chapter 20 cardiac emergencies we're going to explore the c in our abcs and see what we need to do to address these cardiac emergencies start off with a review of the basic cardiac anatomy physiology need to review the composition of the blood knowing the different parts of the blood the flow of the blood around the chambers of the heart the right atrium right ventricle left atrium left ventricle how the blood flows through the arteries veins arterials granules and capillaries and the circulation of the blood between the heart and lungs and between the heart and the rest of the body so it's important things we need to kind of understand as we go through the process here helps us understand the diseases and the reactions of the heart to the different uh problems that are going to happen the only job of the heart is to pump blood that's all it's it's only function there's no generation of hormones there's no digesting no processing of any nutrients it only processes blood it's a mechanical function pushes the blood through it's a pump it has its own electrical system with its own conductivity system which generates that electrical signal signal so it's it's always functioning and it's always moving forward for force so some basic understanding of the anatomy you get the aorta which is the first artery coming off the heart sends the blood to the rest the body we have the right coronary artery which goes around the right side of the heart supplies the blood there then we have the left coronary artery that has the left ascendi or descending branch and then the circumflex that goes around the back so those are the three main arteries that feed the coronary muscle so let's talk about acute coronary syndrome it's also called cardiac compromise the blood supply to one of those arteries that we just pointed out is blocked somehow it's a clot it's uh cholesterol buildup it's all kinds of potential problems but something has got the blood flow to the heart muscle disrupted when the heart goes without oxygen you have cellular death as you start having that hypoxic condition create created by the disruption of the blood flow you start getting ischemia or muscle death without that blood flow the cells die as they die they do not regenerate so you have parts of the heart that do not have blood flow or function the rest of the person's life so it's important that we catch these when they initially start get them to the right care and get that artery opened up so they get that blood flow moving forward again most common and most frequent symptoms you run across for acute coronation syndrome is the chest pain many different ways to describe it many different ways people say it even the same person has different symptoms if they have the same type of chest pain they'll describe it as pressure squeezing aching someone sitting on their chest somebody doing a bear hug around their chest it kind of depends on where the artery is and what part of the heart is impacted we also have pain that radiates to the jaw arm neck upper abdomen the the common thing here is that the nerve endings that come from the heart also go through these areas so the brain senses pain but it can't isolate the pain and it its gives a signal that you have pain all along that nerve path another problem you run into is dyspnea people that are having chest pain sometimes can't breathe mainly in older patients and female patients we also have nausea or vomiting syncope maybe their heartbeat isn't going actually correctly so they lose some blood some kind of flow to the brain sudden onset of sweating is a very profuse sweat you'll notice that when you put your ekg pads on they won't stick because they're so sweaty and they haven't been doing anything abnormal pulse tachycardia or bradycardia either one it could be irregular and here is the one that almost always occurs is that impending feeling of doom they tell you they're dying and they they really believe all patients with any type of chest pain you get your primary assessment secure your abc's get the chief complaint of chest pain test discomfort squeezy in the chest whatever they want to call it do your o p q s t to get the history the present illness get your past medical history your sample history get some baseline vitals and start moving them towards the hospital the quicker we get them into the hospital into a cath lab the better chance of survival and the better a larger amount of heart muscle that's still available once they get the reperfusion done so those early symptoms are gonna they're probably gonna describe or pain pressure discomfort the chest jaw neck upper arm belly possibly this difficulty breathing they'll also describe what we call palpitations or feels like their heart is beating really strong in their chest they can feel it uh beating extra hard it's because the heart muscles trying to compensate for those areas that are not getting good blood flow sudden onset of sweaty nausea vomiting profuse sweating they just drenched in sweat they may have sinkable episodes anxiety generalized weakness they just don't feel right abnormal pulse not regular maybe the blood pressure's high maybe it's low kind of depends on what's going on in their body at the time but something's not normal about the blood pressure when you look at the patient they're grabbing their chest their feet they're pointing to the center of the chest that it hurts right there that abnormal sweating pale or gray skin very anxious and restless remember they're having that impending feeling of doom may have some pulmonary edema if it's the right side of the heart they are not be able to push the blood completely through the pulmonary system so it kind of hangs out there and they start getting that pulmonary edema in reacting to the pulmonary edema the body tries to shunt the blood down to the ankles and feet so they'll have swollen edema in the the legs and the feet they will possibly have a medical alert bracelet a necklace sometimes they carry their ekg card with them there's lots of things that will tell you that they've got a history of cardiac disease another good sign is they've got a zipper scar down the center of their sternum where they've done open heart surgery before tells you there's a history of heart issues 12 lead ekgs as emts you can actually apply the ekg get the reading and send it to the hospital so you'll put the ekg on the patient you'll hit the send button it'll pick the hospital or you you pick the hospital you want to send it to and then follow your local protocols on how that's processed you are not allowed to interpret the machines do provide a printout accuracy is debatable but we want to get that ekg in the hands of the physician at the hospital to do an ekg first you want to remove the patient's clothing not yours remove the patient's clothing and any jewelry if they've got nipple piercings in those can stay in but any necklaces or anything like that needs to come off the chest remove sweat and dead skin cells so we take a cloth or a towel and start drying off the skin trick that i've learned over the years is carry a can of right guard spray in your ekg you spray it on the skin it stops the sweating and you can put the ekg pads on if there have a hairy chest typically have razors in our ekg kits so we'll shave just where we need to put the electrodes you don't have to shave the whole person's chest place the electrodes on the chest and make sure they have good secure contact so placing the limb leads you do those on each one of the limbs and they are labeled left leg right leg right arm left arm place the v1 and v2 they're on either side of the sternum then you have three and four around to the left and then five and six even further down on the left so you kind of circle the chest around the left side the left side is chosen because that's a bigger side of the heart so here's where the limb leads there's a lot of debate whether you want to put them down on the very distal end of the limbs or whether you put them on the thighs and upper arms or shoulders go with your local protocols but you leave your pads on so when they take the ekg at the hospital they have the same perspective limb leads you got your v1 v2 v4 and then v3 halfway between then 6 and 5 right between it so that's important to get these on we'll practice this in class uh we've got ekg machines we'll practice setting these up and go from there you notice uh there's not much shaving on this chest we're talking like robin williams quality hair that you got to shave so other thing you want to do is keep the patient in the position of comfort that's as simple as saying is it comfortable for you to sit this way do they need oxygen if they are having respiratory distress they need oxygen if they are not and their pulse ox is adequate then you may be putting on two liters of oxygen we do not want to give them high flow oxygen unless they really need it because that increases the amount of free radicals that are coming off the dying muscle in the blood into the bloodstream from the cardiac muscle and causing more problems for our body low oxygen lots of uh low oxygen saturations high concentration notice neurorespiratory distress and oxygen sats above 94 we don't give them oxygen we just that's it's not necessary if you're trained to do the 12 leads you put those on follow your protocols about transmission and we will look at the ekgs we have here and let you guys practice with that administer aspirin 325 milligrams or if you're using the baby aspirins 324 but give them four baby aspirin by mouth have them chew it they do not give it if they may aspirate if they can't control their own airway or they've already had their dose allergies to aspirin gi bleeds or they're already taking a blood thinner if they've got atrial fibrillation or dvts and they're on a blood thinner then you don't want to give them the aspirin again it just will make things worse so the aspirin we prefer the chewable kind this is the orange flavored very tasty much preferred over the other cherry kind nitroglycerin is one of those drugs that is starting to not be a primary drug for cardiac they do have it prescribed to them for chest pain we're going to keep it as an option but that it they have to be having chest pain from that cardiac issue you give them the the patient has the nitroglycerin on their on their person so the nitro stat either the pills or the spray they have to have a blood pressure of at least a hundred so you check the blood pressure they can't have had viagra cialis or any other drug for erectile dysfunction within the last 48 or 72 hours and then you call into medical control and say medical control i've got a 65 year old male severe chest pain has nitroglycer prescribed blood pressures over 90 or over 100 over 110 over 90 whatever the blood pressure is and ask for permission to give up to three doses of nitroglycerin every five minutes maintaining the blood pressure of above 100 doctor will confirm that or deny it and we'll move forward with what then what we need to do after five minutes of giving the first dose ask for the scale of one to ten on the pain if the pain is decreased we're making progress take a blood pressure if it's at least a hundred and medical control is authorized more than one dose give them a second dose if they haven't authorized it ask them if you can so you're making progress there but remember go with your protocol and what's appropriate under your guidelines after you give the three doses the chest pain persists get into the hospital it's probably not the cardiac issue you're thinking it is and we need to get them into a medical care as quick as possible all right let's talk about some other cardiovascular disorders coronary artery disease you get that cholesterol buildup the fatty deposits in the walls of the arteries it narrows them constricting flow so you've got that blockage in your pipes so you don't get a good flow through there you increase the workload on the heart it can't keep up because your pipes are blocked and you start having chest discomfort risk factors heredity your family history says there's a high likelihood you're going to have coronary artery disease as you get older you have higher risk hypertension if you don't control it you go into a higher risk factor obesity lack of exercise elevated blood cholesterol triglycerides smoking cigarette smoking decreases the ability of your vascular system to contract and relax when needed so we'll have chest cane from the insufficient flow like i said the arteries are restricted you can't get good blood flow and you need more and your heart says hey slow down i'm going to give you pain until you do when you re uh reduce that stress or exercise then the pain disappears so it's a i started having chest pain i sat down relaxed and disappeared that is angina pectoris it goes away nitroglycerin gets rip rid of it almost automatically so it dilates the blood vessel re improves the flow the heart says hey that's cool i'm good it's just as good as sitting down and relaxing for a few minutes if the systems go away with rest then it's angina pectoris if they don't go away it may be myocardial infarction if you have any question treat treat them as a myocardial infarction get them to the hospital that has a cath lab and let's move forward give them oxygen give them nitro aspirin whatever your protocol allows get the 12 lead send it to the hospital and transport to the appropriate hospital know which hospitals in our your region have the capabilities to accept a cardiac alert patient one that need can bypass the er and go right to the cath lab myocardial infarction sometimes these vessels get completely blocked with plaque the plaque flakes off because it's kind of kind of tough inside the vessels and when they expand and contract it breaks platelets see that break as a break in the artery so it sends in all the platelets to block it what we don't want it to to bleed out there so your your body's responding appropriately it just didn't realize it wasn't a break of the artery it was just a break of the plaque on the inside we can also have a thrombus one of these clots breaks loose and goes to a smaller part of the arteries and causes the blockage there they include the blood flow downstream so what we do when that happens is they go in with a cardiac cath either break up the clot or they put a stent in to increase the diameter of that area and it puts a little framework inside that builds a little scaffolding to keep the artery open so the blood will flow so here's a illustration of what that looks like so you have coronary blockage right here and you normally we know these arteries go around this area so this area of the heart here is without blood flow that doesn't go well when we're trying to pump blood because you don't have a fully functioning heart so you can't pump the blood as hard as you used to so ischemia is when the tissue is dying that's that area that's not getting blood flow because the tissue is dead the conductivity doesn't work through it either so you start having entryway issues and the paths are changing and it changes what the ek looks like that's where you hear a stemia st elevation myocardial infarction a stemi is when that electrical pathway changes and you can identify that on the ekg as st elevation those dysrhythmias will set up a series of events that can cause problems with the heart and actually push the heart into v-fib or v-tac so that becomes the uh the end result that's a really bad option hopefully we catch things when they're still having chest pain and we can get them corrected before we get to that point acute myocardial infarction causes the heart to not pump efficiently if the heart doesn't pump efficiently then you have hypoperfusion hypo fusion is shock so being that is originating from the cardio cardiac system is the cardiogenic shock cardiac arrest within two hours of onset of symptoms is considered sudden death most people deny that it's chest pain that is cardiac related i know a lot of people that have had exercise induced indigestion their chest hurts but it must be the chili dog they ate two days ago it's not cardiac it can't be cardiac so denial is a huge issue here a lot of our sudden cardiac arrests are really not sudden it's just denied until they get to the death point treatment of ami at the hospital a preferred treatment right now is balloon angioplasty they go in with the roto-rooter they also have fiber fibrinolytics it's kind of like drano that they put in and it goes through and busts open clots the complications here is that busts open any clot it found it finds within the body so as simple as you tried to start two ivs and you only got the second one to work they have a hole in the skin it will break open the cloth there and they will bleed from that clot or anywhere else they may have had any issues so our preferred method is angioplasty after the fact they typically go on aspirin a day to reduce the clotting factors and intake some beta blockers to reduce the function of the heart so that it doesn't beat as hard and causes many problems treatment of the infarct myocardial infarction abc's always doing that and then look for the pattern the chest discomfort dyspnea nausea syncope that's the same as angina pectoris myocardium infarction so we're going to treat them all as biocardial infarction until we prove it otherwise typically that's not done until we get to the hospital so every chest painter gets treated as the most serious kind until we actually get where we get this vanity of care get them to the hospital apply a large dose of diesel therapy a nice easy ride not to get them spooked but on the way to the hospital get the ekg call als get them in route watch out for cardiac arrest do not hook up the aed until they are actually in cardiac arrest but don't stuff it underneath the bench seat have it ready easily to get to and maybe keep an extra person in the back just in case use your aspirin and nitro based on your protocols if they have any type of pulmonary edema now you're talking congestive heart failure maybe it's the right side of the heart that's having the myocardial infarction and causing the heart not to pump efficiently to push the blood through the lungs so they have a hard time getting the blood through the lungs tissue perfusion's bad they can't exercise they get that fluid buildup things just are not going right for them so they're having the heart failure the right side you get the pressure in the right atrium and the superior vena cava jugular vein distinction they stick out on both sides you get the pitolo edema swelling in the gut left side you get the buildup in the avioli gas exchange is impaired lots of pulmonary edema and typically life threatening remember the left side is the the part that pumps most the blood around the body assessment of the heart failure you have a history medication for controlling fluid levels lasiks big one there uh pitolo edema swelling of the belly in the buttocks jvd jugular vein distension all things telling you the fat the fluid is backing up in the system so you find pulmonary edema when you do the the listen to the lungs difficulty breathing crackles pink frothy sputum all bad things sending those back up into the lungs so for your treatment you're going to have your primary assessment may need ventilation use your opks op rst and sample get a good history of the cardiovascular system and take multiple sets of vital signs that's going to give you some trending really good to help you function there treat whatever fine findings you have call als they have some more advanced treatments for pulmonary edema and just a hint the the preferred treatment for pulmonary edema for als is nitroglycerin it is not for you to use because that's not in our protocols to give nitroglycerin for pulmonary edema but it's something that you may see definitely consider the cpap it's a good function there uh aneurysms we get some type of weakening in the wall in the artery somewhere in the body and the pressure actually pushes against it and eventually causing it to burst the aortic aneurysm the abdominal arc aortic aneurysm the aaa is one of those life-threatening things you find it when you do in your belly you find a pulsating mass in there do not call your partner over to say hey check this out the more you poke it the more likely it is to burst we don't want that this is kind of what it looks like you've got that bubble on top eventually it bursts and in two or three seconds the person bleeds out completely into their gut so that's something we don't want to have happen that's treatment is rapid transport to the hospital so as always if you have any questions feel free to jump in there and ask bring them to class and we'll see you there thanks bye