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Circulatory and respiratory disorders
J. Málek
©
Chest pain
• 30% of emergency calls• Diff. dg is complicated. The heart, lungs, oesophagus,
and great vessels provide afferent visceral input through the same thoracic autonomic ganglia. A painful stimulus in these organs is typically perceived as originating in the chest, but because afferent nerve fibres overlap in the dorsal ganglia, thoracic pain may be felt (as referred pain) anywhere between the umbilicus and the ear, including the upper extremities.
• Orientation– history– physical examination– auxiliary methods
Causes• CARDIAC
– Angina: Stable vs. Unstable– Acute myocardial infarction– Pericarditis– Myocarditis– Dissecting aortic aneurysm
• PULMONARY– Pneumonia– Pneumonia with pleuritis– Pneumothorax– Pulmonary embolism– Pulmonary hypertension (e.g. COPD, CHF)
• GI– GERD, gastric reflux– Oesophageal spasm– Peptic ulcer disease
• MSK– Arthritis– Chondritis– Rib fracture
• PSYCHIATRIC– Anxiety– Panic attack
Chest pain - history• onset and duration, past occurrences• point to the pain• what provoked the pain, worse with exertion, rest,
stress• quality of the pain• quantify the pain• radiation• severity• timing – at rest, exertion
– happened before– what alleviates the symptoms– what do you think is wrong–all treatments, doctors seen, investigations done in past
Chest pain 2• Drugs• Physical examination
– observation– auscultation– palpation – percussion
• Appearance of patient: Distress, Cyanosis, Clubbing, Pallor,
Scars, Previous surgeriesBony abnormalitiesSigns of inflammation, chondritis
Chest pain - whole body examination• General: nausea, vomiting, sweats, etc...
- Head and Neck- Cardiac- Respiratory- Neurological
• Important associated symptoms: dyspnoea, shortness of breath, cough, palpitations, ankle
oedema, leg pain, haemoptysis, fever• Past Medical History• Risk Factors Known heart disease, diabetes, high cholesterol, high
blood pressure, smoking, family history of heart disease or stroke or high blood pressure or diabetes
• Medications and Allergies• Social History
Immediately life threatening disorders
• Acute coronary syndromes (acute MI/unstable angina)
• Thoracic aortic dissection
• Tension pneumothorax
• Oesophageal rupture
• Pulmonary embolism (PE)
Red flag findings
• Tachycardia/bradycardia
• Tachypnoea
• Hypotension
• Signs of hypoperfusion (e.g. confusion, ashen colour, diaphoresis)
• Shortness of breath
• Signs of shock
Myocardial ischemia: insufficient blood supply to heart tissue
• Acute, crushing pain radiating to the jaw or arm
• Exertional pain relieved by rest (angina pectoris)
• Red flag findings
• Risk of cardiac arrest
Heart diseases - Angina pectoris
• Chest pain caused by a decrease of blood supply to the heart muscle.
• Stress, physical exercise, cold weather may bring on the chest pain.
• Pain is felt behind the sternum and spreads to the neck, shoulders, to left arm and elbow.
• Giving a rest, medication – relieved in minutes.• Medication: nitroglycerin, isosorbid-dinitrate,
isosorbidtrinitrate
Heart diseases - Heart attack (AIM)
• Occurs when the blood flow in a coronary artery or in one of its branches is decreased or blocked. Irreversible damage of myocardial tissue caused by lack of oxygen.
• Strong pain, similar to angina pectoris. May be upper abdominal pain. Rest and medication do not give relief;
• Fear and apprehension• Pallor;• Nausea, sometimes vomiting;• Profuse sweating;• Dizziness;• Shortness of breath;• Shock or unconsciousness;• Cardiac arrest.
MI – first aid• Call for emergency medical assistance. • Do not move the casualty unnecessarily;• Place him at rest in the comfortable position; usually
semisitting with the head and shoulders raised and supported;• Loosen tight clothing at neck and chest;• Reassure the person to lessen fear and anxiety;• Let chew a ½ regular-strength aspirin. Aspirin can inhibit
blood clotting. Do not use aspirin in case of allergy to aspirin and bleeding problems.
• Give nitroglycerin, if prescribed. • Be prepared for CPR. If the person suspected of having a
heart attack is unconscious, a 155 dispatcher or another emergency medical specialist may advise you to begin cardiopulmonary resuscitation (CPR) until help arrives.
Heart failure• Result of chronic heart disease, when
heart has lost some of its ability to pump blood to the body.
• Inappropriate shortness of breath, especially when person is exercising;
• Shortness of breath when laying down flat;• Coughing bloodstained sputum;• Cyanosis (blueness around lips, nail beds,
ears);• Swelling of ankles.
Thoracic aortic dissection
• Sudden, tearing pain radiating to the back
• Some patients have syncope, stroke, or leg ischemia
• Pulse or BP may be unequal in extremities
• Age > 55
• Hypertension
• Red flag findings
This is how the x-ray appears when the chest is full of blood (right-sided hemothorax) seen here as
cloudiness on the left side of the picture.
Tension pneumothorax
• Significant dyspnoea, hypotension, neck vein distention, unilateral diminished breath sounds and hyperresonance to percussion
• Sometimes subcutaneous air
Oesophageal rupture
• Sudden, severe pain following vomiting or instrumentation (oesophagogastroscopy or transoesophageal echocardiography)
• Subcutaneous crepitus on auscultation
• Multiple red flag findings
Pulmonary embolism
• Often pleuritic pain, dyspnoea, tachycardia• Sometimes mild fever, haemoptysis, shock• More likely with risk factors present
– Clinical signs and symptoms of DVT (objective leg swelling, pain with palpation)
– Heart rate > 100 beats/min– Immobilization ≥ 3 days1– Surgery in previous 4 wk– Previous DVT or PE1– Haemoptysis– Malignancy (including in those stopping cancer
treatment within 6 mo)
Other causes of chest pain
• Pericarditis – Constant or intermittent sharp pain often aggravated
by breathing, swallowing food, or supine position and relieved by sitting leaning forward
– Pericardial friction rub– Jugular venous distention
• Myocarditis – Fever, dyspnoea, fatigue, chest pain, recent viral or
other infection– Sometimes findings of heart failure, pericarditis, or
both
Other causes of chest pain
• Esophageal reflux (GERD) – Recurrent burning pain radiating from epigastrium to
throat that is exacerbated by bending down or lying down and relieved by antacids
• Peptic ulcer– Recurrent, vague epigastric or right upper quadrant
discomfort in a patient who smokes or uses alcohol excessively that is relieved by food, antacids, or both
– No red flag findings
Other causes of chest pain
• Biliary tract disease– Recurrent right upper quadrant or epigastric
discomfort following meals (but not exertion)
• Pancreatitis– Pain in the epigastrium or lower chest that is often
worse when lying flat and is relieved by leaning forward
– Vomiting– Upper abdominal tenderness– Shock– Often history of alcohol abuse or biliary tract disease
Other causes of chest pain• Pneumonia
– Fever, chills, cough, and purulent sputum– Often dyspnea, tachycardia, signs of consolidation on
examination• Pleuritis
– May have preceding pneumonia, pulmonary embolism, or viral respiratory infection
– Pain with breathing, cough– Examination unremarkable
• Musculoskeletal chest wall pain (including trauma, overuse, costochondritis)– Often suggested by history– Pain typically persistent (typically days or longer),
worsened with passive and active motion– Diffuse or focal tenderness
Heart Rhythm Disturbances
• Sinus bradycardia - low sinus rate <50 beats/min. • Sinus tachycardia - high sinus rate of 100-180
beats/min as occurs during exercise or other conditions that lead to increased SA nodal firing rate.
• Sick sinus syndrome - a disturbance of SA nodal function that results in a markedly variable rhythm (cycles of bradycardia and tachycardia).
• Atrial tachycardia - a series of 3 or more consecutive atrial premature beats occurring at a frequency >100/min; usually due to abnormal focus within the atria and paroxysmal in nature. This type of rhythm includes paroxysmal atrial tachycardia (PAT).
• Atrial flutter - sinus rate of 250-350 beats/min. • Atrial fibrillation - uncoordinated atrial depolarizations. • AV blocks - a conduction block within the AV node (or
occasionally in the bundle of His) that impairs impulse conduction from the atria to the ventricles.
Atrial fibrillation
Atrial flutter
Sick Sinus Syndrome
A-V block
Ventricular disturbances
• Ventricular premature beats (VPBs) - caused by ectopic ventricular foci; characterized by widened QRS.
• Ventricular tachycardia (VT) - high ventricular rate caused by aberrant ventricular automaticity or by intraventricular reentry; can be sustained or non-sustained (paroxysmal); characterized by widened QRS; rates of 100 to 200 beats/min; life-threatening.
• Ventricular flutter - ventricular depolarizations >200/min.
• Ventricular fibrillation - uncoordinated ventricular depolarizations.
Ventricular tachycardia
Ventricular fibrilation
http://www.emedu.org/ecg/crapsanyall.php
Dyspnoea
Common causes• Collapsed lung, which can happen if you have
emphysema or asthma, but may also happen spontaneously in young, healthy people
• Heart attack • Heart disease, asthma, emphysema, chronic bronchitis,
or heart failure • High altitudes, which can be a problem even in young
people • Injury to the neck, chest wall, or lungs • Life-threatening allergic reaction • Pulmonary embolism, or a blood clot in the lung, which
can cause very abrupt and severe difficulty breathing • Sudden illness or infections like pneumonia, acute
bronchitis, whooping cough, croup, or epiglottitis
Severity • If the victim feels a little out of breath, but can
still walk and talk, then calling a doctor or taking the victim to the hospital is probably OK.
• If the victim has any of the following signs, call 115 immediately: – blue in the face, chest, or hands – unable to speak more than two words between
breaths – confusion – dizziness – weakness – wheezing
First aid
• The victim should rest in the position that is most comfortable -- usually sitting upright.
• If the victim has a fast-acting inhaler -- encourage him or her to use it.
• Positioning a fan on the victim can help ease the feeling of shortness of breath.
• Follow basic first aid until the ambulance arrives.
Do not
• DO NOT give the person any foods or drinks. • DO NOT move the person if there has been a
chest or airway injury, unless it is absolutely necessary.
• DO NOT place a pillow under the person's head if he or she is lying down. This can close the airway.
• DO NOT wait to see if the person's condition improves before getting medical help. Get help immediately.
Pneumothorax
• Pneumothorax occurs when air leaks to the space between the lung and the chest wall. The lung then collapses.
Pneumothorax - causes
• Trauma - see lecture 7• Rupture of pulmonary
bulla (A small area in the lung that is filled with air, called a bleb, ruptures, and the air leaks into the
space around the lung)
Asthma
• Asthma is caused by inflammation in the airways. When an asthma attack occurs, the muscles surrounding the airways become tight and the lining of the air passages swell. This reduces the amount of air that can pass by, and can lead to wheezing sounds.
• Most people with asthma have wheezing attacks separated by symptom-free periods.
• Asthma attacks can last minutes to days and can become dangerous if the airflow becomes severely restricted.
• In sensitive individuals, asthma symptoms can be triggered by breathing in allergy-causing substances (called allergens or triggers).
During an asthma attack smooth muscles located in the bronchioles of the lung constrict and decrease the flow of air in the airways. The amount of air flow can further be decreased by inflammation or excess mucus secretion.
Common asthma triggers • Animals• Dust • Changes in weather (most often cold weather) • Chemicals in the air or in food • Exercise • Mould • Pollen • Respiratory infections, such as the common cold • Strong emotions (stress) • Tobacco smoke • Aspirin and other nonsteroidal anti-inflammatory
drugs (NSAIDs) provoke asthma in some patients
Asthma – common symptoms• Cough with or without sputum (phlegm) production • Pulling in of the skin between the ribs when breathing
(intercostal retractions) • Shortness of breath that gets worse with exercise or
activity • Wheezing • Comes in episodes • May be worse at night or in early morning • May go away on its own • Gets better when using drugs that open the airways
(bronchodilators) • Gets worse when breathing in cold air • Gets worse with exercise • Gets worse with heartburn (reflux) • Usually begins suddenly
Asthma – sever symptoms
• Bluish color to the lips and face
• Decreased level of alertness such as severe drowsiness or confusion, during an asthma attack
• Extreme difficulty breathing
• Rapid pulse
• Severe anxiety due to shortness of breath
• Sweating
Asthma – first aid
• Fresh air• Medicines? Help with
administereing of prescribed drugs
• Warm and humidified air
• Urgent medical aid!
Allergy
• Skin symptoms. Severe itching, flushing, swallowing;
• Swelling of tissues about the face mouth and throat
• Respiratory symptoms. Bronchial asthma. Sneezing, coughing. Difficulties to breath.
• Circulation. Weak pulse, pallor, unconsciousness.
• Allergy may be life-threatening!
Allergy - First aid
• A severe allergic reaction can only be reversed by appropriate medical treatment.
• First aid is limited to providing care for shock, maintaining breathing and circulation.
• Urgent transportation to a medical facility.• Remove, if possible, the reason of allergy• History of allergy? Medicines?• Urgent medical aid!• Basic life support
Intoxication (poisoning)
Intoxication
• A poison is any substance that can cause illness or death when it is absorbed into the body.
• An antidote is a substance that acts against a poison to offset its effects.
• Prevention: most accidental poisonings can be prevented if the presence of poisons is recognized and proper care is taken in their use and storage.
Epidemiology
• Poisonings: acute X chronic
• Incidence: 1,7 - 1,9 : 1000 inhibitans /year
(severe poisonings 1 : 3500 inhibitans/ year, myocardial infarction 0,6 - 0,8 : 1000)
• Lethality of acute poisonings: < 1 %
Acute poisonings
• Aimed (suicides)
• Accidental– Self-treatment– Misuse of chemicals and drugs
• At home• In medicine
General rules
• Safety of a rescuer and by-standers is a priority
• Symptomatic therapy, prevent secondary trauma
• Stop further absorption of the poison
• Eliminate the poison, if possible
• Use antidotes
History• Identify the poisonous substance. Look for bottles, pills,
containers or remnants of poisonous material, even vomitus, that can be used to identify the toxic agent.
• Determine the quantity taken. Estimate, from the container’s size, the number of pills or amount of chemical available and, from remaining chemical or pills, how much of poisonous substance may have been taken.
• Determine the route of entry into the body. First aid will vary according to whether the substance was ingested into the stomach, inhaled into lungs, absorbed through the skin, injected into the bloodstream, or taken by combination of two or more of these.
• Determine the time elapsed since the poisoning occurred
Signs and symptoms vary widely and are dependent about the
quantity and route of of administered poison
• Ingested poisons
• Inhaled poisons
• Absorbed posions through intact skin
• Injected poisons
Oral intoxication - first aid
• Unresponsive patient – recovery position• Conscious patient – induce vomiting (“Restaurant
method”)– If a patient is conscious and clear-mind, provokes
himself the reflex of vomiting and is able to control the airways. Let him drink warm salt water (1 spoon of salt in 1 l) and vomit. You can use animal charcoal for the last portion of the drink.
• Never induce vomiting if victim has swallowed – Corrosive chemicals– Petroleum derivate– Detergent (e.g. dish cleaning or foam producing agent)– Has decreased level of consciousness
Alcohol• Development of signs of poisoning is individual• In case of poisoning the victim cannot be waked
up• Frequent vomiting• In children and teenagers – moderately drunk
should be considered as intoxication• First aid
– Recovery position
• Medical emergency if– The victim is not responding to strong stimuli – Child or teenager severy intoxicated – Frequent vomiting (7...8 times per hour)
Intoxication with drugs
• Every drug is poison if used in too high quantities.– Sedatives, antidepressants – Cardiovascular drugs – Paracetamol, etc.
• Try to identify – The poisonous substance – Quantity taken – Rout of entry into body – Time elapsed since appearance of symptoms
• Prevention!
Chemicals
• Various disorders of organs function – Gastrointestinal distress, vomiting, pain – Unconsciousness, seizures, visual disturbances
• Often lethal• Recovery position• Call EMS• Keep the bottle with chemical• Do not give water to drink, do not induce
vomiting
Ethylene glycol
• Used as an antifreeze agent
• Damage to the kidneys
• Give 0.06 – 0.1 l of 40% alcohol
• Transport to a hospital
Herbicides, pesticides
• Can cause intoxication through intact skin• Use protective aids (polyethylene bags, rubber gloves)• Signs
– Salivation– Cramps– Bradycardia– Muscle weakness
• Remove the clothing without touching the unaffected skin
• Wash • Call EMS
Carbon monoxide intoxication
• Danger– Fire– House-heating– Car with working engine in closed garage
• Symptoms– Moderate headache initially– Disturbances of consciousness (…unconsciousness)– Muscle weakness – Reddish to purple colour of the skin– Death if not rescued
• First aid – Fresh air – Resuscitation breaths, chest compressions– EMS– Oxygen therapy
bright red discoloration, cherry-like colour
Products of burning
• Signs– Chest pain– Dyspnoea– Haemoptysis
• First aid– Fresh air – Call EMS– Rest– Sitting position
Narcotics - Heroin
• Heroin– Small eye pupils– Coma– Stop of breathing– Signs of needle sticks
• First aid– Basic life support, EMS
Narcotics - Exstasy
• Restless• Difficult, fast speech• Fever up to 41• Disturbances of consciousness• Seizures
• First aid– Calm– Cool drinks– If disturbances of consciousness, seizures, fever
above 40 – call EMS
Narcotics - Amphethamine• Hyperactivity, restless, insomnia
• Fast, disturbed speech
• Disturbances of consciousness
• Seizures
• Pulse is fast, high blood pressure
• First aid– Calm– Drink water – If disturbed consciousness, seizures, pulse
above 120, call EMS
Metabolic disordes
Diabetes
• Inability to regulate the glucose levels in the blood
• Two types• Major problems
– Hyperglycaemia (high blood sugar) – Hypoglycaemia (low blood sugar)
• Reasons for hypoglycaemia– Exercise– Low sugar intake and/or high insulin dose
Recognition of hypoglycaemia
• A history of diabetes – casualty may recognise onset of ‘hypo’ attack
• Hunger (a missed or late meal can cause the onset of a ‘hypo’ attack for a diabetic)
• Shallow breathing • Weakness, faintness or hunger • Palpitations and muscle tremors • Strange behaviour – may seem confused or belligerent • Sweating and cold clammy skin • Pulse may be rapid and strong • Deteriorating level of response • Diabetic’s warning card, glucose gel, tablets, or insulin
syringe in casualty’s possession.
Hypoglycaemia – first aid
• Sit the casualty down • Offer a sweet drink or food • If casualty improves, give him/her more to eat
and drink. • If condition does not improve look for other
possible causes. • If consciousness is impaired, do not give
anything to eat or drink, protect from heat loss • If unconscious, carry out CPR, call for an
ambulance.
