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Cardiovascular Emergencies … time is myocardium!
Statistics <ul><li>Cardiovascular disease (CVD) claimed over 1 million lives in 2004. </li></ul><ul><li>CVD has been the l...
Controllable Risk Factors <ul><li>Smoking </li></ul><ul><li>High blood pressure </li></ul><ul><li>Elevated cholesterol lev...
Uncontrollable Risk Factors <ul><li>Age  </li></ul><ul><li>Family history </li></ul><ul><li>Race </li></ul><ul><li>Sex </l...
Anatomy
Circulation
Blood <ul><li>Red blood cells: </li></ul><ul><ul><li>Carries oxygen to tissues and cells </li></ul></ul><ul><ul><li>Remove...
Electrical System
Coronary Arteries
Cardiac Compromise <ul><li>Chest pain results from ischemia. </li></ul><ul><li>Ischemic heart disease involves decreased b...
Atherosclerosis
So… <ul><li>… you are dispatched to a 67 year- old male c/o 9/10 “crushing” chest pressure that radiates to his jaw.  He i...
… w hat are YOU thinking?
Chest Pain Pathophysiology <ul><li>Mediastinum: </li></ul><ul><ul><li>Angina: stable or unstable </li></ul></ul><ul><ul><l...
Chest Pain Pathophysiology <ul><li>Chest Wall: </li></ul><ul><ul><li>Traumatic contusion/ tamponade </li></ul></ul><ul><ul...
Chest Pain Pathophysiology <ul><li>Lungs and pleura: </li></ul><ul><ul><li>Pleurisy </li></ul></ul><ul><ul><li>Pneumonia <...
Chest Pain Pathophysiology <ul><li>Abdomen: </li></ul><ul><ul><li>Gallbladder (cholecystitis, stones) </li></ul></ul><ul><...
Chest Pain <ul><li>Psychogenic: </li></ul><ul><ul><li>Stress </li></ul></ul><ul><ul><li>Hyperventilation </li></ul></ul><u...
Classic Symptoms <ul><li>Pressure, fullness, heaviness, squeezing pain in center of chest with radiation </li></ul><ul><li...
Frequency of Symptoms <ul><li>Diaphoresis  78% </li></ul><ul><li>Chest pain 64% </li></ul><ul><li>Nausea 52% </li></ul><ul...
Atypical Presentations <ul><li>Common in the elderly, diabetics, and females: </li></ul><ul><ul><li>Unusual fatigue </li><...
All chest pain is considered to be an AMI until proven otherwise!
Angina Pectoris <ul><li>Chest pain caused when heart tissues do not get enough oxygen for a brief period of time. </li></u...
Angina
Acute Coronary Syndrome <ul><li>Used to describe the range of conditions from unstable angina to AMI. </li></ul><ul><li>Si...
ACS Signs & Symptoms <ul><li>Shortness of breath </li></ul><ul><li>Signs of inadequate perfusion </li></ul><ul><li>Chest p...
Acute Myocardial Infarct <ul><li>Usually caused by the same mechanism as angina only with resulting tissue death. </li></u...
AMI
Cardiogenic Shock <ul><li>Heart lacks power to force blood through the circulatory system. </li></ul><ul><li>Brought on wh...
Signs & Symptoms <ul><li>Altered LOC </li></ul><ul><li>Rapid, shallow breathing </li></ul><ul><li>Restlessness and anxious...
Congestive Heart Failure <ul><li>Occurs when the ventricles are damaged. </li></ul><ul><li>Heart tries to compensate with ...
CHF
Signs & Symptoms <ul><li>Fatigue </li></ul><ul><li>Cough with pink, frothy sputum </li></ul><ul><li>Dypsnea, tachypnea </l...
Signs & Symptoms
Thoracic Dissection
Aortic Aneurysm
Signs & Symptoms <ul><li>Sudden and severe chest or upper back discomfort.  “Pain shoots to the shoulder blades.” </li></u...
Cardiac Tamponade <ul><li>Trauma  induced, filling of the pericardial sac with blood. </li></ul><ul><li>Signs of shock </l...
Esophageal Rupture <ul><li>Usually underlying alcohol abuse. </li></ul><ul><li>Shock signs. </li></ul><ul><li>Coughing up ...
Pericarditis <ul><li>Inflammation of the pericardium caused by infection. </li></ul><ul><li>Usually presents as sharp disc...
Chest Pain Assessment <ul><li>BSI/Scene Safety </li></ul><ul><li>Initial Assessment (Sick/Not Sick) </li></ul><ul><li>Focu...
Initial Assessment <ul><li>60second clinical picture to determine if Sick or Not Sick (Oxygen) </li></ul><ul><li>Based upo...
Focused Exam (S) <ul><li>Your subjective findings are based upon what the patient or historian tells you: </li></ul><ul><l...
Focused Exam (S) <ul><li>SAMPLE History </li></ul><ul><li>S igns/ S ymptoms (associated with cardiac chest pain): </li></u...
Focused Exam (S) <ul><li>O nset –  </li></ul><ul><ul><li>“ When and at what time did it start”  </li></ul></ul><ul><li>P r...
Focused Exam (S) <ul><li>R egion/ R adiation – </li></ul><ul><ul><li>“ Where does it start?”  </li></ul></ul><ul><ul><li>“...
Focused Exam (S) <ul><li>A llergies </li></ul><ul><li>M edications –  </li></ul><ul><ul><li>Cardiac meds = cardiac problem...
Focused Exam (S) <ul><li>L ast Oral Intake </li></ul><ul><li>E vents Leading to Call –  </li></ul><ul><ul><li>“ What were ...
Listen to the patient… … they will tell you exactly what is wrong!
Focused Exam (O) <ul><li>Objective findings from your physical exam of the patient. </li></ul><ul><li>Look for evidence of...
Focused Exam (O) <ul><li>Listen to breath sounds </li></ul><ul><li>Palpate chest </li></ul><ul><li>Palpate abdomen </li></...
Focused Exam (O) <ul><li>Based upon your clinical findings </li></ul><ul><li>Observe the patient while they are talking wi...
Detailed Exam (O) <ul><li>Complete and thorough neck, head to toe examination with non-critical patients if needed or time...
Assessment (A) <ul><li>This is your best guess (or rule out) as to what is going on with the patient. </li></ul><ul><li>It...
Plan (P) <ul><li>Medics? </li></ul><ul><li>ABC’s/Monitor vitals </li></ul><ul><li>Patient in position of comfort. </li></u...
Other Stuff <ul><li>Coronary artery bypass graft (CABG) and other open heart surgeries </li></ul><ul><li>Percutaneous tran...
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Cardiovascular Emergencies

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Cardiovascular Emergencies

  1. 1. Cardiovascular Emergencies … time is myocardium!
  2. 2. Statistics <ul><li>Cardiovascular disease (CVD) claimed over 1 million lives in 2004. </li></ul><ul><li>CVD has been the leading cause of death for Americans since 1900. </li></ul><ul><li>Sudden cardiac death accounts for over 40% of these deaths. </li></ul><ul><li>The majority of our 911 responses are for chest pain. </li></ul>
  3. 3. Controllable Risk Factors <ul><li>Smoking </li></ul><ul><li>High blood pressure </li></ul><ul><li>Elevated cholesterol levels </li></ul><ul><li>Elevated blood glucose levels </li></ul><ul><li>Diet </li></ul><ul><li>Lack of exercise </li></ul><ul><li>Stress </li></ul>
  4. 4. Uncontrollable Risk Factors <ul><li>Age </li></ul><ul><li>Family history </li></ul><ul><li>Race </li></ul><ul><li>Sex </li></ul>
  5. 5. Anatomy
  6. 6. Circulation
  7. 7. Blood <ul><li>Red blood cells: </li></ul><ul><ul><li>Carries oxygen to tissues and cells </li></ul></ul><ul><ul><li>Removes CO2 and waste </li></ul></ul><ul><li>White blood cells: </li></ul><ul><ul><li>Fight infection </li></ul></ul><ul><li>Platelets: </li></ul><ul><ul><li>Helps blood clot </li></ul></ul>
  8. 8. Electrical System
  9. 9. Coronary Arteries
  10. 10. Cardiac Compromise <ul><li>Chest pain results from ischemia. </li></ul><ul><li>Ischemic heart disease involves decreased blood flow to the heart. </li></ul><ul><li>If blood flow is not restored, the tissue dies (infarct). </li></ul><ul><li>Injury leads to inadequate heart function and death. </li></ul>
  11. 11. Atherosclerosis
  12. 12. So… <ul><li>… you are dispatched to a 67 year- old male c/o 9/10 “crushing” chest pressure that radiates to his jaw. He is also complaining of shortness of breath and nausea, with no previous cardiac history… </li></ul>
  13. 13. … w hat are YOU thinking?
  14. 14. Chest Pain Pathophysiology <ul><li>Mediastinum: </li></ul><ul><ul><li>Angina: stable or unstable </li></ul></ul><ul><ul><li>AMI </li></ul></ul><ul><ul><li>Esophagitis, esophageal rupture </li></ul></ul><ul><ul><li>Pericarditis </li></ul></ul><ul><ul><li>Mediastinal air </li></ul></ul><ul><ul><li>Thoracic dissection </li></ul></ul><ul><ul><li>Mitral valve prolapse </li></ul></ul>
  15. 15. Chest Pain Pathophysiology <ul><li>Chest Wall: </li></ul><ul><ul><li>Traumatic contusion/ tamponade </li></ul></ul><ul><ul><li>Cysts and infections </li></ul></ul><ul><ul><li>Rib cartilage inflammation </li></ul></ul><ul><ul><li>Shingles (Herpes Zoster) </li></ul></ul><ul><ul><li>Muscle strain, overuse syndromes </li></ul></ul>
  16. 16. Chest Pain Pathophysiology <ul><li>Lungs and pleura: </li></ul><ul><ul><li>Pleurisy </li></ul></ul><ul><ul><li>Pneumonia </li></ul></ul><ul><ul><li>Pneumothorax, hemothorax </li></ul></ul><ul><ul><li>Pulmonary embolus </li></ul></ul><ul><ul><li>Asthma, bronchitis, URI </li></ul></ul>
  17. 17. Chest Pain Pathophysiology <ul><li>Abdomen: </li></ul><ul><ul><li>Gallbladder (cholecystitis, stones) </li></ul></ul><ul><ul><li>Stomach (gastritis, GERD, perforated peptic ulcer) </li></ul></ul><ul><ul><li>Pancreas (pancreatitis) </li></ul></ul><ul><ul><li>Esophagitis, perforation </li></ul></ul>
  18. 18. Chest Pain <ul><li>Psychogenic: </li></ul><ul><ul><li>Stress </li></ul></ul><ul><ul><li>Hyperventilation </li></ul></ul><ul><ul><li>Anxiety and panic attacks </li></ul></ul>
  19. 19. Classic Symptoms <ul><li>Pressure, fullness, heaviness, squeezing pain in center of chest with radiation </li></ul><ul><li>Diaphoresis </li></ul><ul><li>Nausea </li></ul><ul><li>Shortness of breath </li></ul><ul><li>Weakness </li></ul>
  20. 20. Frequency of Symptoms <ul><li>Diaphoresis 78% </li></ul><ul><li>Chest pain 64% </li></ul><ul><li>Nausea 52% </li></ul><ul><li>Shortness of breath 47% </li></ul><ul><li>No signs/symptoms 25% </li></ul><ul><li>N Engl J Med 1984;311:1144-7 </li></ul>
  21. 21. Atypical Presentations <ul><li>Common in the elderly, diabetics, and females: </li></ul><ul><ul><li>Unusual fatigue </li></ul></ul><ul><ul><li>Sudden onset of unusual shortness of breath </li></ul></ul><ul><ul><li>Nausea, dizziness </li></ul></ul><ul><ul><li>Belching, burping, indigestion </li></ul></ul><ul><ul><li>Palpitations, new dysrhythmia </li></ul></ul><ul><ul><li>Pain only in jaw, neck, back, arm </li></ul></ul>
  22. 22. All chest pain is considered to be an AMI until proven otherwise!
  23. 23. Angina Pectoris <ul><li>Chest pain caused when heart tissues do not get enough oxygen for a brief period of time. </li></ul><ul><li>Typically crushing or squeezing. </li></ul><ul><li>Onset with the 3-E’s. </li></ul><ul><li>Usually resolves with rest or meds. </li></ul><ul><li>May be difficult to diagnose from AMI </li></ul>
  24. 24. Angina
  25. 25. Acute Coronary Syndrome <ul><li>Used to describe the range of conditions from unstable angina to AMI. </li></ul><ul><li>Signs and symptoms usually caused by acute myocardial ischemia. </li></ul>
  26. 26. ACS Signs & Symptoms <ul><li>Shortness of breath </li></ul><ul><li>Signs of inadequate perfusion </li></ul><ul><li>Chest pain, pressure, or discomfort (with or without radiation to back, neck, jaw, arm, wrists) </li></ul><ul><li>Nausea </li></ul><ul><li>Weakness/syncope </li></ul><ul><li>Dysrhythmias </li></ul>
  27. 27. Acute Myocardial Infarct <ul><li>Usually caused by the same mechanism as angina only with resulting tissue death. </li></ul><ul><li>Time is myocardium: </li></ul><ul><li>Consequences can be serious: </li></ul><ul><ul><li>Congestive heart failure </li></ul></ul><ul><ul><li>Cardiogenic shock </li></ul></ul><ul><ul><li>Sudden death </li></ul></ul>
  28. 28. AMI
  29. 29. Cardiogenic Shock <ul><li>Heart lacks power to force blood through the circulatory system. </li></ul><ul><li>Brought on when 40% of left ventricle is infarcted. </li></ul><ul><li>Onset may be immediate or not apparent for 24 hours. </li></ul>
  30. 30. Signs & Symptoms <ul><li>Altered LOC </li></ul><ul><li>Rapid, shallow breathing </li></ul><ul><li>Restlessness and anxiousness </li></ul><ul><li>Pale, cool skin </li></ul><ul><li>Tachycardia/dysrhythmia </li></ul><ul><li>Hypotension </li></ul>
  31. 31. Congestive Heart Failure <ul><li>Occurs when the ventricles are damaged. </li></ul><ul><li>Heart tries to compensate with increased heart rate. </li></ul><ul><li>Enlarged, ineffective left ventricle </li></ul><ul><li>Fluid builds up into lungs or body as “pump” fails. </li></ul>
  32. 32. CHF
  33. 33. Signs & Symptoms <ul><li>Fatigue </li></ul><ul><li>Cough with pink, frothy sputum </li></ul><ul><li>Dypsnea, tachypnea </li></ul><ul><li>Pulmonary edema </li></ul><ul><li>Agitation and confusion </li></ul><ul><li>Hypertension </li></ul><ul><li>Pedal edema, ascities </li></ul>
  34. 34. Signs & Symptoms
  35. 35. Thoracic Dissection
  36. 36. Aortic Aneurysm
  37. 37. Signs & Symptoms <ul><li>Sudden and severe chest or upper back discomfort. “Pain shoots to the shoulder blades.” </li></ul><ul><li>Anxiety </li></ul><ul><li>Diaphoresis </li></ul><ul><li>Nausea </li></ul>
  38. 38. Cardiac Tamponade <ul><li>Trauma induced, filling of the pericardial sac with blood. </li></ul><ul><li>Signs of shock </li></ul><ul><li>JVD </li></ul><ul><li>Decrease pulse pressures </li></ul>
  39. 39. Esophageal Rupture <ul><li>Usually underlying alcohol abuse. </li></ul><ul><li>Shock signs. </li></ul><ul><li>Coughing up bright red blood. </li></ul>
  40. 40. Pericarditis <ul><li>Inflammation of the pericardium caused by infection. </li></ul><ul><li>Usually presents as sharp discomfort. </li></ul><ul><li>Changes with breathing and movement. </li></ul>
  41. 41. Chest Pain Assessment <ul><li>BSI/Scene Safety </li></ul><ul><li>Initial Assessment (Sick/Not Sick) </li></ul><ul><li>Focused Exam </li></ul><ul><li>Detailed Exam </li></ul><ul><li>Assessment </li></ul><ul><li>Treatment and Plan </li></ul>
  42. 42. Initial Assessment <ul><li>60second clinical picture to determine if Sick or Not Sick (Oxygen) </li></ul><ul><li>Based upon your initial impression: </li></ul><ul><ul><li>Body position </li></ul></ul><ul><ul><li>skin signs and color </li></ul></ul><ul><ul><li>respiratory rate and effort </li></ul></ul><ul><ul><li>mental status </li></ul></ul><ul><ul><li>pulse rate and character </li></ul></ul><ul><li>Correct immediate life threats! </li></ul>
  43. 43. Focused Exam (S) <ul><li>Your subjective findings are based upon what the patient or historian tells you: </li></ul><ul><li>Patient Age </li></ul><ul><li>Sex </li></ul><ul><li>Chief Complaint </li></ul>
  44. 44. Focused Exam (S) <ul><li>SAMPLE History </li></ul><ul><li>S igns/ S ymptoms (associated with cardiac chest pain): </li></ul><ul><ul><li>Diaphoresis (78%) </li></ul></ul><ul><ul><li>Shortness of Breath (47%) </li></ul></ul><ul><ul><li>Pain/discomfort (64%) </li></ul></ul><ul><ul><li>Nausea/vomiting (52%) </li></ul></ul><ul><ul><li>No signs or symptoms (25%) </li></ul></ul><ul><ul><ul><li>N Eng Journal Med 1984;311:11444-7 </li></ul></ul></ul>
  45. 45. Focused Exam (S) <ul><li>O nset – </li></ul><ul><ul><li>“ When and at what time did it start” </li></ul></ul><ul><li>P rovocation – </li></ul><ul><ul><li>“ Does anything make it better or worse?” </li></ul></ul><ul><ul><li>“ Does it change with position, palpitation, inspiration?” </li></ul></ul><ul><li>Q uality – </li></ul><ul><ul><li>“ Describe the pain/discomfort in your own words” </li></ul></ul>
  46. 46. Focused Exam (S) <ul><li>R egion/ R adiation – </li></ul><ul><ul><li>“ Where does it start?” </li></ul></ul><ul><ul><li>“ Does it radiate anywhere?” </li></ul></ul><ul><li>S everity – </li></ul><ul><ul><li>“ On a scale of 1 to 10, what was the pain/discomfort at onset?” </li></ul></ul><ul><ul><li>“ What is the pain/discomfort at now?’ </li></ul></ul><ul><li>T ime – </li></ul><ul><ul><li>“ When did this episode start?” </li></ul></ul><ul><ul><li>“ How long has it been going on?” </li></ul></ul>
  47. 47. Focused Exam (S) <ul><li>A llergies </li></ul><ul><li>M edications – </li></ul><ul><ul><li>Cardiac meds = cardiac problems. </li></ul></ul><ul><ul><li>Ask about OTC meds, natural supplements, vitamins? </li></ul></ul><ul><li>P ast Medical History – </li></ul><ul><ul><li>“ Do you have any cardiac history?” </li></ul></ul><ul><ul><li>“ Risk factors such as smoking, diabetes, HTN, weight/diet?”” </li></ul></ul>
  48. 48. Focused Exam (S) <ul><li>L ast Oral Intake </li></ul><ul><li>E vents Leading to Call – </li></ul><ul><ul><li>“ What were you doing when this event started?” </li></ul></ul><ul><ul><li>Think activity induce vs. non activity </li></ul></ul>
  49. 49. Listen to the patient… … they will tell you exactly what is wrong!
  50. 50. Focused Exam (O) <ul><li>Objective findings from your physical exam of the patient. </li></ul><ul><li>Look for evidence of trauma/injury </li></ul><ul><li>Evaluate: </li></ul><ul><ul><li>Level of consciousness </li></ul></ul><ul><ul><li>Skin color and temperature </li></ul></ul><ul><ul><li>Respiratory rate and effort </li></ul></ul><ul><ul><li>Pupillary reaction </li></ul></ul><ul><ul><li>Pulse rate </li></ul></ul><ul><ul><li>Blood pressure (bilateral for chest pain!) </li></ul></ul>
  51. 51. Focused Exam (O) <ul><li>Listen to breath sounds </li></ul><ul><li>Palpate chest </li></ul><ul><li>Palpate abdomen </li></ul><ul><li>Check pedal pulses </li></ul><ul><li>BGL if diabetic with DLOC </li></ul><ul><li>SpO2 after BP, confirm with pulses, RA & after administration of O2 </li></ul><ul><li>Rhythm strip? </li></ul>
  52. 52. Focused Exam (O) <ul><li>Based upon your clinical findings </li></ul><ul><li>Observe the patient while they are talking with you, note any distress/discomfort (Levine sign) </li></ul><ul><li>Watch for acute clinical signs: jugular vein distension, tracheal deviation, paradoxial chest movement. </li></ul>
  53. 53. Detailed Exam (O) <ul><li>Complete and thorough neck, head to toe examination with non-critical patients if needed or time permits. </li></ul><ul><li>Elicit further information and necessary interventions. </li></ul><ul><li>Key in on critical findings! </li></ul>
  54. 54. Assessment (A) <ul><li>This is your best guess (or rule out) as to what is going on with the patient. </li></ul><ul><li>It is based upon YOUR Subjective and Objective findings and should help you develop and implement your Plan for patient care. </li></ul>
  55. 55. Plan (P) <ul><li>Medics? </li></ul><ul><li>ABC’s/Monitor vitals </li></ul><ul><li>Patient in position of comfort. </li></ul><ul><li>Oxygen via? </li></ul><ul><li>Assist with medications. </li></ul><ul><li>Maintain body temperature. </li></ul><ul><li>Calm and reassure. </li></ul><ul><li>Minimize patient movement. </li></ul><ul><li>Rapid transport! </li></ul>
  56. 56. Other Stuff <ul><li>Coronary artery bypass graft (CABG) and other open heart surgeries </li></ul><ul><li>Percutaneous transluminal coronary angioplasty (PTCA) </li></ul><ul><li>Automatic implantable cardiac defibrillators (ACID) </li></ul><ul><li>Pacemakers </li></ul>

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