Cardiovascular Cardiovascular Emergencies andEmergencies and 12 Lead EKG’s 12 Lead EKG’s

Condell Medical CenterCondell Medical Center

EMS SystemEMS System

ECRN PacketECRN Packet

Module III 2007Module III 2007

Prepared by:Sharon Hopkins, RN, BSN, EMT-P

ObjectivesObjectivesUpon successful completion of this Upon successful completion of this

program, the ECRN should be able to:program, the ECRN should be able to:– understand the normal anatomy & understand the normal anatomy &

physiology of the cardiovascular systemphysiology of the cardiovascular system– describe anatomical changes to the describe anatomical changes to the

heart during ischemic episodesheart during ischemic episodes– differentiate presentations of patients differentiate presentations of patients

with cardiorespiratory complaintswith cardiorespiratory complaints

– –recognize ST elevation onrecognize ST elevation on

the 12 lead EKGthe 12 lead EKG– identify and appropriately state identify and appropriately state

interventions for a variety of interventions for a variety of dysrhythmiasdysrhythmias

– review discussion of case review discussion of case presentationspresentations

– successfully complete the quiz with successfully complete the quiz with a score of 80% or bettera score of 80% or better

Cardiovascular SystemCardiovascular System This system is composed of the heart This system is composed of the heart

and blood vesselsand blood vessels Delivers oxygenated blood to all cellsDelivers oxygenated blood to all cells Transports hormones throughout the Transports hormones throughout the

bodybody Transports waste products for waste Transports waste products for waste

disposaldisposal The heart is a pumpThe heart is a pump

– right pump is under low pressureright pump is under low pressure– left pump is under high pressureleft pump is under high pressure

3 Components of The 3 Components of The Circulatory SystemCirculatory System

Functioning heartFunctioning heart Sufficient blood volumeSufficient blood volume Intact blood vesselsIntact blood vessels

If any one of the above 3 are not If any one of the above 3 are not working properly, the patient may be working properly, the patient may be symptomatic and could be in need of symptomatic and could be in need of interventionintervention

AortaAorta

LeftLeftatriumatrium

SuperiorSuperiorvena cavavena cava

Right Right atriumatrium

Right Right ventricleventricle

Left Left ventricleventricle

Myocardial Blood FlowMyocardial Blood Flow The heart is a muscle (myocardium)The heart is a muscle (myocardium) 3 layers3 layers

epicardium - smooth outer surfaceepicardium - smooth outer surfacemyocardium - thick middle layer, responsible for myocardium - thick middle layer, responsible for

cardiac contraction activitycardiac contraction activityendocardium - innermost layer of thin connective endocardium - innermost layer of thin connective

tissuetissue Myocardial blood flowMyocardial blood flow

– via coronary arteries immediately off aortavia coronary arteries immediately off aorta– heart is the 1heart is the 1stst structure to receive oxygenated blood structure to receive oxygenated blood

- it’s that important!- it’s that important!

Coronary ArteriesCoronary ArteriesLeft main coronary arteryLeft main coronary artery

– left anterior descending coronary artery left anterior descending coronary artery (LAD)(LAD)

supplies left ventricle, septumsupplies left ventricle, septum–circumflex coronary arterycircumflex coronary artery

supplies left atrium, left ventricle, supplies left atrium, left ventricle, septum, part of right ventricleseptum, part of right ventricle

Right coronary artery (RCA)Right coronary artery (RCA)supplies right atrium & ventricle and supplies right atrium & ventricle and part of left ventriclepart of left ventricle

Coronary Blood Flow

Collateral CirculationCollateral Circulation Development of new blood vessels to Development of new blood vessels to

reroute blood flow around blockage in reroute blood flow around blockage in a coronary arterya coronary artery

New arteries may not be able to supply New arteries may not be able to supply enough oxygenated blood to heart enough oxygenated blood to heart muscle in time of increased demandmuscle in time of increased demand

Ischemia occurs when blood supply to Ischemia occurs when blood supply to the heart is inadequate to meet the the heart is inadequate to meet the demandsdemands

Influences of Heart FunctionInfluences of Heart Function PreloadPreload

– pressure under which a ventricle fills; volume of blood pressure under which a ventricle fills; volume of blood returning to fill the heartreturning to fill the heart

AfterloadAfterload– the resistance the ventricle has to pump against to eject the resistance the ventricle has to pump against to eject

blood out of the heartblood out of the heart– the higher the afterload the harder the ventricle has to workthe higher the afterload the harder the ventricle has to work

Ejection fraction (EF)Ejection fraction (EF)– percentage of blood pumped by the ventricle with each percentage of blood pumped by the ventricle with each

contraction (healthy >55%)contraction (healthy >55%)– damage to heart muscle decreases EFdamage to heart muscle decreases EF

Influences On Preload & Influences On Preload & AfterloadAfterload

AfterloadAfterload arteriosclerosis arteriosclerosis

induced high B/P induced high B/P can cause left can cause left ventricle to ventricle to become exhausted become exhausted & stop working & stop working efficientlyefficiently

PreloadPreload increased oxygen increased oxygen

demand increases demand increases volume of blood volume of blood returning to heartreturning to heart

temporarily not a temporarily not a problemproblem

heart enlarges when heart enlarges when preload remains preload remains increased (Frank-increased (Frank-Starling law)Starling law)

Problems That Decrease Problems That Decrease Ejection Fraction (EF)Ejection Fraction (EF)

Myocardial infarction (MI)Myocardial infarction (MI) Congestive heart failure (CHF)Congestive heart failure (CHF) Coronary artery disease (CAD)Coronary artery disease (CAD) Atrial fibrillationAtrial fibrillation CardiomyopathyCardiomyopathy AnemiaAnemia Excess body weightExcess body weight Poorly controlled blood pressurePoorly controlled blood pressure

Coronary Artery Disease (CAD)Coronary Artery Disease (CAD) Leading cause of death in USALeading cause of death in USA

– Narrowing or blockage in coronary artery decreasing Narrowing or blockage in coronary artery decreasing blood flowblood flow

– Atherosclerosis - thickening & hardening of the Atherosclerosis - thickening & hardening of the arteries due to fatty deposits in vesselsarteries due to fatty deposits in vessels

– Plaque deposits build up in arteriesPlaque deposits build up in arteriesarteries narrowarteries narrowarteries become blockedarteries become blockedblood clots formblood clots form

Overtime, CAD can contribute to heart failure & Overtime, CAD can contribute to heart failure & dysrhythmiasdysrhythmias

Coronary Artery Disease (CAD)Coronary Artery Disease (CAD)Plaque in a coronary artery breaks apart Plaque in a coronary artery breaks apart

causing blood clot to form and blocks artery causing blood clot to form and blocks artery

Symptoms of Cardiovascular Symptoms of Cardiovascular ProblemsProblems

Breathing problemsBreathing problems– Shortness of breath (SOB)Shortness of breath (SOB)– Paroxysmal nocturnal dyspnea (PND)Paroxysmal nocturnal dyspnea (PND)

suddenly awakens with shortness of suddenly awakens with shortness of breathbreath

– OrthopneaOrthopneadyspnea when lying downdyspnea when lying down

– Breath soundsBreath soundsare they clear or not clear?are they clear or not clear?

Peripheral edemaPeripheral edema– excess fluid found in tissues of the most excess fluid found in tissues of the most

dependent part of the bodydependent part of the bodypresacral area in bedridden personpresacral area in bedridden personfeet and ankles in someone up and aboutfeet and ankles in someone up and about

SyncopeSyncope– fainting when cardiac output fallsfainting when cardiac output falls– fainting while lying down is considered fainting while lying down is considered

cardiac in nature until proven otherwisecardiac in nature until proven otherwise PalpitationsPalpitations

– sensation of fast or irregular heartbeatsensation of fast or irregular heartbeat PainPain

Initial ImpressionInitial Impression Not necessarily important to know exactly what Not necessarily important to know exactly what

to “name” the patient’s problem (diagnosis)to “name” the patient’s problem (diagnosis) Important to identify signs and symptoms that Important to identify signs and symptoms that

need to be treatedneed to be treated– think “what’s the worse case scenario?”think “what’s the worse case scenario?”

Important to recognize the possible medical Important to recognize the possible medical condition the signs and symptoms may be condition the signs and symptoms may be representingrepresenting

Important to determine the right treatment Important to determine the right treatment approachapproach

Patient Assessment:Patient Assessment:OPQRST of Pain SymptomsOPQRST of Pain Symptoms

OnsetOnset– Sudden or gradual?Sudden or gradual?– Anything like this before?Anything like this before?

Provocation or palliationProvocation or palliation– What makes it better/worse?What makes it better/worse?– What was the patient doing at the time?What was the patient doing at the time?

QualityQuality– What does it feel like (in patient’s own What does it feel like (in patient’s own

words)?words)?

RadiationRadiation– From where to where?From where to where?

SeveritySeverity– How bad is it on a scale of 0-10?How bad is it on a scale of 0-10?

TimingTiming– When did it startWhen did it start– How long did it last?How long did it last?– Continuous or intermittent?Continuous or intermittent?

Vital Signs: Tools for Pt AssessmentVital Signs: Tools for Pt Assessment Heart rateHeart rate

– too fasttoo fastventricle does not stay open long enough to ventricle does not stay open long enough to

adequately filladequately fill

– too slowtoo slowrate too slow to pump often enough to maintain an rate too slow to pump often enough to maintain an

adequate volume outputadequate volume output

Blood pressureBlood pressure – could be elevated in anxiety and paincould be elevated in anxiety and pain– low in shocklow in shock– serial readings (trending) tell muchserial readings (trending) tell much

RespirationsRespirations– Abnormally fast, slow, labored, noisy?Abnormally fast, slow, labored, noisy?Clear - hear breath sounds enter & exitClear - hear breath sounds enter & exit

normalnormalCrackles - pop, snap, click, crackleCrackles - pop, snap, click, crackle

fluid in lower airwaysfluid in lower airwaysRhonchi - rattling sounds; resembles snoringRhonchi - rattling sounds; resembles snoring

mucus in the airwaysmucus in the airwaysWheezes - whistling sound; initially heard on exhalationWheezes - whistling sound; initially heard on exhalation

narrowing airways (ie: asthma)narrowing airways (ie: asthma) Absence of sound - not good!!!Absence of sound - not good!!!

Pulse oximetry (SaOPulse oximetry (SaO22))

– Measures percent of saturated Measures percent of saturated hemoglobin in arterial bloodhemoglobin in arterial blood

– <95% indicates respiratory <95% indicates respiratory compromisecompromise

– <90% indicates dire problem<90% indicates dire problem– Need to evaluate reading with Need to evaluate reading with

patient’s clinical presentation -patient’s clinical presentation -

do they match?do they match?

Inaccurate SaOInaccurate SaO22 Readings Readings

Hypotensive or cold patient (falsely low)Hypotensive or cold patient (falsely low) Carbon monoxide poisoning (falsely high)Carbon monoxide poisoning (falsely high) Abnormal hemoglobin (sickle-cell disease) Abnormal hemoglobin (sickle-cell disease)

(falsely low)(falsely low) Incorrect probe placement (falsely low)Incorrect probe placement (falsely low) Dark nail polish (falsely low)Dark nail polish (falsely low) Anemia (falsely high - whatever Anemia (falsely high - whatever

hemoglobin patient has is saturated)hemoglobin patient has is saturated)

EKG monitoringEKG monitoring– Indicates electrical activity of the heartIndicates electrical activity of the heart– Evaluate mechanical activity by measuring Evaluate mechanical activity by measuring

pulse, heart rate and blood pressurepulse, heart rate and blood pressure– Can indicate myocardial insult and locationCan indicate myocardial insult and location

ischemiaischemia - initial insult; ST depression - initial insult; ST depression injuryinjury - prolonged myocardial hypoxia or - prolonged myocardial hypoxia or

ischemia; ST elevation; injury reversibleischemia; ST elevation; injury reversible infarctioninfarction - tissue death - tissue death

– dead tissue no longer contractsdead tissue no longer contracts– amount of dead tissue directly relates to amount of dead tissue directly relates to

degree of muscle impairmentdegree of muscle impairment– may show Q waves may show Q waves

ST depressionST depression

ST elevationST elevation

Q waveQ wave

Acute Coronary SyndromeAcute Coronary Syndrome Variety of events that represent acute myocardial Variety of events that represent acute myocardial

ischemic pain (plaque rupture)ischemic pain (plaque rupture)Unstable anginaUnstable angina

Intermediate severity of disease between stable angina Intermediate severity of disease between stable angina and acute MI; tissue ischemiaand acute MI; tissue ischemia

Non-Q wave infarct (NSTEMI)Non-Q wave infarct (NSTEMI)No ST elevation but MI is present with tissue necrosis No ST elevation but MI is present with tissue necrosis

(death)(death)Q wave infarct (STEMI)Q wave infarct (STEMI)

ST elevation MI with tissue necrosis (death)ST elevation MI with tissue necrosis (death)Usually a large/significant infarctUsually a large/significant infarct

Acute Myocardial InfarctionAcute Myocardial Infarction Coronary blood flow deprived so that Coronary blood flow deprived so that

portion of muscle diesportion of muscle dies– occlusion by a thrombus (blood clot occlusion by a thrombus (blood clot

superimposed on ruptured plaque)superimposed on ruptured plaque)– spasm of coronary arteryspasm of coronary artery– reduction in blood flow (shock, arrhythmias, reduction in blood flow (shock, arrhythmias,

pulmonary embolism)pulmonary embolism) Location and size of infarct depends on Location and size of infarct depends on

which coronary artery is blocked & wherewhich coronary artery is blocked & where– left ventricle most commonleft ventricle most common

AMI Signs & SymptomsAMI Signs & Symptoms Chest pain - most common especially Chest pain - most common especially

in menin men– lasts >15 minuteslasts >15 minutes– does not go away with restdoes not go away with rest– typically felt beneath sternumtypically felt beneath sternum– typically described as heavy, squeezing, typically described as heavy, squeezing,

crushing, tightcrushing, tight– can radiate down the arm (usually left), can radiate down the arm (usually left),

fingers, jaw,upper back, epigastriumfingers, jaw,upper back, epigastrium Pain not influenced by coughing, deep Pain not influenced by coughing, deep

breathing, movementbreathing, movement

Atypical AMI Signs & SymptomsAtypical AMI Signs & SymptomsPersons with diabetes, elderly, women, and Persons with diabetes, elderly, women, and

heart transplant patientsheart transplant patients Atypical presentation - from drop in cardiac Atypical presentation - from drop in cardiac

output (CO)output (CO)– sudden dyspneasudden dyspnea– sudden lose of consciousness (syncope) or near-sudden lose of consciousness (syncope) or near-

syncopesyncope– unexplained drop in blood pressureunexplained drop in blood pressure– apparent strokeapparent stroke– confusionconfusion– generalized weaknessgeneralized weakness

Atypical AMI Signs & SymptomsAtypical AMI Signs & Symptoms Women at greater riskWomen at greater risk

– symptoms ignored (by patient & MD)symptoms ignored (by patient & MD)– under-recognizedunder-recognized– under-treatedunder-treated

Typical presentation in womenTypical presentation in women– nauseanausea– lightheadednesslightheadedness– epigastric burningepigastric burning– sudden onset weaknesssudden onset weakness– unexplained tiredness/weaknessunexplained tiredness/weakness

Region X SOP Initial Treatment Region X SOP Initial Treatment Acute Coronary SyndromeAcute Coronary Syndrome

Regardless of the end diagnosis, all Regardless of the end diagnosis, all patients treated initially the samepatients treated initially the same– IV-OIV-O22-monitor-vital signs-history-monitor-vital signs-history

– aspirinaspirin– nitroglycerinnitroglycerin– morphine if necessarymorphine if necessary– 12 lead EKG obtained (transmitted to ED by 12 lead EKG obtained (transmitted to ED by

EMS)EMS) Treatment fine-tuned as more diagnostic Treatment fine-tuned as more diagnostic

information is obtainedinformation is obtained

Congestive Heart FailureCongestive Heart Failure Heart unable to pump efficientlyHeart unable to pump efficiently Blood backs up into systemic system, pulmonary Blood backs up into systemic system, pulmonary

system or bothsystem or both– Right heart failureRight heart failure

most often occurs due to left heart failuremost often occurs due to left heart failurecan occur from pulmonary embolismcan occur from pulmonary embolismcan occur from long-standing COPD (esp chronic can occur from long-standing COPD (esp chronic

bronchitis)bronchitis)– Left heart failureLeft heart failure

most commonly from acute MImost commonly from acute MIalso occurs due to chronic hypertensionalso occurs due to chronic hypertension

Right Heart FailureRight Heart Failure Blood backs up into systemic circulationBlood backs up into systemic circulation

– gradual onset over days to weeksgradual onset over days to weeks– jugular vein distension (JVD)jugular vein distension (JVD)– edema (most visible in dependent parts of the body) edema (most visible in dependent parts of the body)

from fluids pushed out of veinsfrom fluids pushed out of veins– engorged, swollen liver due to edemaengorged, swollen liver due to edema– right sided failure alone seldom a life threatening right sided failure alone seldom a life threatening

situationsituation Pre-hospital treatment most often symptomaticPre-hospital treatment most often symptomatic More aggressive treatment needed when accompanied More aggressive treatment needed when accompanied

with left heart failurewith left heart failure

Left Sided Heart FailureLeft Sided Heart Failure

Heart unable to effectively pump Heart unable to effectively pump blood from pulmonary veinsblood from pulmonary veins

Blood backs up behind left ventricleBlood backs up behind left ventricle Pulmonary veins engorged with bloodPulmonary veins engorged with blood Serum forced out of pulmonary Serum forced out of pulmonary

capillaries and into alveoli (air sacs)capillaries and into alveoli (air sacs) Serum mixes with air to produce Serum mixes with air to produce

foam (pulmonary edema)foam (pulmonary edema)

Progression Left Heart FailureProgression Left Heart Failure

Think “Think “lleft - eft - llungs”ungs” Impaired oxygenationImpaired oxygenation

– compensates by compensates by respiratory rate respiratory rate Fluid leaks into interstitial spacesFluid leaks into interstitial spaces

– auscultate cracklesauscultate crackles interstitial pressure narrows bronchiolesinterstitial pressure narrows bronchioles

– auscultate wheezingauscultate wheezing Dyspnea & hypoxemiaDyspnea & hypoxemiapanicpanicrelease of release of

adrenalineadrenalineincreased work load on heartincreased work load on heart

Left Heart FailureLeft Heart Failure Sympathetic nervous system responseSympathetic nervous system response

– Peripheral vasoconstrictionPeripheral vasoconstrictionperipheral resistance (afterload) increasesperipheral resistance (afterload) increasesweakened heart has to pump harder to weakened heart has to pump harder to

eject blood out through narrowed vesselseject blood out through narrowed vesselsblood pressure initially elevated to keep up blood pressure initially elevated to keep up

with the demands and to pump harder with the demands and to pump harder against increased vessel resistanceagainst increased vessel resistance

diaphoretic, pale, cold skindiaphoretic, pale, cold skin

Asthma or Heart Failure?Asthma or Heart Failure?AsthmaAsthma younger patientyounger patient hx of asthmahx of asthma unproductive coughunproductive cough meds for asthmameds for asthma wheezingwheezing accessory muscles accessory muscles

being usedbeing used

Left heart failureLeft heart failure older patientolder patient poss hx heart problemsposs hx heart problems orthopneaorthopnea recent rapid weight gainrecent rapid weight gain cough with watery or foamy cough with watery or foamy

fluidfluid meds for heart problemsmeds for heart problems wheezingwheezing JVDJVD Pedal or sacral edemaPedal or sacral edema

Which Came First - CHF or AMI?Which Came First - CHF or AMI? Not unusual to see the AMI patient in pulmonary Not unusual to see the AMI patient in pulmonary

edema - watch for it!edema - watch for it! Often hard to determine which came first and Often hard to determine which came first and

triggered the development of the other problemtriggered the development of the other problemHeart failureHeart failurepoor perfusion & hypoxemiapoor perfusion & hypoxemia

myocardium suffers from inadequate blood & oxygen myocardium suffers from inadequate blood & oxygen supplysupplyacute myocardial ischemiaacute myocardial ischemiaacute coronary acute coronary syndromesyndrome

AMIAMIpoor pumping performance of heartpoor pumping performance of heartacute acute failure of left heart pumpfailure of left heart pumpleft heart failureleft heart failure

Cardiogenic ShockCardiogenic Shock

Heart extensively damaged; it can no Heart extensively damaged; it can no longer function as a pumplonger function as a pump

25% of heart damage causes left 25% of heart damage causes left heart failureheart failure

if if >>40% of the left ventricle is 40% of the left ventricle is infarcted, cardiogenic shock occursinfarcted, cardiogenic shock occurs

High mortality rateHigh mortality rate

Signs & Symptoms Signs & Symptoms Cardiogenic ShockCardiogenic Shock

Altered level of consciousnessAltered level of consciousness– confusion to unconsciousnessconfusion to unconsciousness

Restless, anxiousRestless, anxious Massive peripheral vasoconstrictionMassive peripheral vasoconstriction

– pale, cold skin, poor renal perfusionpale, cold skin, poor renal perfusion Pulse rapid and threadyPulse rapid and thready Respirations rapid and shallowRespirations rapid and shallow Falling blood pressureFalling blood pressure

Treatment Goals Treatment Goals Acute Coronary SyndromeAcute Coronary Syndrome

Goals Goals – early recognition of a possible cardiac early recognition of a possible cardiac

problemproblem– minimize size of infarctionminimize size of infarction– reduce myocardial oxygen demandreduce myocardial oxygen demand– decrease patient’s fear & pain (minimizes decrease patient’s fear & pain (minimizes

sympathetic discharge)sympathetic discharge)– salvage ischemic myocardiumsalvage ischemic myocardium– prevent development of dysrhythmiasprevent development of dysrhythmias– improve chances of survivalimprove chances of survival

Region X SOP - Acute Coronary Region X SOP - Acute Coronary SyndromeSyndrome

OxygenOxygen– may limit ischemic injurymay limit ischemic injury

Aspirin - 324 mg chewedAspirin - 324 mg chewed– blocks platelet aggregation (clumping) to blocks platelet aggregation (clumping) to

keep clot from getting biggerkeep clot from getting bigger– chewing breaks medication down faster & chewing breaks medication down faster &

allows for quicker absorptionallows for quicker absorption– hold if patient allergic or for a reliable hold if patient allergic or for a reliable

patient that states they have taken aspirin patient that states they have taken aspirin within last 24 hourswithin last 24 hours

Nitroglycerin 0.4 mg sl every 5 minutesNitroglycerin 0.4 mg sl every 5 minutes– dilates coronary vessels to relieve vasospamsdilates coronary vessels to relieve vasospams– increases collateral blood flowincreases collateral blood flow– dilates veins to reduce preload to reduce workload dilates veins to reduce preload to reduce workload

of heartof heart– if pain persists after 2 doses, Morphine to be if pain persists after 2 doses, Morphine to be

startedstarted Morphine - 2 mg slow IVPMorphine - 2 mg slow IVP

– decreases pain & apprehensiondecreases pain & apprehension– mild venodilator & arterial dilator mild venodilator & arterial dilator

reduces preload and afterloadreduces preload and afterload

– 2mg slow IVP repeated every 2 minutes as 2mg slow IVP repeated every 2 minutes as needed, max total dose 10 mgneeded, max total dose 10 mg

Treatment GoalsTreatment GoalsCongestive Heart FailureCongestive Heart Failure

GoalsGoals– improve oxygenationimprove oxygenation– decrease workload of the heart decrease workload of the heart

(ie: decrease preload & afterload)(ie: decrease preload & afterload)

Region X SOPRegion X SOPTreatment Treatment StableStable Acute Acute

Pulmonary Edema (B/P>100)Pulmonary Edema (B/P>100) Nitroglycerin - 0.4 mg slNitroglycerin - 0.4 mg sl

– Vasodilator to create venous poolingVasodilator to create venous pooling– Reduces preload & afterloadReduces preload & afterload– Maximum 3 doses (repeated every 5 Maximum 3 doses (repeated every 5

minutes if blood pressure remains >100)minutes if blood pressure remains >100) Consider CPAP - use if indicatedConsider CPAP - use if indicated

Region X SOP cont’dRegion X SOP cont’d

Lasix - 40 mg IVPLasix - 40 mg IVP– Diuretic - excess fluid excreted via Diuretic - excess fluid excreted via

kidneyskidneys– Venodilating effect to pool venous bloodVenodilating effect to pool venous blood– Dose Dose to 80 mg IVP if patient on Lasix at to 80 mg IVP if patient on Lasix at

homehome

Morphine - 2 mg slow IVPMorphine - 2 mg slow IVP– Venodilator to increase pooling of bloodVenodilator to increase pooling of blood– Anxiolytic to calm anxious patientAnxiolytic to calm anxious patient– May repeat 2mg dose every 2 minutesMay repeat 2mg dose every 2 minutes– Maximum total dose 10 mgMaximum total dose 10 mg

Albuterol - 2.5 mg/3ml nebulizerAlbuterol - 2.5 mg/3ml nebulizer– Wheezing may indicate Wheezing may indicate

bronchoconstriction from excessive fluidbronchoconstriction from excessive fluid– Bronchodilator could be helpfulBronchodilator could be helpful

Region X SOP cont’dRegion X SOP cont’d

Hypotensive side effects from Hypotensive side effects from treatments used for stable treatments used for stable pulmonary edemapulmonary edema– Treatment used (NTG, Lasix, Morphine, Treatment used (NTG, Lasix, Morphine,

CPAP) can all cause venodilation CPAP) can all cause venodilation B/PB/P– Blood pressure needs to be carefully Blood pressure needs to be carefully

monitoredmonitored

Region x SOP Region x SOP Treatment Treatment UnstableUnstable Acute Acute

Pulmonary Edema (B/P<100)Pulmonary Edema (B/P<100) Contact Medical ControlContact Medical Control CPAP on orders of Medical ControlCPAP on orders of Medical Control Consider Cardiogenic Shock ProtocolConsider Cardiogenic Shock Protocol If wheezing (indicating If wheezing (indicating

bronchoconstriction), contact Medical bronchoconstriction), contact Medical Control for Albuterol orderControl for Albuterol order– if patient needs to be intubated, Albuterol to if patient needs to be intubated, Albuterol to

be delivered via in-linebe delivered via in-line

Treatment GoalsTreatment GoalsCardiogenic ShockCardiogenic Shock

GoalsGoals– Improve oxygenationImprove oxygenation– Improve peripheral perfusionImprove peripheral perfusion– Avoid adding any workload to the heartAvoid adding any workload to the heart

Region X SOPRegion X SOPTreatment Cardiogenic ShockTreatment Cardiogenic Shock

Oxygen via nonrebreather maskOxygen via nonrebreather mask– BVM if respirations ineffectiveBVM if respirations ineffective– Intubation may become necessaryIntubation may become necessary

PositioningPositioning– Supine if lungs are clearSupine if lungs are clear– Head somewhat elevated if pulmonary edema is Head somewhat elevated if pulmonary edema is

present (semi-fowler’s)present (semi-fowler’s) IV/IO fluid challenge in 200ml increments if IV/IO fluid challenge in 200ml increments if

lung sounds are clearlung sounds are clear– The shock may include a hypovolemic componentThe shock may include a hypovolemic component

Treatment Cardiogenic ShockTreatment Cardiogenic Shock Cardiac monitorCardiac monitor

– Arrhythmias are likelyArrhythmias are likelyMay cause hypotension decreasing cardiac outputMay cause hypotension decreasing cardiac output

Dopamine Infusion - maintain B/P Dopamine Infusion - maintain B/P >>100100– Effects dose related & dependent on clinical Effects dose related & dependent on clinical

condition of patientcondition of patient

– 5 - 20 5 - 20 g/kg/min has beta influence on the g/kg/min has beta influence on the heartheartIncreases contractility strength of heartIncreases contractility strength of heartTo a lesser degree increases heart rate To a lesser degree increases heart rate

Dopamine cont’dDopamine cont’d– Doses >20Doses >20g/kg/ming/kg/min

Alpha stimulation predominate & Alpha stimulation predominate & vasoconstriction my negatively affect vasoconstriction my negatively affect circulationcirculation

Extravasation - leaking out of vesselsExtravasation - leaking out of vessels– Can cause tissue necrosisCan cause tissue necrosis– IV infiltration reported to ED staff; documentIV infiltration reported to ED staff; document

Dosing - start at 5 Dosing - start at 5 g/kg/ming/kg/min– Refer to table in SOP page 13 Refer to table in SOP page 13 OROR– Take patient’s weight in pounds, take 1Take patient’s weight in pounds, take 1stst 2 2

numbers, & subtract 2 (ie: 185 pounds: 18 numbers, & subtract 2 (ie: 185 pounds: 18 - 2 = 16 - 2 = 16 gtts/min to start drip)gtts/min to start drip)

EKG Monitoring & 12 Lead EKG’sEKG Monitoring & 12 Lead EKG’s Goal EKG monitoringGoal EKG monitoring

– Identify a disturbance in the normal cardiac rhythmIdentify a disturbance in the normal cardiac rhythm– Arrhythmias caused byArrhythmias caused by

IschemiaIschemiaElectrolyte imbalancesElectrolyte imbalancesDisturbances or damage in electrical conduction Disturbances or damage in electrical conduction

systemsystem Goal of obtaining 12 lead EKGGoal of obtaining 12 lead EKG

– Early recognition Acute Coronary SyndromeEarly recognition Acute Coronary Syndrome Treat clinical condition, not the monitor!Treat clinical condition, not the monitor!

12 Lead EKG’s12 Lead EKG’s

EMS to transmit EKG to Medical EMS to transmit EKG to Medical control when following the Acute control when following the Acute Coronary Syndrome SOPCoronary Syndrome SOP

Many patients can be monitored by a Many patients can be monitored by a Lead II but not all patients need a 12 Lead II but not all patients need a 12 lead.lead.

Some patients experiencing angina or Some patients experiencing angina or an acute MI will an acute MI will notnot yet have any EKG yet have any EKG changes indicated on the 12 lead.changes indicated on the 12 lead.

12 Lead Transmitted From The 12 Lead Transmitted From The FieldField

ECRN to complete the radio reportECRN to complete the radio report ECRN immediately after radio report ECRN immediately after radio report

to retrieve faxed copy of the field 12 to retrieve faxed copy of the field 12 lead EKGlead EKG

12 lead EKG to be immediately 12 lead EKG to be immediately presented to the ED physicianpresented to the ED physician

12 lead EKG from EMS is to be placed 12 lead EKG from EMS is to be placed on the patient’s chart after MD reviewon the patient’s chart after MD review

A normal EKG DOESA normal EKG DOES NOTNOT necessarily necessarily mean there is mean there is

nothing acute going nothing acute going on!on!

Cardiac Conduction SystemCardiac Conduction System SA node - dominant pacemakerSA node - dominant pacemaker

– upper right atriumupper right atrium– blood supply from RCAblood supply from RCA

Internodal pathwaysInternodal pathways– to spread electrical impulse thru-out atriato spread electrical impulse thru-out atria

AV node in region of AV junctionAV node in region of AV junction– in 85-90% of people, blood supplied by RCA to in 85-90% of people, blood supplied by RCA to

AV nodeAV node– in 10-15% of people, blood supplied by left in 10-15% of people, blood supplied by left

circumflex circumflex

Conduction System cont’dConduction System cont’d bundle of Hisbundle of His Right and left bundle branchesRight and left bundle branches Purkinje fibers - through ventricular musclePurkinje fibers - through ventricular muscle

Changes in electrolyte concentrations Changes in electrolyte concentrations influence depolarization and repolarization influence depolarization and repolarization sodium (Nasodium (Na++), ), potassium (Kpotassium (K++), ),

calcium (Cacalcium (Ca++++), ), Magnesium (MgMagnesium (Mg++++))

Conduction SystemConduction System

LlLeft bundlebranches

EKG Wave FormsEKG Wave Forms P waveP wave

– depolarization of atriadepolarization of atria PR intervalPR interval

– depolarization of atria & delay at AV junctiondepolarization of atria & delay at AV junction– normal PR interval 0.12 - 0.20 secondsnormal PR interval 0.12 - 0.20 seconds

QRS complexQRS complex– depolarization of ventriclesdepolarization of ventricles– normal QRS complex <0.12 secondsnormal QRS complex <0.12 seconds

T wavesT waves– repolarization of ventricles (and atria)repolarization of ventricles (and atria)

J point - end of QRS complex & beginning J point - end of QRS complex & beginning of ST segmentof ST segment

ST segment elevation - evaluated 0.04 ST segment elevation - evaluated 0.04 seconds after J point seconds after J point

The J PointThe J Point

Precordial Chest LeadsPrecordial Chest LeadsFor every person, each precordial lead placed in For every person, each precordial lead placed in

the same relative positionthe same relative position V1 - 4V1 - 4thth intercostal space, R of sternum intercostal space, R of sternum V2 - 4V2 - 4thth intercostal space, L of sternum intercostal space, L of sternum V4 - 5V4 - 5thth intercostal space, midclavicular intercostal space, midclavicular V3 - between V2 and V4, on 5V3 - between V2 and V4, on 5thth rib or in rib or in

55thth intercostal space intercostal space V5 - 5V5 - 5thth intercostal space, anterior intercostal space, anterior

axillary lineaxillary line V6 - 5V6 - 5thth intercostal space, mid-axillary intercostal space, mid-axillary

Precordial Precordial LeadsLeads

Lead PlacementLead Placement

The more accurate the lead placement, The more accurate the lead placement, the more accurate the 12-lead the more accurate the 12-lead interpretation when interpreted from interpretation when interpreted from all other EKG’s taken on this patientall other EKG’s taken on this patient

12-leads are often evaluated on a 12-leads are often evaluated on a sequential basis, each interpretation sequential basis, each interpretation made trying to consider the previous made trying to consider the previous oneone

V4-6 should be in a straight lineV4-6 should be in a straight line

12 Lead Printout12 Lead Printout

Standard format 8Standard format 811//22 x 11 x 11 paper paper 12 lead views printed on top half12 lead views printed on top half

II aVR aVR V1 V1 V4 V4

IIII aVL aVL V2 V2 V5 V5

IIIIII aVF aVF V3 V3 V6 V6 Additional single view of rhythm strips Additional single view of rhythm strips

usually printed on bottom of reportusually printed on bottom of report Machines can analyze data obtained Machines can analyze data obtained

but humans must interpret databut humans must interpret data

Limb Leads (Bipolar)Limb Leads (Bipolar) Lead I - views the Lead I - views the

left (lateral) side of left (lateral) side of heartheart

Lead II - views the Lead II - views the bottom (inferior) bottom (inferior) side of heartside of heart

Lead III - another Lead III - another inferior view of the inferior view of the heartheart

I+I+

Limb Leads Limb Leads (Unipolar)(Unipolar)

aVR - view from aVR - view from right arm right arm

aVL - lateral view aVL - lateral view from left armfrom left arm

aVF - inferior aVF - inferior view from left legview from left leg

Precordial (Chest) LeadsPrecordial (Chest) Leads

Views the Views the septal, septal, anterior, anterior, & lateral & lateral portions portions of the of the heartheart

Heart in the Thoracic CavityHeart in the Thoracic Cavity

Myocardial InsultMyocardial Insult IschemiaIschemia

– lack of oxygenationlack of oxygenation– ST depression or T wave inversionST depression or T wave inversion– permanent damage avoidablepermanent damage avoidable

InjuryInjury– prolonged ischemiaprolonged ischemia– ST elevationST elevation– permanent damage avoidablepermanent damage avoidable

InfarctInfarct– death of myocardial tissuedeath of myocardial tissue– may have Q wavemay have Q wave

Evolution of AMIEvolution of AMIA - pre-infarctA - pre-infarct

B - Tall T waveB - Tall T wave

C - Tall T wave & ST C - Tall T wave & ST elevationelevation

D - Elevated ST, D - Elevated ST, inverted T wave, inverted T wave, Q wave Q wave

E - Inverted T wave, E - Inverted T wave, Q wave Q wave

F - Q wave F - Q wave

ST DepressionST Depression

Can indicateCan indicateischemiaischemiaelectrolyte abnormalityelectrolyte abnormalityrapid heart raterapid heart ratedigitalis influencedigitalis influencereciprocal changes to ST elevationreciprocal changes to ST elevation

ST depression measurementST depression measurement– 1 mm (1 small box) below baseline 1 mm (1 small box) below baseline

measured 2 mm (2 small boxes) after measured 2 mm (2 small boxes) after end of QRSend of QRS

ST elevation ST elevation is more is more

significant so significant so should be should be

looked for in looked for in opposite opposite

leads when leads when depression depression

notednoted

T Wave InversionT Wave Inversion T wave represents ventricular repolarizationT wave represents ventricular repolarization

– Normally upright in all leads except V1 and aVRNormally upright in all leads except V1 and aVR

Inverted T waves tend to represent ischemiaInverted T waves tend to represent ischemia

NoteNote

T wave T wave

inversioninversion

aVL,aVL,

V4 -6V4 -6

ST Segment ElevationST Segment Elevation

Myocardium exposed to prolonged Myocardium exposed to prolonged hypoxia or ischemiahypoxia or ischemia

Finding indicates injury or damage Finding indicates injury or damage Injury probably due to occluded Injury probably due to occluded

coronary arterycoronary artery Muscle can still be salvagedMuscle can still be salvaged If corrective intervention not taken in If corrective intervention not taken in

timely manner, tissue necrosis/death is timely manner, tissue necrosis/death is likely (infarction)likely (infarction)

TIME IS MUSCLE!TIME IS MUSCLE!

Significant ST ElevationSignificant ST Elevation ST segment elevation measurementST segment elevation measurement

– 0.04 seconds after J point0.04 seconds after J point ST elevationST elevation

– > 1mm (1 small box) in 2 or more contiguous > 1mm (1 small box) in 2 or more contiguous chest leads (V1-V6)chest leads (V1-V6)

– >1mm (1 small box) in 2 or more anatomically >1mm (1 small box) in 2 or more anatomically contiguous leadscontiguous leads

Contiguous leadContiguous lead– limb leads that “look” at the same area of the limb leads that “look” at the same area of the

heart or are numerically consecutive chest leadsheart or are numerically consecutive chest leads

Contiguous LeadsContiguous Leads

Inferior wall: II, III, avFInferior wall: II, III, avF Lateral wall: I, aVL, V5, V6Lateral wall: I, aVL, V5, V6 Septum: V1 and V2Septum: V1 and V2 Anterior wall: V3 and V4Anterior wall: V3 and V4 Posterior wall: V7-V9 (leads Posterior wall: V7-V9 (leads

placed on the patient’s back 5placed on the patient’s back 5thth intercostal space creating a 15 lead intercostal space creating a 15 lead EKG)EKG)

ST Segment ElevationST Segment Elevation

Coved Coved shape shape usually usually indicates indicates acute acute injuryinjury

Concave Concave shape is shape is usually usually benign if benign if patient is patient is asympto-asympto-matic matic

Groups of EKG LeadsGroups of EKG Leads Inferior wall - II, III, aVFInferior wall - II, III, aVF Septal wall - V1, V2Septal wall - V1, V2 Anterior wall - V3, V4Anterior wall - V3, V4 Lateral wall - I, aVL, V5, V6 Lateral wall - I, aVL, V5, V6

aVR is not evaluated in typical groups aVR is not evaluated in typical groups Standard lead placement does not look at Standard lead placement does not look at

posterior wall or right ventricle of the heart - posterior wall or right ventricle of the heart - need special lead placement for these viewsneed special lead placement for these views

Pathological Q Waves - InfarctionPathological Q Waves - Infarction Death of tissueDeath of tissue Pathological Q wave Pathological Q wave

– >0.04 seconds wide or>0.04 seconds wide or

– 11//33 of R wave height of R wave height

– when seen with ST elevation indicates when seen with ST elevation indicates ongoing myocardial infarctionongoing myocardial infarction

Remember: ST segment probably single Remember: ST segment probably single most important element on EKG when most important element on EKG when looking for evidence of AMIlooking for evidence of AMI

Pathological Q WavePathological Q Wave

Reciprocal ChangesReciprocal Changes Changes seen in the wall of the heart Changes seen in the wall of the heart

opposite the location of the infarctionopposite the location of the infarction Observe ST segment depressionObserve ST segment depression Usually observed at the onset of infarctionUsually observed at the onset of infarction Usually a short lived changeUsually a short lived change Lead Lead Reciprocal changesReciprocal changes II, III, aVFII, III, aVF I, aVL I, aVL I, aVL, V5, V6I, aVL, V5, V6 II, III, aVF II, III, aVF V1-V4V1-V4 V7-V9 V7-V9

Acute MI Locator TableAcute MI Locator TableLocation Leads Reciprocal

changesInferior(RCA)

I I , I I I , aVF I , aVL

Septal(LAD)

V1, V2

Anterior(LAD)

V3, V4 I I , I I I , aVF

Lateral(Circumflex)

V5, V6, I ,aVL

I I , I I I , aVF

Acute Myocardial InfarctionAcute Myocardial Infarction Acute myocardial infarction (AMI) is part of a Acute myocardial infarction (AMI) is part of a

spectrum of disease known as acute coronary spectrum of disease known as acute coronary syndrome (ACS)syndrome (ACS)

ACSACS– Larger term to cover a group of clinical syndromes Larger term to cover a group of clinical syndromes

compatible with acute myocardial ischemiacompatible with acute myocardial ischemia– Chest pain is due to insufficient blood supply to Chest pain is due to insufficient blood supply to

the heart muscle that results from coronary artery the heart muscle that results from coronary artery disease (CAD)disease (CAD)

– Clinical conditions include unstable angina to non-Clinical conditions include unstable angina to non-Q wave MI and Q wave MIQ wave MI and Q wave MI

Common Complications of AMICommon Complications of AMI

V1-2: septal wall - infranodal V1-2: septal wall - infranodal heartblock, BBBheartblock, BBB

V3-4: anterior wall - LV dysfunction, V3-4: anterior wall - LV dysfunction, CHF, BBB, 3CHF, BBB, 3rdrd degree HB, PVC’s degree HB, PVC’s

I, aVL, V5-6: lateral wall -LV I, aVL, V5-6: lateral wall -LV dysfunction, AV nodal block in somedysfunction, AV nodal block in some

II, III, aVF: inferior & posterior wall LV - II, III, aVF: inferior & posterior wall LV - hypotension, sensitivity to hypotension, sensitivity to Nitroglycerin & MorphineNitroglycerin & Morphine

Practice Identifying ST Segment Practice Identifying ST Segment ElevationElevation

> 1mm (1 small box) in 2 leads from any > 1mm (1 small box) in 2 leads from any group or 2 or more contiguous leadsgroup or 2 or more contiguous leads

(>2 mm (2 small boxes) in limb leads (>2 mm (2 small boxes) in limb leads considered alternative elevation by some) considered alternative elevation by some) measured 0.04 seconds after J pointmeasured 0.04 seconds after J point

Think Pattern RecognitionThink Pattern RecognitionInferior Wall MIInferior Wall MI

ILateral

aVR V1Septum

V4Anterior

I IInferior

aVLLateral

V2Septum

V5Lateral

I I IInferior

aVFInferior

V3Anterior

V6Lateral

Think Pattern RecognitionThink Pattern RecognitionLateral Wall MILateral Wall MI

ILateral

aVR V1Septum

V4Anterior

I IInferior

aVLLateral

V2Septum

V5Lateral

I I IInferior

aVFInferior

V3Anterior

V6Lateral

Think Pattern RecognitionThink Pattern RecognitionAnterior Wall MIAnterior Wall MI

ILateral

aVR V1Septum

V4Anterior

I IInferior

aVLLateral

V2Septum

V5Lateral

I I IInferior

aVFInferior

V3Anterior

V6Lateral

Think Pattern RecognitionThink Pattern RecognitionSeptal Wall MISeptal Wall MI

ILateral

aVR V1Septum

V4Anterior

I IInferior

aVLLateral

V2Septum

V5Lateral

I I IInferior

aVFInferior

V3Anterior

V6Lateral

Test Yourself -Test Yourself -What pattern would indicate an What pattern would indicate an

anterior/septal wall MI?anterior/septal wall MI?

ILateral

aVR V1Septum

V4Anterior

I IInferior

aVLLateral

V2Septum

V5Lateral

I I IInferior

aVFInferior

V3Anterior

V6Lateral

Practice Identifying Practice Identifying

Leads Showing ST ElevationLeads Showing ST Elevation

Evaluate the top 3 rows of the 12-Evaluate the top 3 rows of the 12-lead EKGlead EKG

Answers follow the 12 leadAnswers follow the 12 lead

ST Elevation II, III, aVF ST Elevation II, III, aVF Inferior Wall InvolvementInferior Wall Involvement

ST Elevation V5, V6, aVL - LateralST Elevation V5, V6, aVL - Lateral

ST Elevation V1-V4 - Ant/SeptalST Elevation V1-V4 - Ant/Septal

ST Elevation II, III, aVF, V6ST Elevation II, III, aVF, V6Inferior & Lateral Wall Inferior & Lateral Wall

ST Elevation I, aVL, V2-6ST Elevation I, aVL, V2-6

ST Elevation II, III, aVFST Elevation II, III, aVF

Case Discussion #1Case Discussion #1

66 year-old male presents with 66 year-old male presents with “indigestion” for past 2 hours, “indigestion” for past 2 hours, frequent belching, nausea, paleness, frequent belching, nausea, paleness, diaphoresis, left arm discomfortdiaphoresis, left arm discomfort

Vital signsVital signs– 102/76 HR 98 RR 20 SaO102/76 HR 98 RR 20 SaO22 98% 98%

What is your impression and what What is your impression and what initial treatment is indicated in the initial treatment is indicated in the prehospital setting?prehospital setting?

Case #1Case #1 Impression: possible AMI Impression: possible AMI (assume and treat for the (assume and treat for the

worse)worse) SOP: Acute Coronary SyndromeSOP: Acute Coronary Syndrome Prehospital treatment:Prehospital treatment:

– IV-OIV-O22-monitor-pulse ox-monitor-pulse ox

– Vitals stableVitals stable– History unremarkableHistory unremarkable– Aspirin chewed (any contraindications?)Aspirin chewed (any contraindications?)– Nitroglycerin sl (ask about Viagra use)Nitroglycerin sl (ask about Viagra use)– Morphine if pain unrelieved after 2 NTGMorphine if pain unrelieved after 2 NTG– 12 lead transmitted to ED for interpretation12 lead transmitted to ED for interpretation

Case #1 12-LeadCase #1 12-Lead

Case #1Case #1 Impression of 12 lead?Impression of 12 lead?

– no ST segment elevation notedno ST segment elevation noted Does lack of ST segment elevation Does lack of ST segment elevation

change field treatment for this change field treatment for this patient?patient?– Normal EKG does not preclude that Normal EKG does not preclude that

acute myocardial event is occurringacute myocardial event is occurring– Acute Coronary Syndrome SOP to be Acute Coronary Syndrome SOP to be

followedfollowed

Case Discussion #2Case Discussion #2

77 year-old female with history of CABG, 77 year-old female with history of CABG, hypertension, hypertension, cholesterol, and long cholesterol, and long standing diabetesstanding diabetes

Presents with vague complaints of not Presents with vague complaints of not feeling well, very tired & no energy over feeling well, very tired & no energy over the last daythe last day

Meds:Meds:– Aspirin, Isoptin, Toprol, Aspirin, Isoptin, Toprol,

Hydrochlorothiazide, Lipitor, Hydrochlorothiazide, Lipitor, GlucophageGlucophage

Case #2Case #2 Vitals: 110/72 HR-72 RR-18 SaOVitals: 110/72 HR-72 RR-18 SaO22 97% 97% Monitor (lead II rhythm strip):Monitor (lead II rhythm strip):

Case #2Case #2 What is your initial impression?What is your initial impression? Need to at least consider possible MINeed to at least consider possible MI Remember:Remember:

– women, elderly, and long standing women, elderly, and long standing diabetics report the most atypical diabetics report the most atypical complaintscomplaints

Remember:Remember:– a lead II only looks at one view of the a lead II only looks at one view of the

heartheart– a normal EKG does not rule out AMIa normal EKG does not rule out AMI

Case #2Case #2 Prehospital treatment:Prehospital treatment:

– IV-OIV-O22-monitor (SR with PVCs)-vitals-monitor (SR with PVCs)-vitals

– Aspirin appropriate?Aspirin appropriate?– Nitroglycerin indicated?Nitroglycerin indicated?– 12 lead EKG necessary?12 lead EKG necessary?– What about antidysrhythmic for the PVC’s?What about antidysrhythmic for the PVC’s?

call Medical Control for guidancecall Medical Control for guidanceoxygen is often enough to suppress PVC oxygen is often enough to suppress PVC

activityactivity

Case #2Case #2 AspirinAspirin

– if patient reliable and took own dose within last 24 if patient reliable and took own dose within last 24 hours, can omit, document why omitted and when hours, can omit, document why omitted and when takentaken

NitroglycerinNitroglycerin– patient not having chest pain. Defer to Medical patient not having chest pain. Defer to Medical

Control for ordersControl for orders– no contraindications noted (B/P >100; no viagra type no contraindications noted (B/P >100; no viagra type

drug used within past 24 hours - ask, don’t assume!)drug used within past 24 hours - ask, don’t assume!) 12 lead should be obtained on high index of 12 lead should be obtained on high index of

suspicionsuspicion

Case #3Case #3 81 year-old female complaining of shortness of 81 year-old female complaining of shortness of

breath for past 2 days. Unable to tolerate lying breath for past 2 days. Unable to tolerate lying flat; JVD notedflat; JVD noted

History of CHF, angina, arthritis, and mild COPDHistory of CHF, angina, arthritis, and mild COPD Vitals:126/92 HR-170 RR-24 SaOVitals:126/92 HR-170 RR-24 SaO22 97% 97% Medications: Medications: nitroglycerin PRNnitroglycerin PRN, ,

– Lasix 40 mg dailyLasix 40 mg daily– PotassiumPotassium– Aspirin, one dailyAspirin, one daily– Proventil inhaler PRNProventil inhaler PRN

Case #3 - What is this rhythm?Case #3 - What is this rhythm?Check the rhythm strip on the bottomCheck the rhythm strip on the bottom

Case #3Case #3 RhythmRhythm

Rapid atrial fibrillationRapid atrial fibrillation Initial impression?Initial impression?

Rapid atrial fibrillationRapid atrial fibrillation heart rate heart rate ineffective pumping ineffective pumping cardiac output cardiac output

Prehospital treatment initiatedPrehospital treatment initiated

IV-OIV-O22-monitor-vitals-history-monitor-vitals-history Goal of therapy - slow down heart rateGoal of therapy - slow down heart rate Is patient stable or unstable?Is patient stable or unstable?

– Stable - B/P Stable - B/P >>100, alert & cooperative100, alert & cooperative

Case #3Case #3 Prehospital ALS treatmentPrehospital ALS treatment

– If Diltiazem not available, then what?If Diltiazem not available, then what? VerapamilVerapamil

– 5 mg IVP slowly over 2 minutes5 mg IVP slowly over 2 minutes– If no response after 15 minutes and B/P remains If no response after 15 minutes and B/P remains

>>100, repeat 5mg slow IVP100, repeat 5mg slow IVP Carefully monitor patient for development of Carefully monitor patient for development of

further deterioration and increased difficulty further deterioration and increased difficulty breathingbreathing

Position of comfort - usually sitting upPosition of comfort - usually sitting up

Verapamil / IsoptinVerapamil / Isoptin®®

ActionAction Calcium channel blockerCalcium channel blocker Slows conduction thru AV node to Slows conduction thru AV node to

control ventricular ratecontrol ventricular rate Relaxes vascular smooth muscleRelaxes vascular smooth muscle Dilates coronary arteriesDilates coronary arteries

Region X SOP - VerapamilRegion X SOP - VerapamilIndicationsIndications Alternative to Diltiazem/cardizemAlternative to Diltiazem/cardizem SVT not responsive to 2 doses of Adenosine - to SVT not responsive to 2 doses of Adenosine - to

terminate rhythmterminate rhythm Stable rapid atrial flutter/fibrillation - to control Stable rapid atrial flutter/fibrillation - to control

heart rateheart rate

DosingDosing 5 mg IVP slowly over 2 minutes5 mg IVP slowly over 2 minutes If no response after 15 minutes and B/P If no response after 15 minutes and B/P >>100, may 100, may

repeat Verapamil 5 mg IVP slowly over 2 minutesrepeat Verapamil 5 mg IVP slowly over 2 minutes

VerapamilVerapamilSide EffectsSide Effects Headache, dizzinessHeadache, dizziness B/P from vasodilationB/P from vasodilation nausea & vomitingnausea & vomiting

ContraindicationsContraindications B/PB/P Wide complex tachycardias of uncertain originWide complex tachycardias of uncertain origin Heart block without implanted pacemakerHeart block without implanted pacemaker WPW, short PR & sick sinus syndromesWPW, short PR & sick sinus syndromes

Case #4Case #4 32 year-old male patient with complaints 32 year-old male patient with complaints

of chest tightness, shortness of breath, of chest tightness, shortness of breath, and just not feeling well for past 2 days. and just not feeling well for past 2 days. Also states sore throat and ear pain. Very Also states sore throat and ear pain. Very anxious & scared.anxious & scared.

No history, no medsNo history, no meds Jogs 2-3 miles 5 times per weekJogs 2-3 miles 5 times per week Vitals: 110/70 HR-68 RR-20 SaOVitals: 110/70 HR-68 RR-20 SaO22 98% 98% Lungs clear; skin warm, dry & pinkLungs clear; skin warm, dry & pink

Case #4Case #4 Initial impressionInitial impression

Cardiac?Cardiac?

Musculoskeletal (what has patientMusculoskeletal (what has patient

been doing)?been doing)?

Viral illness (sore throat & ear pain)?Viral illness (sore throat & ear pain)? What treatment would EMS begin?What treatment would EMS begin?

Cardiac - can give Aspirin but callCardiac - can give Aspirin but call

Medical Control for NTG or MorphineMedical Control for NTG or Morphine

Normal EKG cannot rule out ACSNormal EKG cannot rule out ACS

processprocess

Case #5Case #5 68 year-old male called 911 due to non-68 year-old male called 911 due to non-

radiating chest discomfort (not relieved radiating chest discomfort (not relieved with 3 of the patient’s own nitroglycerin) with 3 of the patient’s own nitroglycerin) with some minor shortness of breathwith some minor shortness of breath

History:History:– stable anginastable angina– GERDGERD– hypertension (controlled with medications)hypertension (controlled with medications)– Type II diabetic (recently diagnosed)Type II diabetic (recently diagnosed)

Case #5Case #5 Allergies - aspirinAllergies - aspirin MedicationsMedications

– nitroglycerin PRNnitroglycerin PRN– isordilisordil– nexiumnexium– verapamilverapamil– glucophageglucophage

Vital signsVital signs– 136/78 HR-78 RR-18 SaO136/78 HR-78 RR-18 SaO22 99% 99%

What is the initial impression & what What is the initial impression & what prehospital treatment is initiated? prehospital treatment is initiated?

Case #5Case #5 Initial impression: acute coronary syndromeInitial impression: acute coronary syndrome IV-OIV-O22-monitor-SaO-monitor-SaO22-vitals & history-vitals & history Lead II EKG strip:Lead II EKG strip:

The patient in case #5 was just hooked up The patient in case #5 was just hooked up for a 12-lead EKG when they grabbed their for a 12-lead EKG when they grabbed their chest and became unresponsivechest and became unresponsive

Case #5Case #5 What is this rhythm strip?What is this rhythm strip?

What action needs to be taken by EMS?What action needs to be taken by EMS?

Case #5 - VFCase #5 - VF Confirm no breathing, no pulseConfirm no breathing, no pulse Begin CPR until the defibrillator is ready and is Begin CPR until the defibrillator is ready and is

charged to maximum joulescharged to maximum joules Clear the patient & deliver 1 shockClear the patient & deliver 1 shock Immediately resume CPR for 2 minutes (5 cycles Immediately resume CPR for 2 minutes (5 cycles

of 30:2)of 30:2) Check rhythm, defibrillateCheck rhythm, defibrillate Meds: vasopressor (Epinephrine)Meds: vasopressor (Epinephrine)

antidysrhythmic (choose 1)antidysrhythmic (choose 1) 1 shock in between meds & 2 min CPR1 shock in between meds & 2 min CPR

VF/Pulseless VT SOP MedsVF/Pulseless VT SOP Meds Epinephrine 1mg every 3-5 minutes IV/IO for Epinephrine 1mg every 3-5 minutes IV/IO for

duration of arrestduration of arrest Antidysrhythmic:Antidysrhythmic:

Amiodarone 300 mg IV/IO 1Amiodarone 300 mg IV/IO 1stst dose dose

OROR

Lidocaine 1.5 mg/kg IV/IO 1Lidocaine 1.5 mg/kg IV/IO 1stst dose dose Repeat dose antidysrhythmic x1 in 5 min:Repeat dose antidysrhythmic x1 in 5 min:

If Amiodarone given, then 150 mg IV/IO If Amiodarone given, then 150 mg IV/IO

OROR

If Lidocaine given, then 0.75 mg/kg IV/IOIf Lidocaine given, then 0.75 mg/kg IV/IO

Antidysrhythmics in VF/VTAntidysrhythmics in VF/VT Amiodarone needs to be diluted (irritable to the Amiodarone needs to be diluted (irritable to the

vein)vein)– total of 20 ml syringe (med mixed with saline)total of 20 ml syringe (med mixed with saline)– rapid push in VF/VT (slow if pt has pulse!)rapid push in VF/VT (slow if pt has pulse!)

Lidocaine - Lidocaine - – if unsuccessful defibrillationif unsuccessful defibrillation

contact Medical Control for 3contact Medical Control for 3rdrd dose order dose order– if defib successful & bolus given if defib successful & bolus given << 10 min, begin drip 10 min, begin drip

2mg/min (30 mcgtts)2mg/min (30 mcgtts)– if defib successful & bolus given >10 min, give Lido if defib successful & bolus given >10 min, give Lido

0.75 mg/kg IV/IO & start drip0.75 mg/kg IV/IO & start drip

Case #5Case #5 The patient was defibrillated twice and received The patient was defibrillated twice and received

1 dose of epinephrine1 dose of epinephrine After the 3After the 3rdrd shock, 2 minutes of immediate CPR shock, 2 minutes of immediate CPR

resumedresumed After 2 min of CPR, what is the rhythm?After 2 min of CPR, what is the rhythm?

Case #5Case #5 Rhythm: sinus rhythmRhythm: sinus rhythm EMS action?EMS action?

– Determine if there is a pulse (yes!!!)Determine if there is a pulse (yes!!!)– Reevaluate airway, breathing, circulation-B/PReevaluate airway, breathing, circulation-B/P– Medications: Medications:

because no antidysrhythmic were given, need to call because no antidysrhythmic were given, need to call Medical Control for directionMedical Control for direction

if Lidocaine, usually 0.75 mg/kg IV/IOif Lidocaine, usually 0.75 mg/kg IV/IO if Amiodarone, 150 mg diluted into 100 ml bag D5W; run if Amiodarone, 150 mg diluted into 100 ml bag D5W; run

thru mini-drip tubing; run piggyback at rapid drip over 10 thru mini-drip tubing; run piggyback at rapid drip over 10 minutesminutes

May not want any antidysrhythmic givenMay not want any antidysrhythmic given

ETT RouteETT Route Endotracheal tube route is discouraged, not Endotracheal tube route is discouraged, not

eliminated.eliminated. Absorption found to be unpredictableAbsorption found to be unpredictable ETT drugs if this route is usedETT drugs if this route is used

L - LidocaineL - LidocaineE- EpinephrineE- EpinephrineA- AtropineA- AtropineN - NarcanN - Narcan

Double the calculated amount for the IV/IO Double the calculated amount for the IV/IO routeroute

BibliographyBibliography American Heart Association American Heart Association Guidelines Guidelines

CPR ECC 2005CPR ECC 2005 Beasley, B., West, M. Understanding 12-Beasley, B., West, M. Understanding 12-

Lead EKG. Pearson Ed, 2001.Lead EKG. Pearson Ed, 2001. Caroline, Nancy. Caroline, Nancy. Emergency Care in The Emergency Care in The

StreetsStreets, Jones & Bartlett, 2008., Jones & Bartlett, 2008. Page, B. 12-Lead EKG, Pearson, 2005.Page, B. 12-Lead EKG, Pearson, 2005. Phalen, T, Aehlert, B. The 12-Lead EKG in Phalen, T, Aehlert, B. The 12-Lead EKG in

Acute Coronary Syndromes, 2006.Acute Coronary Syndromes, 2006. www.clevelandclinic.orgwww.clevelandclinic.org www.nhlbi.nih.gov/health/dci/Diseaseswww.nhlbi.nih.gov/health/dci/Diseases