emt refresher cardiology christina moore halifax ems nremt-p / ccemt-p
TRANSCRIPT
EMT Refresher Cardiology
Christina Moore
Halifax EMS
NREMT-P / CCEMT-P
Objectives
• Identify Causes of Chest Pain
• Anatomy
• Physiology
• Pathophysiology
• Assessment
• Treatment Options
• Differentiate key origins of C Px
Why?
• Frequency EMS Calls for Chest Pain?– In Halifax, ~ 40%– You?
A Bit of History
• 1960s30-40% chance of death days after heart attack
• Today6%
Chest Pain
• List Types, sources, etc
Chest Pain - Summary• Heart Attack (ACS / AMI)• Cardiac Tamponade• Ischemia• Pericarditis• Pulmonary Embolism• Angina (Stable/Unstable)• Tension Pneumothorax• Myocarditis• Shingles• Muscular-skeletal problems• Aortic Dissection• Aortic Aneurysm• Pleurisy• CHF• Esophogeal Rupture• Aortic Stenosis• Mitral Valve Prolaps• Cardiomyopathy
• Cholecystitis• Pancreatitis• Esophogeal tear• Cocaine-indused chest pain• Coronary Spasm (Prinzmetal’s
Angina)• Cardiac Dysrhythmia
Others?
Chest Pain Sorted• Heart Attack (ACS / AMI)• Cardiac Tamponade• Cardiac Dysrhythmia• Pulmonary Embolism• Tension Pneumothorax• Aortic Dissection• CHF• Esophogeal Rupture
• Cholecystitis• Pancreatitis• Esophogeal tear• Aortic aneurysm • Cocaine-indused chest pain• Coronary Spasm (Prinzmetal’s Angina)• Angina (Stable/Unstable)• Ischemia
• Pericarditis
• Myocarditis
• Shingles
• Muscular-skeletal problems
• Pleurisy
• Aortic Stenosis
• Mitral Valve Prolaps
• Cardiomyopathy
The Killers
What tools do we have• Eyes – inspect• Ears/Stethoscope - auscultate• Hands – palpate• History – personal and familial• Watch – time• EKG 4/12 lead• Phone-a-friend• Medication Administration• Knowledge/skills/experience• Capnography• Lab Tests (bio-markers, chem7, ABG, etc)• X-Ray• Ultrasound• Cardiac Cath• Cardiac Echo
Anatomy
• Go to
http://www.visiblebody.com/start
Goals - cardiac circulatory system
- cardiac conductive system
- And the other fun stuff
Key Physiology Points
• Cardiac Tissue– Automaticity– Conductivity– Contractility– Rhythmicity– Excitability
Physiology Continued
• Gas of Life?
• Nutrients: O2, Sugar• Waste: CO2, H2O• pH: 7.35 – 7.45• Exhaled CO2: 35 – 45 mmHg
What Happens to Tissue when WRONG
Pathophysiology
• What happens when it goes wrong
• No O2, dirty combustion & bad byproducts
• No Sugar – see above
• Too Many bad byproducts– Expanding field of injury
• No O2 & No Sugar - dying
Pathophysiology Measured
• Pain
• Blood Sugars
• Capnography
• Blood pH
• SpO2
• Troponin/bio-markers
• Urine
Pathophysology Observed
•SHOCK
Case Study
• 63 yof, teeth/jaw pain and a “tight neck”, sweating
• Initial Observations
• From Across the Room
Case Study
• Initial Life-Threatening Diagnoses/Interventions• Differentiate?
• Heart Attack (ACS / AMI)• Cardiac Tamponade• Cardiac Dysrhythmia• Pulmonary Embolism• Tension Pneumothorax• Aortic Dissection• CHF• Esophogeal Rupture
• Cholecystitis• Pancreatitis• Esophogeal tear• Aortic aneurysm • Cocaine-indused chest pain• Coronary Spasm (Prinzmetal’s Angina)• Angina (Stable/Unstable)• Ischemia
• Pericarditis
• Myocarditis
• Shingles
• Muscular-skeletal problems
• Pleurisy
• Aortic Stenosis
• Mitral Valve Prolaps
• Cardiomyopathy
Assessment
• SAMPLER
• OPQRST
• Diagnostics– EKG 4 & 12 lead
EMS Treatment
• Oxygen
• Aspirin
• Nitroglycerin (NTG)
• IV – 2 lines preferred
• STEMI Alert
• Paramedic Request
• Rapid Transport to Cath Lab
Oxygen
• Per American Heart Assoc, 2010 Guidelines:
• 2-6 lpm O2 via Nasal Cannula
• Titrate to SpO2 approx 96% (not 100%)
• Why?
Aspirin
• Class of Medication
• Mechanism of Action
• Indications
• Contra-Indications
• Dosing?
• Dude, Dose, Delivery, Date, Document
Nitroglycerin
• Class of Medication
• Mechanism of Action
• Indications
• Contra-Indications
• Dosing?
• Dude, Dose, Delivery, Date, Document
EKG
• Mechanism of Action
• Indications
• Contra-Indications
• Dude,Date, Document
Case Study
STEMI Alert
• When 12-lead EKG prints
* * * ACUTE MI * * *
• When you have confirmation from medic
• When you have transmitted & confirmed
STEMI Alert
• DHMC Zone 2
• Valid reason to call DHART Helicopter
• “Drip & Ship” via Critical Access Hospital
• Timed process from: – 911 to “Balloon”– EMS to Balloon– Door to Balloon
• Goals: 90 minutes
Next Steps• One link in a many link chain• Paramedic Interventions
– Pain Control– IV Beta Blocker
• ER Interventions– IV Heparin Bolus, Hep drip– IV Fibrinolytic– IV NTG
• Cath Lab
Cardiac Circulation
Cardiac Cath
• YouTube
http://www.youtube.com/watch?v=3Z2DaU0GBAE&feature=feedf_more
Acute Coronary Syndrome
• Questions/Discussion on ACS?
• Let’s do the next one
Induced Hypothermia
• What happens to pissed off tissue?
• Sprained Ankle…– Swelling– Pain
• Treatment– RICE: Rest, Ice, Compression, Elevation
Induced Hypothermia
• Compartment Syndrome?
• What is it?
• Where can it happen?
Induced Hypothermia
• CPR – with return of spontaneous circulation
• Pt’s mental state deteriorated
• Induce hypothermia with cold (4d C) IV fluids
• Keep chilled and “medical coma” for 3 days
Future of Hypothermia
• Trauma?
• Strokes?
• Kids?
• Lots of potential… lots of unanswered questions
Other “Chest Pain”
• Chest Pain with Respiratory Distress– Tension Pneumothorax– Pulmonary Embolism– Esophogeal Rupture– Acute Pulmonary Edema / CHF
Tension Pneumothorax
• History?
• Progressive deterioration
• Pressure on the heart/great vessels
• Disrupting blood flow
Tension Pneumothorax
• Assessment– Chest Discomfort– Severe Respiratory Distress– Decreased or absent breath sounds on
affected side
• Obstructive Shock
• Treatment?
Tension Pneumothorax
• Decompression– Paramedic – large needle to chest– MD/PA – large tube in chest
• Field Treatment:– Rapid transport, – high flow O2,– Intercept
Pulmonary Embolism (PE)
• Cause?– Blood clot in an artery in the lungs– Often starts somewhere else, travels through
heart to lungs and lodges in there– If <30% impact, few symptoms unless…
• COPD, etc
PE
• Assessment– Chest Pain– Tachypnea (96%)– SoB (82%)– Chest Pain (49%)– Cough (20%)– Hemoptysis (7%)
• EKG – Sinus Tachycardia
PE
• History / Risk Factors
• Young women who smoke and use birth control
• Deep Vein Thrombosis (DVT)– Traveller’s Syndrome– Leg Cramps
PE Diagnostic
• In Field: History, Assessment
• In ED:– CTA (CT-angiogram)– D-Dimer– X-Ray
• Treatment– Thrombolytics \ anticoagulantion therapy
Esophogeal Rupture
• Often iatrogenic– Post surgical, post procedural
• Swallowed foreign object (caustic, sharp, etc)
• BFT , Penetrating Trauma
• Forceful vomitting
Esophogeal Rupture
• Assessment: History
• Treatment: Supportive
CHF
• Pump Failure– Brian Richard’s Drawing
CHF
• Assessment
• Management– V.S., EKG, Lung Sounds
• CPAP
• Treat shock/symptoms
Other Chest Pain
• Chest Discomfort with Altered Vital Signs– Cardiac Dysrhythmia– Aortic Aneurysm \ Dissection– Pericardial Tamponade– Acute Coronary Syndrom (covered)
Other Chest Pain
• Unstable Angina
• Coronary Spasm / Prinzmetal Angina
• Cocaine-Induced Chest Pain
Other Chest Pain
• Chest Pain due to Infection– Pericaditis– Myocarditis
• Simple Pneumothorax
Other Chest Pain
• Intra-abdominal Causes of Chest Discomfort– Cholecystitis– Pancreatitis– Esophogeal Tear
• Neurological Causes of Chest Pain– Thoracic Outlet Syndrome (pg 205)– Herpes Zoster (Shingles)
Others - continued
• Other Pulmonary Causes– Pneumonitis– Pleurisy
• Heart-related Causes– Aortic Stenosis– Mitral Valve Prolapse– Cardiomyopathy
Others – Continued
• Did we miss some?– YES
Objectives Reviewed
• Identify Causes of Chest Pain
• Anatomy
• Physiology
• Pathophysiology
• Assessment
• Treatment Options
• Differentiate key origins of C Px