Download Angina, AMI

Workshop Cardiovascular Emergencies Competencies:
Angina/AMI, CHF/Cardiogenic Shock/Hypertensive Emergency,
Aspirin/Nitro/Atherosclerosis, ACS/Arrhythmias
Angina, AMI
Equipment Required:
none
Competencies:
Medical, Behavioral, and OB/GYN competencies
5
Demonstrate assessment and care for chest pain pt. in scenario
Proctor guidelines:
1. Have a discussion with students about cardiovascular emergencies using the scenarios
below and the teaching points.
Scenarios:
1. You arrive on scene of a 60-year-old male having chest pain. Your gloves are on and
the scene is safe. He states he has a history of angina.
What is angina? A type of myocardial ischemia that occurs when the heart's need for
oxygen exceeds the available oxygen
What are the signs and symptoms of angina? Sub sternal chest pain that can radiate to
arms, jaw, mid back, or epigastrum; usually described as crushing or squeezing;
shortness of breath; nausea; sweating; usually lasts 3 to 8 min., rarely longer than 15
min.; triggered by exertion, a large meal, sudden fear, etc.; symptoms usually disappear
promptly with rest, supplemental oxygen, and/or nitroglycerin
What causes angina? Spasm of an artery or usually a symptom of atherosclerotic
coronary artery disease
What are the two types of angina and what are the differences? Unstable and stable,
unstable requires fewer stimuli to produce, lasts longer, does not respond to rest or
nitroglycerin
How do you treat and transport a patient with angina? Oxygen 15 LPM non-rebreather
mask or 2-6 LPM nasal cannula, aspirin 2-4 81 mg tablets, nitroglycerin 3 doses of tablet
or spray, rest, call ALS, reassess every 5 minutes, rapid transport, in position of comfort
2. You arrive on scene at a 55-year-old female having chest pain. Your gloves are on and
the scene is safe. She states that she thinks she's having a heart attack. She's had one in
the past and this feels exactly the same.
What is the medical term for a heart attack? Acute myocardial infarction
What does myocardial infarction mean? The death of heart tissue
What causes an AMI? Blood flow to a part or parts of the heart is obstructed
What are the signs and symptoms of an AMI? Chest pain that can radiate to the jaw,
arms, back, abdomen, or neck; shortness of breath; sweating; nausea; weakness;
irregular, rapid, or slow pulse; syncope; pale, gray, and/or cyanotic skin color; low
blood pressure due to diminished cardiac output, usually normal or elevated blood
pressure; frightened; feeling of impending doom; sudden death
How are the signs and symptoms of AMI different from angina? AMI symptoms can
occur at any time, do not resolve in a few minutes and can last between 30 min. and
several hours, may or may not be relieved by rest and/or nitroglycerin
Why is AMI considered a more serious condition than angina? Because during an AMI
the cells of the heart are dying and once dead they cannot be revived, if enough of the
heart muscle dies the heart will not pump properly causing reduced cardiac output and
possible death
What are major risk factors placing a person at higher risk for having an AMI? Smoking,
high blood pressure, high cholesterol level, diabetes, lack of exercise, stress, age, family
history, male
How do you treat and transport a patient with an AMI? Oxygen 15 LPM non-rebreather
mask or 2-6 LPM nasal cannula, aspirin 2-4 81 mg tablets, nitroglycerin 3 doses of tablet
or spray, rest, call ALS, rapid transport, reassess every 5 min., it position of comfort
Why is it so important to get a patient with an AMI to the hospital rapidly? The hospital
can give the patient medications to break up clots or perform angioplasty to open the
arteries, there is a short window of time for these treatments to be effective
What are three serious conditions that AMI can cause? Sudden death, cardiogenic shock,
CHF
CHF, Cardiogenic Shock, Hypertensive Emergency
Equipment Required:
none
Competencies:
Medical, Behavioral, and OB/GYN competencies
5
Demonstrate assessment and care for chest pain pt. in scenario
Proctor guidelines:
1. Have a discussion with students about cardiovascular emergencies using the scenarios
below and the teaching points.
Scenarios:
1. You arrive on scene of a 50-year-old female having breathing difficulty. Your gloves
are on and the scene is safe. She states that she called 911 today because her CHF
symptoms have gotten worse. She normally takes Lasix but has been unable to fill the
prescription this month due to financial issues.
What are the signs and symptoms of CHF? Breathing difficulty, rales, pink frothy sputum,
edema in the legs and feet or other parts of the body, JVD, difficulty breathing when
laying down, coughing
What causes CHF? The heart cannot pump effectively so fluid builds up in the body, the
lungs, or both
What are the two types of CHF? Right-sided heart failure, left-sided heart failure
What does the right side of the heart do and what does the left side of the heart do? The
right side pumps the blood from the body into the lungs, the left side pumps the blood
from the lungs into the body
What is the difference between the two types of CHF? Right-sided heart failure- causes
fluid to build up in the body causing edema and possible JVD, left-sided heart failurecauses fluid to build up in the lungs causing breathing difficulty, rales, pink frothy
sputum, coughing; patients can have both
What can cause someone to develop CHF? Diseased heart valves, chronic hypertension,
past AMI, atrial fibrillation, congenital defects
What position should you transport a person with CHF in? Sitting up or position of
comfort
2. You arrive on scene of a 55-year-old female complaining of chest pain. Your gloves
are on and the scene is safe. You assess the patient and determined she's having a heart
attack. She is also showing signs of shock.
What type of shock would she be showing signs of? Cardiogenic shock
What causes shock of any type? Poor perfusion of oxygenated blood to the tissues
What is required for good perfusion? A well functioning heart, adequate blood volume,
well functioning blood vessels
What is cardiogenic shock? The heart lacks the power to pump enough blood through the
circulatory system causing body tissues to not get enough oxygen causing organs to
malfunction
What are the signs and symptoms of cardiogenic shock? Hypotension, rapid weak
thready pulse, cool clammy skin, cyanosis, altered LOC, rapid deep ventilations,
pulmonary edema, anxiety
What can cause cardiogenic shock? Most common cause heart attack (AMI),
arrhythmias, cardiomyopathy, cardiac valve problems, myocarditis (inflammation of
heart muscle), toxic substance ingestion, CHF
It is more common in a heart attack affecting what areas of the heart? Inferior and
posterior regions of the left ventricle
How do you treat and transport a patient in cardiogenic shock? Oxygen 15 LPM nonrebreather mask, call ALS, rapid transport, reassess every 5 min., in position of comfort,
cover with blanket
Why do you not place a patient in cardiogenic shock in the supine position lying flat on
their back? Because they can develop pulmonary edema
3. You arrive on scene of a 40-year-old male who developed a sudden severe headache.
Your gloves are on and the scene is safe. He also complains of a bounding pulse and
dizziness.
What do you think is causing this patient's symptoms? A hypertensive emergency
What is the definition of a hypertensive emergency? A systolic blood pressure greater
than 160 mm Hg or a rapid increase in the systolic pressure
What are some other signs and symptoms of a hypertensive emergency? Ringing in the
ears, nausea and vomiting, nosebleed, altered mental status, sudden pulmonary edema,
warm skin can be dry or moist
What are two serious conditions that a hypertensive emergency can lead to if untreated?
Stroke, dissecting aortic aneurysm
How would you treat and transport this patient? Oxygen 15 LPM non-rebreather mask or
2-6 LPM nasal cannula, call ALS, reassess every 5 min., rapid transport, in position of
comfort
Aspirin, Nitro, Atherosclerosis
Equipment Required:
Aspirin
Nitroglycerin
Competencies:
Medical, Behavioral, and OB/GYN competencies
1
2
5
10
Demonstrate General steps for assisting pt. with self administration of meds
Read labels and inspect each type of meds
Demonstrate assessment and care for chest pain pt. in scenario
Perform steps for use of Nitro for chest pain/discomfort in scenario
Proctor guidelines:
1. Have a discussion with students about cardiovascular emergencies using the scenarios
below and the teaching points.
Scenarios:
1. You arrive on scene of a 60-year-old male having chest pain. Your gloves are on and
the scene is safe. After assessing the patient you have decided to administer aspirin to the
patient.
What conditions can you consider giving aspirin? AMI, angina, chest pain
What is the recommended dose for aspirin? 2 81 mg (162 mg) or 4 81 mg (324 mg)
chewable tablets, Virginia Beach dose is 324 mg
What is the mechanism of action of aspirin for patients with chest pain? Inhibits platelet
aggregation, which is one direct cause of a heart attack
What are the contraindications for administering aspirin? The patient has taken the
maximum dose prior to your arrival, allergy, pre-existing liver damage, bleeding
disorders, asthma,a history of internal bleeding such as stomach ulcers require medical
control permission
Do you need to call medical control to administer aspirin? No under normal conditions,
call medical control if patient is on blood thinning medication or history of internal
bleeding
Where do you obtain the aspirin to give to the patient? IV box or drug box from
ambulance
What do you need to do before administering aspirin to the patient? Obtain the 6 rights of
medication administration, a set of vital signs, assess the patient's signs and
symptoms/condition including SAMPLE and OPQRST
What are the 6 rights of medication administration? Right medication- make sure the
patient has the condition that the medication is prescribed for and that it is the correct
medication, right route-make sure you administer the medication properly, right dosemake sure you do not administer more than the prescription calls for, right date-make
sure that the medication has not expired, right patient-make sure that the medication is
prescribed to the patient, right documentation-make sure you document all pertinent
information pertaining to medication administration
Proctor: because aspirin is not prescribed to the patient the right of right patient is
modified for aspirin
What is the route of medication administration for aspirin? Sublingual
What are the contraindications for administering all sublingual medications? The patient
is not awake, alert, able to follow commands, or able to maintain his or her airway
Assist the patient in the administration of aspirin.
How else would you treat and transport this patient? Oxygen 15 LPM non-rebreather
mask, consider nitroglycerin administration, call ALS, reassess every 5 min., rapid
transport, in position of comfort
2. You arrive on scene of a 55-year-old female having chest pain. Your gloves are on and
the scene is safe. She tells you she has a history of angina. After assessing the patient you
determine she is having an angina attack. You decide to administer patient assisted
medication.
What patient assisted medications can you administer to this patient? Aspirin,
nitroglycerin
You administer the aspirin to the patient and are preparing to give her the nitroglycerin.
What is the mechanism of action of nitroglycerin? Relaxes blood vessel wall muscles
which causes blood vessels to dilate, increases blood flow and oxygen supply to the heart,
decreases workload of the heart because less blood is returned to the heart due to
relaxed veins
What are three ways of nitroglycerin administration? Sublingual pill, sublingual spray,
medication patch
What do you need to do before you can give the patient her nitroglycerin? Obtain the six
rates of medication administration and medical control permission, complete set of vital
signs, assess the SAMPLE and current OPQRST of the patient, make sure the systolic
blood pressure is more than 100 mm Hg, determine that the patient has not used erectile
dysfunction drugs within 24 hours (including females), the patient does not have a head
injury, make sure you are wearing gloves when handling the nitroglycerin
Why does the blood pressure need to be more than 100 mm Hg before administering
nitroglycerin? Nitroglycerin can lower the patient's blood pressure, which can lead to
severe hypotension, because it relaxes the blood vessel wall muscles and dilates the blood
vessels
Why do you need to make sure the patient has not taken any erectile dysfunction drugs
within 24 hours before administering nitroglycerin? Erectile dysfunction drugs dilate
blood vessels so when used together with nitroglycerin it can cause severe hypotension
What are the side effects of nitroglycerin? Headache, dizziness, low blood pressure,
nausea, tingling or burning sensation at the site of administration
The patient does not have had injury, has not taken any erectile dysfunction drugs within
the past 24 hours, and has a blood pressure of 120/80 mm Hg. You have taken a complete
set of vitals, obtained the six rights of medication administration, and contacted medical
control who gave you permission to administer the Nitroglycerin.
Assist the patient in the administration of her nitroglycerin.
What should you do after the administration of each nitroglycerin dose? Reassess the
patient's vital signs and the patient's signs and symptoms/condition including OPQRST
After you administer the second dose of nitroglycerin the patient's blood pressure is now
90/66 mm Hg. You were given permission to give the patient three doses of nitroglycerin
from medical control.
Should you give the third dose of nitroglycerin to this patient and why? No, because the
patient's blood pressure is below 100 mm Hg systolic
What conditions, other than angina, can you consider administering patient assisted
nitroglycerin for? AMI, pulmonary edema, CHF
3. You arrive on scene of a 70-year-old male having chest pain. Your gloves are on and
the scene is safe. After completing your assessment and vital signs of the patient you
suspect he is having an AMI. During your assessment he tells you he has atherosclerosis.
What is atherosclerosis? The formation of a plaque inside the walls of blood vessels
caused by the buildup of calcium and cholesterol
Why can atherosclerosis lead to an AMI? The plaque narrows the inner diameter of the
blood vessels and can cause complete blockage of a coronary blood vessels or other
blood vessels of the body; also the plaque causes the inner wall of the blood vessels to
become rough and brittle, if the plaque develops a crack the ragged edge of the crack
activates blood clotting system resulting in a blood clot that can partially or completely
block the blood vessel
What is another name for atherosclerosis? Coronary artery disease
What are some risk factors for developing coronary artery disease? Smoking, high blood
pressure, high cholesterol level, diabetes, lack of exercise, stress, age, family history,
male
ACS, Arrhythmias
Equipment Required:
none
Competencies:
Medical, Behavioral, and OB/GYN competencies
5
Demonstrate assessment and care for chest pain pt. in scenario
Proctor guidelines:
1. Have a discussion with students about cardiovascular emergencies using the scenarios
below and the teaching points.
Scenarios:
1. You arrive on scene of a 65-year-old male complaining of chest pain. Your gloves are
on and the scene is safe. You assess the patient and take his vital signs. He states he has a
history of acute coronary syndrome (ACS).
What is acute coronary syndrome (ACS)? A group of symptoms caused by myocardial
ischemia including angina and AMI
What is myocardial ischemia? Restriction in blood supply to the heart tissues causing
lack of oxygen to the heart tissues
Why is a lack of blood supply and oxygen to the heart tissues dangerous? Because like
every other organ in the body the heart muscle requires blood and oxygen to function
properly
If the heart is functioning properly how does it pump blood throughout the body starting
at the right atrium? Oxygen poor blood enters the heart into the right atrium, blood is
pumped into the right ventricle, the right ventricle pumps the blood into the lungs where
the blood picks up oxygen and drops off CO2, oxygenated blood is pumped from the
lungs into the left atrium, blood is pumped into the left ventricle from the left atrium,
blood is pumped from the left ventricle to the body
What organ is supplied first with the oxygenated blood from the left ventricle? The heart
What are the blood vessels called that deliver oxygenated blood to the body and
specifically the heart? Arteries, coronary arteries supply the blood to the heart tissues
What are the blood vessels called that return oxygen poor blood to the heart? Veins
What are the small blood vessels called that connect the arteries and veins? Capillaries
connect the arterioles (smallest branches of the arteries) to the venules (smallest
branches of the veins)
What happens when the blood flows through the capillaries? Nutrients and oxygen is
exchanged for waste at the cellular level
What are two vital signs you can take to help determine how well the heart is
functioning? Pulse and blood pressure
What is the blood pressure measuring? The pressure of circulating blood against the
artery walls
What are the two numbers of a blood pressure called and what do they measure? Systolic
(top number) measures maximum pressure of left ventricle as it contracts, diastolic
(bottom number) measures pressure of left ventricle at rest
What are the two types of pulses and when is a pulse felt? peripheral pulse felt in
extremities, central pulse felt near trunk of body, pulse is felt when blood passes through
an artery during systole
What is another measurement that can help determine how well the heart is functioning?
Cardiac output
What is cardiac output and how is it calculated? The volume of blood that passes through
the heart in 1 min., calculated by multiplying the pulse by the volume of blood ejected
with each contraction (volume of blood ejected with each contraction = stroke volume)
If the heart is ischemic and the blood flow to the heart tissue is not restored what will
happen? The heart will begin to not function properly and eventually the affected tissue
will die
2. You arrive on scene of a 40-year-old female who has a history of heart arrhythmias.
Your gloves are on and the scene is safe. You begin your assessment and vital signs.
What is a heart arrhythmia? Abnormal heart rhythm
What are some examples of heart arrhythmias? Premature ventricular contractions,
tachycardia, bradycardia, ventricular tachycardia, ventricular fibrillation, asystole
What is the normal average heart rate for an adult? 60-100 bpm
What is tachycardia? Rapid heartbeat over 100 BPM
What is bradycardia? Slow heartbeat less than 60 BPM
What is ventricular tachycardia? A very rapid heartbeat at 150-200 BPM can deteriorate
into ventricular fibrillation (V fib)
What is ventricular fibrillation? Disorganized ineffective quivering of ventricles, no blood
is pumped through body
What are premature ventricular contractions? Extra beats of the ventricle, normally the
ventricle contracts after the atrium has contracted and filled the ventricle with blood, in a
PVC the ventricle contracts before the atrium has finished filling it with blood, usually
harmless and common among healthy and sick people, becomes dangerous when a
patient has several PVCs in a row, PVCs are caused by heartbeat initiated further down
the electrical path of the heart rather than the sinoatrial node
What is asystole? Absence of all heart electrical activity
What is different about cardiac muscle regarding its electrical activity? The heart
generates its own electrical impulse independent of the central nervous system that
controls the heart rate and coordinates the work of the atria and ventricles
Where does the electrical impulse for the heart begin? Sinoatrial node
What happens after the sinoatrial node generates its electrical impulse? The atria contract
in unison, then the electrical impulse is conducted throughout the rest of the cardiac
muscle cells causing the ventricles to contract
What happens if the electrical impulse from the sinoatrial node does not reach the other
cardiac muscle cells? The other cells can create their own impulse and cause a
contraction
TEACHING POINTS FOR CARDIOVASCULAR EMERGENCIES
ANATOMY AND PHYSIOLOGY
Heart – Job is to pump blood supplying oxygen rich red blood cells to body
tissues. Divided into left and right sides, each side has an atrium (upper
chamber) and ventricle (lower chamber). Right side heart receives and then
pumps deoxygenated blood to lungs. Left side heart pumps oxygenated blood to
body, and is more muscular than right because must pump blood into aorta and
all other arteries of the body. One way valves separate the chambers and keep
blood moving through circulatory system in proper direction.
Atrium – upper chamber of heart, receives incoming blood
Ventricle – lower chamber of heart, pumps outgoing blood
Aorta – body’s main artery, receives blood from the left ventricle, delivers to all
other arteries
Cardiac muscle – known as myocardium
Deoxygenated blood from vena cava enters right atrium, flows thru valve into
right ventricle, right ventricle contracts and blood flows through pulmonary valve
into left pulmonary artery into the pulmonary circulation in the lungs where it
becomes oxygenated and waste is removed (at the level of the alveoli).
Oxygenated blood returns to heart through the pulmonary vein and into the left
atrium, goes through the mitral valve into the left ventricle (most muscular section
of the heart) and when the ventricle contracts the blood flows into the aorta and
then to all other arteries in the body.
Electrical system of the heart – this controls heart rate and coordinates the
work of the atria and ventricles so they work together. Electrical impulse begins
in the upper part of the right atrium, in the sinus node ( also known as sinoatrial
node). Electrical impulse travels across both atria, so they both contract.
Between atria and ventricles the impulse crosses a abridge of special electrical
tissue called atrioventricular node, where the signal is slowed for about one to
two tenths of second to allow time for the blood to pass from the atria to
ventricles. Impulse then exits the atrioventricular node and spreads throughout
both ventricles via the Purkinje fibers, which causes the ventricles to contract.
Cardiac muscle has special characteristic not found in any other type of muscle
cell – Automaticity . Automaticity allows spontaneous contraction without a
stimulus from a nerve source. This starts in the sinoatrial node and as long as it
originates there all other myocardial cells will contract when the impulse reaches
them. If no impulse reaches them, the other myocardial cells can create their
own impulses and stimulate a contraction. (At a slower rate than it would be had
it started in the sinoatrial node.) This stimulus is controlled by impulses from the
brain and arrive at the heart by way of the autonomic nervous system.
Autonomic Nervous System – controls involuntary activities of the body, such
as heartbeat, respirations, dilation and constriction of blood vessels, digestion of
food. Has two parts: Sympathetic nervous system, and the parasympathetic
nervous system. Sympathetic nervous system is known as the “fight or flight
system”. It makes adjustments to allow for physical activity. Speeds up heart
rate, increases respiratory rate and depth, dilates blood vessels in muscles,
constricts blood vessels in digestive system. In times of stress, this system takes
primary control. Parasympathetic nervous system slows various bodily functions
down. Slows hear and respiratory rates, constricts blood vessels in muscles,
dilates blood vessels in digestive system. In times of relaxation this system takes
primary control.
Circulation: In order to pump blood the heart muscle (myocardium) must have
continuous supply of oxygen and nutrients. Myocardium Increases oxygen
demand during periods of physical exertion. In normal heart increased oxygen
demand of the myocardium itself is handled by the dilation of the coronary
arteries, increasing blood flow to the heart itself. The heart will increase cardiac
output to meet increased metabolic requirements of body, this is accomplished
increasing the heart rate or stroke volume. Stroke volume is volume of blood
ejected with each ventricular contraction.
Coronary arteries – blood vessels that supply blood to the heart muscle, starting
at the first part of the aorta, just above aortic valve. Right coronary artery
supplies blood to right ventricle and usually the inferior wall (bottom part) of the
left ventricle. Left coronary artery divides into two major branches both supplying
the left ventricle. Blood supply to different parts of the body is delivered by: right
and left carotid arteries supply head and brain; subclavian arteries supply upper
extremities; brachial artery supplies the arms; 4radial and ulnar arteries supply
the hands; right and left iliac arteries supply groin and pelvis; right and left
femora arteries supply legs; anterior and posterior tibial and peroneal arteries
supply feet.
After the blood passes thru arteries it enters smaller and smaller vessels –
arterioles and capillaries. Capillaries are one-cell thick and connect arterioles to
venules. Capillaries are found in all parts of body, allow for exchange of nutrients
and waste at the cellular level. As blood goes thru capillaries is gives off oxygen
and picks up carbon dioxide and other waste products for removal from the body.
Venules are smallest branches of veins. Oxygen poor blood begins is journey
back to the heart in these. The veins become larger and larger and eventually
form the two large vena cava – Superior (upper) vena cava carries blood from
the head and arms back to the right atrium; Inferior (lower) vena cava carries
blood from the abdomen, kidneys and legs back to the right atrium. The superior
and inferior vena cava join together at the right atrium of the heart, and the
oxygen poor blood then enters the right atrium of the heart.
Blood consist of several types of cells and fluid: Red blood cells are most
numerous, give blood its red color, and carry oxygen and remove carbon dioxide.
White blood cells fight infection. Platelets help blood to clot. Plasma (mixture of
water, salts, nutrients, and proteins) and is fluid that cells float in.
Blood pressure – defined as pressure of circulating blood against artery walls.
Systolic is maximum pressure generated by the left ventricle as it contracts.
Diastolic is pressure against artery walls while the left ventricle is at rest. Cardiac
cycle consists of one systolic and one diastolic period. Pulse is felt as blood
passes through an artery during systole. Peripheral pulse felt in extremity (eg.
Radial and posterior tibialis). Central pulses felt near the trunk of body (eg,
femoral and carotid).
Rate of cardiac contractions can be increased or decreased by autonomic
nervous system. Heart also has ability to increase or decrease volume of blood it
pumps with each contraction based on autonomic nervous system response. To
get accurate measure of efficiency of heart need to measure volume of blood
pumped and heart rate, done by calculating cardiac output.
Cardiac output is volume of blood that passes through the heart in one minute.
Calculated by multiplying the heart rate by the volume of blood ejected with each
contraction (stroke volume). In the field, stroke volume can be roughly
determined by the strength of a patient’s pulse.
Perfusion – constant flow of oxygenated blood to the tissues. To have good
perfusion you need: 1) well functioning heart (pump) operating at an appropriate
rate to allow proper volume of blood to be circulated; 2) Adequate volume of
blood. Reduced volume limits amount of tissue that can be perfused. 3) Blood
vessels must be appropriately constricted to match volume of blood available.
Dilated vessels mean reduced perfusion. When perfusion fails, cellular death
occurs and eventually patient death.
PATHOPHYSIOLOGY
Ischemia – decreased blood flow to the heart or inefficient supply of oxygen and
nutrients. Heart-related chest pain usually stems from ischemia. Ischemic heart
disease involves decrease in blood flow to one or more portions of heart muscle.
If blood flow not restored tissue dies.
Atherosclerosis – disorder where calcium and cholesterol build up and form
plaque inside walls of blood vessels, eventually can cause complete occlusion
(blockage). As person ages, more of the plaque is deposited and the lumen
(inside diameter of artery) narrows. Inner wall of artery becomes rough and
brittle. Brittle plaque may develop a crack (not known why), this ragged edge of
crack activates the blood-clotting system which results in blood clot that may
partially or completely block the lumen of the artery. If the clot does not
completely block the artery, it may break loose and float in the blood. This is
known as a thromboembolism, and will float thru the blood vessels until it
reaches one that is too narrow for it to pass thru, thus blocking the flow of blood.
Tissues downstream of this block will suffer ischemia, if too much time passes
before blood flow is restored the tissues will die. If this happens in a coronary
artery, an acute myocardial infarction (AMI) will occur. (classic heart attack).
Infarction means death of tissue. Death of heart muscle can cause severely
diminish the heart’s ability to pump and may cause cardiac arrest.
In US, coronary artery disease is number one cause of death for men and
women. Peak incidence of heart disease is between 40 and 70 years of age, but
can strike in teens and older than 70.
Risk factors: Controllable: cigarette smoking, high blood pressure, elevated
cholesterol level, diabetes, lack of exercise, stress. Uncontrollable: older age,
family history, male.
Acute Coronary Syndrome – also called ACS, is a group of symptoms caused
by myocardial ischemia.
Angina Pectoris – occurs when heart’s need for oxygen exceeds the available
supply, usually during physical or emotional stress. Can result from spasm of an
artery, but most often symptom of atherosclerotic coronary artery disease. Large
meal or sudden fear may trigger it. When increased oxygen demand goes away,
pain typically goes away.
Pain usually described as crushing, squeezing, or “like somebody is standing on
my chest”. Generally felt mid portion of the chest, under the sternum, can radiate
to jaw, arms (most often left), mid portion of the back or epigastrium. (uppermiddle region of the abdomen). Pain usually lasts 3 to 8 minutes, rarely longer
than 15 minutes. Patient may also experience shortness of breath, nausea or
sweating. Disappears promptly with rest, supplemental oxygen, or nitroglycerin,
all of these decrease the need for increased oxygen to heart. Angina pectoris is
frightening, but does not mean that heart cells are dying or cause permanent
heart damage. It is a warning sign.
Angina can be placed in one of two categories: Stable and Unstable. Stable
angina is pain in the chest (coronary) that responds to rest or nitro. Unstable
angina is also pain in the chest (coronary origin) but occurs in response to less
stimulus than normally required. Example may happen with just a little exercise.
Also unstable angina will not respond to normal treatment done by patient, rest or
nitro (up to 3 tablets) do not relieve it. Unstable angina can lead to AMI. A
patient experiencing chest pain should always be treated as if they are having an
AMI.
Acute Myocardial Infarction – Pain of AMI signals actual death of cells in the area
of the heart where the blood flow is obstructed. Dead cells cannot be revived.
The dead cells will form scar tissue and become burden to the beating heart. 30
minutes after blood flow is cut off, some heart muscle begin to die, after 2 hours
as any as half the cells in the area may be dead and after 4 to 6 hours more than
90% of the cells will be dead. Opening the coronary artery with either “clotbusting” (thrombolytic) drugs or angioplasty (mechanical clearing of the artery)
can prevent damage if done within the first hour after the onset of symptoms.
Immediate transport is essential. An AMI is more likely to occur in the larger,
thick-walled left ventricle (more muscular than right so requires more blood and
oxygen).
Signs and Symptoms of AMI: 1) sudden onset of weakness, nausea, sweating,
2) chest pain that does not change with each breath, 3) pain in the lower jaw,
arms, back, abdomen or neck, 4) irregular heartbeat and syncope (faint) 5)
shortness of breath 6) pink, frothy sputum, 7) sudden death.
Pain of Acute Myocardial Infarction – differs from angina in three ways: 1) may
or may not be caused by exertion and can occur at any time, sometimes when a
person is sitting quietly or even sleeping 2) does not resolve in a few minutes,
rather it can last between 30 minutes and several hours, 3) may or may not be
relieved by rest or nitro. Not all patients having an AMI experience pain or
recognize it when it occurs Some patients may only feel mild discomfort and
think it is indigestion, some especially diabetics will not experience any pain
during an AMI, some older women may only experience fatigue. Heart disease is
the number one killer of women in the US. When called to a call with chest pain
as the chief complaint, complete a thorough assessment, no matter what the
patient says.
Physical Findings of Acute Myocardial Infarction and Cardiac Compromise – vary
depending on extent and severity of heart muscle damage. General
Appearance: frightened, nausea, vomiting, and cold sweat; skin often pale or
ashen gray, occasionally the skin will have bluish tint (cyanosis). Pulse:
increases in response to pain, stress, fear or injury to the myocardium, irregular
or slow due to arrhythmias, bradycardia is due to damage to the inferior area of
the heart. Blood Pressure: may decrease due to diminished cardiac output and
left ventricle function, most patients with AMI will have normal or elevated BP.
Respiration: usually normal unless patient has CHF, if so then respirations may
be rapid and labored. Patient complaining of breathing difficulty is common with
cardiac compromise. Mental status: May have overwhelming feeling of
impending doom – I think I am going to die.
Consequences of Acute Myocardial Infarction: Sudden death, Cardiogenic shock
and Congestive Heart Failure.
Sudden Death: Approx 40% with AMI do not reach hospital alive. Sudden death
usually result of cardiac arrest. Arrhythmia is an abnormal heart rhythm. Variety
of lethal and nonlethal arrhythmias may occur after an AMI, usually within the first
hour.
Premature ventricular contractions are extra beats in a damaged ventricle
(harmless and common in healthy and sick people).
Tachycardia is rapid beating of the heart, at 100 beats/minute or more.
Bradycardia is unusually slow beating of the heart, at 60 beats/min or less.
Ventricular Tachycardia is very rapid heart rhythm at 150 to 200 beats/min
This rhythm does not allow adequate time between beats for the left
ventricle to fill with blood so the patients blood pressure may fall and the
pulse may be lost. Patient may feel weak or ligh-headed or even be
unresponsive. Most cases of ventricular tachycardia will be sustained and
may deteriorate into ventricular fibrillation.
Ventricular fibrillation is disorganized, ineffective quivering of the
ventricles. No blood is pumped through the body and the patient becomes
unconscious within seconds. The only way to convert this rhythm is to
defibrillate the heart. Defibrillation is shocking the heart with AED or
LifePak and can save lives CPR must be initiated until an AED is
available. Chances of survival diminish 10% each minute until
defibrillation is accomplished.
Asystole is the absence of all heart electrical activity. Uncorrected
unstable ventricular tachycardia or ventricular fibrillation will eventually
lead to asystole. Asystole usually means there has been a long period of
ischemia. Nearly all patients in asystole will die.
Cardiogenic Shock: occurs when body tissues do not get enough
oxygen, causing body organs to malfunction. It is caused by a heart
attack, the heart is unable to force enough blood through the circulatory
system. More common in an AMI affecting the inferior and posterior
regions of the left ventricle. Can occur immediately or as late as 24 hours
after onset of AMI. Important to recognize sock in early stages.
Congestive Heart Failure – can occur any time after myocardial
infarction, heart valve damage, or long-standing high blood pressure,
usually happens between the first few hours and few days after a heart
attack. When heart muscle can no longer contract effectively, the heart
tries to maintain cardiac output. Two changes occur: heart rate increases
and left ventricle enlarges in effort to increase amount of blood pumped
each minute. When these no longer make up for the decreased heart
function, CHF develops. Called “congestive” because lungs become
congested with fluid (pulmonary edema). The heart is failing to pump
blood effectively so it backs up in the pulmonary veins, which increases
the pressure in the capillaries. The pulmonary edema may occur
suddenly or slowly over months. In acute nset CHF, severe pulmonary
edema will be accompanied by pink, frothy sputum and severe dyspnea..
If the right side of the heart is damaged, the fluid will collect in the feet and
legs. This is called dependent edema and causes relatively few
symptoms other than discomfort. If this is a chronic issue it may indicate
underlying heart disease.
Hypertensive Emergencies – involves any systolic blood pressure
greater than 160 mm Hg or a rapid increase in systolic pressure. Signs
and symptoms are related to the effects of the hypertension. Some
patients with chronic hypertension may not experience S/S until their
systolic pressure is significantly higher.
Signs and symptoms: Sudden, severe headache is a common sign (may
be described as the worst headache I’ve ever had) this can also be a sign
of cerebral hemorrhage;
Strong bounding pulse, ringing in the ears, nausea and vomiting,
dizziness, warm skin (dry or moist), nosebleed, altered mental status, and
sudden development of pulmonary edema.
Untreated can lead to stroke or dissecting aortic aneurysm. These
patients need transported quickly, in position of comfort, monitor the BP,
and consider ALS.
Aortic aneurysm –weakness in the wall of the aorta, the aorta dilates in
this area making it susceptible to rupture. If it ruptures blood loss will
cause the patient to die almost immediately.
Dissecting aneurysm – occurs when the inner layers of the aorta become
separated, allowing blood flow at high pressure between the layers. This is
primarily caused by uncontrolled hypertension. The separation of layers
weaken the wall of the aorta significantly making it more likely to rupture.
Signs and Symptoms: Sudden chest pain located in the anterior part of
the chest or in the back between the shoulder blades, the pain comes on
full force from one minute to the next, there may be a difference in blood
pressure between arms or diminished pulses in the lower extremities, may
be described as sharp or tearing pain, does not stop once it starts. A
dissecting aneurysm is difficult to diagnose pre-hospital, but consider it a
possibility in a patient exhibiting these symptoms, rapid transport and call
ALS.
Patient Assessment
A. Scene size-up
1. Ensure scene safety.
a. Ensure the scene is safe for you, your partner, your patient, and
bystanders.
b. Determine the necessary standard precautions and whether you will
need additional resources to assist in moving the patient(s).
2. Determine the mechanism of injury (MOI)/nature of illness (NOI).
a. Use information from the dispatcher, clues at scene, and the
comments of family members and bystanders.
B. Primary assessment
1. Form a general impression.
a. If the patient is unresponsive, evaluate the ABCs and assess for AED
use (apply to pulseless, apneic, and unresponsive patients).
2. Assess the patient’s airway and breathing.
a. If dizziness or fainting has occurred due to cardiac compromise,
consider the possibility of a spinal injury from a fall.
b. Assess breathing to determine whether the ailing heart is receiving
adequate oxygen.
i. Shortness of breath, with no signs of respiratory distress
(a) Apply oxygen with a nonrebreather mask at 10 to 15 L/min.
ii. Not breathing or inadequate breathing
(a) Apply 100% oxygen with a bag-mask device
iii. Pulmonary edema
(a) Positive-pressure ventilation with a bag-mask device or
continuous positive airway pressure (CPAP)
3. Assess the patient’s circulation.
a.
b.
c.
d.
Pulse rate and quality
Skin color, moisture, and temperature
Capillary refill time
Begin treatment for cardiogenic shock early to reduce the workload of
the heart.
e. Position the patient sitting up and well supported.
f. Manage bleeding.
4. Make a transport decision.
a. Stabilize life threats, then determine if immediate transport is
necessary.
i. Most patients with chest pain should be transported immediately.
ii. Follow local protocol for determining what receiving facility is most
appropriate (ie, the nearest facility or a medical center with special
capabilities).
b. Determine whether to use the lights and siren for each patient, partially
based on estimated transport time.
c. As a general rule, patients with cardiac problems should be
transported in the most gentle, stress-relieving manner possible.
C. History taking
1. Investigate the chief complaint.
a. Because patients experiencing AMI will have different signs and
symptoms, seriously consider all complaints of chest pain, shortness of
breath, and dizziness.
b. If the patient is having respiratory difficulty:
i. Is it due to exertion or related to the patient’s position?
ii. Is it continuous or does it change (eg, with deep breathing)?
c. If the patient has a cough:
i. Does it produce sputum?
d. Does the patient have nausea and vomiting, fatigue, headache, and/or
palpitations?
e. Ask about recent past trauma.
2. Obtain the SAMPLE history from a conscious patient.
a. Has the patient ever had a heart attack?
b. Has the patient been told that he or she has heart problems?
i. Angina, heart failure, or heart valve disease
ii. High blood pressure
iii. Aneurysm
c. Has the patient been told that he or she has other related medical
problems?
i. Emphysema or chronic bronchitis
ii. Diabetes or other blood sugar problems
iii. Kidney disease
d. Does the patient have any risk factors for coronary artery disease?
i. Smoking
ii. High blood pressure
iii. High-stress lifestyle
iv. Family history of heart disease
v. Current medications
e. What are the patient’s signs and symptoms?
f. Has the patient had the same pain before?
i. What medication(s) does the patient currently take?
(a) Does the patient have the medication(s) with him or her?
ii. Has the patient experienced a heart attack or angina?
(a) Is the pain similar?
g. What allergies does the patient have?
h. Is the patient taking medications?
i. Prescribed
(a) For what condition?
ii. Over the counter
iii. Recreational
3. Include the OPQRST mnemonic for assessing pain as part of the
SAMPLE history:
a.
b.
c.
d.
e.
f.
Onset
Provocation/palliation
Quality
Region/radiation
Severity
Timing
D. Secondary assessment
1. Perform a focused physical examination.
a. Focus on the cardiac and respiratory systems.
i. Circulation
(a) Skin color
(b) Skin temperature
(c) Skin condition
ii. Respirations
(a) Are lung sounds clear?
(b) Are breath sounds equal?
(c) Are neck veins distended?
(d) Is the trachea deviated or midline?
2. Obtain a complete set of vital signs.
a.
b.
c.
d.
e.
Airway, breathing, and circulation (ABCs)
Systolic and diastolic blood pressures
If available, use pulse oximetry.
If continuous blood pressure monitoring is available, use it as well.
Repeat at appropriate intervals and note the time that each set of vital
signs is taken.
E. Reassessment
1. Reassess vital signs every 5 minutes or any time significant changes in
the patient’s condition occur.
2. Sudden cardiac arrest is always a risk with patients experiencing a
cardiovascular emergency.
3. Provide interventions (see Skill Drill 14-1).
a. Ensure a proper position of comfort.
i. Allow patients to sit up if most comfortable.
ii. Loosen tight clothing.
b. Give oxygen.
i. Use nasal cannula for patients with mild dyspnea.
ii. Use nonrebreathing face mask for patients with more serious
respiratory difficulty.
c. Assist unconscious patients with breathing as well as those with
respiratory distress.
i. Use bag-mask device or positive-pressure ventilation device,
according to local protocols.
d. Depending on protocol:
i. Administer low-dose aspirin.
(a) Effects:
(1) Prevents blood clots from forming or getting bigger
(b) 81-mg chewable tablets
(c) Recommended dose: 162 mg (two tablets) to 324 mg (four
tablets)
ii. Assist the patient with prescribed nitroglycerin after obtaining
permission from medical control.
(a) Mechanism of action:
(1) Relaxes blood vessel wall muscles
(2) Increases blood flow and oxygen supply to heart
(3) Decreases workload of heart
(4) Dilates blood vessels
(b) Side effects:
(1) May cause change in patient’s pulse rate (eg, tachycardia or
bradycardia)
(c) Available forms:
(1) Sublingual pill
(2) Sublingual spray
(3) Skin patch applied to chest
(d) Indications:
(1) Ischemic pain
(2) Pulmonary edema
(3) Acute angina pectoris
(4) CHF
(e) Contraindications:
(1) After administering nitroglycerin, if the patient’s blood
pressure is less than 100 mm Hg, do not administer more
medication.
(2) Presence of head injury
(3) Use of erectile dysfunction drugs within 24 hours
(4) Maximum prescribed dose has already been given (usually 3
doses)
e. Make sure medications are neither expired nor contaminated before
administering them to the patient.
f. Make sure prescription medications are prescribed for the patient.
g. Wear gloves when administering medication.
h. If cardiac arrest occurs:
i. Perform CPR immediately until an AED is available.
4. Reassess your interventions.
5. Provide rapid patient transport if not performed already.
6. Communication and documentation
a. Alert the emergency department about the patient’s condition and
estimated time of arrival.
b. Report to the hospital while en route.
i. SAMPLE history
ii. OPQRST
iii. Vital signs
iv. Reassessment of vital signs
v. Medications taken
vi. Pre-hospital treatment
c. Document your assessment and interventions.
Heart Surgeries and Pacemakers
A. Over the last 20 years, hundreds of thousands of open-heart operations were
performed to bypass damaged segments of coronary arteries in the heart.
B. In the coronary artery bypass graft (CABG) operation, a blood vessel from the
chest or leg is sewn directly from the aorta to a coronary artery beyond the
point of obstruction.
C. Percutaneous transluminal coronary angioplasty (PTCA) involves the
following steps:
1. A tiny balloon is attached to the end of a long, thin tube.
2. The tube is threaded into the narrowed coronary artery and inflated.
3. The balloon is then deflated, and the tube and balloon are removed.
D. Patients who have had a bypass procedure may or may not have a long scar
on the chest.
E. Treat chest pain in a patient who has had any of these procedures in the
same way you would treat chest pain in patients who have not had heart
surgery.
F. Some people have cardiac pacemakers.
1. Pacemakers help maintain a regular cardiac rhythm and rate. come in
different
2. They are inserted when the electrical system of the heart is so damaged
that it cannot function properly.
3. These battery-powered devices deliver an electrical impulse through wires
that are in direct contact with the myocardium.
4. The generating unit typically resembles a silver dollar and is usually
placed under a heavy muscle or fold of skin in the left upper portion of the
chest.
5. EMTs normally do not need to be concerned about problems with
pacemakers.
6. When they do not function properly, pacemakers can cause a patient to
experience syncope, dizziness, or weakness due to an excessively slow
heart rate.
7. The pulse will ordinarily be less than 60 beats/min.
8. A patient with a malfunctioning pacemaker should be
1. These devices continuously monitor the heart rhythm and deliver promptly
transported to the emergency department.
9. When an AED is used, place the pads 1″ from the pacemaker.
G. Automatic implantable cardiac defibrillators (AICDs) are sometimes used by
patients who have survived cardiac arrest due to ventricular fibrillation.
1. These devices continuously monitor the heart rhythm and deliver shocks
as needed.
2. Treat these patients like all other patients having an AMI, including
performing CPR and using an AED if the patient goes into cardiac arrest.
3. The electricity from an AICD is so low that it will have no effect on
responders.
4. Do not place AED patches over the pacemaker.
Cardiac Arrest
A. Cardiac arrest is the complete cessation of cardiac activity—electrical,
mechanical, or both.
1. It is indicated in the field by the absence of a carotid pulse.
Follow AHA guidelines for CPR and your local protocols. Get the AED