Redwood Memorial Hospital, PreHospital Care, Field Care Audit, Lecture on Cardiac Issues and new AHA Guidelines and goals. Presented 02/16/11

1. Affairs of the Heart
Veronica Bonales, M.D.
CEP Emergency Physician
Redwood Memorial Hospital

3. Affairs of the Heart

4. Affairs of the Heart
Anatomy of heart and electrical system
Heart problems - Arrythmias
Heart problems - Ischemia
Mega Code with new AHA Guidelines

5. Heart Anatomy

6. Heart Anatomy

7. Heart Anatomy

8. Heart Anatomy

9. Heart Anatomy

10. Heart Anatomy

11. Heart Anatomy

12. Heart Anatomy

13. Heart Anatomy

14. Heart Anatomy

15. Heart Anatomy

16. Heart Tissues
Cardiac Myocytes
Specialized
Intrinsic Rhythm

17. Heart Anatomy

18. Heart Anatomy

19. Heart Anatomy

20. Heart Anatomy

21. Heart Anatomy

22. Intrinsic Rhythm
SA Node - 100 beats per minute (70 normal)
AV Node - 40 - 60 beats per minute
Purkinje Fibers - 30 - 40 beats per minute

23. Fight or Flight / Rest
and Digest
Sympathetic and Parasympathetic Nervous
System - on SA Node
Sympathetic
Norepinephrine (beta-1 receptors)
Parasympathetic
Vagus Nerve (ACh)

24. Balance

25. Cardiac Filling

26. Cardiac Filling

27. When Good Hearts Go
Bad

28. Heart Problems -
Arrhythmias
Rate
Rhythm

29. Normal Sinus

30. Heart Problems - Rate

31. Heart Problems - Rate
Too fast
Too slow
Not beating at all

32. Heart Problems -
Rhythm
Regular
Irregular

33. Heart Problems -
Rhythm
Regular
Irregular

35. Atrial Fibrillation

37. 3rd Degree Heart Block

38. 3rd Degree Heart Block

40. Atrial Flutter

42. Ventricular Tachycardia

44. Torsades de Pointes

46. Ventricular Fibrillation

47. Cardiac Drugs

48. Drugs
Aspirin Furosemide
Atropine Lidocaine
Adenosine Morphine
Amiodarone Nitroglycerin
Epinephrine Oxygen

49. Drugs
Aspirin Furosemide
Atropine Lidocaine
Adenosine Morphine
Amiodarone Nitroglycerin
Epinephrine Oxygen

50. Sympathetic and Parasympathetic Nervous
System - on SA Node
Sympathetic
Norepinephrine (beta-1 receptors)
Parasympathetic
Vagus Nerve (ACh)

51. Atropine
increases firing of the sinoatrial node (SA) and
conduction through the atrioventricular node (AV) of
the heart, opposes the actions of the vagus nerve,
blocks acetylcholine receptor sites

52. Atropine
increases firing of the sinoatrial node (SA) and
conduction through the atrioventricular node (AV) of
the heart, opposes the actions of the vagus nerve,
blocks acetylcholine receptor sites
x

53. Adenosine
Blocks the AV node

54. Adenosine
Blocks the AV node
x

55. Amiodarone
Beta blocker, prolongs action potential via
sodium channels and potassium channels

56. Amiodarone
Beta blocker, prolongs action potential via
sodium channels and potassium channels
x

57. Epinephrine
Works at ACh junctions

58. Epinephrine
Works at ACh junctions

59. Lidocaine
Blocks sodium channels

60. Lidocaine
Blocks sodium channels
x

61. Lidocaine
Blocks sodium channels
x
x

64. Heart Problems -
Ischemia

65. Coronary Anatomy

66. Coronary Anatomy

67. The Heart Electric

68. EKG Regions

76. STEMI

77. STEMI

84. LM

85. LM
LCx

86. LAD
LM
LCx

87. LAD
LM
LCx

88. Angiography
Opening the lesion

89. EMS called to office building with report
of “man down.” Found 54 y.o. male patient
in PEA arrest. CPR & ACLS for 35
minutes & pronounced at scene.

98. MEGA Code

100. 54 yo with hx of multiple medical problems riding in car
with family on Sunday afternoon, going home after lunch.

101. 54 yo with hx of multiple medical problems riding in car
with family on Sunday afternoon, going home after lunch.
911 call - Family reports patient “passed out” in car.
Pulled over to side of the road and family performing
CPR.

102. 54 yo with hx of multiple medical problems riding in car
with family on Sunday afternoon, going home after lunch.
911 call - Family reports patient “passed out” in car.
Pulled over to side of the road and family performing
CPR.
FD is first on scene.... What do you do?

103. 54 yo with hx of multiple medical problems riding in car
with family on Sunday afternoon, going home after lunch.
911 call - Family reports patient “passed out” in car.
Pulled over to side of the road and family performing
CPR.
FD is first on scene.... What do you do?
*AHA - change from ABC to CAB

104. 54 yo with hx of multiple medical problems riding in car
with family on Sunday afternoon, going home after lunch.
911 call - Family reports patient “passed out” in car.
Pulled over to side of the road and family performing
CPR.
FD is first on scene.... What do you do?
*AHA - change from ABC to CAB
*Patients should receive CPR until an AED is available

105. AHA:
CPR should be fast (>100) and deep (>2
inches)
Rotate compressor every 2 minutes
No ventilation for first 18 sec (30
compressions)
If no advanced airway 30:2 ratio

106. FD applies AED; shock advised. One shock given with
ROSC. EMS arrives at this point. What do you do?

107. FD applies AED; shock advised. One shock given with
ROSC. EMS arrives at this point. What do you do?

108. EMT’s place patient in back of ambulance and see this on
monitor....

109. EMT’s place patient in back of ambulance and see this on
monitor....

110. EMT’s place patient in back of ambulance and see this on
monitor....
“Andy, Andy, are you ok? Patient is unresponsive. No
pulse. What do you do?

115. PEA Arrest

116. PEA Arrest
CPR for 2 minutes

117. PEA Arrest
CPR for 2 minutes
Epinephrine every 3 minutes

118. PEA Arrest
CPR for 2 minutes
Epinephrine every 3 minutes
Consider advanced airway (passive O2 via mask with
an open airway showed improved survival)

119. PEA Arrest
CPR for 2 minutes
Epinephrine every 3 minutes
Consider advanced airway (passive O2 via mask with
an open airway showed improved survival)
8 - 10 breaths per minute, continuous CPR

120. Coronary Artery
Perfusion Pressure
9 strokes

121. Epinephrine x 2 (*no atropine), intubated with minimal
interruption of chest compressions (*<10 sec), wave-form
capnography in place...

122. Epinephrine x 2 (*no atropine), intubated with minimal
interruption of chest compressions (*<10 sec), wave-form
capnography in place...

123. Epinephrine x 2 (*no atropine), intubated with minimal
interruption of chest compressions (*<10 sec), wave-form
capnography in place...

129. Then on the monitor you see this....

130. Then on the monitor you see this....

131. Then on the monitor you see this....
Now what?

132. Ventricular tachycardia
Shock
CPR for 2 minutes

133. Then on the monitor you see this....

134. Then on the monitor you see this....

135. Then on the monitor you see this....
Now what?

137. Ventricular fibrillation

138. Ventricular fibrillation
Shock

139. Ventricular fibrillation
Shock
CPR for 2 minutes

140. Ventricular fibrillation
Shock
CPR for 2 minutes
Another drug....?

141. Ventricular fibrillation
Shock
CPR for 2 minutes
Another drug....?
Amiodarone & treat reversible causes

142. Ventricular fibrillation
Shock
CPR for 2 minutes
Another drug....?
Amiodarone & treat reversible causes

143. Ventricular fibrillation
Shock
CPR for 2 minutes
Another drug....?
Amiodarone & treat reversible causes

144. Reversible Causes:

145. Reversible Causes:
Hypovolemia

146. Reversible Causes:
Hypovolemia
Hypoxia

147. Reversible Causes:
Hypovolemia
Hypoxia
H+ (Acidosis)

148. Reversible Causes:
Hypovolemia
Hypoxia
H+ (Acidosis)
Hypo/Hyper K+

149. Reversible Causes:
Hypovolemia
Hypoxia
H+ (Acidosis)
Hypo/Hyper K+
Hypothermia

150. Reversible Causes:
Hypovolemia Tension PTx
Hypoxia
H+ (Acidosis)
Hypo/Hyper K+
Hypothermia

151. Reversible Causes:
Hypovolemia Tension PTx
Hypoxia Tamponade
H+ (Acidosis)
Hypo/Hyper K+
Hypothermia

152. Reversible Causes:
Hypovolemia Tension PTx
Hypoxia Tamponade
H+ (Acidosis) Toxins
Hypo/Hyper K+
Hypothermia

153. Reversible Causes:
Hypovolemia Tension PTx
Hypoxia Tamponade
H+ (Acidosis) Toxins
Hypo/Hyper K+ Thrombosis, PE
Hypothermia

154. Reversible Causes:
Hypovolemia Tension PTx
Hypoxia Tamponade
H+ (Acidosis) Toxins
Hypo/Hyper K+ Thrombosis, PE
Hypothermia Thrombosis, Coronary

155. Amiodarone 300mg loading dose given with
ROSC.
Now what?

156. Amiodarone 300mg loading dose given with
ROSC.
Now what?

157. Amiodarone 300mg loading dose given with
ROSC.
Now what?

158. AHA Post Cardiac Arrest Goals
- control body temperature to
optimize survival & neurological
recovery
- Tx of ACS (Cath Lab Activation)

159. Patient arrives in hospital E.D. Therapeutic hypothermia
started with cold saline in the field. Patient placed on
cooler. EKG showed STEMI. Cath Lab activated and
patient underwent angiography which showed LAD lesion.
Stented in the Cath Lab and went to CCU where
rewarmed about 24 hours later. Extubated and
eventually went to cardiac rehab.

160. Questions...??