Cardiovascular Emergencies

time is myocardium!

Statistics
Cardiovascular disease (CVD)

claimed over 1 million lives in 2004. CVD has been the leading cause of death for Americans since 1900. Sudden cardiac death accounts for over 40% of these deaths. The majority of our 911 responses are for chest pain.

Controllable Risk Factors

Smoking High blood pressure Elevated cholesterol levels Elevated blood glucose levels Diet Lack of exercise Stress

Uncontrollable Risk Factors Age Family history Race Sex

Anatomy

Circulation

Blood
Red blood cells: Carries oxygen to tissues and cells Removes CO2 and waste White blood cells: Fight infection Platelets: Helps blood clot

Electrical System

Coronary Arteries

Cardiac Compromise
Chest pain results from ischemia. Ischemic heart disease involves

decreased blood flow to the heart. If blood flow is not restored, the tissue dies (infarct). Injury leads to inadequate heart function and death.

Atherosclerosis

So
you are dispatched to a 67 year- old male c/o 9/10 crushing chest pressure that radiates to his jaw. He is also complaining of shortness of breath and nausea, with no previous cardiac history

what are YOU thinking?

Chest Pain Pathophysiology

Mediastinum:

Angina: stable or unstable AMI Esophagitis, esophageal rupture Pericarditis Mediastinal air Thoracic dissection Mitral valve prolapse

Chest Pain Pathophysiology

Chest Wall: Traumatic contusion/tamponade Cysts and infections Rib cartilage inflammation Shingles (Herpes Zoster) Muscle strain, overuse syndromes

Chest Pain Pathophysiology

Lungs and pleura: Pleurisy Pneumonia Pneumothorax, hemothorax Pulmonary embolus Asthma, bronchitis, URI

Chest Pain Pathophysiology

Abdomen: Gallbladder (cholecystitis, stones) Stomach (gastritis, GERD, perforated peptic ulcer) Pancreas (pancreatitis) Esophagitis, perforation

Chest Pain
Psychogenic: Stress Hyperventilation Anxiety and panic attacks

Classic Symptoms
Pressure, fullness, heaviness,

squeezing pain in center of chest with radiation Diaphoresis Nausea Shortness of breath Weakness

Frequency of Symptoms
Diaphoresis Chest pain Nausea Shortness of breath No signs/symptoms
N Engl J Med 1984;311:1144-7

78% 64% 52% 47% 25%

Atypical Presentations
Common in the elderly, diabetics, and

females:
Unusual fatigue Sudden onset of unusual shortness of breath Nausea, dizziness Belching, burping, indigestion Palpitations, new dysrhythmia Pain only in jaw, neck, back, arm

All chest pain is considered to be an AMI until proven otherwise!

Angina Pectoris
Chest pain caused when heart

tissues do not get enough oxygen for a brief period of time. Typically crushing or squeezing. Onset with the 3-Es. Usually resolves with rest or meds. May be difficult to diagnose from AMI

Angina

Acute Coronary Syndrome

Used to describe the range of conditions from unstable angina to AMI. Signs and symptoms usually caused by acute myocardial ischemia.

ACS Signs & Symptoms

Shortness of breath Signs of inadequate perfusion Chest pain, pressure, or discomfort

(with or without radiation to back, neck, jaw, arm, wrists) Nausea Weakness/syncope Dysrhythmias

Acute Myocardial Infarct

Usually caused by the same mechanism as angina only with resulting tissue death. Time is myocardium: Consequences can be serious:
Congestive heart failure Cardiogenic shock Sudden death

AMI

Cardiogenic Shock
Heart lacks power to force blood through the circulatory system.

Brought on when 40% of left ventricle is infarcted. Onset may be immediate or not apparent for 24 hours.

Signs & Symptoms

Altered LOC Rapid, shallow breathing Restlessness and anxiousness Pale, cool skin Tachycardia/dysrhythmia Hypotension

Congestive Heart Failure

Occurs when the ventricles are damaged.

Heart tries to compensate with increased heart rate. Enlarged, ineffective left ventricle Fluid builds up into lungs or body as pump fails.

CHF

Signs & Symptoms

Fatigue Cough with pink, frothy sputum Dypsnea, tachypnea Pulmonary edema Agitation and confusion Hypertension Pedal edema, ascities

Signs & Symptoms

Thoracic Dissection

Aortic Aneurysm

Signs & Symptoms

Sudden and severe chest or

upper back discomfort. Pain shoots to the shoulder blades. Anxiety Diaphoresis Nausea

Cardiac Tamponade
Trauma induced,

filling of the pericardial sac with blood. Signs of shock JVD Decrease pulse pressures

Esophageal Rupture
Usually

underlying alcohol abuse. Shock signs. Coughing up bright red blood.

Pericarditis
Inflammation of the

pericardium caused by infection. Usually presents as sharp discomfort. Changes with breathing and movement.

Chest Pain Assessment

BSI/Scene Safety Initial Assessment (Sick/Not Sick) Focused Exam Detailed Exam Assessment Treatment and Plan

Initial Assessment
60second clinical picture to determine if Sick or Not Sick (Oxygen) Based upon your initial impression:
Body position skin signs and color respiratory rate and effort mental status pulse rate and character

Correct immediate life threats!

Focused Exam (S)

Your subjective findings are based upon what the patient or historian tells you: Patient Age Sex Chief Complaint

Focused Exam (S)

SAMPLE History Signs/Symptoms (associated with cardiac chest pain):
Diaphoresis (78%) Shortness of Breath (47%) Pain/discomfort (64%) Nausea/vomiting (52%) No signs or symptoms (25%)
N Eng Journal Med 1984;311:11444-7

Focused Exam (S)

Onset
When and at what time did it start

Provocation
Does anything make it better or worse? Does it change with position, palpitation, inspiration?

Quality
Describe the pain/discomfort in your own words

Focused Exam (S)

Region/Radiation
Where does it start? Does it radiate anywhere?

Severity
On a scale of 1 to 10, what was the pain/discomfort at onset? What is the pain/discomfort at now?

Time
When did this episode start? How long has it been going on?

Focused Exam (S)

Allergies Medications
Cardiac meds = cardiac problems. Ask about OTC meds, natural supplements, vitamins?

Past Medical History

Do you have any cardiac history? Risk factors such as smoking, diabetes, HTN, weight/diet?

Focused Exam (S)

Last Oral Intake Events Leading to Call
What were you doing when this event started? Think activity induce vs. non activity

Listen to the patient

they will tell you exactly what is wrong!

Focused Exam (O)

Objective findings from your physical exam of the patient. Look for evidence of trauma/injury Evaluate:
Level of consciousness Skin color and temperature Respiratory rate and effort Pupillary reaction Pulse rate Blood pressure (bilateral for chest pain!)

Focused Exam (O)

Listen to breath sounds Palpate chest Palpate abdomen Check pedal pulses BGL if diabetic with DLOC SpO2 after BP, confirm with pulses, RA & after administration of O2 Rhythm strip?

Focused Exam (O)

Based upon your clinical findings Observe the patient while they are talking with you, note any distress/discomfort (Levine sign) Watch for acute clinical signs: jugular vein distension, tracheal deviation, paradoxial chest movement.

Detailed Exam (O)

Complete and thorough neck, head to toe examination with non-critical patients if needed or time permits. Elicit further information and necessary interventions. Key in on critical findings!

Assessment (A)
This is your best guess (or rule out) as to what is going on with the patient.
It is based upon YOUR Subjective and Objective findings and should help you develop and implement your Plan for patient care.

Plan (P)
Medics? ABCs/Monitor vitals Patient in position of comfort. Oxygen via? Assist with medications. Maintain body temperature. Calm and reassure. Minimize patient movement. Rapid transport!

Other Stuff
Coronary artery bypass graft (CABG)

and other open heart surgeries Percutaneous transluminal coronary angioplasty (PTCA) Automatic implantable cardiac defibrillators (ACID) Pacemakers