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1 Chapter 28, Part 2 Cardiology

2 Part 2: Assessment and Management of the Cardiovascular Patient

3 Assessment of the Cardiovascular Patient

4 Scene Size-up and Initial AssessmentDetermine scene safety.Determine level of ___________________________________.Airway.Breathing:

– Note ___________________________________ sounds indicative of cardiovascular problems.

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

___________________________________.Treat life-threatening problems.

5 Focused HistoryCommon Symptoms:Chest Pain

– ___________________________________ History of PainDyspnea

– Onset– ___________________________________– Provocation/palliation– Orthopnea– ___________________________________

6 Other Signs/Symptoms1 ___________________________________

Restlessness and anxiety Feeling of impending doomNausea/vomiting ___________________________________ Palpitations

2 EdemaHeadache ___________________________________Behavioral changeAnguished facial expressionActivity limitations ___________________________________

7 Acute Coronary Syndrome3 General CategoriesClassic ___________________________________

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– Classic S/S of MI or coronary event ___________________________________ Presentation

– Different S/S ___________________________________ Equivalents

– Considered for high risk patients

8 Atypical Presentation Examples Pain that is sharp or ___________________________________ Pain to teeth (toothache with no inflammation) Pain to neck, ___________________________________, arm or abdomenMostly includes females, ___________________________________ and the elderly Suspect cardiac event with these S/S

9 Anginal EquivalentsDyspnea ___________________________________ Syncope or near syncopeGeneralized weakness with no hx of GI bleed or fever ___________________________________Often, the only S/S presented but may be ___________________________________ in

nature

10 Risk Factors for Anginal Equivalents ___________________________________HypertensionAge Family history of CAD ___________________________________ Stress ___________________________________ life style

11 Acute Coronary Syndrome (1 of 2)

The key to forming accurate impression of cardiac event lies in clinical ___________________________________.

Take into account the patient’s physical presentation, risk factors, and assessment findings

___________________________________ to the patient

12 Acute Coronary Syndrome (2 of 2)

If anginal equivalents or atypical S/S are present, MONITOR ___________________________________

If presentation suggests possible coronary event, consider treatment just as with typical chest pain, even if chest pain is ___________________________________

13 SAMPLE HistoryAllergies___________________________________Nitroglycerin, propranolol, digitalis, diuretics, antihypertensives, antidysrhythmics,

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lipid-lowering agents, ED medsNonprescription drugs

Cocaine Antihistamines ___________________________________

14 SAMPLE HistoryPast Medical History:Cardiac historyHeart problemsOther medical problems ___________________________________ cardiac historyModifiable risk factors for heart disease (___________________________________,

etc.)

15 SAMPLE HistoryLast Oral IntakeCaffeinated beverages, alcohol, sports drinks, etcEvents Preceding the Incident ___________________________________, strenuous or sexual activity

16 Physical ExamInspection of:Tracheal positionThorax ___________________________________

17 Physical ExamAuscultation:___________________________________ Sounds___________________________________ SoundsNormalAbnormal

18 Physical ExamPalpation:______________________________________________________________________CrepitusChest Wall Tenderness

Epigastrium

19 Management of Cardiovascular EmergenciesBasic Life Support: ___________________________________ ___________________________________Vital signs

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Caution: Don’t get so wrapped up in your ALS skills and toys, that you forget the ___________.

20 Management of Cardiovascular EmergenciesAdvanced Life Support:ECG MonitoringVagal Maneuvers Precordial ___________________________________ Pharmacological Management ___________________________________ Synchronized CardioversionTranscutaneous Cardiac Pacing ___________________________________(12-Lead) ECG

21 Monitoring ECGs in The Field2 main components:ECG ___________________________________

– May include 12 lead capabilities ___________________________________

– May include pacing capabilities

22 Components of an ECG MonitorNote: Monitors/Defibrillators are different. You should become very familiar with the

unit you will be using Screen (___________________________________ or LCD) Paper strip recorderBattery/Power source Patient ___________________________________ and electrodesControls for monitoring

– ___________________________________ selection– ECG ___________________________________

23 Using a Monitor ___________________________________ monitor appropriatelyTurn on unit Prepare patients skin

– Clean, dry, shave excess hairAttach 3 or 4 ___________________________________Ask patient to lie still and print a strip ___________________________________ stripTreat the patient NOT the monitor

24 Causes of Poor SignalsExcessive hair, loose or dislodged electrodeDried conductive gel, poor placement, ___________________________________ Patient movement or muscle tremorBroken patient cable or lead ___________________________________

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Low ___________________________________ Faulty grounding Faulty monitor

25 Troubleshooting a Monitor/DefibrillatorProblem Check:No Power Batteries/Power supplyWon’t shock Cables or Synchronize button on____________________ Movement of patient, 60 cycle interference, poor connection of electrodes

26 Troubleshooting a Monitor/DefibrillatorProblem Check:Won’t Print Paper, Paper jamStrange looking rhythm Lead ___________________________________ECG is very small Increase lead ___________________________________

27 Vagal ManeuversIndication

– Stable patient with symptomatic ___________________________________Maneuvers

– ___________________________________ maneuvers– Coughing

Carotid Sinus Massage– Avoid in patients with a history of cerebrovascular or carotid artery disease, or patients

with carotid ___________________________________.

28 Precordial ThumpIndication: ___________________________________ patient who has a witnessed arrest.Most effective when performed ___________________________________ after onset of

VF.Not used in ___________________________________ patients.

29 Antidysrhythmic MedicationsControl or suppress ___________________________________Atropine Sulfate ___________________________________ Procainamide ___________________________________ ___________________________________Verapamil

30 Procainamide (Pronestyl) Indications: Significant PVCs, ___________________________________Contraindications:

– Allergy– 2nd and 3rd Degree ___________________________________ Block

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Dosage: 100mg over 5 minutes slow IV push until:– Suppression– Max of 500mg given– QRS complexes broaden by _______________________________%

31 Procainamide (Pronestyl)Adverse Reaction:

– Fever, Seizures, Hypotension, ___________________________________, V-FibNote: Removed from sales in US

32 Cardizem (Diltiazem) (1 of 2)

Antidysrhythmic (___________________________________ channel blocker)Action: relaxation of vascular smooth muscle and slows conduction through the

___________ node Indications: rapid response ___________________________________ and A-flutter and

PSVT refractory to Adenosine for unstable patientsContraindications: hypotension, cardiogenic shock, wide complex tachycardia

(___________________________________ ), WPW

33 Cardizem (Diltiazem) (2 of 2)

Dosage: ____________ mg/kg IVP over 2 minutes– Standard dose is ______________ mg– Followed by a maintenance drip at 5-15mg/hr (except for PSVTs)

Adverse Reactions: N/V, headache, dizziness, bradycardia, heart block, hypotension, and asystole

Should be ___________________________________ or disposed of after 1 month at room temperature

34 Sympathomimetic AgentsSimilar to naturally occurring hormonesEpinephrine ___________________________________ Isoproterenol ___________________________________Dobutamine ___________________________________

35 NorepinephrineAKA: ___________________________________ Indication: Severe hypotensionContraindications: ___________________________________, profound hypoxiaDosage: Initially ______-_______mcg/min IV drip with maintenance drip of 2-4mcg/min

titrated to maintain BPAdverse Reactions: Headache, dizziness, bradycardia, hypotension, arrhythmias

36 Isoproterenol (Isuprel)Rarely used in prehospital setting Indications: Heart blocks, ___________________________________ arrhythmias

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Contraindications: Bradyarrhythmias or heart blocks caused by Digitalis toxicityDosage: 0.02-0.06mg IV with maintenance drip of 5mcg/minuteAdverse Reactions: ___________________________________, tachycardia, cardiac

arrest, diaphoresis

37 DopamineAKA: ___________________________________Used regularly in prehospital setting Indication: Cardiogenic shock with ___________________________________Contraindications: tachyarrhythmias, V-FibDosage: IV drip at ________-________mcg/kg/min to maintain BPAdverse Reactions: Ectopic beats, dyspnea, necrosis of skin with IV infiltrationOver ________mcg/kg/min will shut off blood flow to kidneys and GI tract

38 Dobutamine (Dobutrex) Indications: Increases cardiac output in short-term treatment of cardiac decompensation

such as ___________________________________ shockContraindications: ___________________________________Dosage: 2-20mcg/kg/min IV drip titrated to ___________________________________Adverse Reactions: Increased heart rate, hypertension, dyspnea

39 Drugs Used for Myocardial IschemiaTreat ischemia or manage painOxygenNitrous Oxide ___________________________________Morphine Sulfate ___________________________________ Fentanyl

40 Nitrous Oxide (___________________________________)Nitrogen and ___________________________________ mixture in a gas state. Medical

Nitrous is a __________-__________ mixture Indications: Pain managementContraindications: Pneumothorax, COPD, bowel obstructionActions: Reduces the ___________________________________ of painDosage: administration via hand held mask. Allow patient to hold mask to prevent over

medicationNitrous leaves the system within ___________ minutes of d/c

41 Morphine Sulfate ___________________________________ based narcotic analgesic. Dilates coronary

arteries Indications: Pain managementContraindications: Hypovolemia, hypotensionDosage: ______-________mg IV push repeated every 5-10 minutes as neededMS should be diluted 1:1 prior to administration

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Adverse Reactions: ___________________________________ depression, sedation, hypotension, N/V

MS can be reversed with ___________________________________

42 Demerol ___________________________________ Narcotic Analgesic Indications: Pain managementContraindications: Hypovolemia, hypotensionDosage: ______-________ mg IV push repeated every 5-10 minutes as neededAdverse Reactions: ___________________________________ depression, sedation,

hypotension, N/VDemerol can be reversed with Narcan

43 Fentanyl (Sublimaze) (1 of 2)

___________________________________ AnalgesicOn a weight basis, 50 to 100 times more potent than MS Indication: pain managementContraindications: hemorrhage, shock, children < ____________ yoaDosage ___________-____________mcg slow IV push

44 Fentanyl (Sublimaze) (2 of 2)

Adverse reactions: respiratory depression, muscle rigidity, ___________________________________

Fentanyl does not affect the ____________ to the extent of MSMay be used on trauma victims where dropping of BP is a concernDoes NOT ___________________________________ the coronary arteriesCan be reversed with Narcan

45 Thrombolytic AgentsAction: to break up blood clots blocking a blood vessel (clot busters)___________________________________AlteplaseRelteplaseThrombolytics (other than asa) are not routinely given by EMS. However, many patients

receiving them are transferred from one facility to another.Greatest concern is reperfusing ___________________________________

46 Other Cardiac Medications

47 Furosemide (Lasix)Action: ___________________________________ that inhibits the reabsorption of

sodium in the kidneys. Also causes venous dilation and reduces cardiac preload Indications: CHF with pedal and/or ___________________________________ edemaContraindications: Hypovolemia, pregnancy, renal failureDosage: ______-________ mg slow IV pushAdverse reactions: volume depletion, muscle spasm

48 Diazepam (Valium)

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Actions: A benzodiazepine. Sedative-hypnotic, ___________________________________ .

Used in EMS for sedation and anticonvulsant Indications: ___________________________________ for cardioversion and RSI.

SeizuresContraindications: Coma

49 Diazepam (Valium)Dosage: ______-________ mg IVP, repeated every 15 minutes to a max of 30mg. Can be

given rectally as well.Adverse Reactions: Sedation, ___________________________________ depression or

arrest, bradycardia

50 Promethazine (Phenergan)Actions: Antiemetic, sedative, antihistamine, anticholinergic Indications: ___________________________________ (for EMS) often needed after

administration of narcotic analgesicContraindications: Children <2yoaDosage: ______-________ mg IVP. Drug should be diluted 1:1 to avoid damage to vein.

May be repeated as neededAdverse reactions: sedation, dry mouth

51 Zofran (Ondansetron) (1 of 2)

Actions: ___________________________________, serotonin 5-HT3 receptor blocker Does not cause the depressed ___________________________________ status as does

Phenergan Indications: nausea and/or vomitingContraindications: children < ___________ yoa

52 Zofran (Ondansetron) (2 of 2)

Adult Dosage: ___________mg IV push Pediatric Dosage: ___________mg/kg up to ____________mgAdverse Reactions: Rarely may cause chest pain, hypotension and tachycardia

53 Sodium NitroprussideActions: ___________________________________ Indications: lowers BP and reduces preload and afterloadContraindications: hypovolemia, compensatory hypertension, head injuriesDosage: ______-________ mcg/kg/min IV drip titrated to BPAdverse Reactions: Increased ____________, bradycardia, muscle tremors

54 Sodium BicarbonateActions: Reverses ___________________________________ Indications: Acidosis due to cardiac/respiratory arrest, metabolic acidosis or

___________________________________ SyndromeContraindications: Alkalosis, renal failureDosage: ________________ of 8.4% solution every 10 minutes as determined by ABGs

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Adverse reactions: metabolic alkalosis, hypokalemiaDo not use in same IV tubing as ___________________________________ drugs. Will

cause formation of crystals

55 LabetalolAKA: ___________________________________ , TrandateAction: Reduces peripheral vascular resistance Indications: Severe ___________________________________ Contraindications: Asthma, cardiac failure, cardiogenic shock, bradycardiaDosage: _____________mg slow IV push repeated at 40-80mg every 10 minutes until

hypertension relieved or a max of _____________ mg givenAdverse Reactions: Ventricular arrhythmias, N/V, hypotension, bronchospasms

56 DigitalisAKA: ___________________________________ ,

___________________________________ Not normally given prehospital but presents challenges for EMSUsed to treat SVTs, ___________________________________ , A-Flutter, and heart

blocksDigitalis Toxicity: characterized by arrhythmias and yellow-green

___________________________________ around visual images, and bradycardiaDigitalis Toxicity may be life threatening and render some drugs

___________________________________

57 Giving Meds Via ETTDuring an emergency situation, certain drugs can be given down the ET tube. IV push is always the route of choice over ETTWhen giving drugs down an ETT, ___________________________________ the amount

of drug but do not give more than ___________cc at a time. If more than ____________cc is required to double the dosage, ventilate the patient for a

few seconds after first half and then give the second half

58 Giving Meds Via ETTThe following drugs can be given via the ETT: LANE ___________________________________ ___________________________________ ___________________________________ ___________________________________

59 DefibrillationChest Wall Resistance:

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

60 DefibrillationDefibrillation is the process of passing an electrical current through a

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“___________________________________ ” heart to depolarize a critical mass of cardiac cells. This allows them to depolarize uniformly, resulting in an organized fashion.

Uses ___________________________________ current (DC) Joules: the shock’s strength

– Energy (Joules) = power (watts) X ___________________________________ (seconds)

61 DefibrillationAll CPR, ventilations, treatment, and touching of patient must be stopped when analyzing

the rhythm and while shockingMake sure no one is touching the patient and/or

___________________________________ before shocking.Do not shock in water or in a wet environment If paddles are used, be sure to use appropriate defib

___________________________________

62 DefibrillatorsThere must be enough “peak” current to reach the heart to defibrillateToo much “peak” current can damage the heart ___________________________________ Defibrillators:

– Current flows in one direction only– Causes a sharp “peak”

63 Defibrillators___________________________________ Defibrillators: Current flows in one direction in the first phase of the shock and then reverses for the

second phase.Research shows biphasic to be more successfulCreates a squared off “peak”Requires less ___________________________________ : Some defibrillators

automatically adjust joules so the 360J setting is still used

64 DefibrillatorsBiphasic Defibrillators (continued): Biphasic wave forms adjust for ___________________________________ by varying

the characteristics of their waveforms thus lowering joules settingThis tends to ensure that high impedance persons will have the same chance for survival

as those who are of low impedance Most, if not all, new defibrillators are ___________________________________

65 Monophasic v. Biphasic Defibrillation

66 DefibrillationSuccess of defibrillation depends on: ___________________________________ since onset of VFCondition of the ___________________________________ Heart size and body weight

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Previous ___________________________________ Proper paddle size, placement, interface, and pressure Properly functioning defibrillator

67 Components of an DefibrillatorDefibrillation ___________________________________ (some models)

– Defibrillation GelDefibrillation/Pacing ___________________________________ (if hands free)

– Defibrillation PadsDefibrillation Controls (on paddles if equipped)

– Energy setting – Discharge Button(s)– ___________________________________ button

Battery or power supply

68 Using a DefibrillatorTurn unit on If using paddles, apply defibrillation ___________________________________ Apply defibrillation pads

– Apex, ___________________________________ Charge unit to desired setting Say “CLEAR” ___________________________________ that everyone is clear

69 Using a DefibrillatorDischarge defibrillator

– Push shock button on hands free– Push ___________________________________ shock button simultaneously on

paddlesDeliver 1 shock at __________J Do NOT check a ___________________________________ after defibrillation, but

resume CPR for 2 minutes, unless patient regains consciousness

70 Using a DefibrillatorAfter 2 minutes of CPR, check ___________________________________Do not check pulse unless there is a ___________________________________ change

71 Emergency Synchronized CardioversionIndications:Unstable, tachycardic patient

– ___________________________________ VT– ___________________________________– Rapid atrial fibrillation– 2:1 atrial flutter

72 Emergency Synchronized CardioversionProcedure

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Similar to defibrillation. ___________________________________ the patient whenever possible.Turn on the ___________________________________ . ___________________________________ discharge buttons until countershock

administered.

73 Transcutaneous Cardiac PacingIndications ___________________________________, unstable patients who do not respond to

pharmacological therapy– Symptomatic bradycardias with high-degree AV

___________________________________ .– Atrial fibrillation with a slow ventricular response.– Other significant bradycardias

74 External Cardiac PacingMust have 3 or 4 limb ___________________________________ applied ___________________________________ if applicable

– Versed or Diazepam Set ___________________________________

– Demand or Fixed Set ___________________________________ Set ___________________________________

75 Pacing Bradyarrhythmias Set pacer in ___________________________________ mode Set rate at _____________ Set current at ___________________________________ setting and increase in

increments of __________mA until capture.Capture is confirmed by ___________________________________ pulseTitrate rate to adequate perfusion

76 Carotid Sinus Massage Indications:

– Paroxysmal supraventricular ___________________________________ 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 ___________________________________ .– Asystole, PVCs, VT, and VF may occur.– Patient may experience bradycardia, nausea, and vomiting.

Only ___________________________________ artery at a time

77 Managing Specific Cardiovascular Emergencies

78 General Cardiac ManagementManagement of the cardiac patient changes significantly at the Paramedic level due to the

increased knowledge and ability to manage dysrrythmias

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Treatment priorities are always:1.___________________________________2.___________________________________3.Blood ___________________________________

79 Angina PectorisPathophysiology:Angina occurs when the heart’s demand for oxygen exceeds the blood’s

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

(Prinzmetal’s angina).Stable vs. Unstable Angina___________________________________ Progression

80 Angina PectorisCauses of Chest Pain:Cardiovascular, including acute coronary syndrome,

___________________________________ , or thoracic dissection of the aortaRespiratory, including pulmonary embolism, pneumothorax, pneumonia, and pleural

irritationGastrointestinal ___________________________________

81 Angina PectorisField Assessment:Signs of inadequate perfusionChest Discomfort

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

– Patient often ___________________________________ chest pain.Duration

– Episodes last ___________________________________ minutes.– Pain relieved with ___________________________________ and/or nitroglycerin.

82 Angina PectorisBreathingHistory of past episodes of angina:

– Episodes of angina that are increasing in frequency, duration, or severity are ___________________________________.

ECG– Do not ___________________________________ scene time.– ___________________________________ ECG preferred:

Angina typically causes nonspecific ST changes.

83 Angina PectorisManagement:

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Relieve ___________________________________ :– Place the patient in a position of physical and emotional comfort.

Administer ___________________________________ .Establish IV access, TKOMonitor ECG.Consider medication administration:

– ___________________________________ tablets or spray– ___________________________________ sulfate

84 Angina PectorisSpecial Considerations: Patients with new-onset or ___________________________________ angina often

require hospitalization. Symptoms ___________________________________ relieved by rest, nitroglycerin, and

oxygen may indicate an overall worsening of the disease or the early stages of a myocardial infarction.

Patients may ___________________________________ transport after pain is relieved, even though the underlying problem is not addressed.

85 Myocardial InfarctionPathophysiology:Death and ___________________________________ of heart muscle due to inadequate

oxygen supply.– Causes may include occlusion, spasm, microemboli, acute volume overload,

hypotension, acute respiratory failure, and trauma.Location and size dependent on the ___________________________________ involved.

86 Myocardial Infarction

87 Myocardial InfarctionEffects of a Myocardial Infarction: ___________________________________Heart FailureVentricular AneurysmGoals of Treatment: ___________________________________ Relief ___________________________________

88 Myocardial InfarctionField Assessment:BreathingSigns of ___________________________________ Chief Complaint

– Typically related to chest pain.– Evaluate using ___________________________________ :

Discomfort > 30 minutes. ___________________________________ to arms, neck, back, or epigastric

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region.– Patients may ___________________________________ symptoms.– Feelings of “impending doom.”

89 Myocardial InfarctionOther Symptoms

– Nausea and vomiting– ___________________________________

Myocardial Infarctions & the ECG– Diagnostic ECGs:

12-lead ECGs S-T ___________________________________ Pathological _________ waves

90 Myocardial InfarctionMyocardial Infarctions & the ECG

– ___________________________________ : Asystole, PEA, VF, VT. ___________________________________ are the leading cause of death in MI.

91 Myocardial InfarctionReperfusion Screening for ___________________________________ therapy

– Time from onset to treatment < ____________ hours.– Reperfusion of ischemic/injured tissue.– Absence of history that would ___________________________________

thrombolytics.Transport

– Rapid ___________________________________ indicated when acute MI suspected

92 Myocardial InfarctionManagement:Assess while you ___________________________________ Administer ___________________________________ .Establish IV access, TKODo NOT allow patient to ___________________________________

93 Myocardial InfarctionConsider medication administration:

– Aspirin– ___________________________________ sulfate for pain if SBP>90-100– ___________________________________ or Zofran for nausea– ___________________________________ if SBP >90-100– Nitrous oxide– Nubain– ___________________________________ medication as indicated

94 Myocardial Infarction

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Management (Continued):Monitor ___________________________________ .Rapid transport as indicated.Avoid patient ___________________________________ if possible. Identify candidates for ___________________________________ therapy.

95 Myocardial InfarctionIn-Hospital Management:

– Diagnostic ECGs.– ___________________________________ levels.– Risk assessment.– Treatment:

Cardiac ___________________________________ and CABG.

96 Heart FailureLeft Ventricular Failure:___________________________________ : Results in increased back pressure into the

pulmonary circulation.Signs/SymptomsLabored breathing/cyanosis, coughing, rales___________________________________Blood in sputum

97 Heart Failure

98 Heart FailureRight Ventricular Failure:Pathophysiology

– Results in increased back pressure into the systemic venous circulation. Normally caused by left sided failure

Signs/Symptoms:______________________________________________________________________ neck veins___________________________________ edema

99 Heart Failure

100 Heart FailureCongestive Heart Failure:Pathophysiology

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

ManifestationNormally is a ___________________________________ processOften caused by an old _______________

101 Congestive Heart FailureField Assessment:

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___________________________________ Edema:– Cough with copious amounts of clear or pink-tinged sputum.– Labored breathing, especially with ___________________________________ .– Abnormal breath sounds, including rales, rhonchi, and wheezes.

102 Congestive Heart FailureParoxysmal Nocturnal ___________________________________ (PND)Medications:

– ___________________________________.– Medications to ___________________________________ cardiac contractile force,

home oxygen.

103 Congestive Heart FailureMental Status

– Mental status changes indicate impending ___________________________________ failure.

Breathing– Signs of labored breathing.– ___________________________________ positioning.

Skin– Color changes.– Peripheral and/or pedal ___________________________________ .

104 Congestive Heart FailureManagementGeneral management:

– Avoid ___________________________________ positioning.– Avoid ___________________________________ such as standing or walking.

Maintain the airway.Administer ___________________________________ .Establish IV access.

– Limit fluid administration. Use minidrip or __________

105 Congestive Heart FailureMonitor ECGConsider medication administration:

– ___________________________________– Morphine (does not have to have chest pain)– ___________________________________– Dopamine/Dobutamine if hypotensive– Promethazine or Zofran if nauseated– Nitrous oxide– ___________________________________ if breathing difficulty

Avoid patient refusals if at all possible.

106 Cardiac TamponadePathophysiology

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– Result of fluid accumulation between visceral ___________________________________ and parietal pericardium.

– Increased intrapericardial pressure impairs diastolic filling.– Typically ___________________________________ progressively until corrected.

Epidemiology– ___________________________________ onset typically the result of trauma or MI.– Benign presentations may be caused by cancer, pericarditis, renal disease, and

hypothyroidism.

107 Cardiac TamponadeField Assessment:Patient History

– Determine precipitating causes.– Patient relates a history of dyspnea and ___________________________________ .

Exam– Rapid, weak ___________________________________ – Decreasing systolic pressure, ___________________________________ pulse

pressures– Pulsus ___________________________________ : drop in BP>10 torr during

inspiration– Faint, ___________________________________ heart sounds

108 Cardiac TamponadeManagement:Maintain airway.Administer ___________________________________ .Establish IV access.Consider medication administration:

– ___________________________________ sulfate– Nitrous oxide– ___________________________________ if edema present– Dopamine/Dobutamine if hypotensive

109 Cardiac TamponadeManagement (Continued):Rapid Transport___________________________________

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

from the pericardium.– Procedure should be performed ___________________________________ if allowed

by local protocol.– Procedure should be performed only by personnel adequately trained in the procedure.

110 Hypertensive EmergenciesCauses:Typically occurs only in patients with a history of

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___________________________________ . Primary cause is ___________________________________ with prescribed

antihypertensive medications.Also occurs with ___________________________________ of pregnancy.Risk Factors: ___________________________________ -related factorsRace-related factors

111 Hypertensive EmergenciesField Assessment:Initial Assessment

– ABCs andAlterations in mental stateSigns & Symptoms

– ___________________________________ accompanied by N/V– Blurred vision– Shortness of breath– ___________________________________– ___________________________________– Tinnitus

112 Hypertensive EmergenciesHistory:Known history of hypertensionCompliance with medicationsExam:BP > ___________________________________ Signs of left ventricular failure Strong, ___________________________________ pulseAbnormal skin color, temperature, and condition Presence of ___________________________________

113 Hypertensive EmergenciesManagement:Maintain airway.Administer ___________________________________ .Establish __________ access.Note: Caution must be used when lowering the BP of a chronically hypertensive patient. Over time, the patient adjusts ___________________________________ perfusion to the hypertensive BP. If lowered, cerebral perfusion could be decreased and the brain become ischemic. Always consult local protocols or medical direction before lowering a BP with medications.

114 Hypertensive EmergenciesIf indicated, consider medication administration:

– ___________________________________ sulfate– ___________________________________– Nitroglycerin

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– Sodium nitroprusside– ___________________________________

115 Cardiogenic ShockPathophysiology:General

– Inability of the heart to meet the body’s ___________________________________ needs.

– Often remains after ___________________________________ of other problems.– Severe form of pump failure.– High ___________________________________ rate.

116 Cardiogenic ShockCauses

– Tension pneumothorax and cardiac ___________________________________ .– Impaired ___________________________________ emptying.– Impaired myocardial ___________________________________ .– Trauma.

117 Cardiogenic ShockField Assessment:Primary AssessmentChief Complaint

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

– Onset may be acute or ___________________________________ .History

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

118 Cardiogenic ShockMental Status

– Restlessness progressing to ___________________________________ Airway and Breathing

– Dyspnea, labored breathing, and cough– PND, tripod position, accessory muscle retraction, and adventitious lung sounds

ECG– ___________________________________ and

___________________________________ dysrhythmiasCirculation

– ___________________________________, Cool, clammy skin

119 Cardiogenic ShockManagement:Maintain airway.Administer ___________________________________ Identify and treat underlying problem.

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Establish IV access, consider fluid challenges if no pulmonary edema.Consider medication administration:

– Vasopressors (___________________________________ )– Other meds or ___________________________________ Challenge

120 Cardiac ArrestCauses: ___________________________________ or acid–base imbalancesElectrocutionDrug intoxication ___________________________________Hypothermia Pulmonary embolism ___________________________________DrowningTraumaEnd-stage renal disease and hyperkalemia

121 Cardiac ArrestField Assessment:Initial Assessment

– Unresponsive, apneic, pulseless patientECG

– ___________________________________History

– ___________________________________ events– Bystander CPR– “___________________________________ time”

122 Cardiac ArrestManagement:___________________________________ aggressively unless contraindicatedGeneral Guidelines

– CPR.– Manage specific dysrhythmias.– Establish IV access– Advanced ___________________________________ management.

CPR takes priority over ___________________________________– Avoid interruptions of CPR

123 Cardiac ArrestPostresuscitation Management:Manage ___________________________________ and problems as presented.Be alert for _______________.Manage BPTransport rapidly:

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– Take care to protect ___________________________________ and IV access.

124 Cardiac ArrestWithholding Resuscitation

– Rigor mortis– Dependent ___________________________________ – Decapitation, decomposition, incineration– Valid ___________________________________

125 Cardiac ArrestIndications for termination of resuscitation: Patient over __________ years old.Cause is presumed ___________________________________ in origin. Successful ___________________________________ intubation. ___________________________________ standards applied throughout the arrest.On-scene effort > ________________ minutes, or four rounds of drug therapy and ECG

remains ___________________________________ or agonal.Blunt trauma victims presenting with or developing asystole.

126 Cardiac ArrestContraindications to termination of resuscitation: Patient under 18 years old.Arrest is of a treatable cause. Present or recurring __________/__________. ___________________________________ return of a pulse. Signs of neurological viability. ___________________________________ arrest. Family or others ___________________________________ to termination of

resuscitation. Suspected criminal activity

127 Cardiac ArrestTerminating CPR:Always follow local protocols related to termination of resuscitation. Support the ___________________________________ or others after termination of

resuscitation.Coordinate with law ___________________________________ as requiredWhen in doubt, ___________________________________ resuscitation

128 Peripheral Vascular and Other Cardiovascular Emergencies

129 AtherosclerosisPathophysiology: Progressive degenerative disease of the medium-sized and large

___________________________________ .Results from the buildup of ___________________________________ on the interior of

the artery. Fatty buildup results in plaques and eventual ___________________________________

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of the artery

130 Aneurysm Pathophysiology:

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

Types:– Atherosclerotic– ___________________________________– Infectious– ___________________________________– Traumatic

131 Abdominal Aortic AneurysmOften the result of atherosclerosis Signs and symptoms

– Abdominal pain– ___________________________________ pain– Hypotension– Urge to ___________________________________ – Pulsating mass

132 Dissecting Aortic AneurysmCaused by degenerative changes in the smooth muscle and elastic tissue.Blood gets between and ___________________________________ the wall of the aorta.Can extend throughout the aorta and into associated

___________________________________.

133 Acute Pulmonary EmbolismPathophysiology:Blockage of a pulmonary artery by a blood ___________________________________ 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 ___________________________________ .History of recent lengthy ___________________________________ .

134 Acute Arterial OcclusionPathophysiology: Sudden ___________________________________ of arterial blood flow due to trauma,

thrombosis, tumor, embolus, or idiopathic means. Frequently involves the ___________________________________ or extremities.

135 Noncritical Peripheral Vascular ConditionsPeripheral Arterial Atherosclerotic Disease:Can be ___________________________________ or chronic.Often associated with diabetes.

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Extremities exhibit ___________________________________ , coldness, numbness, and pallor.

136 Noncritical Peripheral Vascular ConditionsDeep Venous ___________________________________ Blood clot in a vein.Typically occurs in the ___________________________________ veins of the thigh and

calf. ___________________________________, pain, and tenderness, with warm, red skin.___________________________________ VeinsDilated superficial veins, common with pregnancy and obesity.

137 Wolff-Parkinson-White SyndromeWPW is a syndrome of pre- ___________________________________ of the ventricles

due to an accessory pathway called the Bundle of Kent which is an abnormal pathway from the atria to the ventricles.

Effects 0.15 to 0.2% of the populationNormally ___________________________________

138 Wolff-Parkinson-White SyndromeRisk of sudden death due to ___________________________________(rare) Produces a delta wave

– Slurred upstroke in the QRS complex with a short PRI– Type I WPW produces positive ___________________________________ waves– Type II WPW produces negative delta waves

Commonly causes ___________________________________ and/or palpitations

139 WPW

140 WPW

141 WPW

142 Wolff-Parkinson-White Syndrome If patient experiences episodes of A-Fib, the ECG will show a rapid polymorphic wide-

complex ___________________________________ and is very dangerous. In this case, many antiarrhythmic drugs are contraindicated.

___________________________________ is the treatment of choice for unstable patients

143 Management of WPW If unstable tachydysrythmia, cardioversion is indicated If more stable, consider ___________________________________ or Adenosine

– Always consult ___________________________________ Direction prior to administering any medications for WPW

144 General Assessment and Management of Vascular DisordersAssessment: Initial Assessment

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Circulatory Assessment– ___________________________________– Pain– ___________________________________– Paralysis– Paresthesia

145 General Assessment and Management of Vascular DisordersAssessment (Continued):Chief Complaint

– OPQRST Physical Exam

– Prior history of ___________________________________ problems– Differences in ___________________________________ or blood pressures

146 General Assessment and Management of Vascular DisordersManagement:Maintain the airway.Administer ___________________________________ if respiratory distress or signs of

hypoperfusion present.Consider administration of ___________________________________ . ___________________________________ rapidly if signs of hypoperfusion present.

147 12 Lead ECG Provides much better analysis of ECGMost 12 Lead machines have ___________________________________ software: Do

not rely solely on computer Patient must be ___________________________________ Do NOT delay ___________________________________ or transport to obtain 12 leadNormally a left sided ECG, but a right sided ECG can also be performed

148 12 Lead ECG10 Leads:Conventional 4 ___________________________________ Leads

– Right Arm– Left Arm– Right Leg– Left Leg

6 _______________ Leads– V1: 4th Intercostal space just to right of sternum

149 12 Lead ECG6 V Leads (Continued)V2: 4th intercostal space just to left of ___________________________________ V3: In line midway between V2 and V4V4: Midclavicular line in __________th intercostal spaceV5: Anterior axillary line at same level as V4

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V6: ___________________________________ line at same level as V4

150 12 Lead Lead Placement

151 Prehospital ECG Monitoring

152 Prehospital ECG Monitoring

153 Prehospital ECG Monitoring

154 Prehospital ECG Monitoring

155 Prehospital ECG Monitoring

156 Prehospital ECG Monitoring

157 Prehospital ECG Monitoring

158 Right Sided 12 LeadTo perform a right sided ECG, simply ___________________________________ all v-

leads to the right side.Use the same locations, just on the ___________________________________ sided

instead of the left.CANNOT use the monitor’s ___________________________________

S-1 02/01/2011

LEFT SIDED V-LEAD PLACEMENT

V1: Right 4th intercostal space

V2: Left 4th intercostal space

V3: Halfway between V2 and V4

V4: Left 5th intercostal space, mid-clavicular line

V5: Horizontal to V4, anterior axillary line

V6: Horizontal to V5, mid-axillary line

In an emergent situation and time does not permit a complete right sided EKG, move V4 to the V4R position to confirm a right ventricular infarct.

S-2 02/01/2011

RIGHT SIDED V-LEAD PLACEMENT

V1R: Left 4th intercostal space

V2R: Right 4th intercostal space

V3R: Halfway between V2 and V4

V4R: Right 5th intercostal space, mid-clavicular line

V5R: Horizontal to V4, anterior axillary line

V6R: Horizontal to V5, mid-axillary line

In an emergent situation and time does not permit a complete right sided EKG, move V4 to the V4R position to confirm a right ventricular infarct.