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09/28/2016
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Chapter 28, Part 2: Cardiology
Part 2: Assessment and Management of the Cardiovascular Patient
Assessment of the Cardiovascular Patient
Scene Size-up and Primary AssessmentDetermine scene safety.Determine level of
____________________________________________Airway.Breathing:
– Note ____________________________________________ sounds indicative of cardiovascular problems.
Circulation:– Note color, temperature, turgor, moisture, mobility,
____________________________________________.Treat life-threatening problems.
Focused HistoryCommon Symptoms:Chest Pain
– ____________________________________________History of Pain
Dyspnea– Onset– ____________________________________________– Provocation/palliation– ____________________________________________
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– Cough
Other Signs/Symptoms ____________________________________________Restlessness and anxiety Feeling of impending doomNausea/vomiting ____________________________________________Palpitations EdemaHeadache ____________________________________________Behavioral changeAnguished
____________________________________________expressionActivity limitationsTrauma
Acute Coronary Syndrome3 General Categories ____________________________________________Angina
– Classic S/S of MI or coronary event ____________________________________________Presentation
– Different S/S ____________________________________________Equivalents
– Considered for high risk patients
Atypical Presentation ExamplesPain that is ____________________________________________or
intermittent
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Pain to ____________________________________________ (toothache with no inflammation)
Pain to neck, shoulder, arm or abdomenMostly includes females,
____________________________________________and the elderly
Suspect cardiac event with these S/S
Anginal EquivalentsDyspnea ____________________________________________Syncope or near syncopeGeneralized weakness with no hx of GI bleed or fever ____________________________________________Often, the only S/S presented but may be cardiac in
nature
Risk Factors for Anginal Equivalents ____________________________________________Hypertension ____________________________________________ Family history of CAD ____________________________________________StressSedentary life style
Acute Coronary Syndrome (1 of 2)The key to forming accurate impression of cardiac event
lies in clinical ____________________________________________.Take into account the patient’s physical presentation,
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risk factors, and assessment findings ____________________________________________to the patient
Acute Coronary Syndrome (2 of 2) If ____________________________________________equivalents
or atypical S/S are present, MONITOR ECG If presentation suggests possible coronary event,
consider ____________________________________________just as with typical chest pain, even if chest pain is absent
SAMPLE HistoryAllergiesMedications
• Nitroglycerin, propranolol, digitalis, diuretics, antihypertensives, antidysrhythmics, lipid-lowering agents, ____________________________________________meds
• Nonprescription drugs• Cocaine• ____________________________________________• Alcohol
SAMPLE HistoryPast Medical History:Cardiac history ____________________________________________problemsOther medical problems ____________________________________________cardiac historyModifiable risk factors for heart disease (smoking, etc.)
SAMPLE History
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Last Oral IntakeCaffeinated beverages, alcohol,
____________________________________________drinks, etcEvents Preceding the Incident ____________________________________________, strenuous or
sexual activity
Physical ExamInspection of: ____________________________________________position ____________________________________________ Epigastrium
Physical ExamAuscultation: ____________________________________________Sounds ____________________________________________Sounds
– Normal– Abnormal
Physical ExamPalpation: ____________________________________________Thorax
– ____________________________________________– Chest Wall Tenderness
Epigastrium
Management of Cardiovascular EmergenciesBasic Life Support:
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____________________________________________OxygenVital ____________________________________________Caution: Don’t get so wrapped up in your ALS skills and
toys, that you forget the BLS.
Oxygen and the Cardiac PatientThe AHA recommends that patients with cardiac and/or
stroke conditions NOT receive oxygen unless O2 sat is <____________% or there are signs of hypoxia
This is to avoid ____________________________________________and oxygen toxicity which can lead to oxidation (loss of electrons) of tissues and organs
Management of Cardiovascular EmergenciesAdvanced Life Support: ECG Monitoring ____________________________________________ManeuversPrecordial Thump ____________________________________________ManagementDefibrillationSynchronized CardioversionTranscutaneous Cardiac
____________________________________________Diagnostic (12-Lead) ECG
Monitoring ECGs in The Field2 main components: ECG ____________________________________________
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– May include 12 lead capabilities ____________________________________________
– May include pacing capabilities
Components of an ECG MonitorNote: Monitors/Defibrillators are different. You should
become very familiar with the unit you will be using ____________________________________________(Oscilloscope
or LCD)Paper strip recorderBattery/Power sourcePatient Cables and
____________________________________________Controls for monitoring
– Lead selection– ECG Size
Using a Monitor ____________________________________________monitor
appropriatelyTurn on unitPrepare patients
____________________________________________– Clean, dry, shave excess hair
Attach 3 or 4 leadsAsk patient to lie still and
____________________________________________a stripAnalyze stripTreat the patient NOT the monitor
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Causes of Poor Signals Excessive ____________________________________________,
loose or dislodged electrodeDried conductive gel, poor placement, diaphoresisPatient movement or muscle tremorBroken patient
____________________________________________ or lead wire Low battery Faulty ____________________________________________ Faulty monitor
Troubleshooting a Monitor/DefibrillatorProblem Check:
No Power Batteries/Power supplyWon’t shock Cables or Synchronize
button onArtifact Movement of patient, 60
cycle interference, poor connection of electrodes
Troubleshooting a Monitor/DefibrillatorProblem Check:Won’t Print Paper, Paper jamStrange looking rhythm Lead placementECG is very small Increase lead size
Vagal Maneuvers Indication
– Stable patient with symptomatic ____________________________________________
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Maneuvers– ____________________________________________ maneuvers– Coughing
Carotid Sinus ____________________________________________– Avoid in patients with a history of cerebrovascular or
carotid artery disease, or patients with carotid bruits.
Precordial ThumpIndication: ____________________________________________ patient who
has a witnessed arrest.Most effective when performed
____________________________________________ after onset of VF.
Not used in pediatric patients.
Antidysrhythmic MedicationsControl or suppress
____________________________________________Atropine Sulfate ____________________________________________Procainamide ____________________________________________Amiodarone ____________________________________________Cardizem
Procainamide (Pronestyl) Indications: Significant
____________________________________________, V-Tach
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Contraindications: – Allergy– 2nd and 3rd Degree Heart Block
Dosage: ______________mg over 5 minutes slow IV push until:– Suppression– Max of 500mg given– QRS complexes broaden by _______________%
Procainamide (Pronestyl)Adverse Reaction:
– ____________________________________________, Seizures, Hypotension, Bradycardia, V-Fib
Cardizem (Diltiazem) (1 of 2)Antidysrhythmic
(____________________________________________ channel blocker)
Action: ____________________________________________of vascular smooth muscle and slows conduction through the AV node
Indications: rapid response A-fib and A-flutter and PSVT refractory to Adenosine for unstable patients
Contraindications: ____________________________________________, cardiogenic shock, wide complex tachycardia (V-tach), WPW
Cardizem (Diltiazem) (2 of 2)Dosage: 0.25mg/kg IVP over 2 minutes
– Standard dose is ___________________mg– Followed by a maintenance drip at 5-15mg/hr
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(except for PSVTs)Adverse Reactions: N/V, headache, dizziness,
bradycardia, heart block, hypotension, and asystoleShould be ____________________________________________or
disposed of after 1 month at room temperature
Sympathomimetic AgentsSimilar to naturally occurring hormones ____________________________________________Norepinephrine Isoproterenol ____________________________________________DobutamineVasopressin
NorepinephrineAKA: ____________________________________________ Indication: Severe
____________________________________________Contraindications: Hypovolemia, profound hypoxiaDosage: Initially 8-12mcg/min IV drip with maintenance
drip of 2-4mcg/min titrated to maintain BPAdverse Reactions: Headache, dizziness,
____________________________________________, hypotension, arrhythmias
Isoproterenol (Isuprel)Rarely used in prehospital setting Indications: Heart
____________________________________________, ventricular arrhythmias
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Contraindications: ____________________________________________or heart blocks caused by Digitalis toxicity
Dosage: 0.02-0.06mg IV with maintenance drip of 5mcg/minute
Adverse Reactions: Palpitations, tachycardia, cardiac arrest, diaphoresis
DopamineAKA: ____________________________________________Used regularly in prehospital setting Indication: Cardiogenic shock with
____________________________________________Contraindications: tachyarrhythmias, V-FibDosage: IV drip at _____________-
_______________mcg/kg/min to maintain BPAdverse Reactions: Ectopic beats, dyspnea, necrosis of
skin with IV infiltrationOver 20mcg/kg/min will shut off blood flow to kidneys
and GI tract
Dobutamine (Dobutrex) Indications: Increases cardiac output in short-term
treatment of cardiac decompensation such as ____________________________________________ shock
Contraindications: HypertensionDosage: ____________-____________mcg/kg/min IV drip
titrated to affectAdverse Reactions: Increased heart rate, hypertension,
dyspnea
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Drugs Used for Myocardial IschemiaTreat ischemia or manage
____________________________________________OxygenNitrous Oxide ____________________________________________Morphine SulfateDemerol ____________________________________________
Nitrous Oxide (Nitronox)Nitrogen and oxygen mixture in a gas state. Medical
Nitrous is a ____________-_____________ mixture Indications: Pain managementContraindications: Pneumothorax,
____________________________________________, bowel obstruction
Actions: Reduces the perception of painDosage: administration via
____________________________________________held mask. Allow patient to hold mask to prevent over medication
Nitrous leaves the system within 2 minutes of d/c
Morphine SulfateOpium based narcotic analgesic.
____________________________________________coronary arteries
Indications: Pain managementContraindications: Hypovolemia,
____________________________________________
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Dosage: 1-10mg IV push repeated every 5-10 minutes as needed
MS should be diluted 1:1 prior to administrationAdverse Reactions:
____________________________________________depression, sedation, hypotension, N/V
MS can be reversed with Narcan
DemerolOpiod Narcotic Analgesic Indications: Pain managementContraindications: Hypovolemia,
____________________________________________Dosage: 25-100mg IV push repeated every 5-10
minutes as neededAdverse Reactions: Respiratory depression,
____________________________________________, hypotension, N/V
Demerol can be reversed with Narcan
Fentanyl (Sublimaze) (1 of 2)Narcotic AnalgesicOn a weight basis, _____________ to 100 times more
potent than MS Indication: pain managementContraindications: hemorrhage, shock, children < 2 yoaDosage _____________-______________mcg slow IV push
Fentanyl (Sublimaze) (2 of 2)Adverse reactions:
____________________________________________depression,
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muscle rigidity, bradycardia Fentanyl does not affect the ______________ to the extent
of MSMay be used on trauma victims where dropping of BP is
a concernDoes ____________________________________________dilate
the coronary arteriesCan be reversed with Narcan
Thrombolytic AgentsAction: to break up blood
____________________________________________blocking a blood vessel (clot busters)
____________________________________________AlteplaseRelteplaseThrombolytics (other than asa) are not routinely given
by EMS. However, many patients receiving them are transferred from one facility to another.
Greatest concern is ____________________________________________dysrhythmias
Other Cardiac Medications
Furosemide (Lasix)Action: ____________________________________________that
inhibits the reabsorption of sodium in the kidneys. Also causes venous dilation and reduces cardiac preload
Indications: CHF with pedal and/or pulmonary edemaContraindications: Hypovolemia, pregnancy,
____________________________________________failure
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Dosage: _____________-______________mg slow IV pushAdverse reactions: volume depletion, muscle spasm
Diazepam (Valium) (1 of 2)Actions: A ____________________________________________.
Sedative-hypnotic, anticonvulsive. Used in EMS for sedation and
____________________________________________ Indications: Sedation for cardioversion and RSI.
SeizuresContraindications: Coma
Diazepam (Valium) (2 of 2)Dosage: : _____________-______________mg IVP, repeated
every 15 minutes to a max of 30mg. Can be given ____________________________________________ as well.
Adverse Reactions: Sedation, respiratory depression or arrest, bradycardia
Promethazine (Phenergan)Actions: ____________________________________________,
sedative, antihistamine, anticholinergic Indications: Nausea (for EMS) often needed after
administration of narcotic analgesicContraindications: Children <2yoaDosage: _____________-______________mg IVP. Drug
should be ____________________________________________ 1:1 to avoid damage to vein. May be repeated as needed
Adverse reactions: sedation, dry mouth
Zofran (Ondansetron) (1 of 2)
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Actions: Antiemetic, serotonin 5-HT3 receptor blocker Does ____________________________________________ cause
the depressed mental status as does Phenergan Indications: nausea and/or vomitingContraindications: children < __________ yoa
Zofran (Ondansetron) (2 of 2)Adult Dosage: _____________mg IV pushPediatric Dosage: 0.1mg/kg up to 4mgAdverse Reactions: Rarely may cause
____________________________________________pain, hypotension and tachycardia
Sodium NitroprussideActions: ____________________________________________ Indications: lowers BP and reduces preload and
afterloadContraindications: hypovolemia, compensatory
hypertension, head injuriesDosage: _____________-______________mcg/kg/min IV drip
titrated to BPAdverse Reactions: Increased ICP, bradycardia, muscle
tremors
Sodium BicarbonateActions: Reverses
____________________________________________ Indications: Acidosis due to cardiac/respiratory arrest,
metabolic acidosis or Crush SyndromeContraindications: Alkalosis, renal failureDosage: ___________mEq/kg of 8.4% solution every 10
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minutes as determined by ABGsAdverse reactions: metabolic alkalosis, hypokalemiaDo not use in same IV tubing as
____________________________________________drugs. Will cause formation of crystals
LabetalolAKA: ____________________________________________,
TrandateAction: Reduces peripheral vascular resistance Indications: Severe
____________________________________________Contraindications: Asthma, cardiac failure, cardiogenic
shock, bradycardiaDosage: _____________mg slow IV push repeated at 40-
80mg every 10 minutes until hypertension relieved or a max of 300mg given
Adverse Reactions: Ventricular arrhythmias, N/V, hypotension, bronchospasms
DigitalisAKA: ____________________________________________, DigoxinNot normally given prehospital but presents challenges
for EMSUsed to treat SVTs,
____________________________________________, A-Flutter, and heart blocks
Digitalis Toxicity: characterized by arrhythmias and yellow-green ____________________________________________around visual images, and bradycardia
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Digitalis Toxicity may be life threatening and render some drugs ineffective
Giving Meds Via ETTDuring an emergency situation, certain drugs can be
given down the ET tube. IV ____________________________________________is always
the route of choice over ETTWhen giving drugs down an ETT, double the amount of
drug but do not give more than _________cc at a time. If more than 10cc is required to double the dosage,
ventilate the patient for a few seconds after first half and then give the second half
Giving Meds Via ETTThe following drugs can be given via the ETT: LANE ____________________________________________Atropine ____________________________________________ Epinephrine
DefibrillationChest Wall Resistance:Paddle pressure, paddle–skin
____________________________________________, paddle surface area, number of previous countershocks, and inspiratory vs. expiratory phase at time of shock
DefibrillationDefibrillation is the process of passing an electrical
current through a
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“____________________________________________” heart to depolarize a critical mass of cardiac cells. This allows them to depolarize uniformly, resulting in an organized fashion.
Uses direct current (DC) ____________________________________________: the shock’s
strength– Energy (Joules) = power (watts) X Duration (seconds)
DefibrillationAll CPR, ventilations, treatment, and touching of patient
must be ____________________________________________when analyzing the rhythm and while shocking
Make sure no one is ____________________________________________the patient and/or cot before shocking.
Do not shock in ____________________________________________or in a wet environment
If paddles are used, be sure to use appropriate defib gel
DefibrillatorsThere must be enough
“____________________________________________” current to reach the heart to defibrillate
Too much “peak” current can damage the heartMonophasic Defibrillators:
– Current flows in ____________________________________________direction only
– Causes a sharp “peak”
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DefibrillatorsBiphasic Defibrillators: Current flows in one direction in the first phase of the
shock and then ____________________________________________for the second phase.
Research shows biphasic to be more successfulCreates a ____________________________________________off
“peak”Requires less joules: Some defibrillators automatically
adjust joules so the 360J setting is still used
DefibrillatorsBiphasic Defibrillators (continued): Biphasic wave forms adjust for
____________________________________________by varying the characteristics of their waveforms thus lowering joules setting
This tends to ensure that high impedance persons will have the same chance for ____________________________________________as those who are of low impedance
Most, if not all, new defibrillators are biphasic
Monophasic v. Biphasic Defibrillation
DefibrillationSuccess of defibrillation depends on: ____________________________________________ since onset of
VF
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Condition of the myocardiumHeart size and body weight ____________________________________________
countershocksProper ____________________________________________ size,
placement, interface, and pressureProperly functioning defibrillator
Components of an DefibrillatorDefibrillation ____________________________________________
(some models)– Defibrillation Gel
Defibrillation/Pacing Pads (if hands free)– Defibrillation Pads
Defibrillation ____________________________________________ (on paddles if equipped)– Energy setting – Discharge Button(s)– Synchronized button
____________________________________________or power supply
Using a DefibrillatorTurn unit on If using paddles, apply defibrillation gelApply defibrillation pads
– Apex, ____________________________________________Charge unit to desired settingSay “____________________________________________”Visualize that everyone is clear
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Using a DefibrillatorDischarge defibrillator
– Push ____________________________________________button on hands free
– Push ____________________________________________shock button simultaneously on paddles
Deliver 1 shock at ______________J or as recommended by manufacturer
Do NOT check a pulse after defibrillation, but resume ____________________________________________ for 2 minutes, unless patient regains consciousness
Using a DefibrillatorAfter ______________ minutes of CPR, check monitorDo not check pulse unless there is a rhythm change or if
seen rhythm is ____________________________________________ of producing a pulse
Emergency Synchronized CardioversionIndications: ____________________________________________ , tachycardic
patient– Perfusing VT– ____________________________________________ – Atrial fibrillation with rapid ventricular response
(______________) (normally > 150bpm)– 2:1 atrial flutter with RVR
Emergency Synchronized Cardioversion
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ProcedureSimilar to defibrillation. ____________________________________________ the patient
whenever possible.Turn on the ____________________________________________ .Hold discharge buttons until countershock
administered.
Transcutaneous Cardiac PacingIndications ____________________________________________ , unstable
patients who do not respond to pharmacological therapy– Symptomatic bradycardias with high-degree AV
blocks.– Atrial fibrillation with a
____________________________________________ ventricular response.
– Other significant bradycardias
External Cardiac PacingMust have 3 or 4
____________________________________________ leads applied ____________________________________________ if applicable
– Versed or DiazepamSet Mode
– Demand or FixedSet ____________________________________________ Set voltage
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Pacing BradyarrhythmiasSet pacer in ____________________________________________
modeSet rate at ___________Set current at Lowest setting and increase in increments
of __________mA until capture.Capture is confirmed by
____________________________________________ pulseTitrate rate to adequate perfusion
Carotid Sinus Massage Indications:
– Paroxysmal supraventricular tachycardia in a ____________________________________________ patient.
Complications– Do not use in patients with a history of
cerebrovascular or ____________________________________________ artery disease.
– Do not use in patients having carotid ____________________________________________ .
– Asystole, PVCs, VT, and VF may occur.– Patient may experience bradycardia, nausea, and
vomiting.Only ____________________________________________ artery at
a time
Managing Specific Cardiovascular Emergencies
General Cardiac Management
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Management of the cardiac patient changes significantly at the Paramedic level due to the increased knowledge and ability to manage dysrrythmias
Treatment priorities are always:1. ____________________________________________ 2. ____________________________________________ 3. Blood Pressure
Angina PectorisPathophysiology:Angina occurs when the heart’s demand for
____________________________________________ exceeds the blood’s oxygen supply.
Commonly caused by artherosclerosis.May also result from
____________________________________________ of the coronary arteries (Prinzmetal’s angina).
Stable vs. ____________________________________________ Angina
Disease Progression
Angina PectorisCauses of Chest Pain: ____________________________________________ , including
acute coronary syndrome, pericarditis, or thoracic dissection of the aorta
____________________________________________ , including pulmonary embolism, pneumothorax, pneumonia, and pleural irritation
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____________________________________________ Musculoskeletal
Angina PectorisField Assessment:Signs of inadequate
____________________________________________ Chest Discomfort
– Typically ____________________________________________ onset, which may radiate or be localized to the chest.
– Patient often denies chest pain.Duration
– Episodes last __________-___________ minutes.– Pain relieved with rest and/or nitroglycerin.
Angina PectorisBreathingHistory of past episodes of angina:
– Episodes of angina that are increasing in frequency, ____________________________________________ , or severity are significant.
ECG– Do not delay scene time.– ____________________________________________ ECG
preferred:Angina typically causes nonspecific ST changes.
Angina PectorisManagement:Relieve ____________________________________________ :
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– Place the patient in a position of physical and emotional comfort.
Administer oxygen if O2 sats < ____________%. Establish IV access, TKOMonitor ECG.Consider medication administration:
– ____________________________________________ tablets or spray
– Morphine sulfate
Angina PectorisSpecial Considerations:Patients with ____________________________________________
or crescendo angina often require hospitalization.Symptoms not relieved by rest, nitroglycerin, and
oxygen may indicate an overall ____________________________________________ of the disease or the early stages of a myocardial infarction.
Patients may refuse transport after pain is relieved, even though the underlying problem is not addressed.
Myocardial InfarctionPathophysiology:Death and ____________________________________________ of
heart muscle due to inadequate oxygen supply.– Causes may include occlusion, spasm, microemboli,
acute volume overload, hypotension, acute respiratory failure, and trauma.
____________________________________________ and size dependent on the vessel involved.
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Myocardial Infarction
Myocardial InfarctionEffects of a Myocardial Infarction: ____________________________________________ Heart FailureVentricular AneurysmGoals of Treatment: ____________________________________________ ReliefReperfusion
Myocardial InfarctionField Assessment:BreathingSigns of ShockChief Complaint
– Typically related to chest ____________________________________________ .
– Evaluate using OPQRST:Discomfort > ____________ minutes.____________________________________________ to arms,
neck, back, or epigastric region.– Patients may minimize symptoms.– Feelings of “impending doom.”
Myocardial InfarctionOther Symptoms
– Nausea and vomiting– ____________________________________________
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Myocardial Infarctions & the ECG– Diagnostic ECGs:12-lead ECGs____________________________________________
segmentPathological Q waves
Myocardial InfarctionMyocardial Infarctions & the ECG
– Dysrhythmias:____________________________________________ , PEA,
VF, VT.____________________________________________ are the
leading cause of death in MI.
Myocardial InfarctionReperfusion Screening for
____________________________________________ therapy– Reperfusion of ischemic/injured tissue.– Time from onset to treatment < ___________ hours.– Absence of history that would exclude thrombolytics.
Transport– Rapid transport indicated when acute MI suspected
Myocardial InfarctionManagement:Assess while you
____________________________________________ Administer oxygen if indicated Establish IV access,
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____________________________________________ Do NOT allow patient to walk
Myocardial InfarctionConsider medication administration: ____________________________________________ ____________________________________________ if SBP >90-
100Morphine sulfate for pain if SBP>90-100Promethazine or
____________________________________________ for nauseaNitrous oxideNubainAntiarrhythmia medication as indicated
Myocardial InfarctionManagement (Continued):Monitor ____________________________________________ .Rapid transport as indicated.Avoid patient ____________________________________________
if possible. Identify candidates for thrombolytic therapy.
Myocardial InfarctionIn-Hospital Management:Diagnostic ECGs. ____________________________________________ levels.Risk assessment.Treatment:
– Cardiac ____________________________________________
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and CABG.
Heart FailureLeft Ventricular Failure:Pathophysiology: Results in increased back
____________________________________________ into the pulmonary circulation.
Signs/Symptoms: Labored breathing/cyanosis, coughing, rales ____________________________________________ ____________________________________________ in sputum
Heart Failure
Heart FailureRight Ventricular Failure:Pathophysiology
– Results in increased back pressure into the systemic venous circulation. Normally caused by left sided failure
Signs/Symptoms: ____________________________________________ ____________________________________________ neck veins ____________________________________________ edema
Heart Failure
Heart FailureCongestive Heart Failure:• Pathophysiology
• Reduction in the heart’s stroke volume causes fluid
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____________________________________________ throughout the body’s other tissues.
• Manifestation• Normally is a
____________________________________________ process• Often caused by an old MI
Congestive Heart FailureField Assessment:Pulmonary Edema:
– Cough with copious amounts of clear or pink-tinged ____________________________________________ .
– Labored breathing, especially with ____________________________________________ .
– Abnormal breath sounds, including ____________________________________________ , rhonchi, and wheezes.
Congestive Heart Failure• Paroxysmal ____________________________________________
Dyspnea (PND)• Medications:
– ____________________________________________ .– Medications to increase cardiac contractile force,
home oxygen.
Congestive Heart FailureMental Status
– Mental status changes indicate impending respiratory ____________________________________________ .
Breathing
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– Signs of labored breathing.– ____________________________________________
positioning.Skin
– ____________________________________________ changes.– Peripheral and/or pedal edema.
Congestive Heart FailureManagementGeneral management:
– Avoid ____________________________________________ positioning.
– Avoid exertion such as standing or walking.Maintain the airway.Administer ____________________________________________ . Establish IV access.
– Limit ____________________________________________ administration. Use minidrip or INT
Congestive Heart FailureMonitor ECGConsider medication administration:
– Nitroglycerin– ____________________________________________ (does not
have to have chest pain)– ____________________________________________ – Dopamine/Dobutamine if hypotensive– Promethazine or Zofran if nauseated– Nitrous oxide– Nebulized breathing treatment if breathing difficulty
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and ____________________________________________ notedAvoid patient refusals if at all possible.
Cardiac TamponadePathophysiology:Result of ____________________________________________
accumulation between visceral pericardium and parietal pericardium.
Increased intrapericardial ____________________________________________ impairs diastolic filling.
Typically worsens progressively until corrected.Epidemiology:Acute onset typically the result of
____________________________________________ or MI.Benign presentations may be caused by cancer,
pericarditis, renal disease, and hypothyroidism.
Cardiac TamponadeField Assessment:Patient History
– Determine precipitating causes.– Patient relates a history of
____________________________________________ and orthopnea.
Exam– ____________________________________________ , weak
pulse– Decreasing systolic pressure, Narrowing pulse
pressures
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– Pulsus paradoxus: drop in BP>_____________ torr during inspiration
– Faint, ____________________________________________ heart sounds
Cardiac TamponadeManagement:Maintain airway.Administer ____________________________________________ if
indicated. Establish IV access.Consider medication administration:
– Morphine sulfate– Nitrous oxide– ____________________________________________ if edema
present– Dopamine/Dobutamine if hypotensive
Cardiac TamponadeManagement (Continued):Rapid ____________________________________________ Pericardiocentisis
– Pericardiocentisis is the ____________________________________________ treatment.
– Insertion of a cardiac needle and ____________________________________________ of fluid from the pericardium.
– Procedure should be performed only if allowed by local protocol.
– Procedure should be performed only by personnel
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adequately trained in the procedure.
Hypertensive EmergenciesCauses: Typically occurs only in patients with a history of HTN. Primary cause is
____________________________________________ with prescribed antihypertensive medications.
Also occurs with ____________________________________________ of pregnancy.
Risk Factors: ____________________________________________ -related
factors Race-related factors
Hypertensive EmergenciesField Assessment: Initial Assessment
– ABCs and ____________________________________________ in mental state
Signs & Symptoms– ____________________________________________
accompanied by N/V– Blurred vision– Shortness of breath– ____________________________________________ – Vertigo– Tinnitus
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Hypertensive EmergenciesHistory:Known history of hypertensionCompliance with medicationsExam:BP > 160/90Signs of left ____________________________________________
failureStrong, ____________________________________________ pulseAbnormal skin color, temperature, and conditionPresence of ____________________________________________
Hypertensive EmergenciesManagement:Maintain airway.Administer ____________________________________________ as
indicated. Establish IV access.Note: Caution must be used when lowering the BP of a
chronically hypertensive patient. Over time, the patient adjusts cerebral perfusion to the hypertensive BP. If lowered, cerebral perfusion could be ____________________________________________ and the brain become ischemic. Always consult local protocols or medical direction before lowering a BP with medications.
Hypertensive Emergencies If indicated, consider medication administration:
– ____________________________________________ sulfate
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– Furosemide– ____________________________________________ – Sodium nitroprusside– ____________________________________________
Cardiogenic ShockPathophysiology:General
– Inability of the heart to meet the body’s metabolic needs.
– Often ____________________________________________ after correction of other problems.
– Severe form of ____________________________________________ failure.
– High mortality rate.
Cardiogenic ShockCauses:Tension pneumothorax and cardiac
____________________________________________ . Impaired ventricular emptying. Impaired myocardial
____________________________________________ .Trauma.
Cardiogenic ShockField Assessment:Primary AssessmentChief Complaint
– Chief complaint is typically chest pain, shortness of
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breath, unconsciousness, or altered mental state.– Onset may be
____________________________________________ or progressive.
History– History of recent
____________________________________________ or chest pain episode.
– Presence of ____________________________________________ in the absence of trauma.
Cardiogenic ShockMental Status
– ____________________________________________ progressing to confusion
Airway and Breathing– Dyspnea, labored breathing, and cough– PND, ____________________________________________
position, accessory muscle retraction, and adventitious lung sounds
ECG– Tachycardia and
____________________________________________ dysrhythmias
Circulation– Hypotension, Cool, clammy skin
Cardiogenic ShockManagement:Maintain airway.
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Administer oxygen as indicated Identify and treat
____________________________________________ problem. Establish IV access, consider fluid challenges if no
pulmonary edema.Consider ____________________________________________
administration:– Vasopressors (Dopamine)– Other meds or Fluid Challenge
Cardiac ArrestCauses: Electrolyte or acid–base imbalances ____________________________________________ Drug intoxication ____________________________________________ HypothermiaPulmonary embolism ____________________________________________ DrowningTrauma End-stage renal disease and hyperkalemia
Cardiac ArrestField Assessment: Initial Assessment
– Unresponsive, ____________________________________________ , pulseless patient
ECG
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– ____________________________________________ History
– Pre-arrest events– Bystander CPR– “Down time”
Cardiac ArrestManagement:Resuscitate ____________________________________________
unless contraindicatedGeneral Guidelines
– CPR.– Manage specific
____________________________________________ .– Establish IV access– Advanced airway management.
CPR takes priority over defibrillation– Avoid ____________________________________________ of
CPR
Cardiac ArrestPostresuscitation Management:Manage dysrhythmias and problems as presented.Be alert for ____________________________________________ .Manage BPTransport ____________________________________________ :
– Take care to protect intubation and IV access.
Cardiac ArrestWithholding Resuscitation
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– Rigor mortis– Dependent ____________________________________________ – Decapitation, decomposition, incineration– Valid ____________________________________________
Cardiac ArrestIndications for termination of resuscitation:Patient over ________________ years old.Cause is presumed cardiac in origin.Successful endotracheal intubation. ____________________________________________ standards
applied throughout the arrest.On-scene effort > ____________ minutes, or four rounds
of drug therapy and ECG remains asystolic or agonal.Blunt trauma victims presenting with or developing
asystole.
Cardiac ArrestContraindications to termination of resuscitation:Patient under 18 years old.Arrest is of a ____________________________________________
cause.Present or recurring VF/VT.Transient return of a pulse.Signs of neurological viability. ____________________________________________ arrest. Family or others opposed to termination of
resuscitation.Suspected ____________________________________________
activity
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Cardiac ArrestTerminating CPR:Always follow local
____________________________________________ related to termination of resuscitation.
Support the ____________________________________________ or others after termination of resuscitation.
Coordinate with law enforcement as requiredWhen in doubt,
____________________________________________ resuscitation
Peripheral Vascular and Other Cardiovascular Emergencies
AtherosclerosisPathophysiology:Progressive ____________________________________________
disease of the medium-sized and large arteries.Results from the buildup of fats on the interior of the
artery. Fatty buildup results in
____________________________________________ and eventual stenosis of the artery.
AneurysmPathophysiology:
– ____________________________________________ of an arterial wall, usually the aorta, that results from a weakness or defect in the wall
Types:
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– Atherosclerotic– ____________________________________________ – Infectious– ____________________________________________ – Traumatic
Abdominal Aortic AneurysmOften the result of
____________________________________________ Signs and symptoms
– Abdominal pain– Back/____________________________________________ pain– Hypotension– Urge to ____________________________________________ – Pulsating mass
Dissecting Aortic AneurysmCaused by ____________________________________________
changes in the smooth muscle and elastic tissue.Blood gets between and
____________________________________________ the wall of the aorta.
Can extend throughout the aorta and into associated vessels.
Acute Pulmonary EmbolismPathophysiology:Blockage of a pulmonary
____________________________________________ by a blood clot or other particle.
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The area served by the pulmonary ____________________________________________ fails.
Signs and Symptoms:Dependent upon size and location of the blockage.Onset of severe, unexplained
____________________________________________ .History of recent lengthy immobilization.
Acute Arterial OcclusionPathophysiology:Sudden ____________________________________________ of
arterial blood flow due to trauma, thrombosis, tumor, embolus, or idiopathic means.
Frequently involves the ____________________________________________ or extremities.
Noncritical Peripheral Vascular ConditionsPeripheral Arterial Atherosclerotic Disease:Can be acute or
____________________________________________ .Often associated with
____________________________________________ . Extremities exhibit pain, coldness, numbness, and pallor.
Noncritical Peripheral Vascular ConditionsDeep Venous ThrombosisBlood clot in a
____________________________________________ .Typically occurs in the larger veins of the thigh and calf. ____________________________________________ , pain, and
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tenderness, with warm, red skin.Varicose VeinsDilated superficial veins, common with pregnancy and
obesity.
Wolff-Parkinson-White SyndromeWPW is a syndrome of pre-excitation of the ventricles
due to an accessory pathway called the Bundle of ____________________________________________ which is an abnormal pathway from the atria to the ventricles.
Effects 0.15 to 0.2% of the populationNormally ____________________________________________
Wolff-Parkinson-White SyndromeRisk of sudden death due to tachydysrthymias (rare)Produces a delta wave
– Slurred upstroke in the QRS complex with a short PRI– Type I WPW produces
____________________________________________ delta waves– Type II WPW produces
____________________________________________ delta wavesCommonly causes syncope and/or palpitations
WPW
WPW
WPW
Wolff-Parkinson-White Syndrome If patient experiences episodes of
____________________________________________ , the ECG will
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show a rapid polymorphic wide-complex tachycardia and is very dangerous.
In this case, many antiarrhythmic drugs are ____________________________________________ . Cardioversion is the treatment of choice for unstable patients
Management of WPW If unstable tachydysrythmia,
____________________________________________ is indicated If more stable, consider
____________________________________________ or Adenosine– Always consult Medical Direction prior to
administering any medications for WPW
General Assessment and Management of Vascular DisordersAssessment: Initial AssessmentCirculatory Assessment
– ____________________________________________ – Pain– Pulselessness– ____________________________________________ – Paresthesia
General Assessment and Management of Vascular DisordersAssessment (Continued):Chief Complaint
– ____________________________________________
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Physical Exam– Prior history of
____________________________________________ problems– Differences in pulses or blood pressures
General Assessment and Management of Vascular DisordersManagement:Maintain the airway.Administer ____________________________________________ if
respiratory distress or signs of hypoperfusion present.Consider administration of
____________________________________________ .Transport rapidly if signs of hypoperfusion present.
12 Lead ECGProvides much better analysis of ECGMost 12 Lead machines have interpretation software:
Do ____________________________________________ rely solely on computer
Patient must be ____________________________________________
Do NOT ____________________________________________ treatment or transport to obtain 12 lead
Normally a left sided ECG, but a right sided ECG can also be performed
12 Lead ECG10 Leads:Conventional 4
____________________________________________ Leads
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– Right Arm– Left Arm– Right Leg– Left Leg
6 _______________ Leads– V1: 4th Intercostal space just to right of sternum
12 Lead ECG6 V Leads (Continued)V2: 4th intercostal space just to
____________________________________________ of sternumV3: In line ____________________________________________
between V2 and V4V4: Midclavicular line in 5th intercostal spaceV5: Anterior ____________________________________________
line at same level as V4V6: Midaxillary line at same level as V4
12 Lead Lead Placement
Prehospital ECG Monitoring
Prehospital ECG Monitoring
Prehospital ECG Monitoring
Prehospital ECG Monitoring
Prehospital ECG Monitoring
Prehospital ECG Monitoring
Prehospital ECG Monitoring
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Right Sided 12 LeadTo perform a right sided ECG, simply
____________________________________________ all V-leads to the right side.
Use the same locations, just on the right side instead of the left
____________________________________________ use the monitor’s interpretation
VADVentricular Assist Device Electromechanical device for assisting
____________________________________________ that is designed to assist in heart failure
Sometimes used on patients awaiting heart transplantMost common is
____________________________________________ VAD or LVADMost will also have a
____________________________________________
LVAD
LVADPump is implanted into
____________________________________________ left abdominal quadrant and produces a humming sound
A functioning pump is paramount for the patient’s survival
Chest compressions may ____________________________________________ pump and
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could cause patient to bleed to deathSeveral manufacturers with different recommendations
on CPR
Dealing With LVAD PatientsPatient will have a
____________________________________________ that has been trained in trouble shooting; listen to them
All patients have a VAD coordinator available 24/7, always contact him/her
Follow the ____________________________________________ of the coordinator and relay instructions to receiving facility
Listen for ____________________________________________ pump to verify pump operation
Assessing a LVAD Patient ____________________________________________ to family and
coordinator Listen for pump operation in upper left abdominal
quadrant. If functioning you should hear a humming sound
Most patients will NOT have a ____________________________________________ ; even if pump is functioning properly
Cardiac arrest may be determined only by unconsciousness and apnea
Determine if patient has ____________________________________________
Treatment Differences for VAD Patients
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If pump is not functioning and patient is unconscious and apneic, check/replace battery. If still not functioning, then begin CPR with compressions no greater than ____________ inches
Never use ____________________________________________ LVAD patients are pre-load dependent and fluid
boluses often reverse hypoperfusionAvoid drugs that can
____________________________________________ pre-load
Drugs to Avoid in LVAD PatientsAnti-dysrhythmic (Amiodarone, Diltiazem, and
Lidocaine) unless in cardiac arrest ____________________________________________ (aspirin,
Plavix)Anti-hypertensives (Labetalol, Procardia) ____________________________________________ (Diazepam,
Lorazepam, Midazolam)Magnesium Sulfate
Drugs to Avoid in LVAD Patients ____________________________________________ (Epinephrine,
Dopamine, Repeated doses of nebulized beta-agonists) unless in cardiac arrest
____________________________________________ medications (Nitro, Morphine)
Key Points for LVADTake all ____________________________________________ with
patient (batteries, owners manual, charger, etc.)Call ____________________________________________ ASAP
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Take family member/caregiver with you in EMS unit ____________________________________________ to
coordinator and caregiver
S-1 02/01/2011
LEFT SIDED V-LEAD PLACEMENT
V1: Right 4th intercostal space
V2: Left 4th intercostal space
V3: Halfway between V2 and V4
V4: Left 5th intercostal space, mid-clavicular line
V5: Horizontal to V4, anterior axillary line
V6: Horizontal to V5, mid-axillary line
In an emergent situation and time does not permit a complete right sided EKG, move V4 to the V4R position to confirm a right ventricular infarct.
S-2 02/01/2011
RIGHT SIDED V-LEAD PLACEMENT
V1R: Left 4th intercostal space
V2R: Right 4th intercostal space
V3R: Halfway between V2 and V4
V4R: Right 5th intercostal space, mid-clavicular line
V5R: Horizontal to V4, anterior axillary line
V6R: Horizontal to V5, mid-axillary line
In an emergent situation and time does not permit a complete right sided EKG, move V4 to the V4R position to confirm a right ventricular infarct.