Cardiac emergencies

“Mr. Clark. Lowering your cholesterollevel NOW won’t do you a bit of good.”

Aortic &Pulmonarysemilunar

valves

VALVES

18-8.jpg

The Coronary ArteriesThe Coronary Arteries

Left CoronaryArtery

RightCoronary Artery

Anterior Descending Branch

CORONARYCORONARYARTERY: FIRSTARTERY: FIRSTBRANCH OFF BRANCH OFF THE AORTATHE AORTA

Cardiac CompromiseCardiac Compromise

Rapid or slow pulse withRapid or slow pulse with

no apparent causeno apparent cause Palpitation or fluttering Palpitation or fluttering

sensation in chestsensation in chest

Suspect and treat for ifSuspect and treat for ifpatient has:patient has:


Suspect and treat for ifSuspect and treat for if

patient has:patient has: Pain, pressure, or discomfort Pain, pressure, or discomfort

in chest or upper abdomenin chest or upper abdomen Difficulty breathingDifficulty breathing


Sudden onset of sweating,Sudden onset of sweating,

nausea, and vomitingnausea, and vomiting

Anxiety, irritabilityAnxiety, irritability

Suspect and treat for ifSuspect and treat for ifpatient has:patient has:

ANGINA PECTORIS

• The heart has to work harder because of a disease or a clot and the heart can not get enough oxygen

Scanning electron micrograph showingfibrin network of a blood clot

Platelet

Fibrin Network Red Blood Cell

Causes of Cardiovascular Compromise -- Causes of Cardiovascular Compromise --

AtherosclerosisAtherosclerosis

Coronary Artery Disease• Narrowing of the

coronaryarteries caused by thebuildup of cholesterol-containing plaque

Postmortem specimen of large artery withminimal atherosclerotic changes

Marked atherosclerotic changes which causeturbulent blood flow and blood flow restriction

Coronary Artery Disease

–Results in a decreasedblood and oxygen supplyto the heart

ANGINA PECTORIS

• This causes angina – pain from insufficient oxygen

WITH WITH EXERCISE, EXERCISE, THE HEARTTHE HEARTRECEIVES ANRECEIVES ANINSUFFICIENTINSUFFICIENTBLOODBLOODSUPPLY. SUPPLY. PAINPAINRESULTSRESULTS

Symptom of Cardiovascular Compromise -- Symptom of Cardiovascular Compromise -- Angina PectorisAngina Pectoris

Partial blockageproducingchest pain

Area ofdecreased

bloodsupply

Coronaryarteries

AMI

• A portion of the heart muscle dies from lack of oxygen

A complete A complete blockage blockage results in no results in no blood flow to blood flow to the heartthe heart

Causes of Cardiovascular Compromise -- Causes of Cardiovascular Compromise -- Acute Myocardial InfarctionAcute Myocardial Infarction

AREA OFINFARCT

NOTE THEDIFFERENCE

INPERFUSION

TO THEHEART

AFTER 2 STENTSWERE

IMPLANTED

S & S OF MI• Chest

discomfort or pain

• “Funny feeling”

• Pressure sensation

• Squeezing sensation

S & S OF MI• Pain may

radiate to:• Left arm• Right arm• Jaw• Epigastrium• Teeth

“I’M HAVINGCHEST PAIN!”

THE CALL FROM HELL

“WHOA! WE’RE LOOKING ATAT LEAST A DOUBLE

BYPASS HERE.”

S & S OF HEART ATTACK• Shortness of breath• Palpitations:• “Heart is racing”• “Heart is skipping beats”• Aching in chest

OTHER S & S:OTHER S & S:* DYSPNEA* DYSPNEA* NAUSEA* NAUSEA* DIAPHORESIS* DIAPHORESIS* FEELING OF* FEELING OF IMPENDING IMPENDING DOOMDOOM

“WAIT…OKAYNOW TELL MEAGAIN HOW

UNFAIR YOURHEALTH

PROBLEMSHAVE BEEN.”

WOMEN AND M.I. – S & S

• Weakness & fatigue• Diaphoresis• Nausea• Dizziness

WOMEN & M.I. – S & S• Rales• Congestive heart failure• Hot flash• Nonspecific chest

discomfort

VARIATION• Men typically

have M.I. within 4 to 6 hours after waking up

• Women do not have this pattern

VARIATION• Women tend

to have an M.I. more frequently in the autumn & winter

• Men do not have this pattern

TAN YELLOW = DEADTAN YELLOW = DEADMUSCLE TISSUEMUSCLE TISSUE

INCREASED LIKELIHOOD OF VAGUE SYMPTOMS

• Hypertension (HTN)

• Diabetes• Risk for M.I.

4 to 6 times greater for diabetic

““ I CALLED EMS I CALLED EMS FOR YOU. FOR YOU. YOU’RE GOING YOU’RE GOING TO HAVE A TO HAVE A HEART ATTACK HEART ATTACK IN ABOUT IN ABOUT 10 MINUTES.”10 MINUTES.”

ANEURYSM

• A weakened section of an artery bulges outward

• Can burst

ANEURYSM

• Note weakened arterial walls and distention of artery

Causes of Cardiovascular Compromise -- Causes of Cardiovascular Compromise -- AneurysmsAneurysms

ANEURYSM

• Ruptured aneurysm results in massive bleeding

Patient Assessment - Cardiac Compromise

Perform initial assessment.Perform initial assessment.

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

INFORMATION ON CHEST PAIN

• O - Onset• P – Pain• Q – Quality• R – Region / Radiation• S – Severity• T - Time

ONSET

• When did the pain start?

• What were you doing when the pain started?

PAIN

• What makes pain better• What makes pain worse

QUALITY

• What is the pain like?• If they can’t answer that

question, ask is it: tearing, sharp, burning, squeezing, crushing, aching, etc.

REGION / RADIATION

• Where is the pain?• Where does the pain go?

SEVERITY

• How bad is the pain?• On a scale of 1 to 10

TIME• When did the pain start?• What were you doing when it

started?• Have you ever experienced

a similar pain before?

Place patient in position of comfort; Place patient in position of comfort; givegive

high-concentration oxygen byhigh-concentration oxygen bynonrebreather mask.nonrebreather mask.

SAMPLE HISTORY• S = Symptoms• A = Allergies• M = Medications• P = Past history• L = Last meal• E = Events

“YOUNEED TOSTARTTAKINGYOURMEDSMORE

SERIOUSLY.”

Check the four rights. Check the four rights. Check the expiration date.Check the expiration date.

The Four RightsThe Four Rights

Right patient?Right patient?

Right drug?Right drug?

Right dose?Right dose?

Right route?Right route?

NITRO - PRECAUTIONS• Do not

administer nitroglycerine if the pt. Is taking viagra

• Deaths have occurred from this interaction!

“DISPATCHSAYS THE

PUPPY MAY HAVE GOTTEN

INTO THEPATIENT’SVIAGARA.”

CLASSIFICATION:

• Nitrate Coronary vasodilator

• Antianginal

INDICATIONS:

• Myocardial ischemia

• Angina pectoris

• Congestive heart failure

ACTIONS:• Increases coronary blood

flow by relaxing smooth muscle

• Vasodilation acts as an antagonist against vasospasm

ACTIONS:

• Vasodilation causes venous pooling, resulting in decreased blood return to the heart (decreased preload)

ACTIONS:• Systemic vasodilation

causes decreased right heart return which decreases the heart’s ventricular workload and reduces myocardial oxygen consumption

CONTRAINDICATIONS:

• Hypotension• Hypersensitivity to nitrogen• Head trauma• Hypovolemia

CNS SIDE EFFECTS:

• Headache• Weakness• Dizziness

CARDIOVASCULAR SIDE EFFECTS:

• Hypotension• Tachycardia• Fainting

GASTROINTESTINAL SIDE EFFECTS:

• Nausea• Vomiting• Dry mouth

SUPPLIED AS:

• Tablet in air tight brown bottle

• Nitroglycerine is deactivated in sunlight

RATE / ROUTE / DOSE:

• 0.4 mg (1/150 grain)• Sublingually • Repeated every 5 minutes• Maximum 3 doses• Onset – 1 to 3 minutes• Duration – 30 min.

INFORMATION:• Unstable and rapidly

deteriorates when exposed to light, air, or temperature extremes

• Needs to be stored in a dark, room-temperature area

‘HE GETS CONFUSEDWHEN HE TRIES TOPUT HIS TOUPEE

AND NITRO PATCHESON AT THE SAME

TIME.”

INFORMATION:• Tablets taste bitter and may

sting the tongue• If the tablet does not have a

bitter taste, it may have lost its strength

• Check the expiration date

“YOU MIGHT FEEL A SLIGHT BURNING

SENSATIONUNDER YOUR

TONGUE FROMTHE NITRO.”

INFORMATION:• Hypotension caused by nitro is

usually reversible with proper positioning and volume infusion

• Patients should always be sitting down or lying down prior to administration

“HEY, MARK … DID YOUKNOW THAT OUR RIG’SNITRO SPRAY LOOKS A LOT LIKE BREATH

FRESHENER?”

DRUG INTERACTION:

• May produce additive hypotension effects in the presence of alcohol, beta-adrenergic blockers, and calcium channel blockers

NITROSPRAY?

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.

• Administer 2 chewable baby aspirin

• 162 MG


CONTRAINDICATION:

• All ready taking aspirin

• On “blood thinners”

• Sensitivity to ASA

MORPHINEMINTS?

MORPHINE• Classification:• Narcotic analgesic• Indications:• Treat pulmonary edema• Relieve pain of M.I. & other

circumstances

“YEAH, DOC? THE PARAMEDIC WANTS ME

TO TELL YOU THAT I’M GONNA NEED LOTS

OF MORPHINEFOR THE PAIN.”

MORPHINE ACTIONS

• Powerful CNS depressant• Depresses sensory area of

cerebral cortex• Depresses pain impulse

transmission at spinal cord level by interacting with opioid receptors

MORPHINE ACTIONS

• Painful stimuli continue to be received but are no longer interpreted as pain

• Decreases systemic vascular resistance

• This aids in reducing oxygen requirements of the heart

“WOULD YOU LIKE A LITTLESOMETHING FOR THE PAIN

MR. WILKINSON?”

MORPHINE ACTIONS

• Increases the capacity of venous circulation

• Pools blood• Decreases blood return to the

heart• Reduces O2 consumption• Relieves lung congestion

MORPHINE CONTRAINDICATIONS

• Hypersensitivity to the drug• Hypotension• Respiratory depression except

that caused by CHF where morphine may be used if ventilatory support is provided

MORPHINE CONTRAINDICATIONS

• Head injury• Undiagnosed abdominal

pain• Patients taking depressant

drugs including alcohol

MORPHINE SIDE EFFECTS:

• CNS: • Confusion• Sedation• Headache


• Cardiovascular:• Hypotension• Bradycardia


• Respiratory:• Respiratory depression• Eyes:• Dry eyes• Blurred vision


• Gastrointestinal:• Nausea• Vomiting• Skin:• Rash

MORPHINE:• Supplied as:• 1 cc tubex• 2 mg / cc• Total 2 mg• 2 mg IV repeated as needed• Maximum 10 mg

MORPHINE:

• Dose in children:• 0.1 mg/kg• Maximum dose = 10 mg

MORPHINE INFORMATION:

• Use with caution in patients with COPD as it may depress respirations & suppress the cough reflex

MORPHINE INFORMATION:

• Less likely to cause serious respiratory depression if given slowly & in small amounts

NALOXONE (NARCAN):

• Classification:• Narcotic antagonist• Indications:• Overdose of known or

suspected natural or synthetic narcotics

• Coma of unknown etiology

NALOXONE ACTIONS:

• Competes with narcotic drugs opiate receptors in CNS.

• This competitive action displaces narcotic analgesics from their receptor sites

NALOXONE (NARCAN):

• Contraindications:• Hypersensitivity to the

drug

NALOXONE SIDE EFFECTS:

• Cardiovascular:• Ventricular tachycardia• Ventricular fibrillation• Hypotension• Hypertension

NALOXONE (NARCAN):

• Supplied as:• 1 cc ampule• 2 cc prefilled syringe• 0.4 mg / cc• Total 0.4 mg

NALOXONE (NARCAN):• Route &

dose:• 2 mg• IV• IM• ET

NARCAN: 2 MGIV/IM/ET

NARCAN INFORMATION:

• Use caution in administering to patients with:

• Supraventricular arrhythmias• Head injury

NARCAN INFORMATION:

• Use caution in administering to patients with:

• Increased ICP• Seizure disorder• Narcan can cause seizures

NARCAN INFORMATION:

• Duration of Narcan is shorter than narcotics, repeat doses may be necessary

• Use caution in administering to addicted patients because Narcan can precipitate withdrawal syndrome

NARCAN INFORMATION:

• Patients may become violent if they become conscious following administration of narcotics for a narcotics overdose

• Give enough Narcan to correct respiratory depression only

SOB:

• 78 y/o male seated upright in obvious distress

• Speaks 3 to 4 words in a row• Swelling to legs• Crackles ¾ of lungs• Hx. Emphysema & heart trouble• What do you suspect?

CONGESTIVE HEART FAILURE (CHF):

• The heart can no longer pump effectively causing blood to back up into the lungs and other parts of the body

LEAKED FLUID

HEART

COLOR-ENHANCEDCHEST X-RAY

HYPERTROPHY

LEFT HEART FAILURE:

• Left side of the heart is pumping ineffectively causing blood to back up into the lungs

BACKUP INTO

THELUNGS

BACKUP INTO

THELUNGS

S & S – LEFT HEART FAILURE:

• Dyspnea• Rales or

possibly wheezing

• Pink frothy sputum

Pulmonary Edema

S & S – LEFT HEART FAILURE:

• Tachycardia• Tachypnea

NORMAL ALVEOLAR /CAPILLARY UNIT

PULMONARY EDEMA

INTERSTITIAL SPACE IMPAIRED GAS EXCHANGE

RIGHT HEART FAILURE:

• The right side of the heart is pumping ineffectively causing blood to back up into the body

BACK UP INTO THE BODY

BACK UP INTO THE BODY

S & S – RIGHT HEART FAILURE

• Pedal edema


• Distended neck veins (JVD)


• Ascites – swollen abdomen

• Enlargened liver

S & S – RIGHT HEART FAILURE:

• Distended neck veins (JVD)

• Pedal edema• Ascites –

swollen abdomen

• Enlargened liver

MEDICATIONS:

• Nitroglycerine• Lasix• Morphine

LASIX (FUROSEMIDE):

• Classification:• Loop diuretic• Indications:• Pulmonary

edema• Congestive

heart failure (CHF)

“BEING TERRITORIAL AGAIN,

MR. WILKS?”

LASIX - ACTIONS:• Furosemide is a potent

diuretic• Inhibits primary

reabsorption of sodium and chloride in proximal and distal tubules as well as the loop of Henle

KIDNEYS & LOOP

OF HENLE

LOOP OFHENLE

LASIX – ACTIONS:

• Stimulates the kidneys to excrete water, sodium, & potassium

• This leads to decreased circulating blood volume

“YOU’RE NOTTAKING YOUR

LASIX, ARE YOU MRS.SMITH?”

LASIX – ACTIONS:• Causes vasodilation• This reduces left

ventricular preload and pulmonary congestion

• Venous dilation starts within 2 – 5 min.

LASIX – ACTIONS:• Onset of action IV:• Within 5 min.• Duration = 2 hours• Metabolized by liver• Excreted by kidneys

unchanged

“AND JUST HOW MUCH %&#@! LASIXDID YOU GIVE HIM?”

LASIX – CONTRAINDICATIONS:

• Under 18 years of age• Sulfa allergies• Pregnancy• Renal disease• Liver disease

LASIX – SIDE EFFECTS

• Rash• Numbness• Hearing loss• Transient hypotension

LASIX – SUPPLIED AS:

• 4 cc pre-loaded syringe• 10 mg / cc• Total 40 mg• 4 cc ampule• 10 mg / cc• Total 40 mg


• 80 to 120 mg over 1 minute

• Can be repeated

“THIS SHOULD HOLD YOU ‘TIL YOU GET YOUR

LASIX REFILLED.”

LASIX - PRECAUTIONS:

• Dehydration & blood volume depletion can result from long term use of potent diuretics & can contribute to circulatory collapse

LASIX - PRECAUTIONS:

• Potassium depletion is common and may pose a serious threat to the pt. with acute heart disease as well as the pt. on digitalis therapy

• Hyperosmolity may occur

“WHAT? AGAIN? YOU JUST WENT 20 MINUTES AGO.”

“LET’S GETTHE HELLOUT OFHERE!”

NURSE!

LASIX - INFORMATION:• Onset of

diuresis after IV administration starts within minutes

• Reaches a peak within 30 minutes

• Lasts 2 hours

LASIX - INFORMATION:

• The venous dilatation starts within 2 to 5 minutes resulting in almost immediate alleviation of some symptoms

SYNCOPAL EPISODE:• Dispatched to a 37 year old female who

became dizzy & fell while changing a light bulb

• Hit her head and is c/o tenderness to neck & headache

• Starts to c/o SOB

SYNCOPAL EPISODE:• B/P = 200/116• Pulse = 130 & regular• Resp. = 28 & shallow• Slight wheezes in lower lobes• Hx. – Diabetes & heart attack 2 years

ago

SYNCOPAL EPISODE:• As start to backboard pt., she doubles

over & starts to cough• Continues coughing & very short of

breath• Now has rales & pink sputum• Glucose level = 146

SYNCOPAL EPISODE:• What tx. is appropriate?• Enroute resp rate decreases to 6 per

minute• At hospital – continued tx. for CHF &

later undergoes open heart surgery for severe coronary artery disease

HIATAL HERNIA• Sliding of part of the stomach

into the chest cavity• Slides through a natural hole

in the diaphragm where the esophagus passes through to the stomach

ABDOMINAL PAIN• Dispatched to 68 y/o female

c/o moderate abdominal pain• Feels weak & nauseous• Hx. – HTN• Note pulsating mass to

abdomen• What do you suspect?

AAA• Aortic

abdominal aneurysm

• May rupture with trauma

• May rupture with no trauma

S & S AAA• May have

abrupt severe pain

• Diffuse abdominal tenderness

• May have pulsating mass

Ruptured Aneurysm

BACK PAIN• Dispatched to 73 y/o male c/o

severe, sharp, tearing sensation to back

• Sudden onset• Hx. – HTN• What do you suspect?

BLOOD VESSEL WALLS

• 3 layers:• Tunica intima• Tunica media• Tunica adventitia

TUNICA INTIMA

• Inner layer of blood vessels

• Smooth, thin lining

TUNICA MEDIA

• Middle layer• Thickest of the 3 layers• Composed of elastic

tissue & smooth muscle

TUNICA MEDIA

• Allows blood vessels to expand & contract in response to changes in blood pressure and tissue demand

TUNICA ADVENTITIA

• Outer layer• Consists of elastic & fibrous

connective tissue• Provides strength to

withstand high blood pressure

LUMEN

• Cavity or channel within a tubular organ

• Size or diameter changes with the size of the organ

• Changes in the size of the lumen in arteries play an important role in regulating blood pressure

TUNICA INTIMA

TUNICA MEDIA

TUNICA ADVENTITIA

LUMEN

DISSECTINGAORTA

AORTA

DISSECTINGAORTA

S & S:• Often C/O

tearing pain to the back

• May have decreased or absent pulse in one extremity

• Hypotension

CHEST PAIN

• Dispatched to a possible heart• 67 year old man sitting in a

chair holding onto his chest• Appears gray in color• What should you do?• Put the pt. on oxygen as you

assess vital and sample history

CHEST PAIN

• What information do you need?• Chest pain X 20 min. that

started while watching TV• Pressure in the right side of

the chest going to the shoulder

• 5 on a scale of 1 – 10

CHEST PAIN

• Similar to pain from heart attack last year

• Took 1 Nitro with no relief• Pulse = 148 and irregular• Respirations = 22 and shallow• B/P = 152/86• Skin = cool, moist, & pale

CHEST PAIN

• Denies palpitations• Mild SOB• Some nausea but no

vomiting• Has a bag of meds but no

allergies• What do you do?

CHEST PAIN• At hospital

diagnosed with dissection & thrombus of left coronary artery

Coronary angiogram of left coronary artery = total

occlusion & dissection ofleft anterior descending

artery

Left anterior descending

artery

Left mainartery

Leftcircumflex

artery

REVIEW:• Chest pain from a decreased oxygen

supply is called:• Angina• Chest pain when a portion of the heart

muscle dies is:• Myocardial infarction

REVIEW:• A weakened section of the artery that

bulges outward is:• Aneurysm• What is the acronym for questions that

should be asked about chest pain?• OPQRST

REVIEW:• What do each of the letters stand for?• O = Onset• P = Pain• Q = Quality• R = Radiation• S = Severity• T = Time

REVIEW:• What are the 4 rights for medication

administration?• Right patient; Right drug; Right dose;

Right route• How is nitroglycerine classified?• Vasodilator

REVIEW:• What are the indications for nitro?• Cardiac ischemia; Angina; CHF• What are contraindications for nitro?• Hypotension; Viagra• What are common side effects• Hypotension; Headache

REVIEW:

• What is the rate, route, & dose of nitro?• 0.4 mg. sl q 5 min. Maximum of 3 doses• What is the rate, route, & dose of ASA?• 162 mg. Chewable• What is the rate, route, & dose of

morphine?• 2 mg. Slow IV repeated as needed

maximum 10 mg

REVIEW:

• What is the most severe side effect of morphine?

• Respiratory depression• What drug counteracts morphine?• Narcan (Naloxone)• What is the rate, route, & dose of Lasix?• 80 to 120 mg. IV over 1 minute

REVIEW:

• Dyspnea, rales, & pink frothy sputum are classic signs of:

• Left heart failure• What meds are used for CHF?• Nitro, Lasix, Morphine• Abrupt diffuse or severe abdominal pain

and a pulsating mass are s& s of:• AAA

REVIEW:• What is the name of the inner lining of

blood vessels?• Tunica intima• What is the term for the channel in a

tubular organ?• Lumen

REVIEW:• Severe stabbing back pain,

hypotension, & decreased pulses in one lower extremity may indicate:

• Dissecting aorta

Cardiac emergencies

Health & Medicine

Transcript of Cardiac emergencies