1 Cardiac Emergencies. 2 Cardiovascular Disease 63,400,000 Americans have one or more forms of heart...

1

Cardiac Cardiac EmergenciesEmergencies

2

Cardiovascular DiseaseCardiovascular Disease

• 63,400,000 Americans have one or 63,400,000 Americans have one or more forms of heart or blood vessel more forms of heart or blood vessel diseasedisease

• 50% of all deaths are cardiovascular 50% of all deaths are cardiovascular diseasedisease

3


• AAcute cute MMyocardial yocardial IInfarction (Heart nfarction (Heart Attack) - leading cause of death in U.S.Attack) - leading cause of death in U.S.

• 1.5 million Americans will have AMI’s 1.5 million Americans will have AMI’s this yearthis year• Of these .5 million will die!Of these .5 million will die!

• 350,000 will die in first two hours!350,000 will die in first two hours!

4

Cardiovascular Disease Cardiovascular Disease Risk FactorsRisk Factors

• Major UncontrollableMajor Uncontrollable• AgeAge

• SexSex

• RaceRace

• HeredityHeredity

5


• Major Controllable Major Controllable • SmokingSmoking

• High BPHigh BP

• High blood cholesterolHigh blood cholesterol

• DiabetesDiabetes

6


• Minor ControllableMinor Controllable• ObesityObesity

• Lack of exerciseLack of exercise

• StressStress

• PersonalityPersonality

7


Control risk factors - decrease Control risk factors - decrease Coronary Artery Disease and Coronary Artery Disease and Acute Myocardial Infarction Acute Myocardial Infarction

8

Coronary Artery DiseaseCoronary Artery Disease

• Myocardium (heart muscle) requires Myocardium (heart muscle) requires continuous oxygen and nutrient supplycontinuous oxygen and nutrient supply

• Myocardial blood supply passes Myocardial blood supply passes through coronary arteriesthrough coronary arteries

9

Coronary Artery DiseaseCoronary Artery Disease

• AtherosclerosisAtherosclerosis• Narrowing of lumenNarrowing of lumen

• plaque formation - related to Risk Factorsplaque formation - related to Risk Factors• results in decreased myocardial perfusionresults in decreased myocardial perfusion

• Poor tissue perfusion causes:Poor tissue perfusion causes:

• tissue damage (ischemia)tissue damage (ischemia)

• tissue death (infarction)tissue death (infarction)

10

Atherosclerotic Plaque Atherosclerotic Plaque FormationFormation

11

Angina PectorisAngina Pectoris “A choking in the chest”“A choking in the chest”

• AngereAngere - to choke - to choke

• Myocardial oxygen Myocardial oxygen demand exceeds supply demand exceeds supply during periods of during periods of increased activity, increased activity, exercise, or stressful eventexercise, or stressful event

12

Angina PectorisAngina Pectoris

• During stress the myocardium During stress the myocardium demands more Odemands more O22

• Coronary arteries would normally Coronary arteries would normally dilate to supply more blood and Odilate to supply more blood and O22

• In Angina Pectoris, the coronary In Angina Pectoris, the coronary arteries are unable to dilate sufficiently arteries are unable to dilate sufficiently to increase perfusionto increase perfusion

13

Symptoms -Angina PectorisSymptoms -Angina Pectoris

• PainPain• SubsternalSubsternal

• Squeezing/Crushing/HeavinessSqueezing/Crushing/Heaviness

• May radiate to arms, shoulders, jaw, May radiate to arms, shoulders, jaw, upper back, upper abdomen backupper back, upper abdomen back

• May be associated with shortness of May be associated with shortness of breath, nausea, sweatingbreath, nausea, sweating

14


• Pain usually associated with 3E’sPain usually associated with 3E’s• ExerciseExercise

• EatingEating

• EmotionEmotion

15


• Pain seldom lasts > 30 minutes Pain seldom lasts > 30 minutes

• Pain relieved byPain relieved by• RestRest

• NitroglycerinNitroglycerin

16


• Great anxiety/FearGreat anxiety/Fear

• Fixation of the body Fixation of the body

• Pale, ashen, or livid facePale, ashen, or livid face

• Dyspnea (SOB) may be associatedDyspnea (SOB) may be associated

17

Symptoms -Angina Symptoms -Angina PectorisPectoris

• NauseaNausea

• DiaphoresisDiaphoresis

• BP usually up during attackBP usually up during attack

• Dysrhythmia may be presentDysrhythmia may be present

18

Angina PectorisAngina Pectoris

• Following an angina attack there is Following an angina attack there is no residual damage to the no residual damage to the myocardiummyocardium

19

Forms of Angina PectorisForms of Angina Pectoris

• Stable AnginaStable Angina• Occurs with exerciseOccurs with exercise

• PredictablePredictable

• Relieved by rest or NitroglycerinRelieved by rest or Nitroglycerin

20

Forms of Angina PectorisForms of Angina Pectoris

• Unstable AnginaUnstable Angina• More frequent/severeMore frequent/severe

• Can occur during restCan occur during rest

• May indicate impending MIMay indicate impending MI

• Requires immediate treatment and Requires immediate treatment and transport to appropriate facilitytransport to appropriate facility

21

Acute Myocardial InfarctionAcute Myocardial Infarction “Heart Attack”“Heart Attack”

• Inadequate perfusion Inadequate perfusion of myocardiumof myocardium• Death of myocardiumDeath of myocardium

• InfarctInfarct• Damage to myocardiumDamage to myocardium

• Ischemia Ischemia

22

Symptoms - AMISymptoms - AMI

• Chest Pain - cardinal sign of Chest Pain - cardinal sign of myocardial infarctionmyocardial infarction• Occurs in 85% of MI’sOccurs in 85% of MI’s

• SubsternalSubsternal

• ““Crushing,” “squeezing,” “tight,” Crushing,” “squeezing,” “tight,” “heavy”“heavy”

23

Symptoms - AMISymptoms - AMI• Chest PainChest Pain

• May radiate to arms, shoulders, jaw, upper May radiate to arms, shoulders, jaw, upper back, upper abdomen backback, upper abdomen back

• May vary in intensityMay vary in intensity

• Unaffected by:Unaffected by:• swallowingswallowing

• coughingcoughing

• deep breathingdeep breathing

• movementmovement

24


• Chest PainChest Pain• Unrelieved by rest/nitroglycerinUnrelieved by rest/nitroglycerin

• Pain lasts longer than angina pain Pain lasts longer than angina pain (up to 12 hours)(up to 12 hours)

• ““Silent’ MI Silent’ MI • 15% of patients with MI, 15% of patients with MI, • particularly common in elderly and particularly common in elderly and

diabeticsdiabetics

25


• Shortness of breathShortness of breath

• Weakness, dizziness, faintingWeakness, dizziness, fainting

• Nausea, vomitingNausea, vomiting

• Pallor and diaphoresis (heavy Pallor and diaphoresis (heavy sweating)sweating)

26


• Sense of impending doomSense of impending doom

• Denial Denial • 50% of deaths occur in first two hours50% of deaths occur in first two hours

• Average patient waits 3 hours before Average patient waits 3 hours before seeking helpseeking help

27


• Changes in pulse, BP, Changes in pulse, BP, respiration are not diagnostic of respiration are not diagnostic of AMI AMI

28

Acute Myocardial Acute Myocardial InfarctionInfarction

• Early recognition of MI is Early recognition of MI is criticalcritical

29

Management of Cardiac Management of Cardiac Chest PainChest Pain

• When in doubt, manage When in doubt, manage all chest pain as MIall chest pain as MI

30


• Begin management immediately if Begin management immediately if angina or MI are suspected.angina or MI are suspected.

• Complete the history and physical Complete the history and physical exam as you treat.exam as you treat.

• Request early ALS back-upRequest early ALS back-up• Deaths in MI result from arrhythmia'sDeaths in MI result from arrhythmia's• Arrhythmia's can be prevented with early Arrhythmia's can be prevented with early

drug therapydrug therapy

31


• Position of ComfortPosition of Comfort

• Patent AirwayPatent Airway

• O2 via NC 4lpm in the absence of O2 via NC 4lpm in the absence of dyspneadyspnea

• If Dyspnea is present, High If Dyspnea is present, High concentration O2 viaconcentration O2 via non-rebreather non-rebreather

mask 10-15 lpmmask 10-15 lpm

32


• Request ACLSRequest ACLS• Cardiac MonitoringCardiac Monitoring

• 12lead if available12lead if available

• Reassure the patientReassure the patient

• Obtain a brief history and physical Obtain a brief history and physical examexam

• Aspirin 325mg p.o.Aspirin 325mg p.o.

33


• IV NS kvo if systolic BP > 110, IV NS kvo if systolic BP > 110, • be prepared to administer boluses 200-300cc if be prepared to administer boluses 200-300cc if

hypotension develops. hypotension develops.

• Nitroglycerin 0.4mg tablet sublingualNitroglycerin 0.4mg tablet sublingual• Patient should be sitting or lying downPatient should be sitting or lying down• Has Pt. Taken nitroglycerin in last 10 minutes? Has Pt. Taken nitroglycerin in last 10 minutes?

Is pain relieved? Headache?Is pain relieved? Headache?• Is BP > 90 systolic?Is BP > 90 systolic?• q 5 minutes until pain relieved or three tablets q 5 minutes until pain relieved or three tablets

administeredadministered

34


• If pain is unrelieved by rest, oxygen, If pain is unrelieved by rest, oxygen, nitroglycerin or if a change has nitroglycerin or if a change has occurred in pattern of angina, occurred in pattern of angina, transport immediatelytransport immediately

• Transport in semi-sitting position if BP Transport in semi-sitting position if BP normal or elevated; flat if BP lownormal or elevated; flat if BP low

35


• Do not walk patient to the ambulanceDo not walk patient to the ambulance

• Do not use lights/siren if patient is Do not use lights/siren if patient is awake, alert, breathing without awake, alert, breathing without distressdistress

• Monitor vital signs every 5-10 minutesMonitor vital signs every 5-10 minutes

36

Congestive Heart FailureCongestive Heart Failure

• CHF = Inability of heart to pump CHF = Inability of heart to pump blood out as fast as it enters.blood out as fast as it enters.

• May be left-sided, right-sided, or May be left-sided, right-sided, or both.both.

37


• Usually begins with left-sided failure.Usually begins with left-sided failure.• Left ventricle failsLeft ventricle fails

• Blood “stacks up” in lungsBlood “stacks up” in lungs

• High pressure in capillary bedsHigh pressure in capillary beds

• Fluid forced out of capillaries into alveoliFluid forced out of capillaries into alveoli

38


• Right-sided failure most commonly Right-sided failure most commonly caused by Left-sided failure. Blood caused by Left-sided failure. Blood “backs up” into systemic circulation“backs up” into systemic circulation• Distended neck veinsDistended neck veins

• Fluid in abdominal cavityFluid in abdominal cavity

• Pedal edemaPedal edema

39

Causes of CHFCauses of CHF

• Coronary Artery DiseaseCoronary Artery Disease

• Chronic hypertension (high blood Chronic hypertension (high blood pressure)pressure)

• AMIAMI

• Valvular heart diseaseValvular heart disease

40

Symptoms of CHFSymptoms of CHF• WeaknessWeakness

• DyspneaDyspnea

• Dyspnea on exertionDyspnea on exertion

• Paroxysmal nocturnal dyspneaParoxysmal nocturnal dyspnea• Attacks of SOB that usually occur at Attacks of SOB that usually occur at

night that awakens the patientnight that awakens the patient

41

Symptoms of CHFSymptoms of CHF

• OrthopneaOrthopnea• Difficulty breathing in any position other Difficulty breathing in any position other

than standing or sittingthan standing or sitting

• Abdominal discomfortAbdominal discomfort

• Jugular Vein Distention (JVD)Jugular Vein Distention (JVD)

• Pedal “Pitting” edema in lower Pedal “Pitting” edema in lower extremitiesextremities

42

Symptoms of CHFSymptoms of CHF

• TachycardiaTachycardia

• Pulmonary EdemaPulmonary Edema• Noisy, labored breathingNoisy, labored breathing

• CoughingCoughing

• Rales, wheezingRales, wheezing

• Pink, frothy sputumPink, frothy sputum

43

Management of CHFManagement of CHF• Request ACLSRequest ACLS

• Cardiac MonitoringCardiac Monitoring• 12lead if available12lead if available

• Sit patient up, let feet dangleSit patient up, let feet dangle• Administer high concentration OAdminister high concentration O22

• IV NS kvo, or Saline Lock IV NS kvo, or Saline Lock • NTG .4mg S/L every 5 minutesNTG .4mg S/L every 5 minutes

• Contraindicated with BP < 90/systolicContraindicated with BP < 90/systolic• Contraindicated if Viagra taken within 24 hoursContraindicated if Viagra taken within 24 hours

44

Pacemaker FailurePacemaker Failure• Position of comfortPosition of comfort

• Patent airwayPatent airway

• High Concentration OHigh Concentration O22

• Assist ventilations as neededAssist ventilations as needed

• ACLS InterceptACLS Intercept

• CPR as neededCPR as needed• DO NOT worry about damage to DO NOT worry about damage to

pacemakerpacemaker

45

Coronary Artery BypassCoronary Artery Bypass• Position of comfortPosition of comfort

• Patent airwayPatent airway

• High Concentration OHigh Concentration O22

• Assist ventilations as neededAssist ventilations as needed

• ALS InterceptALS Intercept

• CPR as neededCPR as needed• DO NOT worry about damage to DO NOT worry about damage to

sutures/staples or by-passed arteriessutures/staples or by-passed arteries

46

Implanted DefibrillatorImplanted Defibrillator

• If performing CPR on a patient:If performing CPR on a patient:• Implanted defibrillator may “fire”Implanted defibrillator may “fire”

• May feel slight “tingle”May feel slight “tingle”

47

QUESTIONSQUESTIONS

??

1 Cardiac Emergencies. 2 Cardiovascular Disease 63,400,000 Americans have one or more forms of heart...

Documents

Transcript of 1 Cardiac Emergencies. 2 Cardiovascular Disease 63,400,000 Americans have one or more forms of heart...