Cardiac Emergencies

7-16. List the functions of the circulatory

(cardiovascular) system.

Functions of the Circulatory System

Provide medium for cell perfusion and pH

balance of body

7-17. Describe the anatomy and physiology

of the heart to include: !!!!!!!!!a. Location and size !!!!!!!!!b. Tissue layers !!!!!!!!!c. Chambers !!!!!!!!!d.Valves !!!!!!!!!e. Blood supply !!!!!!!!!f. Blood ow through the heart !!!!!!!!!g. Conduction system

Transport blood to pulmonary system and

cells of the body

Reservoir to hold blood Distribution of nutrients, hormones, cells for

clotting and infection control

17-3. Describe the structure and function of the

circulatory system, including: !!!!!!!!!a. The cardiac conduction system !!!!!!!!!b. Conductive tissue and conductivity !!!!!!!!!c. Contractile tissue and contractility !!!!!!!!!d. Automaticity !!!!!!!!!e. Effects of the autonomic nervous system (sympathetic and parasympathetic) on the heart !!!!!!!!!f. Gross anatomy of the heart !!!!!!!!!g. Systemic and pulmonary circulation !!!!!!!!!h. Coronary arteries !!!!!!!!!i. Plasma and formed elements of the blood

The Heart

Tissue Layers Location and Size 1. Endocardium 2. Myocardium 3. Pericardium

The heart lies in the central part of the

chest, the mediastinum, with its apex located inferiorly and its base superiorly Its size is approximately the size of a st

Visceral (Epicardium) Parietal

2- Myocardium- heart muscle 1- Endocardium- innermost layer

lines the chambers and is in direct contact with blood

Muscle cells resemble skeletal muscle but have electrical properties similar to smooth muscle Cells exhibit automaticity Specialized structures allow for electrical conduction

3- Pericardium- outer layers that protect heart, prevent overlling, and bind to vasculature a. Visceral (organ) pericardium (aka epicardium)layer attached to myocardium b. Parietal pericardium- outer, brous layer Between these layers is the pericardial space lled with lubricating uid to reduce friction

Heart Chambers

Upper Chambers- Atria pump blood into ventricles Lower Chambers- Ventricles pump blood out of heart

Chambers

Atrioventricular (AV) Valves

Atria (holding chambers) and Ventricles (strong pumps) Atria receive blood from veins; ventricles pump blood into arteries Thickness of chambers corresponds to their function

Tricuspid Mitral

Semilunar Valves Pulmonic Aortic

Circulation Through the Heart

Right side of the heart handles deoxygenated blood- aka pulmonary circuit or lesser circulation Left side of the heart handles oxygenated blood- aka systemic circuit or greater circulation Valves prevent backow of blood in system

The concept of circulatory is that blood travels in a circular path You can trace the path of blood starting at any point and end up going through the same anatomy

Right Atrium

Receives O2 depleted blood via

Blood passes from the right atrium through the tricuspid valve and into the right ventricle The tricuspid is the rst of the 2 atrioventricular (AV) valves Tricuspid has 3 cusps

superior vena cava inferior vena cava

After passing through the tricuspid valve, blood enters the right ventricle The right ventricle contracts, sending the deoxygenated blood into the pulmonary artery The pulmonic valve is the rst of the 2 semilunar valves

After being oxygenated in the lungs, blood returns through the pulmonic vein into the left atrium Blood passed through the mitral valve into the right ventricle

lm Pu y ar on

The mitral valve is also known as the bicuspid due to its 2 cusps Mitral refers to the mitre, a bishops headdress

in Ve

Vena Cava

RA T P RV

LA

M LV A
Aorta

Toilet Paper My Ass

Through the mitral valve and into the left ventricle, oxygenated blood is now prepared for systemic circulation The left ventricle, which forms the apex of the heart, pumps the blood through the second semilunar valve, the aortic valve, into the aorta and to systemic arteries, capillaries and veins

Blood enters the aorta during systole, during which time the aortic valves cusps block the main coronary arteries- during diastole, the aortic valve closes and allows coronary perfusion

The Cardiac Conduction System

Autonomic Nervous System Control

Heart muscle is specialized in several ways

Conductivity- cells can rapidly conduct

electrical impulses to other cells electrically stimulated

Sympathetic Nervous System

Contractility- cells can contract when

Automaticity- the ability to contract without receiving an impulse

innervates SA, AV nodes and Purkinje network; it increases the hearts rate and contractile strength innervates only SA and AV nodes; it slows rate and lessens contractile force

Parasympathetic Nervous System

Electric impulses originate in the SA node and

travel across the atria through the Bachmann bundle, making the atria contract

Following the pause, the impulse continues

through the Bundle of His and into the left an right bundle branches, where they terminate in the Purkinje Fibers, causing ventricular contraction

Impulse arrives at the AV node and pauses

17-4. Explain the relationship between 17-5. Describe the processes of

electrical and mechanical events in the heart. depolarization and repolarization, and relate the waves and intervals of a normal electrocardiogram (ECG) to the physiological events they represent.

 When heart cells depolarize, the heart

cells should contract relax

The electrocardiogram (EKG or ECG) is a

graphic display of the hearts electrical activity

When cells repolarize, heart cells should Cell electrical activity normally matches up
with mechanical activity- depolarization should generate contraction

Positive deections from the isoelectric

(base) line indicate electrical activity toward the apex (bottom) of the heart line indicate electrical activity toward the base (top) of the heart

Negative deections from the isoelectric

Dysrhythmias- Irregular or absent heart rhythm due to a problem with the cardiac conduction system

VTach- ventricular tachycardia PEA- pulseless electrical activity Asystole- atline

VFib,VF- ventricular brillation

17-6. Discuss the relationship between

hypoxia, damage to the cardiac conduction system, premature ventricular contractions, ventricular tachycardia, and ventricular brillation.

 If the heart becomes hypoxic, damage can

occur to the cells and conduction system and the heart muscle (myocardium) becomes irritable heart rhythms

Rapid ring of the ventricles (Premature

Ventricular Complexes, or PVCs) can result in Ventricular Tachycardia or VF), an uncoordinated, chaotic ring of the myocardium that results in no mechanical contraction of the heart

This can result is dysrhythmias, or abnormal

This can lead to Ventricular Fibrillation (VFib

Vasculature refers to the blood vessels that

Vasculature

carry blood within the body is hemorrhaging (bleeding)

Blood is always within a vessel unless the pt

Arteries- carry blood away from the heart Pulmonary Artery brings blood from R
ventricle to lungs the body

Central pulse points are stronger than

peripheral pulse points directly over the heart

Aorta brings blood from L ventricle to Arteries are under pressure since they are
coming directly from the pump

The apical pulse is felt on the chest itself, The sensation felt is the actual contraction
of the left ventricle, so it does not give a sense of systemic pressure

 Blood Pressure- the force exerted with

arteries

Systolic- when the heart is contracting Diastolic- when the heart is relaxed

17-7. Describe the roles of the heart and

blood vessels in maintaining normal blood pressure.

Blood vessels can change their size, Vasodilation lowers BP Vasoconstriction raises BP

rerouting (shunting) blood or changing systemic pressure

Arterioles- the smallest arteries, they carry

blood to the capillaries

The heart can also increase the strength of

its contractions, raising the BP

Capillaries- the smallest blood vessels, so

thin that diffusion through them allows materials to pass into cells

Veins- carry blood to the heart Inferior vena cava is a large vein that
drains lower body to heart

Perfusion of cells occurs at the capillary level

Superior vena cava is a large vein that

drains upper body to heart

Veins often have one-way valves to keep

blow owing a single direction

 Venules- smallest veins, they leasd from

capillaries to veins

Arteries Arterioles Capillaries Venules Veins

Hydrostatic Pressure- the force exerted on the inside of a vessel as a result of blood pressure and volume

Perfusion

Increased hydrostatic pressure forces uid

(plasma) from blood vessels, causing edema (swelling)

Blood ow through tissue that provides O ,

glucose, and other nutrients and the elimination of cellular wastes
2

Gas Transport

The movement of gasses within the body

(primarily O2 and CO2)

Oxygen (O ) 97% attached to RBCs 3% dissolved in plasma Carbon Dioxide (CO ) 70% as bicarbonate in plasma 23% attached to RBCs 7% dissolves in plasma
2 2

Cell Metabolism- the conversion of the bodys energy sources (usually glucose) into energy

Aerobic- the normal, efcient method

when O2 is present in a cell

Blood

Anaerobic- the abnormal, insufcient

method when O2 is absent- creates dangerous acidic byproducts and little energy

Blood Composition

Plasma Formed Elements Red Blood Cells (RBCs) White Blood Cells (WBCs) Platelets

Plasma- the liquid part of blood Made primarily of water with electrolytes,
proteins

Carries nutrients, a small amount of

oxygen, carbon dioxide

Red Blood Cells (RBCs) aka erythrocytes disk-shaped, exible cells iron-based hemoglobin bonds with oxygen carries a small amount of CO
2

White Blood Cells (WBCs) aka leukocytes part of the bodys immune system, WBCs
ght infection

 Platelets/clotting factors Platelets are fragments of other blood

cells

If coronary arteries become occluded,

Involved in clotting

ischemic tissue makes the heart irritable, and cells may begin ring randomly, causing dysrhythmia

17-2. Describe the relationship between 17-8. Explain the importance of early

Though some people do experience silent

heart attacks, many experience chest discomfort (pain, pressure) that signals cardiac compromise

chest pain or discomfort, heart disease, and cardiac arrest. recognition of signs and symptoms and the early treatment of patients with cardiac emergencies.

Time is critical in caring for cardiac

and lives

compromise- hypoxic heart tissue dies and cannot be replaced

Recognizing signs & symptoms saves time

7-9. Explain the pathophysiology and the

appropriate assessment and management of the following conditions that may be classied as cardiac compromise or acute coronary syndrome: !!!!!!!!!a. Angina pectoris !!!!!!!!!b. Myocardial infarction !!!!!!!!!c. Aortic aneurysm or dissection !!!!!!!!!d. Congestive heart failure !!!!!!!!!e. Cardiogenic shock !!!!!!!!!f. Hypertensive emergencies !!!!!!!!!g. Cardiac arrest

Terminology

Cardiac Compromise (aka Acute

Coronary Syndrome or ACS)- any type of problem with the heart hours of the onset of cardiac symptoms

Sudden Cardiac Death- Death within 2 Ischemia- local area deprived of oxygen

Indications of Cardiac Compromise

Chest discomfort (pain, pressure) May radiate to neck, jaw, arm 10-15% report no chest symptoms,
especially diabetics and the elderly

Anxiety, irritability Nausea, vomiting, epigastric pain Syncope

Dyspnea

Etiologies of Cardiac Compromise

CAD Aneurysm Arrhythmia Angina AMI CHF Cardiac Tamponade

Coronary Artery Disease (CAD)- thinning of vessels lumen due to obstruction by deposits; perfusion affected

Atherosclerosis- fatty deposits (plaque) in

blood vessels

Arteriosclerosis- calcium deposits on

plaque causing hardening of the arteries

CADs Role in Cardiac Compromise

Angina Pectoris

Thrombosisdevelopment of clot Occlusion- blockage of artery material capable of occluding a distal vessel

Heart tissue becomes ischemic due to

inadequate perfusion

Embolism- traveling

exertion-based ischemia vascular spasm-based ischemia

 Indications are identical to those of a heart

attack

Chest discomfort, dyspnea, nausea,

diaphoresis

Two types of angina Stable- symptoms occur when the heart is

stressed by exercise, anxiety, etc.

Unlike an AMI, no tissue damage occurs

Unstable- onset independent of cardiac

stress, due only to severe CAD; aka preinfarct angina

Acute Myocardial Infarction (AMI)

Angina generally responds to nitroglycerin Attacks last no longer than 3-5 No death of heart tissue

aka heart attack; results from coronary

artery occlusion or aneurysm

Lasts longer than 3-5 minutes May or may not respond to nitro Death of heart tissue

(local inadequate perfusion)

Ischemia

Infarction
(irreplaceable tissue death)

Heart

Angina Pectoris

Acute Myocardial Infarction (AMI, heart attack)

17-10. Explain the typical presentation of myocardial ischemia or infarction in females.

Brain

Transient Ischemic Attack (TIA)

Cerebral Vascular Accident (CVA, stroke)

Typical (Classical) AMI Presentation

Many studies on AMI and angina have been

based on males; females may present differently (atypically) present atypically

Geriatric and diabetic pts also tend to

Dull substernal chest pain or discomfort Dyspnea Nausea, vomiting Diaphoresis

Atypical (Non-Classical) AMI Presentation

Neck ache (nuchal pain) Chest pressure Pain in back, breast, upper abdomen Tingling ngers Unexplained weight gain (water)/fatigue Insomnia

Aneurysm- a weakened blood vessel that

balloons and ruptures

AAA- Abdominal Aortic Aneurysm-

may present as a tearing pain; creates rapid blood loss within the body

Advanced Care for CAD

Coronary Artery Bypass Graft (CABG) Thrombolytics

Angioplasty/Stents

Congestive Heart Failure (CHF)- uid build-up in lungs due to cardiac compromise, hypertension, COPD, or heart valve disease

Edema of lungs (pulmonary edema)

Indications

Tachycardia, normal or elevated BP Dyspnea Cyanosis, diaphoresis JVD and pedal edema Abdominal distention Pt may be on diuretics

Hypertensive Emergencies- dened as:

systolic pressure over 160 mm/Hg or

diastolic pressure over 94 mm/Hg

Primary Hypertension- idiopathic

hypertension

Evaluate the pt based on his normal baseline

BP

Secondary Hypertension- caused by another

disease; e.g., kidney (renal) disease

Treat underlying cause

Signs and Symptoms of Hypertensive Emergencies

Elevated BP, bounding pulse, nosebleed Severe headache, ringing in ears Nausea, vomiting Respiratory distress, chest pain Seizures

Cardiac (Pericardial) Tamponade

Blood collects between pericardium and

myocardium, decreasing volume of blood ejected from compressed chambers with each contraction

Most often results from penetrating trauma

Indications

Tachycardia Pulsus Paradoxus (fall in systolic pressure by

>10 mm Hg during inspiration) hypotension

Cardiac Arrest

Becks Triad: JVD, distant heart sounds,

Pulseless pt Begin CPR/utilize AED when appropriate

Interviewing the Cardiac Pt

17-13. Explain the assessment-based Hx of cardiac problems Hx of chest discomfort Hx of cardiac compromise (AMI, angina,
dysrhythmias, etc.)

approach to assessment and emergency medical care for cardiac compromise and acute coronary syndrome.

Cardiac meds Previous cardiac emergencies, evaluations or

care

Onset- what was pt doing when symptoms

started?

Examining the Cardiac Pt

Inspect for Levine sign (clenched st over
chest)

Provocation- what makes the discomfort

better/worse

Quality of pain Radiation of pain to another area Severity of pain (1-10 scale) Time- onset of symptoms

Inspect/auscutate for breathing quality Inspect for diaphoresis Palpate pulse/take BP

Pediatric Considerations

17-12. Explain the special considerations in

assessing and managing pediatric and geriatric patients with cardiac emergencies.

Most children presenting with cardiac

compromise have a congenital Hx respiratory arrest

Cardiac arrest is usually secondary to

Geriatric Considerations

Most cardiac compromise will occur in

this age group

Cardiac Medications

Geriatric pts are less likely to experience

chest discomfort

Nitroglycerin

17-11. Explain the indications,

Actions- dilation of coronary arteries,

decrease workload/O2 consumption of heart lowered BP, tachycardia, headache, burning under tongue, lightheadedness compromise and prescription for nitroglycerin

contraindications, forms, dosage, administration, actions, side effects, and reassessment for nitroglycerin.

Side Effects- systemic vascular dilation, Indications- Pt with diagnosed cardiac

 Contraindications Systolic BP < 100 Possible occult injury/bleed Use of ED drugs 24-48 hours Pediatric pt Maximum dose attained

Taking any of these

drugs within 48 hours is a relative contraindication for nitroglycerin. for direction after getting a BP.

Call medical control

Forms- pills, spray Dosage- up to 3 doses (0.3-0.4 mg)

sublingually 5 apart remains >100

Aspirin (ASA)

Reassessment- Every 5 to assure systolic BP

Actions- interferes with blood clotting Side Effects- stomach irritation Indications- Pt with signs/symptoms of cardiac
compromise

Contraindications Allergy to aspirin Possible occult injury/bleed Pregnant Pt on blood thinners/ bleeding disorder Maximum dose attained

Forms- childrens chewable 81mg tablets Dosage- 2-4 tablets (160-325 mg) Reassessment- Every 5 to assure systolic BP
remains >100

 17-14. Discuss the indications and

contraindications for brinolytic therapy in patients with cardiac emergencies.

Indications: Fibrinolytic therapy dissolves clots,

reestablishing perfusion some strokes

Can be used for both heart attacks and

Contraindications: Fibrinolytic therapy dissolves all clots, Pts with recent hemorrhagic stroke Pts who have recently had surgery

MA Protocols
ABCs O by non-rebreather (15 lpm) Activate ALS Vitals every 5 If BP <100, treat for shock Notify receiving hospital
2

which may initiate bleeding in areas where clots exist

Other Supportive Care

BLS Meds

Position of comfort Minimize movement Dont use sirens or create any more anxiety Take a good SAMPLE Hx Bring meds with you to hospital

NTG- 1 tablet/spray very 5 minutes;

contraindicated if BP <100, has had maximum dose (3) within last 24 hours, has taken ED medication within 48 hours (call if after 24), trauma with occult bleed possible contraindicated if allergic, has had this dose within 24 hours, has active GI or possible occult bleed, child

Aspirin- 162-325mg, chewable;