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