The Beat Goes On…

“The mind can only learn,

What the butt can endure! ”

Mnemonics

CTHCTH JPN, JFNJPN, JFN OTD, AMFOTD, AMF FIGFIG LOLNADWADAOLOLNADWADAO OGMOFOGMOF TSTDTSTD TMBDTMBD DRTDRT

Crazier than hellCrazier than hell Just plain nuts….Just plain nuts…. Out the door, Adios my Out the door, Adios my

friendfriend Found in gutterFound in gutter Little old lady, no apparent Little old lady, no apparent

distress, weak and dizzy all distress, weak and dizzy all overover

Oh great mound of fleshOh great mound of flesh Too stupid to dieToo stupid to die Too many birthdaysToo many birthdays Dead right thereDead right there

Cardiac Arrest

Cessation of cardiac mechanical activity as Cessation of cardiac mechanical activity as confirmed by the absence of signs of confirmed by the absence of signs of circulationcirculation

Cardiac Arrests in the U.S.

330,000 coronary heart disease deaths occur out-of-330,000 coronary heart disease deaths occur out-of-hospital on in hospital E.R.’s annuallyhospital on in hospital E.R.’s annually

2/32/3rdrd’s of unexpected cardiac deaths occur without ’s of unexpected cardiac deaths occur without prior recognition of cardiac diseaseprior recognition of cardiac disease

60% of unexpected cardiac deaths are treated by 60% of unexpected cardiac deaths are treated by EMSEMS

EMS treats 107,000-240,000 cardiac arrests in the EMS treats 107,000-240,000 cardiac arrests in the U.S.U.S.

Of these, 20 to 38% have V-fib or V-tach as the Of these, 20 to 38% have V-fib or V-tach as the first recorded rhythm (21,000-91,000 v-fib arrests first recorded rhythm (21,000-91,000 v-fib arrests annuallyannually

Get Back To The Basics

O-ONSETO-ONSET P-PROVOCATIONP-PROVOCATION Q-QUALITYQ-QUALITY R-RADIATIONR-RADIATION S-SEVERITYS-SEVERITY T-TIMET-TIME

Onset

SleepingSleeping ExercisingExercising RestingResting Beating the kidsBeating the kids

Provocation

ActivityActivity SportsSports RestingResting LiftingLifting Strenuous actionsStrenuous actions

Quality

SharpSharp Knifelike, stabbing, piercingKnifelike, stabbing, piercing

DullDull ““There’s an elephant sitting on my chest”There’s an elephant sitting on my chest”

SqueezingSqueezing ““Tight band around my chest”Tight band around my chest”

Pain through to the backPain through to the back

Radiation

Men:Men: left jaw, left neck, left chest, left armleft jaw, left neck, left chest, left arm

Women: Any presentation of pain anywhere Women: Any presentation of pain anywhere can result in cardiac complications! can result in cardiac complications! (almost)(almost)

Severity

Ask them:Ask them:

““On a scale of one to ten, with ten being the On a scale of one to ten, with ten being the worst pain you have ever had, what number worst pain you have ever had, what number would you rate your pain?”would you rate your pain?”

Time

““How long have you been bothered by this How long have you been bothered by this episode of pain?”episode of pain?” Minutes, hours, daysMinutes, hours, days

Visual and Tactile Assessment(yes, you have to look at and touch your patient!)

What are their living conditions like? What are their living conditions like? (clean, dirty, poverty)(clean, dirty, poverty)

What do they look like? (thin, fat, goofy, What do they look like? (thin, fat, goofy, dirty, or extremely clean and organized)dirty, or extremely clean and organized)

Skin condition: pale, diaphoretic, cool, Skin condition: pale, diaphoretic, cool, clammy, hot, red, moist, dryclammy, hot, red, moist, dry

Multiple pill bottlesMultiple pill bottles

…meanwhile back at the Ranch

A-airwayA-airway B-breathingB-breathing C-circulationC-circulation D-deficitsD-deficits E-exposureE-exposure F-FahrenheitF-Fahrenheit G-gadgetsG-gadgets H-historyH-history I-inspectI-inspect

Gadgets Cardiac monitorCardiac monitor Blood pressureBlood pressure Saturation Saturation

monitormonitor Glucose monitorGlucose monitor Medications Medications

OXYGENOXYGEN MORPHINEMORPHINE ASAASA NITRO!NITRO!

REMEMBER!

Treat the PatientNot

The machine!

Drug therapy

OxygenOxygen 15 liters non-rebreather mask15 liters non-rebreather mask

AspirinAspirin 81 mg p.o.81 mg p.o.

NitroglycerinNitroglycerin 0.4 mg S.L. every five min. up to 30.4 mg S.L. every five min. up to 3

Morphine (Intermediate, Paramedic)Morphine (Intermediate, Paramedic) 2-5 mg I.V.2-5 mg I.V.

A cardiac patient needs TWO things…

YOU CANNOT PROVIDE EITHER YOU CANNOT PROVIDE EITHER OF THESE TWO THINGSOF THESE TWO THINGS

Rhythm Interpretation

The 4 “thingy’s” to Rhythm Interpretation

Is there a P wave?Is there a P wave? Is there a QRS Is there a QRS

complex?complex? Are they “married” Are they “married” (p(p

wave with every QRS complex)wave with every QRS complex)

Is the rate regular, fast, Is the rate regular, fast, or slow?or slow?

What is the “P” wave?

The first “bump” in the tracingThe first “bump” in the tracing It represents the Atrium depolarizingIt represents the Atrium depolarizing

What is the “Q” wave?

The first downward deflection in the tracingThe first downward deflection in the tracing The Q wave is often not present.The Q wave is often not present.

What is the “R” wave?

It is the first upward deflection in the It is the first upward deflection in the tracingtracing

It is associated with the ventricle It is associated with the ventricle depolarizingdepolarizing

What is the “S” wave?

The downward deflection after the “R” The downward deflection after the “R” wave in the tracing.wave in the tracing.

Ventricle depolarizingVentricle depolarizing

What is the “T” wave?

The first bump after the QRS complex in The first bump after the QRS complex in the tracing.the tracing.

It represents the ventricle repolarizingIt represents the ventricle repolarizing

How to figure out the Rate

First: Find a specific R wave that falls on a First: Find a specific R wave that falls on a heavy black line.heavy black line.

Next: Count off “300, 150, 100” for each Next: Count off “300, 150, 100” for each heavy black line that follows.heavy black line that follows.

Then: Count off the next three lines after Then: Count off the next three lines after “300, 150, 100” as “75, 60, 50.”“300, 150, 100” as “75, 60, 50.”

Memorize these triplicates.Memorize these triplicates.

Still figuring the Rate

At the top of the EKG tracing are small At the top of the EKG tracing are small marks which signify “three second” marks which signify “three second” intervals.intervals.

Taking two of the three second intervals, Taking two of the three second intervals, we have a six second strip.we have a six second strip.

Count the number of complete cycles (R Count the number of complete cycles (R wave-to-R wave)wave-to-R wave)

Multiply the number you get by 10.Multiply the number you get by 10.

Normal Sinus Rhythm

Sinus Bradycardia

Sinus Tachycardia

Ventricular Tachycardia

Ventricular Fibrillation

Asystole

Idioventricular Rhythm

Atrial Fibrillation

Atrial Flutter

Premature Ventricular Contractions(P.V.C.’s)

Pacer Spikes

Pulseless Electrical Activity

1st Degree Block

Lengthening P-R intervalLengthening P-R interval Regular RhythmRegular Rhythm

2nd Degree BlockWenckebach or Type 1

P-R Interval lengthens and then drops a P-R Interval lengthens and then drops a QRS complexQRS complex

2nd Degree BlockType 2

QRS complex drops without warningQRS complex drops without warning

3rd Degree or Complete Block

Complete disassociation of the P-waves and Complete disassociation of the P-waves and the QRS complex’sthe QRS complex’s

What about your patient? What changes will you see, or should you see in What changes will you see, or should you see in

your patient?your patient? Oxygen—decrease in chest painOxygen—decrease in chest pain ASA—makes RBC’s slick, decreases clotting ASA—makes RBC’s slick, decreases clotting

abilitiesabilities NTG.—decrease in chest pain, hypotension, NTG.—decrease in chest pain, hypotension,

nausea, dizziness.nausea, dizziness. Morphine—Decreases work load of the heart, Morphine—Decreases work load of the heart,

decrease in chest pain, decrease in all pain, decrease in chest pain, decrease in all pain, hypotension, nausea, dizziness, respiratory hypotension, nausea, dizziness, respiratory depression.depression.

Now that we are allEDUCATED

(or if your from Utah County, learned)

What good is it?What good is it?

What causes cardiac pain?Lack of oxygen enriched blood to the heart tissues

BlockageBlockage Narrowing of the passagewaysNarrowing of the passageways Lack of oxygen in the blood streamLack of oxygen in the blood stream Damaged or inefficient pumpDamaged or inefficient pump

Complete obstruction of the Left Anterior Descending Coronary Artery

Circumflex Artery

Heart Catheter

Left Anterior Descending Coronary ArteryOpened to blood flow

….and how do we cure it?

INCREASE THE INCREASE THE OXYGEN IN THE OXYGEN IN THE BLOOD!BLOOD!

GET THAT BLOOD TO GET THAT BLOOD TO THE HEART!THE HEART!

There are two things a cardiac patient needs…and you cannot provide either of the two.

ThrombolyticsThrombolyticsCath labCath lab

Soooooo, after all that, what else causes CHEST PAIN? Muscle achesMuscle aches PneumoniaPneumonia PleurisyPleurisy CostochrondritisCostochrondritis Rib fracturesRib fractures Virus’Virus’ FluFlu

One of the best diagnostics tool you have is…..

…….your GUT instinct!.your GUT instinct!

Thank YouThe End!The End!