Chapter 14
Cardiovascular
Emergencies
National EMS Education
Standard Competencies (1 of 5)
Pathophysiology
Applies fundamental knowledge of the
pathophysiology of respiration and perfusion
to patient assessment and management.
National EMS Education
Standard Competencies (2 of 5)
Medicine
Applies fundamental knowledge to provide
basic emergency care and transportation
based on assessment findings for an acutely
ill patient.
National EMS Education
Standard Competencies (3 of 5)
Cardiovascular
• Anatomy, signs, symptoms, and
management of:
– Chest pain
– Cardiac arrest
National EMS Education
Standard Competencies (4 of 5)
Cardiovascular (cont’d):
• Anatomy, physiology, pathophysiology,
assessment, and management of:
– Acute coronary syndrome
• Angina pectoris
• Myocardial infarction
– Aortic aneurysm/dissection
National EMS Education
Standard Competencies (5 of 5)
Cardiovascular (cont’d):
• Anatomy, physiology, pathophysiology,
assessment, and management of:
– Thromboembolism
– Heart failure
– Hypertensive emergencies
Introduction (1 of 2)
• Cardiovascular disease has been leading
killer of Americans since 1900.
• Accounts for 1 of every 2.8 deaths
Introduction (2 of 2)
• EMS can help reduce deaths by:
– Encouraging healthy life-style
– Early access
– More CPR training of laypeople
– Public access to defibrillation devices
– Recognizing need for advanced life support
(ALS)
Anatomy and Physiology (1 of 21)
• Heart’s job is to pump blood to supply
oxygen-enriched red blood cells to tissues.
• Divided into left and right sides
Anatomy and Physiology (2 of 21)
Anatomy and Physiology (3 of 21)
• Atria receives incoming blood, and
ventricles pump outgoing blood.
• One-way valves keep blood flowing in the
proper direction.
• Aorta, body’s main artery, receives blood
ejected from left ventricle.
Anatomy and Physiology (4 of 21)
Cardiac A&P
Four Chambers of the Heart
Right Atrium
Left Atrium
Receives blood from
veins; pumps to right
ventricle.
Receives blood from
lungs; pumps to left
ventricle.
Right Ventricle
Left Ventricle
Pumps blood to the
lungs.
Pumps blood through
the aorta to the body.
Anatomy and Physiology (5 of 21)
• Heart’s electrical system controls heart rate
and coordinates atria and ventricles.
• The cardiac muscle is the myocardium.
• Automaticity allows cardiac muscles to
spontaneously contract.
Anatomy and Physiology (6 of 21)
Electrical conduction system of the heart
Cardiac Conduction System
Anatomy and Physiology (7 of 21)
Anatomy and Physiology (8 of 21)
• Autonomic nervous system (ANS) controls
involuntary activities.
• The ANS has two parts:
– Sympathetic nervous system
• “Fight-or-flight” system
– Parasympathetic nervous system
• Slows various bodily functions
Anatomy and Physiology (9 of 21)
• The myocardium must have a continuous
supply of oxygen and nutrients to pump
blood.
• Increased oxygen demand by myocardium
is supplied by dilation (widening) of
coronary arteries.
Anatomy and Physiology (10 of 21)
• Stroke volume is the volume of blood
ejected with each ventricular contraction.
• Coronary arteries are blood vessels that
supply blood to heart muscle.
Anatomy and Physiology (11 of 21)
• Coronary arteries start at the first part of the
aorta:
– Right coronary artery
– Left coronary artery
Anatomy and Physiology (12 of 21)
Blood Vessels
Anatomy and Physiology (13 of 21)
• Arteries supply oxygen to different parts of
the body:
– Right and left carotid
– Subclavian
– Brachial
– Radial and ulnar
– Right and left iliac
Anatomy and Physiology (14 of 21)
• Arteries supply
oxygen to different
parts of the body
(cont’d):
– Right and left
femoral
– Anterior and
posterior tibial and
peroneal
Anatomy and Physiology (15 of 21)
• Arterioles and capillaries are smaller.
– Capillaries connect arterioles to venules.
• Venules are the smallest branches of the
veins.
– Vena cavae return blood to the heart.
• Superior vena cava: from the head and arms
• Inferior vena cava: from the abdomen,
kidneys, and legs
Anatomy and Physiology (16 of 21)
• Blood consists of:
– Red blood cells,
which carry oxygen
– White blood cells,
which fight infection
– Platelets, which help
blood to clot
– Plasma, which is the
fluid cells float in
Anatomy and Physiology (17 of 21)
• Blood pressure is the pressure of circulating
blood against artery walls.
– Systolic blood pressure
• The max pressure generated by left ventricle
• Top number in the reading
– Diastolic blood pressure
• The pressure while the left ventricle is at rest
Anatomy and Physiology (18 of 21)
• A pulse is felt when blood passes through
an artery during systole.
– Peripheral pulses felt in the extremities
– Central pulses felt near the body’s trunk
Anatomy and Physiology (19 of 21)
Brachial
Carotid
Femoral
Radial
Posterior tibial
Dorsalis pedis
Anatomy and Physiology (20 of 21)
• Cardiac output is the volume of blood that
passes through the heart in 1 min.
– Heart rate × volume of blood ejected with each
contraction (stroke volume)
• Perfusion is the constant flow of oxygenated
blood to tissues
Anatomy and Physiology (21 of 21)
• Good perfusion requires:
– A well-functioning heart
– An adequate volume of blood
– Appropriately constricted blood vessels
• If perfusion fails, cellular and eventually
patient death occur.
Pathophysiology (1 of 26)
• Chest pain usually stems from ischemia,
which is decreased blood flow.
– Ischemic heart disease involves a decreased
blood flow to one or more portions of the heart.
– If blood flow is not restored, the tissue dies.
Pathophysiology (2 of 26)
• Atherosclerosis is
the buildup of
calcium and
cholesterol in the
arteries.
– Can cause
occlusion of
arteries
– Fatty material
accumulates with
age.
Pathophysiology (3 of 26)
Pathophysiology (4 of 26)
• A thrombo-embolism is a blood clot
floating through blood vessels.
• If clot lodges in coronary artery, acute
myocardial infarction (AMI) results.
Pathophysiology (5 of 26)
• Coronary artery disease is the leading
cause of death in the US.
• Controllable AMI risk factors:
– Cigarette smoking, high blood pressure, high
cholesterol, high blood glucose level (diabetes),
lack of exercise, and stress
Coronary Artery Disease
• Conditions that narrow or block arteries of heart
• Often result from fatty deposit build-up on inner
walls of arteries
• Build-up narrows inner vessel diameter,
restricts flow of blood
Coronary Artery Disease
• Thrombus—occlusion of blood flow caused
by formation of a clot on rough inner surface
of diseased artery
• Thrombus can break loose and form an
embolism
• Emboli can move to occlude flow of blood
downstream in a smaller artery
continued
Coronary Artery Disease
• Reduced blood supply to myocardium
causes emergency in majority of cardiacrelated medical emergencies
• Chest pain is most common symptom of
reduced blood supply
Aneurysm
• Weakened
sections of blood
vessels begin to
dilate (balloon)
• Bursting can
cause rapid, lifethreatening
internal bleeding
Pathophysiology (6 of 26)
• Uncontrollable AMI risk factors:
– Older age, family history, and being a male
• Acute coronary syndrome (ACS) is caused
by myocardial ischemia.
– Angina pectoris
– Acute myocardial infarction
Pathophysiology (7 of 26)
• Angina pectoris occurs when the heart’s
need for oxygen exceeds supply.
– Crushing or squeezing pain
– Does not usually lead to death or permanent
heart damage
– Should be taken as a serious warning sign
Pathophysiology (8 of 26)
• Unstable angina
– In response to fewer stimuli than normal
• Stable angina
– Is relieved by rest or nitroglycerin
• Treat angina patients like AMI patients.
Angina Pectoris
• Chest pain caused by insufficient blood flow
to the myocardium
• Typically due to narrowed arteries secondary
to coronary artery disease
• Pain usually during times of increased
myocardial oxygen demand, such as
exertion or stress
Pathophysiology (9 of 26)
• AMI pain signals actual death of cells in
heart muscle.
– Once dead, cells cannot be revived.
– “Clot-busting” (thrombolytic) drugs or
angioplasty within 1 hour prevent damage.
– Immediate transport is essential.
Pathophysiology (10 of 26)
• Signs and symptoms of AMI
– Weakness, nausea, sweating
– Chest pain that does not change
– Lower jaw, arm, back, abdomen, neck pain
– Irregular heartbeat and syncope (fainting)
– Shortness of breath (dyspnea)
Pathophysiology (11 of 26)
• Signs and symptoms of AMI (cont’d)
– Pink, frothy sputum
– Sudden death
• AMI pain differs from angina pain
– Not always due to exertion
– Lasts 30 minutes to several hours
– Not always relieved by rest or nitroglycerin
Pathophysiology (12 of 26)
• AMI patients may not realize they are
experiencing a heart attack.
• AMI and cardiac compromise physical
findings:
– Fear, nausea, poor circulation
– Faster, irregular, or bradycardic pulse
Pathophysiology (13 of 26)
• AMI and cardiac compromise physical
findings (cont’d):
– Decreased, normal, or elevated BP
– Normal or rapid and labored respirations
– Patients express feelings of impending doom.
Pathophysiology (14 of 26)
• Three serious consequences of AMI:
– Sudden death
• Resulting from cardiac arrest
– Cardiogenic shock
– CHF
Pathophysiology (15 of 26)
• Arrhythmias:
heart rhythm
abnormalities
Source: From Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.
– Premature
ventricular
contractions
– Tachycardia
– Bradycardia
Source: From Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.
Pathophysiology (16 of 26)
• Arrhythmias
(cont’d)
– Ventricular
tachycardia
Source: From Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.
Source: From Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.
– Ventricular
fibrillation
Pathophysiology (17 of 26)
• Defibrillation restores cardiac rhythms.
– Can save lives
– Initiate CPR until a defibrillator is available.
• Asystole: no heart electrical activity
– Reflects a long period of ischemia
– Nearly all patients will die.
Source: From Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.
Electrical
Malfunction of the Heart
• Malfunction of heart’s electrical system
generally results in dysrhythmia
• Dysrhythmias include bradycardia,
tachycardia, and rhythms that may be
present when there is no pulse
Congestive
Heart Failure (CHF)
• Inadequate pumping of the heart
• Often leads to excessive fluid build-up in
lungs and/or body
• May be brought on by diseased heart valves,
hypertension, obstructive pulmonary disease
• Often a complication of AMI
Progression of CHF
• Patient sustains AMI
• Myocardium of left ventricle dies
• Because of damage to left ventricle, blood
backs up into pulmonary circulation and
lungs
• If untreated, left heart failure commonly
causes right heart failure
Signs and
Symptoms of CHF
• Tachycardia
• Dyspnea and cyanosis
• Normal or elevated blood pressure
• Diaphoresis
• Pulmonary edema
continued
Signs and
Symptoms of CHF
• Anxiety or confusion due to hypoxia
• Pedal edema
• Engorged, pulsating neck veins (late sign)
• Enlarged liver and spleen
continued
Signs and
Symptoms of CHF
Acute Myocardial
Infarction (AMI)
• Death of a portion of the myocardium due to
lack of oxygen
• Coronary artery disease is usually the
underlying reason
Mechanical
Malfunctions of the Heart
• Angina pectoris
• Acute myocardial infarction (AMI)
• Congestive Heart Failure (CHF)
Pathophysiology (18 of 26)
• Cardiogenic shock
– Often caused by heart attack
– Heart lacks power to force enough blood
through circulatory system
– Inadequate oxygen to body tissues causes
organs to malfunction.
Pathophysiology (19 of 26)
• Cardiogenic shock (cont’d)
– Often caused by a heart attack
– Heart lacks the power to pump
– Recognize shock in its early stages.
• Congestive heart failure
– Often occurs a few days following heart attack
Pathophysiology (20 of 26)
• Congestive heart failure
– Increased heart rate and enlargement of left
ventricle no longer make up for decreased heart
function
– Lungs become congested with fluid
– May cause dependent edema
Pathophysiology (21 of 26)
• Hypertensive emergencies
– Systolic pressure greater than 160 mm Hg
– Common symptoms
• Sudden, severe headache
• Strong, bounding pulse
• Ringing in the ears
Pathophysiology (22 of 26)
• Hypertensive emergencies (cont’d)
– Common symptoms
• Nausea and vomiting
• Dizziness
• Warm skin (dry or moist)
• Nosebleed
Pathophysiology (23 of 26)
• Hypertensive emergencies (cont’d)
– Common symptoms include altered mental
status and pulmonary edema.
– If untreated, can lead to stroke or dissecting
aortic aneurysm.
– Transport patients quickly and safely.
Pathophysiology (24 of 26)
• Aortic aneurysm is weakness in the wall of
the aorta.
– Susceptible to rupture
– Dissecting aneurysm occurs when inner layers
of aorta become separated (Table 14-1).
– Primary cause: uncontrolled hypertension
Pathophysiology (25 of 26)
Pathophysiology (26 of 26)
• Aortic aneurysm (cont’d)
– Signs and symptoms
• Very sudden chest pain
• Comes on full force
• Different blood pressures
– Transport patients quickly and safely.
Patient Assessment
• Patient assessment steps
–
–
–
–
Scene size-up
Primary assessment
History taking
Secondary assessment
– Reassessment
Scene Size-up
• Scene safety
– Ensure the scene is safe.
– Follow standard precautions.
• Mechanism of injury (MOI)/nature of illness
(NOI)
– Clues often include report of chest pain,
difficulty breathing, loss of consciousness.
– Obtain clues from dispatch, the scene,
patient, bystanders
Primary Assessment (1 of 2)
• Form a general impression.
– If unresponsive, pulseless, or apneic, assess
for use of AED.
• Airway and breathing
– If difficulty breathing: apply oxygen via
nonrebreathing mask; if not breathing: give
100% oxygen via bag-mask device.
– CHF patients: use CPAP.
Primary Assessment (2 of 2)
• Circulation
– Check skin color, temperature, condition.
• Transport decision
– Transport in a stress-relieving manner.
History Taking (1 of 2)
• Investigate the chief complaint (eg, chest
pain, difficulty breathing).
– Ask about recent trauma.
• Obtain a SAMPLE history from a conscious
patient.
– Use OPQRST (Table 14-2).
History Taking (2 of 2)
Secondary Assessment
• Physical examination
– Focus on cardiac and respiratory systems.
• Circulation
• Respirations
• Vital signs
– Obtain a complete set of vital signs
– If available, use pulse oximetry
Reassessment (1 of 4)
• Reassess vital signs every 5 min or when
patient’s condition changes significantly.
• Sudden cardiac arrest is always a risk.
• Interventions
– Give oxygen.
– Assist unconscious patients with breathing.
– Follow local protocol for administration of lowdose aspirin or prescribed nitroglycerin (see
Skill Drill 14-1).
Reassessment (2 of 4)
Treatment
• Indications for administering nitroglycerin
– Chest pain
– History of cardiac problems and prescribed
nitroglycerin
– Patient has nitroglycerin
– Medical direction
authorizes administration
continued
Treatment
• Contraindications for administering
nitroglycerin
– Systolic blood pressure less than 90–100
(consult local protocol)
– Patient has taken Viagra or similar drug for
erectile dysfunction within 48–72 hours
continued
Treatment
• Indications for administering aspirin
– Chest pain
– Ability to safely swallow
– Medical control authorization
continued
Treatment
• Contraindications for administering aspirin
–
–
–
–
Inability to swallow
Allergy to aspirin
History of asthma
Patient already taking other anti-clotting
medications
Reassessment (3 of 4)
• Interventions (cont’d)
– If cardiac arrest occurs, perform CPR
immediately until an AED is available.
• Reassess your interventions.
• Provide rapid patient transport.
Reassessment (4 of 4)
• Communication and documentation
– Alert emergency department about patient
condition and estimated time of arrival.
– Report to hospital while en route.
– Document assessment and interventions.
Heart Surgeries and
Pacemakers (1 of 6)
• Many open-heart operations have been
performed in the last 20 years.
• Coronary artery bypass graft (CABG)
– Chest or leg blood vessel is sewn from the aorta
to a coronary artery beyond the point of
obstruction.
• Others have implanted cardiac pacemakers.
Heart Surgeries and
Pacemakers (2 of 6)
• Percutanous transluminal coronary
angioplasty (PTCA)
– A tiny balloon is inflated inside a narrowed
coronary artery.
• Patients who have had open-heart
procedures may have long chest scar.
Heart Surgeries and
Pacemakers (3 of 6)
• Cardiac pacemakers
– Maintain regular cardiac rhythm and rate
– Deliver electrical impulse through wires in direct
contact with the myocardium
– Implanted under a heavy muscle or fold of skin
in the upper left portion of the chest
Heart Surgeries and
Pacemakers (4 of 6)
• Cardiac pacemakers
(cont’d)
– This technology is very
reliable.
Source: © Carolina K. Smith, MD/ShutterStock, Inc.
– Pacemaker malfunction
can cause syncope,
dizziness, or weakness
due to an excessively
slow heart rate.
• Transport patients
promptly and safely.
Heart Surgeries and
Pacemakers (5 of 6)
• Automatic implantable cardiac defibrillators
(AICDs)
– Used by some patients who have survived
cardiac arrest due to ventricular fibrillation
– Monitor heart rhythm and shock as needed.
– Treat chest pain patients with AICDs like they
are experiencing a heart attack.
Heart Surgeries and
Pacemakers (6 of 6)
• AICDs (cont’d)
– Electricity is low; it
will not affect
responders.
– When an AED is
used, do not place
patches directly
over pacemaker.
Cardiac Arrest
• The complete cessation of cardiac activity
• Absence of a carotid pulse
• Was terminal before CPR and external
defibrillation were developed in the 1960s
Automated External
Defibrillation (1 of 14)
• Analyzes electrical
signals from heart
– Identifies
ventricular
fibrillation
– Administers shock
to heart when
needed
Source: The LIFEPAK® 1000 Defibrillator (AED) courtesy of Physio-Control.
Used with Permission of Physio-Control, Inc, and according to the
Material Release Form provided by Physio-Control.
Automated External
Defibrillation (2 of 14)
• AEDs are relatively
easy to use.
• AED models:
– All require some operator
interaction.
• Operator must press a
button to deliver shock.
– Most have a computer
voice synthesizer
advising steps to take.
Automated External
Defibrillation (3 of 14)
• AED models
(cont’d):
– Most are
semiautomated
– Monophasic vs.
biphasic shocks
•Source: The LIFEPAK® 20e Defibrillator monitor courtesy of Physio-Control.
Used with permission of Physio-Control, Inc, and according to
the Material Release Form provided by Physio-Control
Automated External
Defibrillation (4 of 14)
• Potential problems:
– Check daily and exercise the battery as
recommended by manufacturer.
– Apply to pulseless, unresponsive patients.
– Most computers identify rhythms faster than 150
to 180 beats/min as ventricular tachycardia,
which should be shocked.
Automated External
Defibrillation (5 of 14)
• Advantages of AED use:
– Quick delivery of shock
– Easier than performing CPR
– ALS providers do not need to be on scene
– Remote, adhesive pads safer than paddles
– Larger pad area = more efficient shocks
Automated External
Defibrillation (6 of 14)
• Other considerations
– Though all cardiac arrest patients should be
analyzed, not all require shock.
– Asystole (flatline) = no electrical activity
– Pulseless electrical activity usually refers to a
state of cardiac arrest.
Automated External
Defibrillation (7 of 14)
• Early defibrillation
– Few cardiac arrest patients survive outside a
hospital without a rapid sequence of events.
– Chain of survival:
• Early recognition and activation of EMS
• Immediate bystander CPR
Automated External
Defibrillation (8 of 14)
• Early defibrillation (cont’d)
– Chain of survival (cont’d):
• Early defibrillation
• Early advanced cardiac life support
• Integrated post-arrest care
Source: American Heart Association.
Automated External
Defibrillation (9 of 14)
• Early defibrillation (cont’d)
– CPR prolongs period during which defibrillation
can be effective.
– Has resuscitated patients with cardiac arrest
from ventricular fibrillation
– Nontraditional responders are being trained in
AED use.
Automated External
Defibrillation (10 of 14)
• Integrating the AED and CPR
– Work the AED and CPR in sequence.
– Do not touch the patient during analysis and
defibrillation.
– CPR must stop while AED performs its job.
Automated External
Defibrillation (11 of 14)
• AED maintenance
– Maintain as manufacturer recommends.
– Read the operator’s manual.
– Document AED failure.
– Check equipment at beginning of shift.
– Ask manufacturer for maintenance checklist.
Automated
External
Defibrillation
(12 of 14)
Automated External
Defibrillation (13 of 14)
• AED maintenance (cont’d)
– Report AED failures to manufacturer and US
Food and Drug Administration (FDA).
• Follow local protocol for notifying.
• Medical direction
– Should help to teach AED use or approve
written protocol for AED use
Automated External
Defibrillation (14 of 14)
• Medical direction (cont’d)
– Works with quality improvement officer to
review incidents where AED is used
– Reviews focus on time from the initial call to the
shock.
– Continuing education with skill competency
review is generally required every 3–6 months.
Emergency Medical Care for
Cardiac Arrest (1 of 7)
• Preparation
– Make sure the electricity injures no one.
– Do not defibrillate patients in pooled water.
– Do not defibrillate patients touching metal.
Emergency Medical Care for
Cardiac Arrest (2 of 7)
• Preparation (cont’d)
– Carefully remove nitroglycerin patch and wipe
with dry towel before shocking.
– Shave hairy chest to increase conductivity.
– Determine the NOI and/or MOI.
• Perform spinal stabilization.
• Performing defibrillation
– See Skill Drill 14-2.
Emergency Medical Care for
Cardiac Arrest (3 of 7)
Emergency Medical Care for
Cardiac Arrest (4 of 7)
• Follow local protocol for patient care after
AED shocks.
– After AED protocol is completed, one of the
following is likely:
• Pulse regained
• No pulse regained and no shock advised
• No pulse regained and shock advised
• Wait for ALS, and continue shocks and
CPR on scene.
Emergency Medical Care for
Cardiac Arrest (5 of 7)
• If ALS is not responding and protocols
agree, begin transport when:
– The patient regains a pulse.
– 6 to 9 shocks are delivered.
– AED gives three consecutive messages
(every 2 min of CPR) advising no shock.
Emergency Medical Care for
Cardiac Arrest (6 of 7)
• Transport considerations:
– 2 EMTs in patient compartment, 1 driving
– Deliver additional shocks on scene or, if medical
control approves, en route.
– AEDs cannot analyze if vehicle is in motion.
Emergency Medical Care for
Cardiac Arrest (7 of 7)
• Coordination with ALS personnel
– If AED available, do not wait for ALS.
– Notify ALS of cardiac arrest.
– Do not delay defibrillation.
– Follow local protocols for coordination.
Cardiac Arrest
The Chain of Survival
• Five elements
1.
2.
3.
4.
Immediate recognition and activation
Early CPR
Rapid defibrillation
Effective advanced life support
5. Integrated post-cardiac arrest care
• Teamwork
• Coordination
Immediate
Recognition and Activation
• Requires prompt notification of EMS system
• Most likely a bystander responsibility
Early CPR
• Increases survival chances significantly
• Three ways CPR can be delivered earlier
– Get CPR-trained professionals to patient faster
– Train laypeople in CPR
– Train dispatchers to instruct callers how to
perform CPR
Rapid Defibrillation
• Sooner defibrillator arrives, more likely
patient will survive cardiac arrest
Effective
Advanced Life Support
• Generally EMT-paramedics who respond to
scene or rendezvous with BLS unit en route
to hospital
• Rapid transport to hospital may be the most
time-efficient means of obtaining ALS
Integrated
Post-Cardiac Arrest Care
• Coordinating numerous means of
assessment and interventions that together
maximize the chance of neurologically intact
survival
continued
Integrated
Post-Cardiac Arrest Care
• Maintaining adequate oxygenation
• Avoiding hyperventilation
• Performing 12-lead ECG
• Managing treatable causes of arrest
• Appropriate destination for patient
• Possibly inducing hypothermia
Management of Cardiac Arrest
• EMT provides two links in chain of survival
– Early CPR
– Rapid defibrillation
Treatment of Cardiac Arrest
• Standard Precautions
• ALS (when available)
• One- and two-rescuer CPR
• Using an automated external defibrillator
continued
Treatment of Cardiac Arrest
• Artificial ventilations and airway
management
• Interviewing bystanders and family members
• Lifting and moving patients
Automated
External Defibrillator (AED)
• Semiautomatic
– Advises EMT to press button that causes
machine to deliver shock through pads
• Fully automatic
– Does not advise EMT to take any action; delivers
shock automatically
continued
Automated
External Defibrillator (AED)
• Classified by type of shock delivered
– Monophasic: sends single shock from negative
pad to positive pad
– Biphasic: sends shock in one direction and then
the other
continued
Automated External
Defibrillator (AED)
• Analyzes cardiac rhythm to determine
whether shock is indicated
continued
Automated
External Defibrillator (AED)
• Most common conditions resulting in cardiac
arrest are shockable rhythms
– Ventricular fibrillation
– Ventricular tachycardia
AED Safety
• Do not defibrillate soaking-wet patient
• Do not defibrillate if patient is touching
anything metallic that other people are
touching
• Remove nitroglycerin patches before
defibrillating
continued
AED Safety
• Verbally and visually “CLEAR” patient
before defibrillating
AED Safety
• Defibrillation can be performed on patient
with an implanted device
• Position defibrillation pads on patient’s chest
to avoid contact with the device
AED Maintenance
• Use checklist at beginning of every shift to
ensure you have all supplies and AED is
functioning properly
• Make sure battery is charged and you have
a spare with defibrillator
AED Quality Improvement
• Involves multiple functions
–
–
–
–
Medical direction
Initial training
Maintenance of skills
Case review
– Trend analysis
– Strengthening links in chain of survival
Coordinating CPR and AED
• Interrupt CPR only when absolutely
necessary and for as short a period as
possible
• CPR must be paused for rhythm analysis
and defibrillation
Patient Assessment
• Perform primary assessment
– If bystanders are doing CPR when
you arrive, have them stop
– Verify pulselessness, apnea,
absence of other signs of life no
longer than 10 seconds
• Apply AED
– Bare patient’s chest; quickly shave
area where pads will be placed if
necessary
– If available, use pediatric AED pads
– If using adult pads, do not overlap
Patient Care
continued
Patient Care
• Use AED
– Turn on AED
– Attach pads to cables and
then to patient
– Stop CPR and analyze
– Clear patient and shock if
indicated
continued
Patient Care
• Immediately begin CPR after delivering a shock
• Reassess patient after providing 2 minutes or 5
cycles of CPR
continued
Patient Care
• If AED finds no shockable ECG rhythm, will
advise that no shock is indicated
– Pulseless electrical activity
– Asystole
• Resume CPR immediately
continued
Patient Care
• When providing CPR
– Compressions must not be interrupted for any
longer than 10 seconds
– Compressions at least 2 inches deep for adult
and at least one-third depth of chest for infants
and children with full chest recoil
– Rate should be at least 100 per minute
– Rotate personnel through compressor position to
prevent fatigue
continued
Patient Care
• If patient wakes or begins to
move
– Obtain baseline vital signs
– Administer highconcentration oxygen
– Transport
continued
Post-Resuscitation Care
• Patient has a pulse
– Manage airway; avoid hyperventilation
– Keep defibrillator on patient during transport in
case patient goes back into arrest
– Reassess frequently (every 5 minutes)
– Consider hypothermia protocols
continued
Post-Resuscitation Care
• Patient goes back into cardiac arrest
–
–
–
–
Stop vehicle, resume CPR
Analyze rhythm as soon as possible
Deliver shock if indicated
Continue with 2 shocks separated by 2 minutes
(5 cycles)
Mechanical CPR Devices
• Mechanical devices assist EMTs to provide
high-quality compressions
– Thumper®
– Auto-Pulse™
Using an AED Video
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Cardiac Arrest Video
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AEDs Video
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Understanding
Myocardial Infarctions Video
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Chapter Review
Chapter Review
• Patients with cardiac compromise or ACS
can have many different presentations.
• Some complain of pressure or pain in the
chest with difficulty breathing. Others may
have just mild discomfort that they ignore or
that goes away and returns.
continued
Chapter Review
• Between 10%–20% of heart attack patients
have no chest discomfort.
• Because of these possibilities and the
severe complications of heart problems,
have a high suspicion and treat patients with
these symptoms for cardiac compromise.
continued
Chapter Review
• ACS patients need high-concentration
oxygen and prompt, safe transportation to
definitive care.
• You may be able to assist patients who have
their own nitroglycerin.
continued
Chapter Review
• To provide maximum chance of survival for
patients in cardiac arrest, EMS agencies
must strengthen their performance of the
chain of survival: immediate recognition and
activation, early CPR, rapid defibrillation,
effective ALS, and integrated post-cardiac
arrest care.
Remember
• The heart is a simple pump that moves
deoxygenated blood to the lungs and
oxygenated blood to the body. Pressure
within the cardiovascular system is critical to
the moving of blood.
continued
Remember
• Acute coronary syndrome (ACS) is a blanket
term that refers to a number of situations in
which perfusion of the heart is inadequate.
• Although there are common symptoms of
ACS, EMTs must recognize atypical findings
and err on the side of caution.
continued
Remember
• Oxygen, nitroglycerine, and aspirin are key
medications indicated to treat ACS.
However, the definitive treatment is
transportation of the patient to a facility that
can open the blocked artery.
continued
Remember
• Most cardiac conditions are caused by
arterial problems. Angina pectoris and acute
myocardial infarction are caused by
inadequate perfusion of the heart.
• Heart failure can be caused by either
electrical or mechanical problems.
continued
Remember
• The most important element of cardiac arrest
care is the administration of high-quality
chest compressions.
• The American Heart Association’s chain of
survival describes the key elements
necessary to maximize the cardiac arrest
patient’s chance of survival.
continued
Remember
• AED provides early defibrillation in cardiac
arrest patients with ventricular tachycardia
and ventricular fibrillation.
• Post-cardiac arrest care is an essential
element of cardiac arrest care.
• Mechanical CPR devices provide automated
chest compressions in cardiac arrest
settings.
Questions to Consider
• What position is best for a patient with:
– Difficulty breathing and a blood pressure of
100/70?
– Chest pain and a blood pressure of 180/90?
• Describe how to “clear” a patient before
administering a shock.
continued
Questions to Consider
• List three safety measures to keep in mind
when using an AED.
• List the steps in the application of an AED.
Critical Thinking
• A 78-year-old male has been complaining of
severe shortness of breath for 20 minutes
prior to your arrival. When you arrive, you
find the patient unconscious and not moving.
What are your immediate priorities?
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Summary (1 of 13)
• The heart has right and left sides, each with
an upper chamber (atrium) and a lower
chamber (ventricle).
• The aortic valve keeps blood moving
through the circulatory system in the proper
direction.
Summary (2 of 13)
• The heart’s electrical system controls heart
rate and coordinates the work of the atria
and ventricles.
• During periods of exertion or stress, the
coronary arteries dilate to increase blood
flow.
Summary (3 of 13)
• Carotid, femoral, brachial, radial, posterior
tibial, and dorsalis pedis arteries provide
pulses.
• Coronary artery atherosclerosis is the
buildup of cholesterol plaques inside blood
vessels. It can eventually lead to occlusion
and cardiac compromise.
Summary (4 of 13)
• AMI, or heart attack, occurs when heart
tissue downstream of a blood clot suffers
from a lack of oxygen and, within 30
minutes, begins to die.
• Angina occurs when heart tissues do not
receive enough oxygen but are not yet
dying.
Summary (5 of 13)
• Signs of AMI include crushing chest pain;
sudden onset of weakness, nausea, and
sweating; sudden arrhythmia; pulmonary
edema; and even sudden death.
Summary (6 of 13)
• Sudden death is usually the result of
cardiac arrest caused by arrhythmias (eg,
tachycardia, bradycardia, ventricular
tachycardia, and, most commonly,
ventricular fibrillation).
Summary (7 of 13)
• Symptoms of cardiogenic shock are
restlessness; anxiety; pale, clammy skin;
increased pulse rate; and decreased blood
pressure.
• CHF occurs when damaged heart muscle
cannot pump blood.
Summary (8 of 13)
• Treat a patient with CHF by monitoring vital
signs. Give oxygen via nonrebreathing face
mask. Allow the patient to remain sitting up.
Summary (9 of 13)
• For patients with chest pain:
– SAMPLE history
– OPQRST
– Vital signs
– Ensure patient is comfortably positioned.
– Administer nitroglycerin and oxygen.
– Transport.
Summary (10 of 13)
• In children older than 1 year, perform
defibrillation using special pediatric pads
and a dose-attenuating system, if available.
If not available, use an adult AED.
• In infants older than 1 month, manual
defibrillation is preferred. If not available,
use pediatric pads and a dose-attenuating
system or an adult AED.
Summary (11 of 13)
• Maintain AED battery.
• Do not apply AED to moving a patient.
• Do not apply AED to responsive patients
with rapid heart rates.
Summary (12 of 13)
• Do not touch the patient during AED
analysis or shocks.
• Effective CPR and AED use are critical to
cardiac arrest patient survival.
Summary (13 of 13)
• Chain of survival:
– Recognition of early warning signs
– Immediate activation of EMS
– Immediate CPR by bystanders
– Early defibrillation
– Early advanced care
– Integrated post-arrest care
Review
1. All of the following are common signs and
symptoms of cardiac ischemia, EXCEPT:
A. headache.
B. chest pressure.
C. shortness of breath.
D. anxiety or restlessness.
Review
Answer: A
Rationale: Cardiac ischemia occurs when the
heart’s demand for oxygen exceeds the
available supply. Common signs and
symptoms of cardiac ischemia include chest
pain or discomfort, shortness of breath
(dyspnea), and anxiety or restlessness.
Headache is not a common symptom of
cardiac ischemia.
Review (1 of 2)
1. All of the following are common signs and
symptoms of cardiac ischemia, EXCEPT:
A. headache.
Rationale: Correct answer
B. chest pressure.
Rationale: Chest pressure is a definite
symptom of a cardiac event.
Review (2 of 2)
1. All of the following are common signs and
symptoms of cardiac ischemia, EXCEPT:
C. shortness of breath.
Rationale: This is a response to decreased
cardiac output and hypoxia.
D. anxiety or restlessness.
Rationale: This is caused by a fear of death
and is a result of hypoxia, decreased cardiac
output, and ischemia.
Review
2. While palpating the radial pulse of a 56year-old man with chest pain, you note that
the pulse rate is 86 beats/min and irregular.
This indicates:
A. pain.
B. fear.
C. anxiety.
D. an arrhythmia.
Review
Answer: D
Rationale: An irregular pulse in a patient with
a cardiac problem suggests an arrhythmia—
an abnormality in the heart’s electrical
conduction system. Patients with signs of
cardiac compromise, who have an irregular
pulse, must be monitored closely for cardiac
arrest.
Review (1 of 2)
2. While palpating the radial pulse of a 56year-old man with chest pain, you note that
the pulse rate is 86 beats/min and irregular.
This indicates:
A. pain.
Rationale: Pain could be a result or symptom
of cardiac ischemia.
B. fear.
Rationale: Fear of impending death is usually
the psychological result of having chest pain.
Review (2 of 2)
2. While palpating the radial pulse of a 56year-old man with chest pain, you note that
the pulse rate is 86 beats/min and irregular.
This indicates:
C. anxiety.
Rationale: Anxiety is also a symptom of a
cardiac event.
D. an arrhythmia.
Rationale: Correct answer
Review
3. A 56-year-old man has an acute
myocardial infarction. Which of the
following blood vessels became blocked
and led to his condition?
A. Coronary veins
B. Coronary arteries
C. Pulmonary veins
D. Pulmonary arteries
Review
Answer: B
Rationale: The coronary arteries, which
branch off the aorta, supply the myocardium
(heart muscle) with oxygen-rich blood.
Occlusion of one or more of these arteries
results in a cessation of oxygenated blood
beyond the area of occlusion and results in
acute myocardial infarction (AMI).
Review (1 of 2)
3. A 56-year-old man has an acute
myocardial infarction. Which of the
following blood vessels became blocked
and led to his condition?
A. Coronary veins
Rationale: Coronary veins do not carry
oxygen and would not be the direct cause of
an acute MI.
B. Coronary arteries
Rationale: Correct answer
Review (2 of 2)
3. A 56-year-old man has an acute
myocardial infarction. Which of the
following blood vessels became blocked
and led to his condition?
C. Pulmonary veins
Rationale: Pulmonary veins are the primary
blood supply to the lungs and not the heart.
D. Pulmonary arteries
Rationale: Pulmonary arteries are the route of
blood return to the left atrium from the lungs.
An obstruction would not cause an acute MI.
Review
4. Major controllable risk factors for an AMI
include:
A. older age.
B. family history.
C. cigarette smoking.
D. male sex.
Review
Answer: C
Rationale: Smoking is a major controllable
risk factor for any cardiovascular disease.
Review (1 of 2)
4. A major controllable risk factor for an AMI
includes:
A. Older age.
Rationale: This is an uncontrollable risk
factor.
B. Family history.
Rationale: This is an uncontrollable risk
factor.
Review (2 of 2)
4. A major controllable risk factor for an AMI
includes:
C. Cigarette smoking.
Rationale: Correct answer.
D. Male sex.
Rationale: This is an uncontrollable risk
factor.
Review
5. A patient with cardiac arrest secondary to
ventricular fibrillation has the greatest
chance for survival if:
A. CPR is initiated within 10 minutes.
B. oxygen and rapid transport are provided.
C. defibrillation is provided within 2 minutes.
D. paramedics arrive at the scene within
5 minutes.
Review
Answer: C
Rationale: Survival from cardiac arrest
secondary to ventricular fibrillation is highest if
CPR is provided immediately and defibrillation
is provided within 1 minute of the patient’s
cardiac arrest. Early high-quality CPR and
defibrillation are the two most important
factors that influence survival from cardiac
arrest.
Review (1 of 2)
5. A patient with cardiac arrest secondary to
ventricular fibrillation has the greatest
chance for survival if:
A. CPR is initiated within 10 minutes.
Rationale: CPR needs to be initiated
immediately.
B. oxygen and rapid transport are provided.
Rationale: Oxygen therapy and transport are
important parts of resuscitation, but CPR and
early defibrillation afford the greatest chance
of survivability.
Review (2 of 2)
5. A patient with cardiac arrest secondary to
ventricular fibrillation has the greatest
chance for survival if:
C. defibrillation is provided within 2 minutes.
Rationale: Correct answer
D. paramedics arrive at the scene within
5 minutes.
Rationale: Not necessarily; CPR and early
defibrillation will provide the greatest chance
of survivability.
Review
6. A 59-year-old woman presents with chest
pressure. She is conscious and alert, but
her skin is cool, pale, and clammy. Your
first step in providing care (treatment)
should be:
A. apply the AED.
B. administer high-flow oxygen.
C. ask her if she takes nitroglycerin.
D. take a complete set of vital signs.
Review
Answer: B
Rationale: Any patient with suspected cardiac
compromise should be given high-flow oxygen
as soon as possible. Obtaining vital signs and
inquiring about the use of nitroglycerin are
appropriate; however, you should administer
oxygen first. The AED is only applied to
patients in cardiac arrest.
Review (1 of 2)
6. A 59-year-old woman presents with chest
pressure. She is conscious and alert, but
her skin is cool, pale, and clammy. Your
first step in providing care (treatment)
should be:
A. apply the AED.
Rationale: The AED is only applied to
patients in cardiac arrest.
B. administer high-flow oxygen.
Rationale: Correct answer
Review (2 of 2)
6. A 59-year-old woman presents with chest
pressure. She is conscious and alert, but
her skin is cool, pale, and clammy. Your
first step in providing care (treatment)
should be:
C. ask her if she takes nitroglycerin.
Rationale: Inquiring about the use of
nitroglycerin is appropriate, but not the first step.
D. take a complete set of vital signs.
Rationale: Obtaining vital signs is important, but
not the first step.
Review
7. If a patient with an implanted pacemaker is
in cardiac arrest, the EMT should:
A. avoid defibrillation with the AED and transport
at once.
B. not apply the AED until he or she contacts
medical control.
C. place the AED pads at least 1″ away from the
pacemaker.
D. apply the AED pads directly over the
implanted pacemaker.
Review
Answer: C
Rationale: The only modification required for
cardiac arrest patients with an implanted
pacemaker is to ensure that the AED pads are
at least 1″ away from the pacemaker. Placing
the AED pads directly over the pacemaker will
result in a less effective defibrillation and may
damage the pacemaker.
Review (1 of 2)
7. If a patient with an implanted pacemaker is
in cardiac arrest, the EMT should:
A. avoid defibrillation with the AED and transport
at once.
Rationale: AEDs can be used with
pacemakers, but avoid placing pads over
pacemakers.
B. not apply the AED until he or she contacts
medical control.
Rationale: EMTs are trained in the use of
AEDs.
Review (2 of 2)
7. If a patient with an implanted pacemaker is
in cardiac arrest, the EMT should:
C. place the AED 1″ away from the pacemaker.
Rationale: Correct answer
D. apply the AED pads directly over the
implanted pacemaker.
Rationale: AEDs should not be placed over
pacemakers.
Review
8. The main advantage(s) of the AED is:
A. it provides quick delivery of a shock.
B. it is easier than performing CPR.
C. there is no need for ALS providers to be on
scene.
D. All of the above.
Review
Answer: D
Rationale: The AED provides quick delivery
of a shock, is easier to perform than CPR, and
does not require ALS providers to operate it.
Review (1 of 2)
8. The main advantage(s) of the AED is:
A. it provides quick delivery of a shock.
Rationale: The AED provides quick delivery
of a shock.
B. it is easier than performing CPR.
Rationale: The AED is easier to perform than
CPR.
Review (2 of 2)
8. The main advantage(s) of the AED is:
C. there is no need for ALS providers to be on
scene.
Rationale: ALS providers do not need to be
on scene to put the AED to use.
D. All of the above.
Rationale: Correct answer.
Review
9. After administering a nitroglycerin tablet to
a patient, the EMT should:
A. check the expiration date of the nitroglycerin.
B. reassess the patient’s blood pressure within 5
minutes.
C. instruct the patient to chew the tablet until it is
dissolved.
D. ensure that the nitroglycerin is prescribed to
the patient.
Review
Answer: B
Rationale: Nitroglycerin is a vasodilator and
can lower the patient’s BP; therefore, you
should reassess the patient’s BP within
5 minutes after giving nitroglycerin. Instruct the
patient to allow the nitroglycerin to dissolve
under his or her tongue; it should not be
chewed. You should check the drug’s expiration
date and ensure that it is prescribed to the
patient before administering it.
Review (1 of 2)
9. After administering a nitroglycerin tablet to
a patient, the EMT should:
A. check the expiration date of the nitroglycerin.
Rationale: This is checked before medication
administration.
B. reassess the patient’s blood pressure within
5 minutes.
Rationale: Correct answer
Review (2 of 2)
9. After administering a nitroglycerin tablet to
a patient, the EMT should:
C. instruct the patient to chew the tablet until it is
dissolved.
Rationale: The tablet is placed under the
patient’s tongue and allowed to dissolve.
D. ensure that the nitroglycerin is prescribed to
the patient.
Rationale: This is checked before medication
administration.
Review
10. Nitroglycerin is contraindicated in
patients:
A. with a systolic blood pressure less than
100 mm Hg.
B. with chest pain of greater than 30 minutes
duration.
C. who are currently taking antibiotics for an
infection.
D. who are less than 40 years of age and have
diabetes.
Review
Answer: A
Rationale: Nitroglycerin is a vasodilator and
may cause a drop in BP; therefore, it is
contraindicated in patients with a systolic BP
of less than 100 mm Hg and in patients who
have taken erectile dysfunction (ED) drugs
(eg, Viagra, Cialis, Levitra) within the past 24
to 36 hours. ED drugs are also vasodilators; if
given in combination with nitroglycerin, severe
hypotension may occur.
Review (1 of 2)
10. Nitroglycerin is contraindicated in
patients:
A. with a systolic blood pressure less than
100 mm Hg.
Rationale: Correct answer
B. with chest pain of greater than 30 minutes
duration.
Rationale: Cardiac chest pain is the primary
indication for the use of nitroglycerin.
Review (2 of 2)
10. Nitroglycerin is contraindicated in
patients:
C. who are currently taking antibiotics for an
infection.
Rationale: Antibiotics are not a contraindication for nitroglycerin use. Prior adverse
reactions to the drug and the use of other
nitrates would be a contraindication.
D. who are less than 40 years of age and have
diabetes.
Rationale: While the patient’s age must be
considered, it is not a contraindication.
Credits
• Background slide image (ambulance):
Galina Barskaya/ShutterStock, Inc.
• Background slide images (non-ambulance):
© Jones & Bartlett Learning. Courtesy of
MIEMSS.