Cardiovascular Emergencies …time is myocardium!. Statistics Cardiovascular disease (CVD) claimed over 1 million lives in 2004. Cardiovascular disease

Cardiovascular Cardiovascular EmergenciesEmergencies

……time is myocardium!time is myocardium!

StatisticsStatistics• Cardiovascular disease (CVD) Cardiovascular disease (CVD)

claimed over 1 million lives in 2004.claimed over 1 million lives in 2004.• CVD has been the leading cause of CVD has been the leading cause of

death for Americans since 1900.death for Americans since 1900.• Sudden cardiac death accounts for Sudden cardiac death accounts for

over 40% of these deaths.over 40% of these deaths.• The majority of our 911 responses The majority of our 911 responses

are for chest pain.are for chest pain.

Controllable Risk FactorsControllable Risk Factors

SmokingSmokingHigh blood pressureHigh blood pressure

Elevated cholesterol levelsElevated cholesterol levelsElevated blood glucose levelsElevated blood glucose levels

DietDietLack of exerciseLack of exercise

StressStress

Uncontrollable Risk FactorsUncontrollable Risk Factors

Age Age

Family historyFamily history

RaceRace

SexSex

AnatomyAnatomy

CirculationCirculation

BloodBlood• Red blood cells:Red blood cells:

• Carries oxygen to tissues and cellsCarries oxygen to tissues and cells• Removes CO2 and wasteRemoves CO2 and waste

• White blood cells:White blood cells:• Fight infectionFight infection

• Platelets:Platelets:• Helps blood clotHelps blood clot

Electrical SystemElectrical System

Coronary ArteriesCoronary Arteries

Cardiac CompromiseCardiac Compromise• Chest pain results from ischemia.Chest pain results from ischemia.• Ischemic heart disease involves Ischemic heart disease involves

decreased blood flow to the heart.decreased blood flow to the heart.• If blood flow is not restored, the If blood flow is not restored, the

tissue dies (infarct).tissue dies (infarct).• Injury leads to inadequate heart Injury leads to inadequate heart

function and death.function and death.

AtherosclerosisAtherosclerosis

So…So…

……you are dispatched to a 67 year- old you are dispatched to a 67 year- old male c/o 9/10 “crushing” chest male c/o 9/10 “crushing” chest

pressure that radiates to his jaw. He pressure that radiates to his jaw. He is also complaining of shortness of is also complaining of shortness of

breath and nausea, with no previous breath and nausea, with no previous cardiac history…cardiac history…

……wwhat are YOU thinking?hat are YOU thinking?

Chest Pain PathophysiologyChest Pain Pathophysiology

• Mediastinum:Mediastinum:• Angina: stable or unstableAngina: stable or unstable• AMIAMI• Esophagitis, Esophagitis, esophageal ruptureesophageal rupture• PericarditisPericarditis• Mediastinal airMediastinal air• Thoracic dissectionThoracic dissection• Mitral valve prolapseMitral valve prolapse


• Chest Wall:Chest Wall:• Traumatic contusion/Traumatic contusion/tamponadetamponade

• Cysts and infectionsCysts and infections

• Rib cartilage inflammationRib cartilage inflammation

• Shingles (Herpes Zoster)Shingles (Herpes Zoster)

• Muscle strain, overuse syndromesMuscle strain, overuse syndromes


• Lungs and pleura:Lungs and pleura:• PleurisyPleurisy

• PneumoniaPneumonia

• Pneumothorax, hemothoraxPneumothorax, hemothorax

• Pulmonary embolusPulmonary embolus

• Asthma, bronchitis, URIAsthma, bronchitis, URI


• Abdomen:Abdomen:• Gallbladder (cholecystitis, stones)Gallbladder (cholecystitis, stones)

• Stomach (gastritis, GERD, Stomach (gastritis, GERD, perforated peptic ulcer)perforated peptic ulcer)

• Pancreas (pancreatitis)Pancreas (pancreatitis)

• Esophagitis, perforationEsophagitis, perforation

Chest PainChest Pain

• Psychogenic:Psychogenic:• StressStress

• HyperventilationHyperventilation

• Anxiety and panic attacksAnxiety and panic attacks

Classic SymptomsClassic Symptoms• Pressure, fullness, heaviness, Pressure, fullness, heaviness,

squeezing pain in center of chest squeezing pain in center of chest with radiationwith radiation

• DiaphoresisDiaphoresis• NauseaNausea• Shortness of breathShortness of breath• WeaknessWeakness

Frequency of SymptomsFrequency of Symptoms

• Diaphoresis Diaphoresis 78%78%• Chest painChest pain 64%64%• NauseaNausea 52%52%• Shortness of breathShortness of breath 47%47%• No signs/symptomsNo signs/symptoms 25%25%

N Engl J Med 1984;311:1144-7N Engl J Med 1984;311:1144-7

Atypical PresentationsAtypical Presentations• Common in the elderly, diabetics, and Common in the elderly, diabetics, and

females:females:• Unusual fatigueUnusual fatigue• Sudden onset of unusual shortness of Sudden onset of unusual shortness of

breathbreath• Nausea, dizzinessNausea, dizziness• Belching, burping, indigestionBelching, burping, indigestion• Palpitations, new dysrhythmiaPalpitations, new dysrhythmia• Pain only in jaw, neck, back, armPain only in jaw, neck, back, arm

All chest pain is All chest pain is considered to be an considered to be an

AMI until proven AMI until proven otherwise!otherwise!

Angina PectorisAngina Pectoris• Chest pain caused when heart Chest pain caused when heart

tissues do not get enough oxygen for tissues do not get enough oxygen for a brief period of time.a brief period of time.

• Typically crushing or squeezing.Typically crushing or squeezing.• Onset with the 3-E’s.Onset with the 3-E’s.• Usually resolves with rest or meds.Usually resolves with rest or meds.• May be difficult to diagnose from AMIMay be difficult to diagnose from AMI

AnginaAngina

Acute Coronary SyndromeAcute Coronary Syndrome

Used to describe the range of Used to describe the range of conditions from unstable angina conditions from unstable angina

to AMI.to AMI.

Signs and symptoms usually Signs and symptoms usually caused by acute myocardial caused by acute myocardial

ischemia.ischemia.

ACS Signs & SymptomsACS Signs & Symptoms• Shortness of breathShortness of breath• Signs of inadequate perfusionSigns of inadequate perfusion• Chest pain, pressure, or discomfort Chest pain, pressure, or discomfort

(with or without radiation to back, (with or without radiation to back, neck, jaw, arm, wrists)neck, jaw, arm, wrists)

• NauseaNausea• Weakness/syncopeWeakness/syncope• DysrhythmiasDysrhythmias

Acute Myocardial InfarctAcute Myocardial InfarctUsually caused by the same mechanism as Usually caused by the same mechanism as

angina only with resulting tissue death.angina only with resulting tissue death.

Time is myocardium:Time is myocardium:

Consequences can be serious:Consequences can be serious:Congestive heart failureCongestive heart failure

Cardiogenic shockCardiogenic shockSudden deathSudden death

AMIAMI

Cardiogenic ShockCardiogenic ShockHeart lacks power to force blood Heart lacks power to force blood

through the circulatory system.through the circulatory system.

Brought on when 40% of left ventricle is Brought on when 40% of left ventricle is infarcted.infarcted.

Onset may be immediate or not Onset may be immediate or not apparent for 24 hours.apparent for 24 hours.

Signs & SymptomsSigns & Symptoms

• Altered LOCAltered LOC• Rapid, shallow breathingRapid, shallow breathing• Restlessness and anxiousnessRestlessness and anxiousness• Pale, cool skinPale, cool skin• Tachycardia/dysrhythmiaTachycardia/dysrhythmia• HypotensionHypotension

Congestive Heart FailureCongestive Heart FailureOccurs when the ventricles are damaged.Occurs when the ventricles are damaged.

Heart tries to compensate with increased Heart tries to compensate with increased heart rate.heart rate.

Enlarged, ineffective left ventricleEnlarged, ineffective left ventricleFluid builds up into lungs or body as Fluid builds up into lungs or body as

“pump” fails.“pump” fails.

CHFCHF

Signs & SymptomsSigns & Symptoms• FatigueFatigue• Cough with pink, frothy sputumCough with pink, frothy sputum• Dypsnea, tachypneaDypsnea, tachypnea• Pulmonary edemaPulmonary edema• Agitation and confusionAgitation and confusion• HypertensionHypertension• Pedal edema, ascitiesPedal edema, ascities


Thoracic DissectionThoracic Dissection

Aortic AneurysmAortic Aneurysm


• Sudden and severe chest or Sudden and severe chest or upper back discomfort. “Pain upper back discomfort. “Pain shoots to the shoulder blades.”shoots to the shoulder blades.”

• AnxietyAnxiety• DiaphoresisDiaphoresis• NauseaNausea

Cardiac TamponadeCardiac Tamponade• Trauma induced, Trauma induced,

filling of the filling of the pericardial sac with pericardial sac with blood.blood.

• Signs of shockSigns of shock• JVDJVD• Decrease pulse Decrease pulse

pressurespressures

Esophageal RuptureEsophageal Rupture• Usually Usually

underlying underlying alcohol abuse.alcohol abuse.

• Shock signs.Shock signs.• Coughing up Coughing up

bright red blood.bright red blood.

PericarditisPericarditis• Inflammation of the Inflammation of the

pericardium caused pericardium caused by infection.by infection.

• Usually presents as Usually presents as sharp discomfort.sharp discomfort.

• Changes with Changes with breathing and breathing and movement.movement.

Chest Pain AssessmentChest Pain Assessment

BSI/Scene SafetyBSI/Scene Safety

Initial Assessment (Sick/Not Sick)Initial Assessment (Sick/Not Sick)

Focused ExamFocused Exam

Detailed ExamDetailed Exam

AssessmentAssessment

Treatment and Plan Treatment and Plan

Initial AssessmentInitial Assessment

60second clinical picture to determine if 60second clinical picture to determine if Sick or Not Sick (Oxygen)Sick or Not Sick (Oxygen)

Based upon your initial impression: Based upon your initial impression: – Body position Body position

– skin signs and color skin signs and color – respiratory rate and effort respiratory rate and effort

– mental status mental status – pulse rate and characterpulse rate and character

Correct immediate life threats!Correct immediate life threats!

Focused Exam (S)Focused Exam (S)

Your subjective findings are based Your subjective findings are based upon what the patient or historian upon what the patient or historian

tells you:tells you:

Patient AgePatient Age

SexSex

Chief ComplaintChief Complaint

Focused Exam (S)Focused Exam (S)SAMPLE HistorySAMPLE History

SSigns/igns/SSymptoms (associated with cardiac ymptoms (associated with cardiac chest pain):chest pain):– Diaphoresis (78%)Diaphoresis (78%)– Shortness of Breath (47%)Shortness of Breath (47%)– Pain/discomfort (64%)Pain/discomfort (64%)– Nausea/vomiting (52%)Nausea/vomiting (52%)– No signs or symptoms (25%)No signs or symptoms (25%)

N Eng Journal Med 1984;311:11444-7N Eng Journal Med 1984;311:11444-7


OOnset – nset – ““When and at what time did it start” When and at what time did it start”

PProvocation –rovocation – “ “Does anything make it better or worse?”Does anything make it better or worse?”

“ “Does it change with position, palpitation, Does it change with position, palpitation, inspiration?”inspiration?”

QQuality – uality – ““Describe the pain/discomfort in your own Describe the pain/discomfort in your own

words”words”


RRegion/egion/RRadiation –adiation –““Where does it start?” Where does it start?” ““Does it radiate anywhere?”Does it radiate anywhere?”

SSeverity – everity – ““On a scale of 1 to 10, what was the On a scale of 1 to 10, what was the

pain/discomfort at onset?” pain/discomfort at onset?” ““What is the pain/discomfort at now?’What is the pain/discomfort at now?’

TTime – ime – ““When did this episode start?” When did this episode start?” ““How long has it been going on?”How long has it been going on?”


AAllergiesllergiesMMedications – edications – Cardiac meds = cardiac problems. Cardiac meds = cardiac problems. Ask about OTC meds, natural supplements, Ask about OTC meds, natural supplements,

vitamins?vitamins?

PPast Medical History – ast Medical History – ““Do you have any cardiac history?” Do you have any cardiac history?” ““Risk factors such as smoking, diabetes, HTN, Risk factors such as smoking, diabetes, HTN,

weight/diet?””weight/diet?””


LLast Oral Intakeast Oral Intake

EEvents Leading to Call – vents Leading to Call – ““What were you doing when this event started?”What were you doing when this event started?”

Think activity induce vs. non activityThink activity induce vs. non activity

Listen to the patient…Listen to the patient…

……they will tell you exactly they will tell you exactly what is wrong!what is wrong!

Focused Exam (O)Focused Exam (O)

Objective findings from your physical exam Objective findings from your physical exam of the patient.of the patient.

Look for evidence of trauma/injuryLook for evidence of trauma/injuryEvaluate:Evaluate:

– Level of consciousnessLevel of consciousness– Skin color and temperatureSkin color and temperature– Respiratory rate and effortRespiratory rate and effort

– Pupillary reactionPupillary reaction– Pulse ratePulse rate

– Blood pressure (bilateral for chest pain!)Blood pressure (bilateral for chest pain!)


Listen to breath soundsListen to breath sounds

Palpate chestPalpate chest

Palpate abdomenPalpate abdomen

Check pedal pulsesCheck pedal pulses

BGL if diabetic with DLOCBGL if diabetic with DLOC

SpO2 after BP, confirm with pulses, RA & SpO2 after BP, confirm with pulses, RA & after administration of O2after administration of O2

Rhythm strip?Rhythm strip?


Based upon your clinical findingsBased upon your clinical findings

Observe the patient while they are Observe the patient while they are talking with you, note any talking with you, note any

distress/discomfort (Levine sign)distress/discomfort (Levine sign)

Watch for acute clinical signs: jugular Watch for acute clinical signs: jugular vein distension, tracheal deviation, vein distension, tracheal deviation,

paradoxial chest movement.paradoxial chest movement.

Detailed Exam (O)Detailed Exam (O)

Complete and thorough neck, head to Complete and thorough neck, head to toe examination with non-critical toe examination with non-critical

patients if needed or time permits.patients if needed or time permits.

Elicit further information and Elicit further information and necessary interventions.necessary interventions.

Key in on critical findings!Key in on critical findings!

Assessment (A)Assessment (A)

This is your best guess (or rule out) as This is your best guess (or rule out) as to what is going on with the patient.to what is going on with the patient.

It is based upon YOUR Subjective and It is based upon YOUR Subjective and Objective findings and should help you Objective findings and should help you develop and implement your Plan for develop and implement your Plan for

patient care.patient care.

Plan (P)Plan (P)Medics?Medics?

ABC’s/Monitor vitalsABC’s/Monitor vitalsPatient in position of comfort.Patient in position of comfort.

Oxygen via ?Oxygen via ?Assist with medications.Assist with medications.

Maintain body temperature.Maintain body temperature.Calm and reassure.Calm and reassure.

Minimize patient movement.Minimize patient movement.Rapid transport!Rapid transport!

Other StuffOther Stuff• Coronary artery bypass graft (CABG) Coronary artery bypass graft (CABG)

and other open heart surgeriesand other open heart surgeries• Percutaneous transluminal coronary Percutaneous transluminal coronary

angioplasty (PTCA)angioplasty (PTCA)• Automatic implantable cardiac Automatic implantable cardiac

defibrillators (ACID)defibrillators (ACID)• PacemakersPacemakers

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Cardiovascular Emergencies …time is myocardium!. Statistics Cardiovascular disease (CVD) claimed over 1 million lives in 2004. Cardiovascular disease