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22-1

Objectives
22-2

Anatomy Review
22-3

Circulatory System
• Components
– Cardiovascular system
– Lymphatic system
22-4

Cardiovascular System
1. Pump (the heart)
2. Fluid (blood)
3. Container (the blood vessels)
22-5

Lymphatic System
• Lymph
• Lymph nodes
• Lymph vessels
• Tonsils
• Spleen
• Thymus gland
22-6

Circulatory System Functions
• Transport
• Maintenance of body temperature
• Protection
22-7

Heart
22-8

Heart Valves
22-9

Conduction System
[Insert figure 22-3]
22-10

Major Blood Vessels
22-11

Arteries
22-12

Coronary Arteries
22-13

Carotid Arteries
22-14

Brachial and Radial Arteries
22-15

Lower Extremity Arteries
22-16

Arterioles and Capillaries
• Arterioles
– Smallest branches of arteries
• Capillaries
– Walls are one cell thick
– Exchange wastes, fluids, and nutrients between the blood and tissues
– Connect arterioles and venules
22-17

Venules and Veins
• Venules
– Smallest branches of veins
• Veins
– Low-pressure vessels
– Major veins
• Pulmonary veins
• Superior vena cava
• Inferior vena cava
22-18

Blood
• Formed elements
– Red blood cells (erythrocytes)
– White blood cells (leukocytes)
– Platelets (thrombocytes)
• Plasma
22-19

Physiology of Circulation
22-20

Double Pump
22-21

• Pulse
– Central
– Peripheral
Perfusion
• Perfusion
– Hypoperfusion
(shock)
• Blood pressure
– Systolic
– Diastolic
22-22

Signs and Symptoms of Shock
• Restlessness, anxiety, or altered mental status
• Pale, cyanotic, cool, clammy skin
• Rapid, weak pulse
• Rapid, shallow breathing
• Nausea and vomiting
• Reduction in total blood volume
• Low or decreasing blood pressure
22-23

Cardiovascular Disease
22-24

Terminology
• Cardiovascular disease
• Coronary heart disease (CHD)
• Coronary artery disease (CAD)
• Acute Coronary Syndrome (ACS)
22-25

Acute Coronary Syndromes
• Conditions caused by temporary or permanent blockage of a coronary artery
• Common causes
• Arteriosclerosis
• Atherosclerosis
22-26

Arteriosclerosis and Atherosclerosis
22-27

Risk Factors
Modifiable
Factors
• Diabetes mellitus
• High blood pressure
• Elevated blood cholesterol
• Tobacco smoke
• Lack of exercise
• Obesity
Nonmodifiable
Factors
• Family history
• Gender
• Race
• Increasing age
Contributing
Factors
• Stress
• Depression
• Heavy alcohol intake
22-28

Myocardial Ischemia
• Ischemia
– A reduced blood supply to an organ or tissue
22-29

Angina Pectoris
• Angina pectoris
– “Choking in the chest”
– Symptom of coronary artery disease
– Heart’s need for oxygen exceeds its supply
22-30

Angina Pectoris
• Stable angina
• Unstable angina
22-31

Acute Myocardial Infarction
22-32

Chest Discomfort
• “Pressing”
• “Tight”
• “Squeezing”
• “Viselike”
• “Aching”
• “Heaviness”
•
•
• “Dull”
• “Burning”
“Crushing”
“Smothering”
Indigestion-type symptoms
22-33

Associated Symptoms
• Palpitations
• Fainting
• Sweating
• Shortness of breath
• Nausea
22-34

Older Adults
• Unexplained newonset or worsened difficulty breathing with exertion
• Unexplained nausea, vomiting
• Sweating
• Unexplained tiredness
• Change in mental status
• Weakness
• Fainting
• Abdominal discomfort
Atypical Presentation
Diabetic
Individuals
• Change in mental status
• Weakness
• Fainting
• Lightheadedness
• Shoulder/back pain
Women
• Pain or discomfort in the chest, arms, back, shoulders, neck, jaw, or stomach
• Anxiety, dizziness
• Shortness of breath
• Weakness
• Unusual tiredness
• Cold sweats
• Nausea, vomiting
22-35

Congestive Heart Failure
• Congestive heart failure = CHF
– CHF = pump failure
– Left ventricular failure
• Blood backs up into the lungs (pulmonary edema)
– Right ventricular failure
• Blood backs up and causes congestion in organs and tissues
22-36

Congestive Heart Failure
• Possible assessment findings and symptoms
– Fatigue
– Nausea
– Palpitations
– Unexplained weight gain
– Shortness of breath
– Dyspnea with exertion
– Paroxysmal nocturnal dyspnea
– Orthopnea
– Swelling of the feet and ankles
– Swelling around the lower back
– Jugular venous distention
22-37

Hypertensive Emergencies
• Hypertension
– Sustained elevation of the systolic or diastolic blood pressure
– Sustained systolic blood pressure of 140 mm Hg or higher or
– Sustained diastolic pressure of 90 mm Hg or higher
22-38

Hypertensive Emergencies
• Prehypertension
– Systolic blood pressure between 120 and 139 or
– Diastolic blood pressure between 80 and 89 on multiple readings
22-39

Hypertensive Emergencies
• Essential hypertension
– No identifiable cause
• Secondary hypertension
– Identifiable cause
22-40

Hypertensive Emergencies
• Hypertensive emergencies
– Situations that require rapid lowering of blood pressure to prevent or limit organ damage
• Systolic blood pressure greater than 160 mm Hg
• Diastolic pressure greater than 94 mm Hg
22-41

Hypertensive Emergencies
• Possible assessment findings and symptoms
– Responsive, altered mental status, or unresponsive
– Strong, bounding pulse
– Skin color may be normal, pale, or flushed
– Skin hydration may be dry or moist
– Skin temperature may be warm or cool
– Headache
– Ringing in the ears
– Nausea/vomiting
– Dizziness
– Shortness of breath
– Paroxysmal nocturnal dyspnea
– Orthopnea
– Nosebleed
– Seizures
22-42

Cardiogenic Shock
• Pump failure
22-43

Cardiogenic Shock
• Possible assessment findings and symptoms
– Altered mental status
– Jugular venous distention
– Labored breathing
– Tachycardia
– Hypotension
– Crackles, with or without wheezes
– Pale, cool, clammy skin
– Pulmonary edema
22-44

Patient Assessment
22-45

Patient Assessment
• Scene size-up
• General impression
• Primary survey
22-46

Patient Assessment
• Establish patient priorities.
• Determine the need for additional resources.
• Make a transport decision.
22-47

Patient Assessment
• Secondary survey
– SAMPLE history
– OPQRST
– Physical exam
• Focused exam if patient responsive
• Rapid medical assessment if unresponsive
22-48

Emergency Care
• Position of comfort
• Provide reassurance
• MONA
– M orphine (ALS only)
– O xygen
– N itroglycerin
– A spirin
22-49

Emergency Care
• Aspirin
– If ordered by medical direction (and there are no contraindications), give as soon as possible after onset of chest discomfort.
22-50

Emergency Care
• Nitroglycerin
– Find out if the patient has prescribed nitroglycerin.
– Find out if the medication is with the patient.
– Find out when the last dose was taken.
– Contact medical direction.
– If instructed to do so, assist the patient with its use.
22-51

Cardiac Arrest
22-52

Cardiac Arrest
•
Possible Causes
• Heart and blood • Severe electrical vessel diseases shock
• Choking or • Poisoning or drug respiratory arrest overdose
• Seizures • Drowning
• Diabetic • Suffocation emergency
• Trauma
Severe allergic reaction
• Severe bleeding
• Abnormalities present at birth
22-53

Sudden Cardiac Death
• Sudden cardiac death
– The unexpected death from cardiac causes early after symptom onset
(immediately or within 1 hour) or without the onset of symptoms
22-54

Chain of Survival
1. Early recognition and activation of the
EMS system
22-55

2. Early CPR
Chain of Survival
22-56

Chain of Survival
3. Early defibrillation (if indicated)
22-57

Chain of Survival
4. Effective advanced life support
5. Integrated post-cardiac arrest care
22-58

The EMT and the Chain of Survival
• Standard precautions
• Using an AED
• Requesting ALS backup
• Suctioning
• Airway adjuncts
• Bag-mask device
• Flow-restricted, oxygen-powered ventilation device
• Safe lifting/ moving
• Interviewing techniques
• Performing effective
CPR
• Assisting ALS personnel
22-59

If no pulse, begin CPR unless …
• Valid Do Not Resuscitate (DNR) order exists
• Signs of obvious death
– Decapitation or other obvious mortal injury
– Putrefaction (decomposition)
– Extreme dependent lividity
– Rigor mortis
22-60

Assessment and Emergency Care
• Scene size-up
• General impression
• Assess responsiveness
– If responsive, perform primary survey
– If unresponsive, check breathing
• If not breathing, check pulse for up to 10 sec
22-61

Patient Age
CPR Review
Adult
More than 12-
14 years
Child
1 to 12
–14 years
Rescue Breaths
Location of
Pulse Check
10
–12 breaths/min
1 every 5 –6 sec
Carotid
Chest
Compressions
Heel of one hand, other hand on top
Infant
Under 1 year
12
–20 breaths/min
1 every 3 –5 sec
12
–20 breaths/min
1 every 3 –5 sec
Carotid or femoral
Heel of 1 hand or same as for adult
Brachial
2 fingers (1 rescuer) or 2 thumbs with the fingers of both hands encircling the chest
(2 rescuers)
22-62

Depth of Chest
Compressions
CPR Review
Adult
At least 2 in
(5 cm)
Child
At least ⅓ the chest depth
(about 2 in [5 cm])
Infant
At least ⅓ the chest depth
(about 1.5 in [4 cm])
Rate of Chest
Compressions
At least 100/minute (all ages)
Ratio of Chest
Compressions to Rescue
Breaths (One
Cycle)
1 or 2 rescuers:
30 compressions to 2 breaths (30:2)
1 rescuer:
30 compressions to 2 breaths (30:2)
2 rescuers:
15 compressions to 2 breaths (15:2)
1 rescuer:
30 compressions to 2 breaths (30:2)
2 rescuers:
15 compressions to 2 breaths (15:2)
22-63

Defibrillation
• Manual defibrillators
22-64

Defibrillation
• Implantable cardioverter-defibrillator
(ICD)
22-65

Defibrillation
• Automated external defibrillator (AED)
22-66

Automated External Defibrillators
• Fully automated external defibrillator
• Semiautomated external defibrillator
22-67

Automated External Defibrillators
[Insert figure 22-16]
22-68

EMTs and AEDs
• Not all patients who have chest pain experience a cardiac arrest
• An AED should only be applied to a patient who is unresponsive, apneic, and pulseless
22-69

AEDs
Advantages
• Easy to operate
• Less training required to operate than with a manual defibrillator
• Remote, hands-free, hands-off defibrillation
22-70

Medical Direction and
Quality Management
• AED use requires authorization from a medical director.
• Quality management review of calls involving use of an AED
22-71

Special Considerations
• Place AED pads at least 3 in (8 cm) from a pacemaker or implanted defibrillator.
• AED pads —ensure no air pockets
• Do not use the AED when patient or rescuers are in contact with water or metal.
• Remove medication patches from patient’s chest.
• Make sure oxygen is not flowing over patient’s chest before delivering shocks.
22-72

AED Operation
[Insert skill drill 22-3 step 1]
22-73

AED Operation
[Insert skill drill 22-3 step 2]
22-74

AED Operation
[Insert skill drill 22-3 step 3]
22-75

AED Operation
[Insert skill drill 22-3 step 4]
22-76

Inappropriate Delivery of Shocks
• To avoid delivering inappropriate shocks:
– Attach an AED only to unresponsive, apneic, pulseless patients
– “Analyze” only when cardiac arrest has been confirmed and all movement has stopped
– Avoid using cell phones, radios, or other devices that emit electrical signals during rhythm analysis
22-77

Interruption of CPR
• CPR must be stopped while you are analyzing the patient’s rhythm and delivering shocks.
• Resume CPR immediately after delivering a shock or when no shock is indicated.
22-78

Postresuscitation Care
• If the patient begins moving, check pulse and breathing.
• Give supplemental oxygen.
• Secure patient to stretcher.
• Use proper lifting and moving techniques.
• Keep AED attached to patient during transport.
• Reassess every 5 minutes en route.
22-79

Cardiac Arrest During Transport
• If a patient stops breathing and becomes pulseless during transport
– Stop the vehicle
– Start CPR and apply the AED
– Analyze the rhythm as soon as the AED is ready
– Deliver a shock, if indicated
– Immediately resume CPR
– Continue resuscitation (and transport) per local protocol
22-80

Support of the Family
• Allow family members to be present, unless they interfere with resuscitation efforts.
• Be sympathetic.
• Listen with empathy.
• Do not give false hope or reassurance.
22-81

When to Stop CPR
• You should stop CPR only if
– Effective breathing and circulation have returned
– The scene becomes unsafe
– You are too exhausted to continue
– You transfer patient care to a healthcare professional with equal or higher certification
– A physician assumes responsibility for the patient
22-82

AED Maintenance
• Perform maintenance procedures according to the manufacturer’s recommendations.
• AED self-test
• Manual AED self-test
• Always have extra batteries on hand.
22-83

Training and Sources of Information
• American Heart Association
• The Health & Safety Institute
• American Red Cross
• National Safety Council
• Use practice drills to maintain skill proficiency.
22-84

Questions?
22-85