Cardiac Emergencies

ChapterChapter

Cardiac Cardiac EmergenciesEmergencies

FourteenFourteen

ChapterChapter

How to assess, recognize,

and manage cardiac emergencies How to assist patients in taking

their nitroglycerin How to attempt resuscitation of a

patient in cardiac arrest by

administering CPR and an AED

FourteenFourteenCORE CONCEPTSCORE CONCEPTS

HeartHeart

Right AtriumRight Atrium

Right VentricleRight Ventricle

Left AtriumLeft Atrium

Left VentricleLeft Ventricle

Receives blood from veins;Receives blood from veins;pumps to right ventriclepumps to right ventricle

Receives blood from lungs;Receives blood from lungs;pumps to left ventriclepumps to left ventricle

Pumps blood to the lungsPumps blood to the lungs Pumps blood through the Pumps blood through the aorta to the body aorta to the body

Four Chambers of the HeartFour Chambers of the Heart

Cardiac Conduction SystemCardiac Conduction System

Coronary ArteriesCoronary Arteries

Vessels of CirculationVessels of Circulation

Capillary bed

Vein Artery

Arterioles

Venules

Valve

CCARDIACARDIACCOMPROMISECOMPROMISE

Cardiac CompromiseCardiac Compromise

Any kind of problem with the heartAny kind of problem with the heart

KKEY TERMEY TERM

Suspect and treat if:Suspect and treat if:


• Pain, pressure, or discomfortPain, pressure, or discomfortin chest or upper abdomenin chest or upper abdomen

• Difficulty breathingDifficulty breathing

• Sudden onset of sweating, nausea, Sudden onset of sweating, nausea,

(Continued)(Continued)


and vomitingand vomiting• Anxiety and irritabilityAnxiety and irritability

• Rapid or slow pulse with noRapid or slow pulse with noapparent causeapparent cause

• Palpitation or fluttering sensationPalpitation or fluttering sensationin the chestin the chest

• Feeling of impending doomFeeling of impending doom



Causes of Cardiovascular Compromise Causes of Cardiovascular Compromise AtherosclerosisAtherosclerosis

Coronary arteries

Partial blockageproducing chest pain

Area of decreasedblood supply

Causes of Cardiac Compromise Causes of Cardiac Compromise Angina PectorisAngina Pectoris

Area of Infarct

Causes of Cardiac Compromise Causes of Cardiac Compromise Acute Myocardial InfarctionAcute Myocardial Infarction

Causes of Cardiovascular Compromise Causes of Cardiovascular Compromise

AneurysmsAneurysms

Mild to severe confusion

Anxiety

Increased respiratory rate

Dyspnea (shortness of breath)

Difficulty breathing while lying flat

Cyanosis

Distended neck veins

Pink sputum

Rapid heart rate Normal to high blood pressure

Abdominal distention

Edema of the lower extremities

Causes of Cardiac CompromiseCauses of Cardiac CompromiseCongestive Heart FailureCongestive Heart Failure

Perform initial assessment.Perform initial assessment.

Perform focused history and physicalPerform focused history and physicalexam; take baseline vital signs.exam; take baseline vital signs.

If patient meets nitroglycerin criteria,If patient meets nitroglycerin criteria,consult medical direction.consult medical direction.

Check the “rights” and Check the “rights” and the expiration date.the expiration date.

Place patient in position of comfort; givePlace patient in position of comfort; givehigh-concentration oxygen byhigh-concentration oxygen by

nonrebreather mask.nonrebreather mask.

Patient Patient CARECARE


Emergency Care StepsEmergency Care Steps

No history of cardiac problems, No history of cardiac problems, OR OR History of cardiac problems butHistory of cardiac problems but no nitroglycerin, no nitroglycerin, OR OR Systolic blood pressure is < 100Systolic blood pressure is < 100

Transport promptly if:Transport promptly if:

Right patient?Right patient?

Right drug?Right drug?

Right dose?Right dose?

Right route?Right route?

Right time?Right time?

Right documentation?Right documentation?

The “Rights”The “Rights”

Remove oxygen mask and ask patientRemove oxygen mask and ask patientto open mouth and lift tongue.to open mouth and lift tongue.

Place tablet or spray medicationPlace tablet or spray medication under tongue.under tongue.

Have patient close mouth. Replace oxygenHave patient close mouth. Replace oxygen mask. Reassess patient; document findings.mask. Reassess patient; document findings.

Patient gets no relief ANDPatient gets no relief AND Systolic blood pressure remainsSystolic blood pressure remains Medical direction authorizesMedical direction authorizes another dose. Maximum three doses. another dose. Maximum three doses.

> 90–100 AND> 90–100 AND

Repeat Nitroglycerin afterRepeat Nitroglycerin after5 Minutes IF5 Minutes IF

Patient must have:Patient must have:•• Chest painChest pain•• No allergies to aspirinNo allergies to aspirin•• No history of asthmaNo history of asthma•• Not taking any other clotting Not taking any other clotting

medicationsmedications•• Ability to swallowAbility to swallow

Medical control authorizes administration.Medical control authorizes administration.

To Administer AspirinTo Administer Aspirin(if Local Protocols Allow)(if Local Protocols Allow)

CCARDIACARDIACCOMPROMISECOMPROMISE

AND BLSAND BLS

You need to be able to do CPR alone while You need to be able to do CPR alone while

your partner is preparing equipment your partner is preparing equipment

or you are transporting a patient in or you are transporting a patient in

cardiac arrest.cardiac arrest.

One-Rescuer CPROne-Rescuer CPR

You must also be able to:You must also be able to:• Use an AED.Use an AED.• Provide high quality compressions.Provide high quality compressions.• Request ALS backup when appropriate.Request ALS backup when appropriate.• Use bag-mask device and FROPVD.Use bag-mask device and FROPVD.• Lift and move patients.Lift and move patients. (Continued)(Continued)

Two-Rescuer CPR:Two-Rescuer CPR:Critical Skill for EMT-BCritical Skill for EMT-B

You must also be able to:You must also be able to:• Suction the airway.Suction the airway.• Use airway adjuncts.Use airway adjuncts.• Employ BSI precautions.Employ BSI precautions.• Interview family/bystanders.Interview family/bystanders.

Two-Rescuer CPR:Two-Rescuer CPR:Critical Skill for EMT-BCritical Skill for EMT-B

High Quality CompressionsHigh Quality Compressions

Research has shown that high quality CPR Research has shown that high quality CPR compressions can double, if not triple, compressions can double, if not triple, survival if applied promptly. Always press survival if applied promptly. Always press hard, fast (at least 100/minute) and allow hard, fast (at least 100/minute) and allow full chest recoil.full chest recoil.

KKEY TERMEY TERM

Many EMS systems have Many EMS systems have resuscitated patients with AEDs.resuscitated patients with AEDs.

The highest survival rates occur inThe highest survival rates occur insystems with strong links in thesystems with strong links in thechain of survival.chain of survival.

Automated ExternalAutomated ExternalDefibrillationDefibrillation

American Heart Association'sAmerican Heart Association'sChain of SurvivalChain of Survival

BiphasicBiphasic• Sends shock in both directions, Sends shock in both directions,

measures resistance, and adjusts measures resistance, and adjusts energy.energy.

• Causes less damage to heart muscle. Causes less damage to heart muscle.

MonophasicMonophasic• Sends shock (energy current) Sends shock (energy current)

from one pad to the otherfrom one pad to the other

Types of AEDsTypes of AEDs

AEDs are extremely accurateAEDs are extremely accurate

in distinguishing between shockablein distinguishing between shockable

and nonshockable rhythms.and nonshockable rhythms.

AED Analysis of AED Analysis of Cardiac RhythmCardiac Rhythm

Very rarely does AED computer Very rarely does AED computer make a mistake. make a mistake.

AED-related errors are almost AED-related errors are almost always human: always human:

• Not clearing patient Not clearing patient • Not stopping ambulance to analyze rhythmNot stopping ambulance to analyze rhythm

Inappropriate ShocksInappropriate Shocks

Ventricular fibrillationVentricular fibrillation• • 50% of cardiac arrest patients50% of cardiac arrest patients

Ventricular tachycardia over a Ventricular tachycardia over a certain ratecertain rate•• 10% of cardiac arrest 10% of cardiac arrest

patientspatients

AEDs will shock two rhythms:AEDs will shock two rhythms:

Shockable RythmsShockable Rythms

An AED is applied ONLY to a An AED is applied ONLY to a patient who is unresponsive and patient who is unresponsive and you believe is in cardiac arrest.you believe is in cardiac arrest.

Safety ConsiderationsSafety Considerations

(Continued)(Continued)

No one should do CPR or touchNo one should do CPR or touchthe patient when the AED isthe patient when the AED isanalyzing the rhythm oranalyzing the rhythm ordelivering a shock.delivering a shock.

Safety ConsiderationsSafety Considerations

You may stop CPR to allow AED You may stop CPR to allow AED analysis and a shock (if detected).analysis and a shock (if detected).

Resume CPR immediately after Resume CPR immediately after delivering a shock or after AED delivering a shock or after AED analysis if no shock detected.analysis if no shock detected.

Other than AED analysis, do not Other than AED analysis, do not interrupt for more than 10 seconds.interrupt for more than 10 seconds.

Interrupting CPRInterrupting CPR

Take BSI. Briefly question bystandersTake BSI. Briefly question bystandersabout pre-arrest events.about pre-arrest events.

Perform initial assessment. Verify patient Perform initial assessment. Verify patient is pulseless and not breathing. Check for is pulseless and not breathing. Check for no longer than 10 seconds.no longer than 10 seconds.

NoteNote

In a witnessed arrest, defibrillation should occur before CPR.

In an unwitnessed arrest, or prolonged downtime, 2 minutes of CPR should precede defibrillation attempts.

AED Indications:

• Adult patients (puberty or older) after 2 minutes of CPR.

• Children (1 year old to puberty) after 2 minutes of CPR and the availability of an AED designed for children.

• Do not use an AED on an infant (under 1 year of age)

NoteNote

Set up AED as partner starts (or resumes) CPR. Set up AED as partner starts (or resumes) CPR. Unless the arrest was witnessed, administer 2 Unless the arrest was witnessed, administer 2 minutes (5 cycles) of CPR.minutes (5 cycles) of CPR.

Turn on power and, if appropriate,Turn on power and, if appropriate,begin verbal report.begin verbal report.

Firmly attach one pad to right upper bare Firmly attach one pad to right upper bare chest. Firmly place one pad over lower left chest. Firmly place one pad over lower left bare ribs.bare ribs.

Proper Placement of AED PadsProper Placement of AED Pads

Say "Clear!" Ensure no one is touchingSay "Clear!" Ensure no one is touchingpatient. Press analyze button.patient. Press analyze button.

If AED advises shock, say "Clear," ensure no If AED advises shock, say "Clear," ensure no one touching patient, and press shock button. one touching patient, and press shock button.

After delivery of shock, immediately perform After delivery of shock, immediately perform CPR for 2 minutes (5 cycles), unless the CPR for 2 minutes (5 cycles), unless the patient wakes up.patient wakes up.

Check effectiveness of CPR by evaluating pulse.Check effectiveness of CPR by evaluating pulse.

Gather additional information on arrest events.Gather additional information on arrest events.

Insert an airway adjunct and ventilate with high-Insert an airway adjunct and ventilate with high-concentration oxygen.concentration oxygen.

After two minutes of CPR, have all individuals After two minutes of CPR, have all individuals stand clear and reanalyze with the AED.stand clear and reanalyze with the AED.

If no shock is advised, check carotid pulse, for If no shock is advised, check carotid pulse, for a maximum of 10 seconds. If present, assess a maximum of 10 seconds. If present, assess adequacy of breathing.adequacy of breathing.

If breathing is adequate, give high- concentration

oxygen by nonrebreather.

If inadequate, ventilate with high-concentration oxygen.

If the AED gives 3 consecutive no-shock messages with no carotid pulse . . .

. . . or a total of 3 shocks are delivered . . . then transport with CPR and oxygen.

If advanced life support is not available, transport when:

Patient regains pulse, OR

You have delivered 3 shocks, OR

AED has given 3 consecutive no-shock messages (separated by 2 minutes of CPR), OR

Your local protocols indicate an earlier transport.

While one EMT–B operates the AED, the partner performs CPR.

CPR must include high-quality compressions.

Defibrillation is the first priority in witnessed arrest or short downtimes.

General AED ProceduresGeneral AED Procedures

Do not touch patient when analyzing rhythm and delivering shocks.

Do not analyze rhythm or defibrillate in a moving ambulance. Stop first.


Be familiar with your model of AED.

Check batteries at beginning of shift.

Follow manufacturer's charging recommendations.

Carry an extra battery.


Coordination of EMTCoordination of EMT––B and ALSB 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.

AED in ProgressAED in Progress

If AED is in use by a first responder

when you arrive, ensure they are

performing properly, and continue with

shock analysis and 2 minutes of CPR

sequence.

Post-Resuscitation CarePost-Resuscitation Care

Maintain airway.

Transfer to ambulance.

Coordinate rendezvous with ALS if appropriate.


Leave AED attached to patient. Patient has a high risk of returning

to cardiac arrest.

Perform focused assessment and ongoing assessment en route.


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.

Single Rescuer with AED

Initial assessment reveals:• Unresponsive

• Apnea

• No pulse

Immediately attach AED and initiate analysis if the arrest was witnessed.

Single Rescuer with AEDSingle Rescuer with AED

Activate EMS system and start CPR:

Immediately, if prolonged downtime, OR

AED gives no-shock message if arrest was witnessed

Pediatrics & AEDPediatrics & 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.

Additional Safety Considerations

Water

• Dry patient’s chest; remove from wet environment.

Metal

• Ensure no one in contact with the patient is touching any metal.

Additional SafetyAdditional SafetyConsiderationsConsiderations

Medication Patch If patch visible on chest, remove it

with gloved hands before

delivering shock.

Advantages of AEDs

Initial training and continuing education are simple.

AEDs are very fast.

Advantages of AEDsAdvantages of AEDs

Use of adhesive pads instead of paddles is safer, provides better electrode placement, and lowers EMT–B's anxiety.

AED Maintenance

AED failure typically results from

inadequate maintenance.

• For example, failing to charge batteries on a regular basis

Use daily checklist to maintain machine and supplies.

AED Quality Improvement

Medical direction

• Review calls• Assist in training and skills

Continuing education

Skill review every 3 months

Data collection

Mechanical CPR Devices

Mechanical CPR compressor devices can assist with high quality compressions during CPR.

Begin use early in the arrest.

Do not interrupt CPR for more than 10 seconds to apply.

1. What signs and symptoms should prompt 1. What signs and symptoms should prompt you to treat a patient for cardiac you to treat a patient for cardiac compromise?compromise?

2. What are the indications, contra-2. What are the indications, contra-indications, and dose for nitroglycerin?indications, and dose for nitroglycerin?

Review Questions

3. How many shocks should you give to a 3. How many shocks should you give to a patient with a shockable rhythm?patient with a shockable rhythm?

4. What should you do when you get a no-4. What should you do when you get a no-shock message?shock message?

Review Questions

5. Which patients in cardiac arrest should not 5. Which patients in cardiac arrest should not have an AED applied?have an AED applied?

6. When using an AED, what safety practices 6. When using an AED, what safety practices should you follow?should you follow?

7. How can you be sure that your AED will 7. How can you be sure that your AED will work when you need it?work when you need it?

Review Questions

Cardiac Emergencies

Health & Medicine

Transcript of Cardiac Emergencies