Ch. 15: Cardiovascular Emergencies

The Heart Enclosed in pericardial sac

Myocardium = heart muscle

Four chambers: two atria, two ventricles

Sides divided by septum

Atrioventricular valves: tricuspid and mitral

Semilunar valves: pulmonic and aortic

Electrical pathways cause contractions

Blood VesselsCarry blood to and from the heart

Arteries: transport blood away from the heartAorta: largest artery in the body

Veins: bring blood to the heartSuper and inferior venae cavae

Capillaries: connect arteries and veins

Aorta – Arteries – Arterioles – Capillaries – Venules – Veins – Venae Cavae

Major Arteries Major Veins

BloodTransports materials

from one area of the body to anotherOxygen, CO2, protein

building blocks, sugars, fats, hormones, waste products, etc

When engaging in physical activity, body needs more oxygen and nutrients than when at rest – heart must pump blood faster

© Catherine R. Gordon

Cardiovascular EmergenciesMost causes of CV system failure traced back to

cardiovascular disease (CVD)

CVD leading cause of death worldwide

More than 1/3 of adult population in US has CVD.

Most cases of CVD attributed to coronary artery disease or atherosclerosis

Atherosclerosis“Hardening of the arteries”

Plaques form and build up along the inner lining of the arteries.

Heart doesn’t receive the oxygen and nutrients it needs, which causes the heart muscle to die

End result of plaque build up is coronary artery disease.

Angina pectoris

Leads to hypertension, heart failure, AMI, and sudden cardiac death.

Figure 15-8 The progression of artery occlusion in atherosclerosis: (a) the patient's risk factors and other factors cause the inner wall to be damaged; (b) fatty deposits develop, which lead to (c) fibrous plaque, which further occludes the vessel's internal diameter; (d) platelets aggregate in these areas, forming blood clots that nearly or completely occlude the artery.

HypertensionAbnormally elevated blood pressure, over 140/90

Internal diameters of small arterioles narrow due to atherosclerosis or other cause that restricts blood flow through arteries

Vessel narrowing causes pressure to build

Damages blood vessels over time

Affects nearly 1B people worldwide; 1/3 in the US

If untreated, it can lead to stroke and kidney failure, and more

Pulmonary EdemaAccumulation of fluid in the lungs

Caused by severe left-sided congestive heart failure, which in turn results from acute MI, direct trauma to the lungs, certain medical conditions, and certain drugs

As the condition worsens, the patient goes into cardiogenic shock from profound hypoxia

Congestive Heart FailureOccurs when the heart can’t adequately pump

blood to the body

Blood backs up into major blood vessels leading to heart, and subsequently into organs

Right-sided heart failure results in back-up into the systemic circulation, and then the dependent tissues, esp. the ankles and feet

Left-sided heart failure causes back-up into the lungs, resulting in pulmonary edema

S/S: Congestive Heart FailureS/S depend on the side affected.

Right heart failure: swollen ankles that can progress up the leg, often with “pitting edema.”

Left heart failure: Shortness of breath is common. If onset is rapid, it can be life-threatening.

Patients can have right and left CHF simultaneously.

Angina PectorisChest pain/discomfort caused by ischemia of the

myocardium

Occurs when the oxygen demands of the heart exceed the available supply

Common occurrence in people with CAD due to narrowing of the arteries

Can also be caused by vasoconstriction or spasm of the coronary arterie

Acute Myocardial Infarction (AMI)Mostly (90%) caused by blood clots that in turn

cause blockage of the coronary arteries.

The result is ischemia and death of heart muscle served by the affected coronary artery(ies).

If enough tissue dies, life is threatened because the heart can’t pump

S/S: AMIChest pain can be crushing or

heavy, stationary or radiating.

Women have painless MI more often than men.

S/S can include anxiety, dizziness, nausea, diaphoresis, feeling of impending doom

Aortic AneurysmA ballooning outwards of the aorta

Two types: abdominal and thoracic

S/S:Abdominal pain radiating to the groin/backDizzinessAbdomen may be tender, with a pulsatile mass

• Ruptured? Profound shock with hypotension and diaphoresis

Cardiogenic Shock

Caused by damage to myocardium

Heart’s output of blood reduced

Blood pressure cannot be maintained

S/S: Cardiogenic ShockPatients appear deathly ill and in shock: pale

skin, diaphoresis, anxiety, respiratory distress.

If caused by AMI, the patient will be tachycardic and hypotensive

If caused by abnormal heart rhythm, the patient might be bradycardic, or tachycardic and hypotensive.

Pericardial TamponadeOccurs when excess

fluid builds up in the pericardial space

Compresses heart, can’t pump adequately

PT is life-threatening, requires emergency fluid removal

S/S: Pericardial TamponadeShortness of breath, anxiety or restlessness, and

pale, cool, diaphoretic skin

Chest pain is common

Hypotension, distended neck veins, and muffled/distant heart tones

Patient might present with only fatigue and tachycardia.

Pulmonary EmbolismOne of the most lethal forms of thromboembolism

Passage of a blood clot (thrombus) formed in a vein through right side of heart and into pulmonary artery where it lodges

Deep venous thrombosis

Decreases or blocks blood flow—no exchange of oxygen or CO2

Arterial carbon dioxide increases, oxygen decreases

Inhibits circulation

S/S: Pulmonary EmbolismSudden onset of chest pain

Shortness of breath

Tachycardia

Sharp pain that increases with deep breaths

Cyanosis and hypoxia

S/S DVT:Severe pain, tenderness to touch, swelling in one

leg

Sudden Cardiac Arrest (SCA)Abrupt cessation of effective pumping of blood

from heart to coronary arteries, brain, and other vital organs

Caused by AMI, ventricular fibrillation, pulseless ventricular tachycardia, asystole.

ArrhythmiasIrregular heart beat or heart rhythm, which can

compromise normal heart function

Primary cause of life-threatening arrhythmia is ischemia of myocardium

Life-threatening arrhythmias (can lead to SCA):Ventricular fibrillation: chaotic and ineffective

contraction of that ventricles that leads to cardiac arrest

Ventricular tachycardia: rapid contraction of the ventricles that can lead to ineffective blood flow to body tissues, cardiac arrest

Asystole: complete absence of a heartbeat due to lack of electrical activity within the heart

Assessment Scene safety

Primary assessment: ABCDs

Patients in SCA will be unresponsive, apneic, pulseless – immediately begin CPR

Secondary assessment: SAMPLE history, pay close attention to complaints of chest pain and any medications (esp. nitroglycerin or aspirin) Patient may have difficulty communicating, talk to relative Assess chest pain using OPQRST (cardiac pain usually described as either

“heavy,” “crushing,” or “tight.” If pain radiates into jaw or down arm, may indicate AMI

Detailed secondary physical exam Check pulse, blood pressure, skin condition, capillary refill, level of

responsiveness – evidence as to whether not tissue perfusion is effective Assess skin for color, temperature, diaphoresis (with chest pain may indicate

that heart is ischemic. Listen to breath sounds

Reassess patient and vital signs Every 3-5 mins if patient is unstable Every 10-15 mins if patient is stable

ManagementEvaluate ABCs and treat problems as they are

found

If patient is in cardiac arrest: Time is of the essence – Golden HourRequest ALS immediately, and call for oxygen and

an AED.Begin CPR.

ManagementChain of Survival

Immediate recognition of cardiac arrest, activation of EMS

Early CPR emphasizing chest compressionsRapid defibrillation if indicatedEarly, effective ALS Integrated post-cardiac arrest care

ManagementCVD Patient NOT in Cardiac Arrest

Call for immediate assistance, oxygen, AED, and ALS.

Keep patient calm, put in position of comfort. If hypotensive, keep supine and warm, and elevate

legs If CHF, sit patient up and put legs in dependent

position

Other ConsiderationsMedications:

Plavix: anti-platelet to prevent formation of clots Nitroglycerin: vasodilator Coumadin: blood thinner Lipitor: lowers harmful cholesterol levels Cordarone: diuretic that removes excess fluid from the

body

Implantable devices may be in place

High flow oxygen therapy is crucial

Nitroglycerin -- assist patient if they have their prescription with them and conditions/protocols allow

Aspirin -- assist patient if they have aspirin and protocols allow for it