1 cardiovascular emergencies. 2 cardiovascular disease 63,400,000 north americans have one or more...
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CARDIOVASCULAR EMERGENCIES
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Cardiovascular Disease
• 63,400,000 North Americans have one or more forms of heart or blood vessel disease
• 50% of all deaths are cardiovascular disease
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Cardiovascular Disease
• Acute Myocardial Infarction (Heart Attack) - leading cause of death in U.S.
• 1.5 million North Americans will have AMI’s this year– Of these .5 million will die!
– 350,000 will die in first two hours!
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Cardiovascular Disease Risk Factors
• Major Uncontrollable–Age
–Sex
–Race
–Heredity
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Cardiovascular Disease Risk Factors
• Major Controllable –Smoking
–High BP
–High blood cholesterol
–Diabetes
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Cardiovascular Disease Risk Factors
• Minor Controllable–Obesity
–Lack of exercise
–Stress
–Personality
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Cardiovascular Disease
Control risk factors - decrease Coronary Artery Disease and Acute Myocardial Infarction
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Coronary Artery Disease
• Myocardium (heart muscle) requires continuous oxygen and nutrient supply
• Myocardial blood supply passes through coronary arteries
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Coronary Artery Disease
• Atherosclerosis– Narrowing of lumen
• plaque formation - related to Risk Factors• results in decreased myocardial perfusion
– Poor tissue perfusion causes:
– tissue damage (ischemia)
– tissue death (infarction)
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Atherosclerotic Plaque Formation
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Angina Pectoris “A choking in the chest”
• Angere - to choke• Myocardial oxygen
demand exceeds supply during periods of increased activity, exercise, or stressful event
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Angina Pectoris
• During stress the myocardium demands more O2
• Coronary arteries would normally dilate to supply more blood and O2
• In Angina Pectoris, the coronary arteries are unable to dilate sufficiently to increase perfusion
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Symptoms -Angina Pectoris
• Pain– Substernal
– Squeezing/Crushing/Heaviness
– May radiate to arms, shoulders, jaw, upper back, upper abdomen back
– May be associated with shortness of breath, nausea, sweating
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Symptoms -Angina Pectoris• Pain usually associated with 3E’s
– Exercise
– Eating
– Emotion
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Symptoms -Angina Pectoris• Pain seldom lasts > 30 minutes
• Pain relieved by– Rest
– Nitroglycerin
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Symptoms -Angina Pectoris• Great anxiety/Fear
• Fixation of the body
• Pale, ashen, or livid face
• Dyspnea (SOB) may be associated
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Symptoms -Angina Pectoris• Nausea
• Diaphoresis
• BP usually up during attack
• Dysrhythmia may be present
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Angina Pectoris
• Following an angina attack there is no residual damage to the myocardium
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Forms of Angina Pectoris
• Stable Angina– Occurs with exercise
– Predictable
– Relieved by rest or Nitroglycerin
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Forms of Angina Pectoris
• Unstable Angina– More frequent/severe
– Can occur during rest
– May indicate impending MI
– Requires immediate treatment and transport to appropriate facility
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Acute Myocardial Infarction
“Heart Attack”• Inadequate perfusion of myocardium– Death of myocardium
• Infarct– Damage to myocardium
• Ischemia
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Symptoms - AMI
• Chest Pain - cardinal sign of myocardial infarction– Occurs in 85% of MI’s
– Substernal
– “Crushing,” “squeezing,” “tight,” “heavy”
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Symptoms - AMI• Chest Pain
– May radiate to arms, shoulders, jaw, upper back, upper abdomen back
– May vary in intensity– Unaffected by:
• swallowing• coughing• deep breathing• movement
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Symptoms - AMI
• Chest Pain– Unrelieved by rest/nitroglycerin
– Pain lasts longer than angina pain (up to 12 hours)
– “Silent’ MI • 15% of patients with MI, • particularly common in elderly and
diabetics
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Symptoms - AMI
• Shortness of breath
• Weakness, dizziness, fainting
• Nausea, vomiting
• Pallor and diaphoresis (heavy sweating)
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Symptoms - AMI
• Sense of impending doom
• Denial – 50% of deaths occur in first two hours
– Average patient waits 3 hours before seeking help
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Symptoms - AMI
• Changes in pulse, BP, respiration are not diagnostic of AMI
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Acute Myocardial Infarction
• Early recognition of MI is critical
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Management of Cardiac Chest Pain
• When in doubt, manage all chest pain as MI
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Management of Cardiac Chest Pain
• Begin management immediately if angina or MI are suspected.
• Complete the history and physical exam as you treat.
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Management of Cardiac Chest Pain
• Position of Comfort
• Patent Airway
• High concentration O2
– non-rebreather mask 10-15 lpm
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Management of Cardiac Chest Pain
• Reassure the patient
• Obtain a brief history and physical exam
• Aspirin 325mg p.o.
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Management of Cardiac Chest Pain
• Nitroglycerin 0.4mg tablet sublingual– Patient should be sitting or lying down
– Has Pt. Taken nitroglycerin in last 10 minutes? Is pain relieved? Headache?
– Is BP > 90 systolic?
– q 5 minutes until pain relieved or three tablets administered
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Management of Cardiac Chest Pain
• If pain is unrelieved by rest, oxygen, nitroglycerin or if a change has occurred in pattern of angina, transport immediately
• Transport in semi-sitting position if BP normal or elevated; flat if BP low
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Management of Cardiac Chest Pain
• Do not walk patient to the ambulance
• Do not use lights/siren if patient is awake, alert, breathing without distress
• Monitor vital signs every 5-10 minutes
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Management of Cardiac Chest Pain
• Request early ALS back-up– Deaths in MI result from arrhythmia's
– Arrhythmia's can be prevented with early drug therapy
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Congestive Heart Failure
• CHF = Inability of heart to pump blood out as fast as it enters.
• May be left-sided, right-sided, or both.
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Congestive Heart Failure
• Usually begins with left-sided failure.– Left ventricle fails
– Blood “stacks up” in lungs
– High pressure in capillary beds
– Fluid forced out of capillaries into alveoli
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Congestive Heart Failure
• Right-sided failure most commonly caused by Left-sided failure. Blood “backs up” into systemic circulation– Distended neck veins
– Fluid in abdominal cavity
– Pedal edema
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Causes of CHF
• Coronary Artery Disease
• Chronic hypertension (high blood pressure)
• AMI
• Valvular heart disease
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Symptoms of CHF• Weakness
• Dyspnea
• Dyspnea on exertion
• Paroxysmal nocturnal dyspnea– Attacks of SOB that usually occur at
night that awakens the patient
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Symptoms of CHF
• Orthopnea– Difficulty breathing in any position other
than standing or sitting
• Abdominal discomfort
• Jugular Vein Distention (JVD)
• Pedal “Pitting” edema in lower extremities
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Symptoms of CHF
• Tachycardia
• Pulmonary Edema– Noisy, labored breathing
– Coughing
– Rales, wheezing
– Pink, frothy sputum
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Management of CHF
• Sit patient up, let feet dangle
• Administer high concentration O2
• Assist ventilation as needed
• Monitor vital signs q 5-10 minutes
• Request early ALS back-up
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Pacemaker Failure• Position of comfort
• Patent airway
• High Concentration O2
• Assist ventilations as needed
• ALS Intercept
• CPR as needed– DO NOT worry about damage to
pacemaker
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Coronary Artery Bypass• Position of comfort
• Patent airway
• High Concentration O2
• Assist ventilations as needed
• ALS Intercept
• CPR as needed– DO NOT worry about damage to
sutures/staples or by-passed arteries
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Implanted Defibrillator
• If performing CPR on a patient:– Implanted defibrillator may “fire”
– May feel slight “tingle”