ambulance.
• Analyze rhythm/deliver shocks per local protocol.
• If AED not available, perform CPR.

85
Single Rescuer with AED
86
Pediatrics and AED

• Do not use on patients less than 1 year old.
• Aggressive airway management and CPR are best
  methods.
• AED may be beneficial if pediatric AED is
  available.

87
Additional Safety Considerations

• Water
• Dry patients chest remove from wet environment.
• Metal
• Ensure no one is touching any metal that the
  patient is in contact with.

(cont.)
88
Additional Safety Considerations

• Medication patch
• If patch is visible on chest, remove it with
  gloved hands before delivering shock.

89
Advantages of AEDs

• Initial training and continuing education are
  simple.
• AEDs are very fast.

(cont.)
90
Advantages of AEDs

• Use of adhesive pads instead of paddles is safer,
  provides better electrode placement, and lowers
  EMTs anxiety.

91
AED Maintenance

• AED failure typically results from inadequate
  maintenance.
• Failing to check and maintain AED
• Use daily checklist to maintain machine and
  supplies.

92
AED Quality Improvement

• Medical direction
• Review calls.
• Assist in training and skills.
• Continuing education
• Skill review every three months
• Data collection

93
Review Questions

• 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?
• What is the best way to transfer a patient with
  difficulty breathing, chest pressure, and a blood
  pressure of 160/100 down a flight of stairs?

(cont.)
94
Review Questions

1. Describe how to clear a patient before
   administering a shock.
2. List three safety measures to keep in mind when
   using an AED.
3. List the steps in the application of an AED.

95
Street Scenes

• What type of emergency equipment needs to be
  taken to the side of every potential cardiac
  patient?
• What are the treatment priorities for this
  patient?

(cont.)
96
Street Scenes

• What assessment information do you need to obtain
  next?
• What should you do next?

97
Sample Documentation