Chapter 17 Cardiac Emergencies - Triton · PDF fileChapter 17 Cardiac Emergencies. Limmer et...

Limmer et al., Emergency Care, 11th Edition

© 2009 by Pearson Education, Inc., Upper Saddle River, NJ

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Chapter 17

Cardiac Emergencies



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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.)



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• 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.)



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• 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.)



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• 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.)



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• 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: Operator’s

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.)



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• 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.)



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• 4-3.46 Explain the rationale for administering nitroglycerin to a patient with chest

pain or discomfort. Slides 35-40

(cont.)



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*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:

Operator’s 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.



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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.

media/S_Respir.htm

media/S_Card01.htm

media/S_Card02.htm

media/S_Card03.htm

media/HeartAnim.htm

media/CardiovascularEmergencies.htm



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Review of

Circulatory System



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Cross-Section of the Heart



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Right Atrium

Right Ventricle

Left Atrium

Left Ventricle

Receives blood from

veins; pumps to right

ventricle.

Receives blood from

lungs; pumps to left

ventricle.

Pumps blood to the

lungs.

Pumps blood through

the aorta to the body.

The Four Chambers of the Heart



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Cardiac Conduction System



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The Coronary Arteries



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Vessels of Circulation



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Cardiac

Compromise



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Causes of Cardiac Compromise



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Aneurysms


(cont.)



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Electrical Malfunctions of the Heart

Bradycardia

– Less than 60 beats per minute

Tachycardia

– Greater than 100 beats per minute

No pulse

– Cardiac arrest


(cont.)



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Mechanical Malfunctions of the Heart

This can lead to cardiac arrest,

shock, pulmonary edema (fluids

“backing up” in the lungs), or

congestive heart failure.


(cont.)



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Angina Pectoris

Coronary arteries

Partial blockage

producing chest pain

Area of decreased

blood supply


(cont.)



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Angina Pectoris

(cont.)

media/4angina.htm



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Acute Myocardial Infarction

Area of Infarct


(cont.)



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Myocardial infarction or ventricular

weakening causes blood back-up to

the lungs with fluid accumulation.




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Congestive Heart Failure




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Chest Pain

Discomfort in chest or upper abdomen

– Pain, pressure, crushing, squeezing,

heaviness

Palpitation/fluttering

May radiate down one or both arms

Symptoms of Cardiac

Compromise



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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.

Signs and Symptoms of

Cardiac Compromise

(cont.)



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Cool, pale skin

Dizziness

Sweating

Abnormal heart rates

–Tachycardia—faster than 100 bpm

–Bradycardia—slower than 60 bpm

Abnormal blood pressures

Signs and Symptoms of

Cardiac Compromise



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Perform a Complete Initial

Assessment



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Place Patient in Position of Comfort;

Give High-Concentration Oxygen by

Nonrebreather Mask



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Perform Focused History and Physical

Exam; Take Baseline Vital Signs



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Transport immediately if:

No history of cardiac problems

OR

History of cardiac problems, but

no nitroglycerin

OR

Systolic blood pressure is <100

Assessing Cardiac Compromise

(cont.)



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Transport decision:

If available, transport patient to

hospitals that have:

– “Clot-buster” capabilities

– Ability to perform angioplasty

Local protocols will provide

guidance.

Assessing Cardiac Compromise



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Nitroglycerin



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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.

To Administer Nitroglycerin



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Five “Rights”

Right patient?

Right medication?

Right dose?Right route?

Right date ?

The Five Rights



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Nitroglycerin Administration



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Patient gets no or only partial relief

AND

Blood pressure remains acceptable

per protocol


another dose

Maximum three doses

Repeat Nitroglycerin if:



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Patient must have:

– Chest pain

– No allergies to aspirin

– No history of asthma

– Not taken any other anti-clotting

medications

– Ability to swallow


administration.

Administration of Aspirin

(if Local Protocols Allow)



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Cardiac

Compromise

and BLS



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Click here to view an animation on cardiac compromise.

Cardiac Compromise

(cont.)

media/1vfib.htm



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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.

Cardiac Compromise



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American Heart Association

“Chain of Survival”



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Public recognizes an emergency

exists.

Public knows emergency access

phone number (911 or other #).

Early Access



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Train the public to perform CPR.

Get CPR-trained professionals to the

patient faster.

Train dispatchers to instruct callers

in CPR.

Early CPR



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Single most important factor in

survivability (time is critical!)

Automated External Defibrillation

(AED)

Use of nontraditional responders

(police, fire, security, for example)

Early Defibrillation



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Advanced Cardiac Life Support

(ACLS)

Typically provided by

EMT-Paramedics (other EMT

levels may have some options)

Also provided by emergency

department physicians

Early Advanced Care



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You must be able to:

– Use an automated external defibrillator.

– Request ALS backup when appropriate.

– Use BVM and FROPVD.

– Lift and move patients.

Management of Cardiac Arrest

(cont.)



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You must also be able to:

– Suction the airway.

– Use airway adjuncts.

– Take Standard Precautions.

– Interview family/bystanders.

Management Cardiac Arrest



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Automated External

Defibrillation



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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.

Automated External Defibrillation



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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.

Types of AEDs

(cont.)



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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



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AEDs are extremely accurate in

distinguishing between shockable

and nonshockable rhythms.

Analysis of Cardiac Rhythm



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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.

Inappropriate Shock



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Ventricular fibrillation

– Up to 50% of cardiac arrest patients

Ventricular tachycardia over certain

rates

– Up to 10% of cardiac arrest patients

AEDs will shock two rhythms:

Shockable Rhythm



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An AED will not shock:

–Asystole (20–50% of victims)

OR

–Pulseless electrical activity (PEA) (15–20% of victims)

Typically, at most 6 to 7 out of 10

patients are in a shockable rhythm.

Non-shockable Rhythm



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An AED must be applied ONLY to a

patient who is unresponsive, apneic,

and pulseless.

Safety Considerations

(cont.)



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No one should do CPR or touch the

patient when the AED is analyzing the

rhythm or delivering a shock.

Safety Considerations



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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.

Shock First or Compressions



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Witnessed Arrest and

Unwitnessed Arrest

Witnessed arrest

–Do not delay defibrillation to perform

CPR.

–Defibrillation is the top priority!

Unwitnessed arrest

–Do not delay CPR to perform

defibrillation.

–CPR is the top priority!



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Take Standard Precautions.

Briefly question bystanders about

pre-arrest events.



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Perform Initial Assessment; Verify

Patient Is Pulseless and Not Breathing



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Is the patient younger than 1 year

old?

Is there any trauma?

If “yes” to either, do not use the

AED.

AED Contraindications



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Set Up AED as Partner Starts

(or Resumes) CPR



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Turn on Power and, if Appropriate,

Begin Verbal Report



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Firmly Attach One Pad to Right-Upper

Bare Chest; Firmly Place One Pad over

Lower-Left Bare Ribs



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Proper Placement of AED Pads



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Say “Clear!”; Ensure No One Is

Touching Patient; Press Analyze Button



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If AED Advises Shock, Say “Clear”;

Ensure No One Is Touching Patient;

Press Shock Button



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Resume CPR for Two Minutes; Check

Effectiveness of CPR by Evaluating

Pulse



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Insert an Airway Adjunct, and Ventilate

with High-Concentration Oxygen



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After Two Minutes of CPR, Clear

Patient and Repeat Sequence



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If No Shock Is Advised, Check Carotid

Pulse; If Present, Assess Adequacy of

Breathing



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If Breathing Is Adequate, Give

High-Concentration Oxygen by

Nonrebreather

If inadequate, ventilate with high-concentration oxygen.



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While one EMT operates the AED,

the partner performs CPR.

Defibrillation and CPR are the top

priorities!

General AED Procedures

(cont.)



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Do not touch patient when analyzing

rhythm and delivering shocks.

Do not analyze rhythm or defibrillate

in a moving ambulance. Stop first.


(cont.)



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Be familiar with your model of AED.

Check batteries at beginning of shift.

Follow manufacturer’s charging

recommendations.

Carry an extra battery.




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Call for ALS as soon as possible.

Local protocols determine if you

should wait for ALS or begin

transport to rendezvous with ALS.

Coordination of EMT and ALS



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If AED is in use by a first responder

when you arrive, ensure that the AED

is being used properly, and continue

with shocks.

AED in Progress



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Maintain airway.

Transfer to ambulance.

Coordinate rendezvous with ALS if

appropriate.

Post-resuscitation Care

(cont.)



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Leave AED attached to patient.

– Patient has a high risk of returning to

cardiac arrest.

Perform focused assessment and

ongoing assessment en route.


(cont.)



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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.




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If the downtime was prolonged,

perform 2 minutes of CPR

If the patient was a witnessed arrest

immediately defibrillate.

Single Rescuer with AED



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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.

Pediatrics and AED



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Water

– Dry patient’s chest; remove from wet

environment.

Metal

– Ensure no one is touching any metal

that the patient is in contact with.

Additional Safety Considerations

(cont.)



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Medication patch

– If patch is visible on chest, remove

it with gloved hands before

delivering shock.

Additional Safety Considerations



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Initial training and continuing

education are simple.

AEDs are very fast.

Advantages of AEDs

(cont.)



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Use of adhesive pads instead of

paddles is safer, provides better

electrode placement, and lowers

EMT’s anxiety.

Advantages of AEDs



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AED failure typically results from

inadequate maintenance.

– Failing to check and maintain AED

Use daily checklist to maintain

machine and supplies.

AED Maintenance



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Medical direction

– Review calls.

– Assist in training and skills.

Continuing education

Skill review every three

months

Data collection

AED Quality Improvement



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1. What position is best for a patient with:

a. Difficulty breathing and a blood

pressure of 100/70?

b. Chest pain and a blood pressure of

180/90?

2. 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?

Review Questions

(cont.)



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3. Describe how to “clear” a patient

before administering a shock.

4. List three safety measures to keep in

mind when using an AED.

5. List the steps in the application of an

AED.

Review Questions



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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?

Street Scenes

(cont.)



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What assessment information do you

need to obtain next?

What should you do next?

Street Scenes



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