Copyright 2009 Seattle/King County EMS Overview of CBT 434 Cardiovascular Emergencies Complete...
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Copyright 2009 Seattle/King County EMS
Overview of CBT 434 Cardiovascular Emergencies
Complete course available at www.emsonline.net
Copyright 2009 Seattle/King County EMS
Introduction
Cardiovascular Emergencies • Leading cause of death in the US
• Hundreds of thousands of Americans die from cardiac arrest each year
• 9 out of 10 cardiac arrest victims die before they get to the hospital
Copyright 2009 Seattle/King County EMS
Practical Skills
• Focused history using SAMPLE/OPQRST
• Assisting with nitroglycerin
• Auscultation and assessing breath sounds
• Assisting ventilations with BVM
• Care for ACS, CHF, aortic dissection, shock
• Use of AED
To receive CBT or OTEP credit, you must perform the following practical skills:
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Termsacute coronary syndrome (ACS) - A term used to describe a range of symptoms and conditions from acute myocardial infarction to unstable angina
aortic dissection - A tear in the lining of the aorta
infarction - Death of tissue due to loss of blood flow
ischemia - Poor oxygen supply to tissue
myocardium - Another term for heart muscle
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Terms, continued
pulmonary edema - Abnormal accumulation of fluid in the tissues and air spaces of the lungs
sustained tachycardia - Persistent heart rate of 100 or greater caused by a clinical condition such as hypoxia or impending shock
thrombus - A clot formed in a blood vessel or in a chamber of the heart
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Anatomy
Thoracic Cavity • Neck to lower ribs
• Divided into mediastinum and pleural cavities
• Diaphragm at its base
• Contains trachea, esophagus, heart, aorta, vena cava and the pulmonary artery
• Pleural cavities
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Structures
Anatomy, continued
• 12 pairs of ribs
• Connect to sternum through a bridge of cartilage
• Lower 5 ribs connect to sternum through the costal arch
• Intercostal muscles between ribs
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Arteries/Veins
Anatomy, continued
Purpose of CV system• Provide cells with oxygen
nutrients• Remove waste
Components • Heart • Arteries• Arterioles• Capillaries • Veins• Venules
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Coronary Arteries
Anatomy, continued
1. Right coronary artery
2. Left coronary artery
3. Atria
4. Ventricles
2211
33
44
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Myocardial IschemiaMyocardial ischemia is the lack of blood flow and oxygen to the myocardium (heart muscle).
•Inadequate blood flow to a part of the body
•Caused by constriction or blockage of the blood vessels
•Cells do not receive adequate supply of O2
Coronary Artery 75% occluded occluded
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Myocardial Ischemia, continued
Obstruction
• Inadequate blood flow to a part of the body
• Caused by constriction or blockage of the blood vessels
• Cells do not receive an adequate supply of oxygen
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Myocardial Ischemia, continued
Reduced blood flow associated with conditions that cause:
• Hypotension (e.g. blood loss)
• Tachycardia
• Bradycardia
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Coronary Thrombosis11
Plaque forms on thePlaque forms on theinner wall of an arteryinner wall of an artery
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Coronary Thrombosis, continued
11
22
Hard surface of the Hard surface of the plaque tears, exposing plaque tears, exposing
the soft under sidethe soft under side
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Coronary Thrombosis, continued
11
22
33
Platelets arrive to Platelets arrive to form a blood clotform a blood clot
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Other Sources of Chest Pain
• Mediastinum
• Chest wall
• Lungs and pleura
• Abdomen
• Psychogenic
Not all chest pain is cardiac related. Not all chest pain is cardiac related.
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ConditionsAngina pectoris is chest pain due to myocardial ischemia.
• Brought on by exercise, stress or cold weather • Possible radiation of pain to jaw, arm or upper back • Sudden onset • Usually relieved with rest within 3-5 minutes and/or
nitro Assessment of Angina
Onset sudden
Provocation physical exertion, stress, cold weather, relieved by rest
Quality pressure or squeezing pain
Radiates pain can radiate to jaw, arm or upper back
Severity mild to moderate
Time relieved with rest and/or nitroglycerin within 3-5 min
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Conditions, continued
Acute coronary syndrome (ACS) describes a range of clinical conditions.
The symptoms, which vary from patient to patient, are caused by acute myocardial ischemia:
• Shortness of breath • Discomfort • Chest pain • Pressure • Nausea • Weakness • Dysrhythmia • Syncope
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Conditions, continued
Acute myocardial infarction (AMI)
• Chest discomfort
• Discomfort in other areas of the upper body
• Shortness of breath
• Diaphoresis, nausea or weakness
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Conditions, continued
Aortic dissection
• Blood gets behind inner layer of the aorta
• Blood starts to fill space between layers of arterial wall
• Aorta widens and significantly disrupts blood flowSymptoms
• Sudden and severe chest or upper back pain
• Anxiety
• Diaphoresis
• Nausea
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Conditions, continued
Congestive heart failure (CHF)
• Occurs when heart is too weak to adequately circulate blood
• In left-sided heart failure, pulmonary edema occurs as blood backs up into lungs
• Increases fluid in alveoli - results in SOB
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Conditions, continued
Congestive heart failure signs
• Fatigue
• Cough, dyspnea
• Pulmonary edema (a severe form of CHF)
• Tachypnea
• Agitation and confusion
• Hypertension
• Swollen feet or lower legs
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Initial Assessment
• Guides initial treatment
• Quickly assess a patient
• Make a decision
SICK or
NOT SICK
SICK or
NOT SICK
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SICK/NOT SICK
A SICK patient is one who can die quickly unless you initiate aggressive BLS and ALS treatment and rapid transport.
A NOT SICK patient is one who can be ill or injured, but not severely enough to be life threatening.
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Key Clinical Indicators
• Respirations (rate, character)
• Pulse (rate, character)
• Mental status
• Skin signs and color
• Body position
SICK or
NOT SICK
SICK or
NOT SICK
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Patient History
OPQRST
Onset What was patient doing when the pain started?
Provocation What makes it better or worse?
QualityCan you describe it?
What does it feel like?
RadiatesWhere do you feel it?
Where does it go?
Severity How bad is it on a scale of 1 to 10 (ten being the worst)?
Time When did the pain begin?
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Physical Exam
• Auscultate breath sounds starting at the bases
• BP in both arms (note difference of 10 mm Hg or more)
• Skin color, moisture and temperature
• Pulse oximetry
• Blood glucometry
• Head, neck-to-toe exam
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Physical Exam, continued
Atypical presentations are common in elderly, diabetics and females.
Classic Symptoms Atypical Symptoms
• Pressure, fullness, heaviness, squeezing pain in center of chest that can radiate to neck, shoulder, jaw or back
• Sweating
• Nausea
• Weakness
• Shortness of breath
• Unusual fatigue
• Sudden onset of unusual SOB during usual activities or at rest
• Nausea, dizziness
• Belching, burping, indigestion
• Palpitations, new dysrhythmia, esp. atrial fibrillation
• Pain experienced only in jaw, neck, back, arm or wrist
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Patient Care
General steps
• Decide SICK or NOT SICK
• Ensure adequate airway and respirations
• Administer oxygen
• Position appropriately
• Assure ALS response
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Patient Care, continued
Other considerations
• Control airway secretions
• Assist ventilations with BVM
• Prepare for cardiac arrest and application of an AED
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Nitroglycerin
• Used to treat angina
• Relaxes vascular muscles
• Increases blood flow & oxygen to myocardium
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Nitroglycerin, continued
You may assist a patient in taking prescribed nitroglycerin if:
1. Pain is the same for which nitroglycerin is normally taken
2. Patient’s BP is greater than 100 mmHg
systolic
*Follow your local protocol if different.
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Nitroglycerin, continued
“Assisting” a patient with nitroglycerin means you can:
• Locate the container
• Open it
• Offer a pill to the patient
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SummaryThoracic cavity is divided into mediastinum and pleural cavities.
Structures within the thoracic cavity include:
• Intercostal muscles • Ribs • Sternum• Costal arch • Diaphragm • Heart• Lungs• Trachea • Aorta • Pulmonary arteries
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Summary, continued
Myocardial ischemia is the lack of blood flow and oxygen to the heart muscle.
Acute coronary syndrome (ACS) is the term used to describe clinical conditions ranging from unstable angina to acute myocardial infarction.
Sources of chest pain include the mediastinum, chest wall, lungs/pleura and abdomen. It can also be due to psychogenic sources.
Common cardiovascular emergencies are angina, AMI, aortic dissection, CHF and cardiogenic shock.
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Summary, continued
OPQRST is a mnemonic that helps assess the character of a complaint.
Principles of care for a cardiovascular emergency include:
• Decision of SICK or NOT SICK
• Ensure an adequate airway and respirations
• Administer oxygen
• Position the patient appropriately
• Assure an ALS response