EMT Refresher Cardiology

Christina Moore

Halifax EMS

NREMT-P / CCEMT-P

Objectives

• Identify Causes of Chest Pain

• Anatomy

• Physiology

• Pathophysiology

• Assessment

• Treatment Options

• Differentiate key origins of C Px

Why?

• Frequency EMS Calls for Chest Pain?– In Halifax, ~ 40%– You?

A Bit of History

• 1960s30-40% chance of death days after heart attack

• Today6%

Chest Pain

• List Types, sources, etc

Chest Pain - Summary• Heart Attack (ACS / AMI)• Cardiac Tamponade• Ischemia• Pericarditis• Pulmonary Embolism• Angina (Stable/Unstable)• Tension Pneumothorax• Myocarditis• Shingles• Muscular-skeletal problems• Aortic Dissection• Aortic Aneurysm• Pleurisy• CHF• Esophogeal Rupture• Aortic Stenosis• Mitral Valve Prolaps• Cardiomyopathy

• Cholecystitis• Pancreatitis• Esophogeal tear• Cocaine-indused chest pain• Coronary Spasm (Prinzmetal’s

Angina)• Cardiac Dysrhythmia

Others?

Chest Pain Sorted• Heart Attack (ACS / AMI)• Cardiac Tamponade• Cardiac Dysrhythmia• Pulmonary Embolism• Tension Pneumothorax• Aortic Dissection• CHF• Esophogeal Rupture

• Cholecystitis• Pancreatitis• Esophogeal tear• Aortic aneurysm • Cocaine-indused chest pain• Coronary Spasm (Prinzmetal’s Angina)• Angina (Stable/Unstable)• Ischemia

• Pericarditis

• Myocarditis

• Shingles

• Muscular-skeletal problems

• Pleurisy

• Aortic Stenosis

• Mitral Valve Prolaps

• Cardiomyopathy

The Killers

What tools do we have• Eyes – inspect• Ears/Stethoscope - auscultate• Hands – palpate• History – personal and familial• Watch – time• EKG 4/12 lead• Phone-a-friend• Medication Administration• Knowledge/skills/experience• Capnography• Lab Tests (bio-markers, chem7, ABG, etc)• X-Ray• Ultrasound• Cardiac Cath• Cardiac Echo

Anatomy

• Go to

http://www.visiblebody.com/start

Goals - cardiac circulatory system

- cardiac conductive system

- And the other fun stuff

Key Physiology Points

• Cardiac Tissue– Automaticity– Conductivity– Contractility– Rhythmicity– Excitability

Physiology Continued

• Gas of Life?

• Nutrients: O2, Sugar• Waste: CO2, H2O• pH: 7.35 – 7.45• Exhaled CO2: 35 – 45 mmHg

What Happens to Tissue when WRONG

Pathophysiology

• What happens when it goes wrong

• No O2, dirty combustion & bad byproducts

• No Sugar – see above

• Too Many bad byproducts– Expanding field of injury

• No O2 & No Sugar - dying

Pathophysiology Measured

• Pain

• Blood Sugars

• Capnography

• Blood pH

• SpO2

• Troponin/bio-markers

• Urine

Pathophysology Observed

•SHOCK

Case Study

• 63 yof, teeth/jaw pain and a “tight neck”, sweating

• Initial Observations

• From Across the Room

Case Study

• Initial Life-Threatening Diagnoses/Interventions• Differentiate?

• Heart Attack (ACS / AMI)• Cardiac Tamponade• Cardiac Dysrhythmia• Pulmonary Embolism• Tension Pneumothorax• Aortic Dissection• CHF• Esophogeal Rupture

• Cholecystitis• Pancreatitis• Esophogeal tear• Aortic aneurysm • Cocaine-indused chest pain• Coronary Spasm (Prinzmetal’s Angina)• Angina (Stable/Unstable)• Ischemia

• Pericarditis

• Myocarditis

• Shingles

• Muscular-skeletal problems

• Pleurisy

• Aortic Stenosis

• Mitral Valve Prolaps

• Cardiomyopathy

Assessment

• SAMPLER

• OPQRST

• Diagnostics– EKG 4 & 12 lead

EMS Treatment

• Oxygen

• Aspirin

• Nitroglycerin (NTG)

• IV – 2 lines preferred

• STEMI Alert

• Paramedic Request

• Rapid Transport to Cath Lab

Oxygen

• Per American Heart Assoc, 2010 Guidelines:

• 2-6 lpm O2 via Nasal Cannula

• Titrate to SpO2 approx 96% (not 100%)

• Why?

Aspirin

• Class of Medication

• Mechanism of Action

• Indications

• Contra-Indications

• Dosing?

• Dude, Dose, Delivery, Date, Document

Nitroglycerin

• Class of Medication

• Mechanism of Action

• Indications

• Contra-Indications

• Dosing?

• Dude, Dose, Delivery, Date, Document

EKG

• Mechanism of Action

• Indications

• Contra-Indications

• Dude,Date, Document

Case Study

STEMI Alert

• When 12-lead EKG prints

* * * ACUTE MI * * *

• When you have confirmation from medic

• When you have transmitted & confirmed

STEMI Alert

• DHMC Zone 2

• Valid reason to call DHART Helicopter

• “Drip & Ship” via Critical Access Hospital

• Timed process from: – 911 to “Balloon”– EMS to Balloon– Door to Balloon

• Goals: 90 minutes

Next Steps• One link in a many link chain• Paramedic Interventions

– Pain Control– IV Beta Blocker

• ER Interventions– IV Heparin Bolus, Hep drip– IV Fibrinolytic– IV NTG

• Cath Lab

Cardiac Circulation

Cardiac Cath

• YouTube

http://www.youtube.com/watch?v=3Z2DaU0GBAE&feature=feedf_more

Acute Coronary Syndrome

• Questions/Discussion on ACS?

• Let’s do the next one

Induced Hypothermia

• What happens to pissed off tissue?

• Sprained Ankle…– Swelling– Pain

• Treatment– RICE: Rest, Ice, Compression, Elevation

Induced Hypothermia

• Compartment Syndrome?

• What is it?

• Where can it happen?

Induced Hypothermia

• CPR – with return of spontaneous circulation

• Pt’s mental state deteriorated

• Induce hypothermia with cold (4d C) IV fluids

• Keep chilled and “medical coma” for 3 days

Future of Hypothermia

• Trauma?

• Strokes?

• Kids?

• Lots of potential… lots of unanswered questions

Other “Chest Pain”

• Chest Pain with Respiratory Distress– Tension Pneumothorax– Pulmonary Embolism– Esophogeal Rupture– Acute Pulmonary Edema / CHF

Tension Pneumothorax

• History?

• Progressive deterioration

• Pressure on the heart/great vessels

• Disrupting blood flow

Tension Pneumothorax

• Assessment– Chest Discomfort– Severe Respiratory Distress– Decreased or absent breath sounds on

affected side

• Obstructive Shock

• Treatment?

Tension Pneumothorax

• Decompression– Paramedic – large needle to chest– MD/PA – large tube in chest

• Field Treatment:– Rapid transport, – high flow O2,– Intercept

Pulmonary Embolism (PE)

• Cause?– Blood clot in an artery in the lungs– Often starts somewhere else, travels through

heart to lungs and lodges in there– If <30% impact, few symptoms unless…

• COPD, etc

PE

• Assessment– Chest Pain– Tachypnea (96%)– SoB (82%)– Chest Pain (49%)– Cough (20%)– Hemoptysis (7%)

• EKG – Sinus Tachycardia

PE

• History / Risk Factors

• Young women who smoke and use birth control

• Deep Vein Thrombosis (DVT)– Traveller’s Syndrome– Leg Cramps

PE Diagnostic

• In Field: History, Assessment

• In ED:– CTA (CT-angiogram)– D-Dimer– X-Ray

• Treatment– Thrombolytics \ anticoagulantion therapy

Esophogeal Rupture

• Often iatrogenic– Post surgical, post procedural

• Swallowed foreign object (caustic, sharp, etc)

• BFT , Penetrating Trauma

• Forceful vomitting

Esophogeal Rupture

• Assessment: History

• Treatment: Supportive

CHF

• Pump Failure– Brian Richard’s Drawing

CHF

• Assessment

• Management– V.S., EKG, Lung Sounds

• CPAP

• Treat shock/symptoms

Other Chest Pain

• Chest Discomfort with Altered Vital Signs– Cardiac Dysrhythmia– Aortic Aneurysm \ Dissection– Pericardial Tamponade– Acute Coronary Syndrom (covered)

Other Chest Pain

• Unstable Angina

• Coronary Spasm / Prinzmetal Angina

• Cocaine-Induced Chest Pain

Other Chest Pain

• Chest Pain due to Infection– Pericaditis– Myocarditis

• Simple Pneumothorax

Other Chest Pain

• Intra-abdominal Causes of Chest Discomfort– Cholecystitis– Pancreatitis– Esophogeal Tear

• Neurological Causes of Chest Pain– Thoracic Outlet Syndrome (pg 205)– Herpes Zoster (Shingles)

Others - continued

• Other Pulmonary Causes– Pneumonitis– Pleurisy

• Heart-related Causes– Aortic Stenosis– Mitral Valve Prolapse– Cardiomyopathy

Others – Continued

• Did we miss some?– YES

Objectives Reviewed

• Identify Causes of Chest Pain

• Anatomy

• Physiology

• Pathophysiology

• Assessment

• Treatment Options

• Differentiate key origins of C Px