cardiology part 2

CardiologyCardiology

Part 2: Assessment Part 2: Assessment and Management of and Management of the Cardiovascular the Cardiovascular

PatientPatient

SectionsSections

Assessment of the Cardiovascular Patient

Management of Cardiovascular Emergencies

Managing Specific Cardiovascular Emergencies

Scene Size-up and Initial Assessment Determine scene safety. Determine level of responsiveness. Airway. Breathing:

Note breath sounds indicative of cardiovascular problems.

Circulation: Note color, temperature, turgor, moisture, mobility,

edema.

Treat life-threatening problems.

Scene Size-up and Initial Assessment Determine scene safety. Determine level of responsiveness. Airway. Breathing:

Note breath sounds indicative of cardiovascular problems.

Circulation: Note color, temperature, turgor, moisture, mobility,

edema.

Treat life-threatening problems.

Assessment of the Assessment of the Cardiovascular Cardiovascular

PatientPatient

Focused History Common Symptoms

Chest Pain• OPQRST History of Pain

Dyspnea• Onset• Duration• Provocation/palliation• Orthopnea

Focused History Common Symptoms

Chest Pain• OPQRST History of Pain

Dyspnea• Onset• Duration• Provocation/palliation• Orthopnea

PatientPatient

Other Signs and Symptoms Level of

consciousness Diaphoresis Restlessness and

anxiety Feeling of impending

doom Nausea and/or

vomiting Fatigue Palpitations

Other Signs and Symptoms Level of

consciousness Diaphoresis Restlessness and

anxiety Feeling of impending

doom Nausea and/or

vomiting Fatigue Palpitations

PatientPatient Other Signs and

Symptoms Edema Headache Syncope Behavioral change Anguished facial

expression Activity limitations Trauma

Other Signs and Symptoms Edema Headache Syncope Behavioral change Anguished facial

expression Activity limitations Trauma

Allergies Medications

Nitroglycerin, propranolol, digitalis, diuretics, antihypertensives, antidysrhythmics, lipid-lowering agents

Nonprescription drugs• Cocaine

• Antihistamines

• Alcohol

Allergies Medications

Nitroglycerin, propranolol, digitalis, diuretics, antihypertensives, antidysrhythmics, lipid-lowering agents

Nonprescription drugs• Cocaine

• Antihistamines

• Alcohol

PatientPatient

Past Medical History Cardiac history Heart problems Other medical problems Family cardiac history Modifiable risk factors for heart disease (smoking, etc.)

Last Oral Intake Caffeinated beverages

Events Preceding the Incident Stress, strenuous or sexual activity

Past Medical History Cardiac history Heart problems Other medical problems Family cardiac history Modifiable risk factors for heart disease (smoking, etc.)

Last Oral Intake Caffeinated beverages

Events Preceding the Incident Stress, strenuous or sexual activity

PatientPatient

Physical Examination Inspection

Tracheal position

Thorax Epigastrium

Physical Examination Inspection

Tracheal position

Thorax Epigastrium

PatientPatient

Auscultation Breath

Sounds• Adventitious

Sounds

Heart Sounds• Normal

• Abnormal

Auscultation Breath

Sounds• Adventitious

Sounds

Heart Sounds• Normal

• Abnormal

PatientPatient

Auscultation Carotid

Artery Bruit

Auscultation Carotid

Artery Bruit

PatientPatient

Palpation Pulse Thorax

• Crepitus

• Chest Wall Tenderness

Epigastrium

Palpation Pulse Thorax

• Crepitus

• Chest Wall Tenderness

Epigastrium

PatientPatient

Basic Life Support Advanced Life Support

ECG Monitoring Vagal Maneuvers Precordial Thump Pharmacological Management Defibrillation Synchronized Cardioversion Transcutaneous Cardiac Pacing Diagnostic (12-Lead) ECG

Basic Life Support Advanced Life Support

ECG Monitoring Vagal Maneuvers Precordial Thump Pharmacological Management Defibrillation Synchronized Cardioversion Transcutaneous Cardiac Pacing Diagnostic (12-Lead) ECG

Management of Management of Cardiovascular Cardiovascular EmergenciesEmergencies

Monitoring ECG in the Field Parts of the

Defibrillator Monitoring

Leads Lead II, MCL1 “Quick-Look”

Paddles

Monitoring ECG in the Field Parts of the

Defibrillator Monitoring

Leads Lead II, MCL1 “Quick-Look”

Paddles

ECG MonitoringECG Monitoring

Monitoring ECG in the Field Causes of Poor Signals

Excessive hair, loose or dislodged electrode Dried conductive gel, poor placement, diaphoresis Patient movement or muscle tremor Broken patient cable or lead wire Low battery Faulty grounding Faulty monitor

Monitoring ECG in the Field Causes of Poor Signals

Excessive hair, loose or dislodged electrode Dried conductive gel, poor placement, diaphoresis Patient movement or muscle tremor Broken patient cable or lead wire Low battery Faulty grounding Faulty monitor

Vagal Maneuvers Indication

Stable patient with symptomatic tachycardia

Maneuvers Valsalva maneuvers Coughing Carotid Sinus Massage

• Avoid in patients with a history of cerebrovascular or carotid artery disease, or patients with carotid bruits.

Vagal Maneuvers Indication

Stable patient with symptomatic tachycardia

Maneuvers Valsalva maneuvers Coughing Carotid Sinus Massage

• Avoid in patients with a history of cerebrovascular or carotid artery disease, or patients with carotid bruits.

Precordial Thump Indication

Pulseless patient who has a witnessed arrest.

Most effective when performed immediately after onset of VF.

Not used in pediatric patients.

Technique

Precordial Thump Indication

Pulseless patient who has a witnessed arrest.

Most effective when performed immediately after onset of VF.

Not used in pediatric patients.

Technique

Pharmacological Management Antidysrhythmics

Atropine Sulfate Lidocaine Procainamide Bretylium Adenosine Amiodarone Verapamil

Pharmacological Management Antidysrhythmics

Atropine Sulfate Lidocaine Procainamide Bretylium Adenosine Amiodarone Verapamil

Sympathomimetic Agents Epinephrine Norepinephrine Isoproterenol Dopamine Dobutamine Vasopressin

Drugs Used for Myocardial Ischemia Oxygen Nitrous Oxide Nitroglycerin Morphine Sulfate Nalbuphine

Sympathomimetic Agents Epinephrine Norepinephrine Isoproterenol Dopamine Dobutamine Vasopressin

Drugs Used for Myocardial Ischemia Oxygen Nitrous Oxide Nitroglycerin Morphine Sulfate Nalbuphine

Thrombolytic Agents Aspirin Alteplase Relteplase

Other Prehospital Drugs Furosemide Diazepam Promethazine Sodium Nitroprusside

Thrombolytic Agents Aspirin Alteplase Relteplase

Other Prehospital Drugs Furosemide Diazepam Promethazine Sodium Nitroprusside

Drugs Infrequently Used in the Prehospital Setting Digitalis Beta Blockers

• Propranolol, metaprolol, labetalol

Calcium Channel Blockers• Verapamil, nifedipine, diltiazem

Alkalinizing Agents• Sodium bicarbonate

Drugs Infrequently Used in the Prehospital Setting Digitalis Beta Blockers

• Propranolol, metaprolol, labetalol

Calcium Channel Blockers• Verapamil, nifedipine, diltiazem

Alkalinizing Agents• Sodium bicarbonate

Defibrillation Chest Wall Resistance

Paddle pressure, paddle–skin interface, paddle surface area, number of previous countershocks, and inspiratory vs. expiratory phase at time of shock

Success of Defibrillation Time until VF Condition of the myocardium Heart size and body weight Previous countershocks Proper paddle size, placement, interface, and pressure Properly functioning defibrillator

Defibrillation Chest Wall Resistance

Paddle pressure, paddle–skin interface, paddle surface area, number of previous countershocks, and inspiratory vs. expiratory phase at time of shock

Success of Defibrillation Time until VF Condition of the myocardium Heart size and body weight Previous countershocks Proper paddle size, placement, interface, and pressure Properly functioning defibrillator

DefibrillationDefibrillation

Emergency Synchronized Cardioversion Indications

Unstable, tachycardic patient• Perfusing VT

• PSVT

• Rapid atrial fibrillation

• 2:1 atrial flutter

Emergency Synchronized Cardioversion Indications

Unstable, tachycardic patient• Perfusing VT

• PSVT

• Rapid atrial fibrillation

• 2:1 atrial flutter

Procedure Similar to

defibrillation. Premedicate the

patient whenever possible.

Turn on the synchronizer.

Hold discharge buttons until countershock administered.

Procedure Similar to

defibrillation. Premedicate the

patient whenever possible.

Turn on the synchronizer.

Hold discharge buttons until countershock administered.

ManagemenManagement of t of

CardiovasculCardiovascular ar

EmergenciesEmergencies

Transcutaneous Cardiac Pacing Indications

Symptomatic, unstable patients who do not respond to pharmacological therapy• Symptomatic bradycardias with high-degree AV blocks.

• Atrial fibrillation with a slow ventricular response.

• Other significant bradycardias, including asystole.

Transcutaneous Cardiac Pacing Indications

Symptomatic, unstable patients who do not respond to pharmacological therapy• Symptomatic bradycardias with high-degree AV blocks.

• Atrial fibrillation with a slow ventricular response.

• Other significant bradycardias, including asystole.

External External Cardiac Cardiac PacingPacing

External Cardiac External Cardiac PacingPacing

Carotid Sinus Massage Indications

Paroxysmal supraventricular tachycardia in a stable patient.

Complications Do not use in patients with a history of cerebrovascular or

carotid artery disease. Do not use in patients having carotid bruits. Asystole, PVCs, VT, and VF may occur. Patient may experience bradycardia, nausea, and vomiting.

Support and Communication

Carotid Sinus Massage Indications

Paroxysmal supraventricular tachycardia in a stable patient.

Complications Do not use in patients with a history of cerebrovascular or

carotid artery disease. Do not use in patients having carotid bruits. Asystole, PVCs, VT, and VF may occur. Patient may experience bradycardia, nausea, and vomiting.

Support and Communication

Carotid Sinus Carotid Sinus MassageMassage

Carotid Carotid Sinus Sinus

MassageMassage

Carotid Sinus Carotid Sinus MassageMassage

Angina Pectoris Myocardial Infarction Heart Failure Cardiac Tamponade Hypertensive Emergencies Cardiogenic Shock Cardiac Arrest Peripheral Vascular and Other

Cardiovascular Emergencies

Angina Pectoris Myocardial Infarction Heart Failure Cardiac Tamponade Hypertensive Emergencies Cardiogenic Shock Cardiac Arrest Peripheral Vascular and Other

Cardiovascular Emergencies

Managing Specific Managing Specific Cardiovascular Cardiovascular EmergenciesEmergencies

Angina PectorisAngina Pectoris Epidemiology & Pathophysiology

Pathophysiology Angina occurs when the heart’s demand for oxygen

exceeds the blood’s oxygen supply. Commonly caused by artherosclerosis. May also result from spasm of the coronary arteries

(Prinzmetal’s angina). Stable vs. Unstable Angina Disease Progression Spectrum of coronary artery disease best

referred to as acute coronary syndrome

Epidemiology & Pathophysiology Pathophysiology

Angina occurs when the heart’s demand for oxygen exceeds the blood’s oxygen supply.

Commonly caused by artherosclerosis. May also result from spasm of the coronary arteries

(Prinzmetal’s angina). Stable vs. Unstable Angina Disease Progression Spectrum of coronary artery disease best

referred to as acute coronary syndrome

Angina PectorisAngina Pectoris Causes of Chest Pain

Cardiovascular, including acute coronary syndrome, pericarditis, or thoracic dissection of the aorta

Respiratory, including pulmonary embolism, pneumothorax, pneumonia, and pleural irritation

Gastrointestinal, including cholecystitis, pancreatitis, hiatal hernia, esophageal disease, gastroesophageal reflux, peptic ulcer disease, and dyspepsia

Musculoskeletal, including chest wall syndrome, costochondritis, acromioclavicular disease, herpes zoster, chest wall trauma, and chest wall tumors

Causes of Chest Pain Cardiovascular, including acute coronary syndrome,

pericarditis, or thoracic dissection of the aorta Respiratory, including pulmonary embolism,

pneumothorax, pneumonia, and pleural irritation Gastrointestinal, including cholecystitis, pancreatitis,

hiatal hernia, esophageal disease, gastroesophageal reflux, peptic ulcer disease, and dyspepsia

Musculoskeletal, including chest wall syndrome, costochondritis, acromioclavicular disease, herpes zoster, chest wall trauma, and chest wall tumors

Angina PectorisAngina Pectoris Field Assessment

Signs of Shock Chest Discomfort

Typically sudden onset, which may radiate or be localized to the chest.

Patient often denies chest pain. Duration

Episodes last 3–5 minutes. Pain relieved with rest and/or nitroglycerin.

Field Assessment Signs of Shock Chest Discomfort

Typically sudden onset, which may radiate or be localized to the chest.

Patient often denies chest pain. Duration

Episodes last 3–5 minutes. Pain relieved with rest and/or nitroglycerin.

Angina PectorisAngina Pectoris Breathing History

Past episodes of angina:• Episodes of angina that are increasing in frequency,

duration, or severity are significant.

ECG Do not delay scene time. 12-Lead ECG preferred:

• Angina typically causes nonspecific ST changes.

Breathing History

Past episodes of angina:• Episodes of angina that are increasing in frequency,

duration, or severity are significant.

ECG Do not delay scene time. 12-Lead ECG preferred:

• Angina typically causes nonspecific ST changes.

Angina PectorisAngina Pectoris Management

Relieve anxiety: Place the patient in a position of physical and emotional

comfort. Administer oxygen. Establish IV access. Monitor ECG. Consider medication administration:

Nitroglycerin tablets or spray Nifedipine or other calcium channel blockers Morphine sulfate

Management Relieve anxiety:

Place the patient in a position of physical and emotional comfort.

Administer oxygen. Establish IV access. Monitor ECG. Consider medication administration:

Nitroglycerin tablets or spray Nifedipine or other calcium channel blockers Morphine sulfate

Angina PectorisAngina Pectoris Special Considerations

Patients with new-onset or crescendo angina often require hospitalization.

Symptoms not relieved by rest, nitroglycerin, and oxygen may indicate an overall worsening 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.

Special Considerations Patients with new-onset or crescendo angina often

require hospitalization. Symptoms not relieved by rest, nitroglycerin, and

oxygen may indicate an overall worsening 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 Myocardial InfarctionInfarction Pathophysiology

Death and necrosis of heart muscle due to inadequate oxygen supply. Causes may include

occlusion, spasm, microemboli, acute volume overload, hypotension, acute respiratory failure, and trauma.

Location and size dependent on the vessel involved.

Pathophysiology Death and necrosis of

heart muscle due to inadequate oxygen supply. Causes may include

occlusion, spasm, microemboli, acute volume overload, hypotension, acute respiratory failure, and trauma.

Location and size dependent on the vessel involved.

Myocardial Myocardial InfarctionInfarction Transmural vs. Subendocardial MIs.

Effects of a Myocardial Infarction Dysrhythmias Heart Failure Ventricular Aneurysm

Goals of Treatment Pain Relief Reperfusion

Transmural vs. Subendocardial MIs. Effects of a Myocardial Infarction

Dysrhythmias Heart Failure Ventricular Aneurysm

Goals of Treatment Pain Relief Reperfusion

Myocardial Myocardial InfarctionInfarction Field Assessment

Breathing Signs of Shock Chief Complaint

Typically related to chest pain. Evaluate using OPQRST:

• Discomfort > 30 minutes.• Radiation to arms, neck, back, or epigastric region.

Patients may minimize symptoms. Feelings of “impending doom.”

Field Assessment Breathing Signs of Shock Chief Complaint

Typically related to chest pain. Evaluate using OPQRST:

• Discomfort > 30 minutes.• Radiation to arms, neck, back, or epigastric region.

Patients may minimize symptoms. Feelings of “impending doom.”

Myocardial Myocardial InfarctionInfarction Other Symptoms

Nausea and vomiting Diaphoresis

Myocardial Infarctions & the ECG Diagnostic ECGs:

• 12-lead ECGs• S-T segment• Pathological Q waves

Dysrhythmias:• Asystole, PEA, VF, VT.• Dysrhythmias are the leading cause of death in MI.

Other Symptoms Nausea and vomiting Diaphoresis

Myocardial Infarctions & the ECG Diagnostic ECGs:

• 12-lead ECGs• S-T segment• Pathological Q waves

Dysrhythmias:• Asystole, PEA, VF, VT.• Dysrhythmias are the leading cause of death in MI.

Myocardial Myocardial InfarctionInfarction Reperfusion Screening

Reperfusion of ischemic/injured tissue. Time from onset to treatment < 6 hours. Absence of history that would exclude

thrombolytics.

Transport Rapid transport indicated when acute MI suspected

Reperfusion Screening Reperfusion of ischemic/injured tissue. Time from onset to treatment < 6 hours. Absence of history that would exclude

thrombolytics.

Transport Rapid transport indicated when acute MI suspected

Myocardial Myocardial InfarctionInfarction Management

Prehospital Administer oxygen. Establish IV access. Consider medication administration:

• Aspirin• Morphine sulfate• Promethazine• Nitroglycerin• Nitrous oxide• Nubain• Antiarrhythmia medication as indicated

Management Prehospital

Administer oxygen. Establish IV access. Consider medication administration:

• Aspirin• Morphine sulfate• Promethazine• Nitroglycerin• Nitrous oxide• Nubain• Antiarrhythmia medication as indicated

Myocardial Myocardial InfarctionInfarction Monitor ECG.

Rapid transport as indicated. Avoid patient refusals if possible. Identify candidates for thrombolytic therapy.

In-Hospital: Diagnostic ECGs. Enzyme levels. Risk assessment. Treatment:

• Cardiac catheterization, PTCA, and CABG.

Monitor ECG. Rapid transport as indicated. Avoid patient refusals if possible. Identify candidates for thrombolytic therapy.

In-Hospital: Diagnostic ECGs. Enzyme levels. Risk assessment. Treatment:

• Cardiac catheterization, PTCA, and CABG.

MyocardiMyocardial al

InfarctioInfarctionn

Heart FailureHeart Failure

Left Ventricular Failure Pathophysiology

Results in increased back pressure into the pulmonary circulation.

Left Ventricular Failure Pathophysiology

Results in increased back pressure into the pulmonary circulation.

Right Ventricular Failure Pathophysiology

Results in increased back pressure into the systemic venous circulation.

Pulmonary Embolism

Right Ventricular Failure Pathophysiology

Results in increased back pressure into the systemic venous circulation.

Pulmonary Embolism

Congestive Heart Failure Pathophysiology

Reduction in the heart’s stroke volume causes fluid overload throughout the body’s other tissues.

Manifestation

Congestive Heart Failure Pathophysiology

Reduction in the heart’s stroke volume causes fluid overload throughout the body’s other tissues.

Manifestation

Heart FailureHeart Failure Field Assessment

Pulmonary Edema: Cough with copious amounts of clear or pink-tinged

sputum. Labored breathing, especially with exertion. Abnormal breath sounds, including rales, rhonchi, and

wheezes. Pulsus paradoxus and pulsus alternans.

Paroxysmal Nocturnal Dyspnea (PND) Medications:

Diuretics. Medications to increase cardiac contractile force. Home oxygen.

Field Assessment Pulmonary Edema:

Cough with copious amounts of clear or pink-tinged sputum.

Labored breathing, especially with exertion. Abnormal breath sounds, including rales, rhonchi, and

wheezes. Pulsus paradoxus and pulsus alternans.

Paroxysmal Nocturnal Dyspnea (PND) Medications:

Diuretics. Medications to increase cardiac contractile force. Home oxygen.

Heart FailureHeart Failure Mental Status

Mental status changes indicate impending respiratory failure.

Breathing Signs of labored breathing. Tripod positioning. “Number of pillows.”

Skin Color changes. Peripheral and/or sacral edema.

Mental Status Mental status changes indicate impending respiratory

failure.

Breathing Signs of labored breathing. Tripod positioning. “Number of pillows.”

Skin Color changes. Peripheral and/or sacral edema.

Management General management:

Avoid supine positioning. Avoid exertion such as standing or walking.

Maintain the airway. Administer oxygen. Establish IV access.

Limit fluid administration.

Management General management:

Avoid supine positioning. Avoid exertion such as standing or walking.

Maintain the airway. Administer oxygen. Establish IV access.

Limit fluid administration.

Heart FailureHeart Failure Monitor ECG. Consider medication administration:

Morphine Nitroglycerine Lasix Dopamine/dobutamine Promethazine Nitrous oxide

Avoid patient refusals if at all possible.

Monitor ECG. Consider medication administration:

Morphine Nitroglycerine Lasix Dopamine/dobutamine Promethazine Nitrous oxide

Avoid patient refusals if at all possible.

Cardiac Cardiac TamponadeTamponade Epidemiology & Pathophysiology

Pathophysiology Result of fluid accumulation between visceral pericardium

and parietal pericardium. Increased intrapericardial pressure impairs diastolic

filling. Typically worsens progressively until corrected.

Epidemiology Acute onset typically the result of trauma or MI. Benign presentations may be caused by cancer,

pericarditis, renal disease, and hypothyroidism.

Epidemiology & Pathophysiology Pathophysiology

Result of fluid accumulation between visceral pericardium and parietal pericardium.

Increased intrapericardial pressure impairs diastolic filling.

Typically worsens progressively until corrected.

Epidemiology Acute onset typically the result of trauma or MI. Benign presentations may be caused by cancer,

pericarditis, renal disease, and hypothyroidism.

Cardiac Cardiac TamponadeTamponade Field Assessment

Patient History Determine precipitating causes. Patient relates a history of dyspnea and orthopnea.

Exam Rapid, weak pulse Decreasing systolic pressure Narrowing pulse pressures Pulsus paradoxus Faint, muffled heart sounds Electrical alternans

Field Assessment Patient History

Determine precipitating causes. Patient relates a history of dyspnea and orthopnea.

Exam Rapid, weak pulse Decreasing systolic pressure Narrowing pulse pressures Pulsus paradoxus Faint, muffled heart sounds Electrical alternans

Cardiac Cardiac TamponadeTamponade Management

Maintain airway. Administer oxygen. Establish IV access. Consider medication administration:

Morphine sulfate Nitrous oxide Furosemide Dopamine/dobutamine

Management Maintain airway. Administer oxygen. Establish IV access. Consider medication administration:

Morphine sulfate Nitrous oxide Furosemide Dopamine/dobutamine

Cardiac Cardiac TamponadeTamponade Rapid Transport

Pericardiocentisis Pericardiocentisis is the definitive treatment. Insertion of a cardiac needle and aspiration of fluid

from the pericardium. Procedure should be performed only if allowed by

local protocol. Procedure should be performed only by personnel

adequately trained in the procedure.

Rapid Transport Pericardiocentisis

Pericardiocentisis is the definitive treatment. Insertion of a cardiac needle and aspiration of fluid

from the pericardium. Procedure should be performed only if allowed by

local protocol. Procedure should be performed only by personnel

adequately trained in the procedure.

Hypertensive Hypertensive EmergenciesEmergencies

Hypertensive Emergency Causes

Typically occurs only in patients with a history of HTN. Primary cause is noncompliance with prescribed

antihypertensive medications. Also occurs with toxemia of pregnancy.

Risk Factors Age-related factors Race-related factors

Hypertensive Emergency Causes

Typically occurs only in patients with a history of HTN. Primary cause is noncompliance with prescribed

antihypertensive medications. Also occurs with toxemia of pregnancy.

Risk Factors Age-related factors Race-related factors

Field Assessment Initial Assessment

Alterations in mental state

Signs & Symptoms Headache accompanied by nausea and/or vomiting Blurred vision Shortness of breath Epistaxis Vertigo Tinnitus

Alterations in mental state

Signs & Symptoms Headache accompanied by nausea and/or vomiting Blurred vision Shortness of breath Epistaxis Vertigo Tinnitus

History Known history of hypertension Compliance with medications

Exam BP > 160/90 Signs of left ventricular failure Strong, bounding pulse Abnormal skin color, temperature, and condition Presence of edema

History Known history of hypertension Compliance with medications

Exam BP > 160/90 Signs of left ventricular failure Strong, bounding pulse Abnormal skin color, temperature, and condition Presence of edema

Morphine sulfate Furosemide Nitroglycerin Sodium nitroprusside Labetalol

Cardiogenic ShockCardiogenic Shock Pathophysiology

General Inability of the heart to meet the body’s metabolic needs. Often remains after correction of other problems. Severe form of pump failure. High mortality rate.

Causes Tension pneumothorax and cardiac tamponade. Impaired ventricular emptying. Impaired myocardial contractility. Trauma.

Pathophysiology General

Inability of the heart to meet the body’s metabolic needs. Often remains after correction of other problems. Severe form of pump failure. High mortality rate.

Causes Tension pneumothorax and cardiac tamponade. Impaired ventricular emptying. Impaired myocardial contractility. Trauma.

Cardiogenic ShockCardiogenic Shock Field Assessment

Initial Assessment Chief Complaint

Chief complaint is typically chest pain, shortness of breath, unconsciousness, or altered mental state.

Onset may be acute or progressive. History

History of recent MI or chest pain episode. Presence of shock in the absence of trauma.

Field Assessment Initial Assessment Chief Complaint

Chief complaint is typically chest pain, shortness of breath, unconsciousness, or altered mental state.

Onset may be acute or progressive. History

History of recent MI or chest pain episode. Presence of shock in the absence of trauma.

Cardiogenic ShockCardiogenic Shock Mental Status

Restlessness progressing to confusion Airway and Breathing

Dyspnea, labored breathing, and cough PND, tripod position, accessory muscle retraction, and

adventitious lung sounds ECG

Tachycardia and atrial dysrhythmias Circulation

Hypotension Cool, clammy skin

Mental Status Restlessness progressing to confusion

Airway and Breathing Dyspnea, labored breathing, and cough PND, tripod position, accessory muscle retraction, and

adventitious lung sounds ECG

Tachycardia and atrial dysrhythmias Circulation

Hypotension Cool, clammy skin

Cardiogenic ShockCardiogenic Shock

Management Maintain airway. Administer oxygen Identify and treat underlying problem. Establish IV access. Consider medication administration:

Vasopressors Other meds

Management Maintain airway. Administer oxygen Identify and treat underlying problem. Establish IV access. Consider medication administration:

Vasopressors Other meds

CardiogeCardiogenic Shocknic Shock

Cardiac ArrestCardiac Arrest Sudden Death

Causes Electrolyte or acid–base imbalances Electrocution Drug intoxication Hypoxia Hypothermia Pulmonary embolism Stroke Drowning Trauma End-stage renal disease and hyperkalemia

Sudden Death Causes

Electrolyte or acid–base imbalances Electrocution Drug intoxication Hypoxia Hypothermia Pulmonary embolism Stroke Drowning Trauma End-stage renal disease and hyperkalemia

Cardiac ArrestCardiac Arrest Field Assessment

Initial Assessment Unresponsive, apneic, pulseless patient

ECG Dysrhythmias

History Prearrest events Bystander CPR “Down time”

Unresponsive, apneic, pulseless patient ECG

Dysrhythmias History

Prearrest events Bystander CPR “Down time”

Cardiac ArrestCardiac Arrest Management

Resuscitation Return of Spontaneous Circulation Survival Role of Basic Life Support General Guidelines

Manage specific dysrhythmias. CPR. Advanced airway management. Establish IV access.

Management Resuscitation Return of Spontaneous Circulation Survival Role of Basic Life Support General Guidelines

Manage specific dysrhythmias. CPR. Advanced airway management. Establish IV access.

Cardiac Cardiac Arrest Arrest

ManagemeManagementnt

Cardiac ArrestCardiac Arrest Postresuscitation Management

Manage dysrhythmias and problems as presented. Be alert for PEA. Transport rapidly:

• Take care to protect intubation and IV access.

Withholding Resuscitation Rigor mortis Dependent lividity Decapitation, decomposition, incineration Valid advanced directive

Postresuscitation Management Manage dysrhythmias and problems as presented. Be alert for PEA. Transport rapidly:

• Take care to protect intubation and IV access.

Withholding Resuscitation Rigor mortis Dependent lividity Decapitation, decomposition, incineration Valid advanced directive

Cardiac ArrestCardiac Arrest Terminating Resuscitation

Indications for termination of resuscitation• Patient over 18 years old.• Cause is presumed cardiac in origin.• Successful endotracheal intubation.• ACLS standards applied throughout the arrest.• On-scene effort > 25 minutes, or four rounds of drug

therapy.• ECG remains asystolic or agonal.• Blunt trauma victims presenting with or developing

asystole.

Terminating Resuscitation Indications for termination of resuscitation

• Patient over 18 years old.• Cause is presumed cardiac in origin.• Successful endotracheal intubation.• ACLS standards applied throughout the arrest.• On-scene effort > 25 minutes, or four rounds of drug

therapy.• ECG remains asystolic or agonal.• Blunt trauma victims presenting with or developing

asystole.

Cardiac ArrestCardiac Arrest Terminating Resuscitation

Contraindications to termination of resuscitation:• Patient under 18 years old.• Arrest is of a treatable cause.• Present or recurring VF/VT.• Transient return of a pulse.• Signs of neurological viability.• Witnessed arrest.• Family or others opposed to termination of resuscitation.

Always follow local protocols related to termination of resuscitation.

Support the family or others after termination of resuscitation.

Coordinate with law enforcement as required.

Terminating Resuscitation Contraindications to termination of resuscitation:

• Patient under 18 years old.• Arrest is of a treatable cause.• Present or recurring VF/VT.• Transient return of a pulse.• Signs of neurological viability.• Witnessed arrest.• Family or others opposed to termination of resuscitation.

Always follow local protocols related to termination of resuscitation.

Support the family or others after termination of resuscitation.

Coordinate with law enforcement as required.

BradycardiBradycardia a

AlgorithmAlgorithm

TachycarTachycardia dia

AlgorithAlgorithmm

Atherosclerosis Pathophysiology

Progressive degenerative disease of the medium-sized and large arteries.

Results from the buildup of fats on the interior of the artery.

Fatty buildup results in plaques and eventual stenosis of the artery.

Arteriosclerosis Claudication

Atherosclerosis Pathophysiology

Progressive degenerative disease of the medium-sized and large arteries.

Results from the buildup of fats on the interior of the artery.

Fatty buildup results in plaques and eventual stenosis of the artery.

Arteriosclerosis Claudication

Peripheral Vascular and Peripheral Vascular and Other Cardiovascular Other Cardiovascular

Aneurysm Pathophysiology

Ballooning of an arterial wall, usually the aorta, that results from a weakness or defect in the wall

Types Atherosclerotic Dissecting Infectious Congenital Traumatic

Aneurysm Pathophysiology

Ballooning of an arterial wall, usually the aorta, that results from a weakness or defect in the wall

Types Atherosclerotic Dissecting Infectious Congenital Traumatic

Abdominal Aortic Aneurysm Often the result

of atherosclerosis

Signs and symptoms• Abdominal pain

• Back/flank pain

• Hypotension

• Urge to defecate

Abdominal Aortic Aneurysm Often the result

of atherosclerosis

Signs and symptoms• Abdominal pain

• Back/flank pain

• Hypotension

• Urge to defecate

Dissecting Aortic Aneurysm Caused by degenerative changes in the smooth

muscle and elastic tissue. Blood gets between and separates the wall of the

aorta. Can extend throughout the aorta and into

associated vessels.

Dissecting Aortic Aneurysm Caused by degenerative changes in the smooth

muscle and elastic tissue. Blood gets between and separates the wall of the

aorta. Can extend throughout the aorta and into

associated vessels.

Acute Pulmonary Embolism Pathophysiology

Blockage of a pulmonary artery by a blood clot or other particle.

The area served by the pulmonary artery fails. Signs and Symptoms

Dependent upon size and location of the blockage. Onset of severe, unexplained dyspnea. History of recent lengthy immobilization.

Acute Pulmonary Embolism Pathophysiology

Blockage of a pulmonary artery by a blood clot or other particle.

The area served by the pulmonary artery fails. Signs and Symptoms

Dependent upon size and location of the blockage. Onset of severe, unexplained dyspnea. History of recent lengthy immobilization.

Acute Arterial Occlusion Pathophysiology

Sudden occlusion of arterial blood flow due to trauma, thrombosis, tumor, embolus, or idiopathic means.

Frequently involves the abdomen or extremities.

Vasculitis Pathophysiology

Inflammation of the blood vessels. Commonly stems from rheumatic diseases and

syndromes.

Acute Arterial Occlusion Pathophysiology

Sudden occlusion of arterial blood flow due to trauma, thrombosis, tumor, embolus, or idiopathic means.

Frequently involves the abdomen or extremities.

Vasculitis Pathophysiology

Inflammation of the blood vessels. Commonly stems from rheumatic diseases and

syndromes.

Noncritical Peripheral Vascular Conditions Peripheral Arterial Atherosclerotic Disease

Can be acute or chronic. Often associated with diabetes. Extremities exhibit pain, coldness, numbness, and pallor.

Deep Venous Thrombosis Blood clot in a vein. Typically occurs in the larger veins of the thigh and calf. Swelling, pain, and tenderness, with warm, red skin.

Varicose Veins Dilated superficial veins, common with pregnancy and

obesity.

Noncritical Peripheral Vascular Conditions Peripheral Arterial Atherosclerotic Disease

Can be acute or chronic. Often associated with diabetes. Extremities exhibit pain, coldness, numbness, and pallor.

Deep Venous Thrombosis Blood clot in a vein. Typically occurs in the larger veins of the thigh and calf. Swelling, pain, and tenderness, with warm, red skin.

Varicose Veins Dilated superficial veins, common with pregnancy and

obesity.

General Assessment and Management of Vascular Disorders Assessment

Initial Assessment Circulatory Assessment

• Pallor• Pain• Pulselessness• Paralysis• Paresthesia

General Assessment and Management of Vascular Disorders Assessment

Initial Assessment Circulatory Assessment

• Pallor• Pain• Pulselessness• Paralysis• Paresthesia

Chief Complaint• OPQRST

Physical Exam• Prior history of vascular problems• Differences in pulses or blood pressures

Management Maintain the airway. Administer oxygen if respiratory distress or signs of

hypoperfusion present. Consider administration of analgesics. Transport rapidly if signs of hypoperfusion present.

Chief Complaint• OPQRST

Physical Exam• Prior history of vascular problems• Differences in pulses or blood pressures

Management Maintain the airway. Administer oxygen if respiratory distress or signs of

hypoperfusion present. Consider administration of analgesics. Transport rapidly if signs of hypoperfusion present.

CardiologyCardiology

Management of Specific Cardiovascular Emergencies

cardiology part 2

establish iv access

increased back pressure

carotid artery disease

carotid bruits

administer oxygen

transport rapidly

typically occurs

medication administration

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