Paramedic study guideConcepts
1. Myocardial infarction- a “heart attack”, is the blockage of blood flow to heart muscle,
causing myocardial irritation and death.
2. Acetylsaliclic acid- oral antiplatelet medication used extensively for the treatment and
prevention of thrombus formation. Administered in the prehospital setting for pt’s
complaining of chest pain and acute coronary syndrome. Also used to treat stroke once
a hemorrhage has been excluded.
3. Angina pectoris- chest pain when the harts supply of O2 doesn’t meet the hearts
demand.
4. Cerebral vascular accident- otherwise known as a stroke. Blood supply to the areas of
the brain are interrupted, by either a hemorrhage or occlusion, causing ischemia to the
brain tissue.
5. Sputum- irritated airways produce secrete more mucus, which is surly swallowed, but
when it is expelled, it is termed as sputum. Sputum can be color tinged if it comes from
fluid filled lungs. Frothy pink sputum is indicative of heart failure. Thick sputum is
indicative of dehydration or antihistamine use. Purulent sputum is indicative of the
infectious process, because the pus contains dead white blood cells. Yellow, green or
brown sputum are older secretions in various stages of decomp. Clear or white sputum
is related to bronchitis. Blood streaked sputum is indicative of tumor, TB, Pulmonary
edema, or trauma from coughing.
6. Coronary circulation physiology- two main arteries- left and right. The left main coronary
artery (LMCA) is the largest in diameter and shortest of the myocardial blood vessels. It
divides into the left anterior descending artery and the circumflex artery. The LAD
supplies blood to the anterior surface of the left ventricle, part of the lateral surface of the
left ventricle, and a portion of the interventricular septum in most patients. The Cx artery
supplies blood to the left atrium, part of the lateral surface of the left ventricle, the inferior
surface of the left ventricle, posterior surface of the left ventricle, the SA node, the AV
bundle. Branches of the Right coronary artery supply blood to the walls of the right
atrium and ventricle, portion of the inferior part of the left ventricle, pot]rtionsa of the
conduction system such as the SA node, AV bundle.
7. AHA guidelines- Refer to the AHA ACLS algorithms. Medicine and Edison.
8. Cardiac cellular action potential phasesa. Phase 4- the start of the cardiac cycle. Cardiac cells are at rest (diastole), waiting
for a spontaneous impulse from within (automaticity)
b. Phase 0- cardiac muscles receive an impulse. Sodium ions rapidly enter through
the sodium channels. Calcium enters slowly, causes the release of calcium for
muscle contraction. Depolarization occurs, altering electrical charge of the cell
and beginning contraction.
c. Phase 1- sodium channels close while potassium exits the cell.
d. Phase 2- sodium and calcium slowly enter the cell, while potassium continues to
leave. Repolarization begins.
e. Phase 3- calcium channels slowly close and calcium leaves the cell while
potassium channels open, enabling the rapid movement of potassium out of the
cell. Repolarization ends.
9. CPAP- noninvasive means of providing ventilators support for pt’s experiencing
respiratory distress.
10. MOA for cardiac medicationsa. Class 1 antidysrhythmic meds- Sodium channel blockers- allow the movement of
sodium through channels in certain cardiac cells. Class 1A- prolongs QRS and
QT intervals. Class 1B- resolves ventricular dysrhythmias and suppresses
ectopic foci.
b. Class 2- Beta-adrenergic block agents- competitively inhibit catecholamine (epi
and norepinephrine) activation at the beta receptor sites. Affects HR, contractility,
cardiac contraction, velocity.
c. Class 3- Potassium channel blockers- increase phase 1,2,3 of cardiac
conduction cycle. Prolong cellular action potential, prolong refractory period,
treating atrial or ventricular tach.
d. Class 4- Calcium channel blockers- reduce BP, control HR and decrease hearts
demand for O2 during ischemia. Displace calcium and certain receptor sites .
Relaxes the smooth muscle present in the heart. Slow conduction through AV
node, decrease automaticity of ectopic foci, decrease velocity fog cardiac
contraction.
e. Adenosine- treats SVT, assists with identifying p or flutter waves.
f. Alpha adrenergic receptor antagonists- “alpha blocker”- prevent endogenous
catecholamines from reaching the alpha receptors, primarily in the smooth
muscle of blood vessels. LOwer BP (diastolic), decrease SVR.
g. Anticholinergic meds- block ACh at synapse in the central and peripheral
nervous system. Inhibit parasympathetic nervous system by selectively blocking
the binding of ACh to receptor sites.
h. Anticoagulants- Decrease clotting ability of the blood.
i. Antiplatelet- Keeps blood clots from forming by preventing blood platelets from
sticking together.
j. ACE inhibitors- Expands blood vessels and decreases resistance by lowering
levels of angiotensin II. Allows blood to flow more easily and makes the hearts
work easier or more efficient.
k. Angiotensin II receptor blockers (inhibitors)- Prevent the chemical from having
any effect on the heart or blood vessels, keeps BP from rising.
l. Digitalis preparations- increases the force of the hearts contraction. Beneficial
for HF and irregular heart beats.
m. Diuretics- causes the body to rid itself of excess fluids and sodium through
urination. Reduces the hearts workload.
n. Catecholamines and sympathomimetics- stimulate the receptor sites in the
sympathetic nervous system.
11. Effects of vagal nerve stimulation- slows HR down.
12. Cardiac electrical conduction system- Starts at the SA node (receives blood from RCA),
spreads through three pathways- Bachman bundle, Wenkebach tract, Thorel. Next is the
Av node. The AV junction (gatekeeper to the ventricles) is comprised of the AVE node
and the bundle of His.next, are the secondary pacemakers. These fire normally from the
SA-AV node tact, or if the SA and AV nodes aren’t working, these can fire on their own.
These secondary pacemakers include the Purkinje fibers. The accessory pathways are
extra heart muscle tissue that connects the atria and ventricles, bypassing the AV node.
These include- James pathways, Mahaim fibers, bundled of Kent. (These accessory
pathways was can trigger abnormally fast heart rates.)
13. Pharmacologic Therapy for cardiogenic shock- Treatment focuses on strengthening
contractility without increasing the heart rate, altering preload and afterload, and
controlling any dysrhythmias that are contributing to shock. Vasoactive IV medications to
treat cardiogenic shock include: Dopamine, Norepinephrine, Epinephrine.
14. Starlings law- effects on intrathoracic pressure on cardiac output- increased venous
return augments preload. Heart muscle fiber stretch in response to the expanded volume
(preload) before contracting. The stretching of the muscle fibers allows the heart to eject
more forcefully the additional volume, thereby boosting the stroke volume. So, in the
normal heart, the greater the preload, the greater the force of the ventricular contraction,
and the greater the stroke volume, resulting in increased CO.
15. Effects of intrathoracic pressure on cardiac output- Increases in intrathoracic pressure
decreases left ventricular afterload and will augment left ventricular ejection. In patients
with hypervolemic heart failure, this afterload reducing effect can result in improved left
ventricular ejection, increased cardiac output and reduced myocardial O2 demand.
16. Signs and symptoms of stroke- Language- Slurred speech, aphasia, agnosia, apraxia.
Movement- hemiparesis, hemiplegia, arm drifting, facial droop, tongue deviation,
swallowing difficulties, ptosis, ataxia. Sensory- Headache, sudden blindness, sudden
unilateral parathesia. Cognitive effects- decreased LOC, difficulty thinking, seizures,
coma. Cardiac- Hypertension. FAST mnemonic to assess for stroke- F- facial droop. Aarm drift. S- Speech impairment. T- time is critical-call 9-1-1
Skills
1. Differentiate and react hemodynamically unstable or a symptomatic arrhythmia.
Hemodynamically unstable- Edison. (TCP for unstable bradycardia, Synchronized
cardioversion for wide complex tach with a pulse, defibrillator for wide complex tach with
no pulse). Hemodynamically stable- medication.(atropine for bradycardia, amiodarone
for wide complex tach, adenosine for SVT narrow complex tach).
2. DIfferentiate diastolic and systolic heart failure- Systolic: left ventricle can’t connect
completely. Heart won't pump forcefully enough to move blood throughout your bodyheart failure with reduced ejection fraction(HFrEF)-too stretched and weak to pump.
Diastolic: heart isn’t able to relax normally between beats, tissue on the left ventricle is
too stiff to relax. Heart failure with preserved ejection fraction (HFpEF).
3. Identify chest pain without cardiac origin- Gastroesophageal reflux disease (GERD) or
Acid reflux, muscle or bone problems in the chest wall or spine, Lung conditions or
diseases of the pleura, the tissue that cover the lungs, Pulmonary embolism (sharp
pinpoint chest pain), stomach problems (ulcers), stress, anxiety or depression.
4. Interpret 3 (4 leads) and 12 lead ECG’sa. 4 Leadi.
Identify Heart rate
ii.
Identify Heart Rhythm
iii.
P waves? (0.08 - .11).
iv.
PR interval. (0.11 - 0.20)
v.
QRS complex. (0.06 - 0.11)
b. 12 Leadi.
Rate- Slow? Fast?
ii.
Rhythm- Reg? Irreg? Reg Irreg? Irregularly irregular?
iii.
P wave- 1-1 ratio? Morphology? PR interval?
iv.
Q- QRS width, voltage
v.
R- R to R progression
vi.
S- ST elev? Depression?
vii.
T- T wave morphology? Inversion? QTc?
viii.
U- U waves present? (Oh dear)
c. Multiple ways to interpret 12 leads. “I See All Leads”, “Big Lie, Little Lie, Say All”=
( L(1)I(2)I(3),x(AVR)L(AVR)I(AVF), S(V1)S(V2)A(V3), A(V4)L(L)L(V6)).
5. Differentiate between cardiac compromise verse compensatory reactiona. Cardiac compromise- refers to any kind of heart problem. Patients may complain
of chest pain, flu-like symptoms, or dyspnea(difficulty breathing). The most
common complaint is chest pain. The pain may radiate down an arm with the left
arm more commonly involved.
b. Compensatory reaction- As the heart begins to fail, the body’s compensatory
mechanisms attempt to improve CO by manipulating the following: Preload,
Afterload, Cardiac contractility, Heart rate. Ultimately, compensatory mechanisms
may worsen heart failure.
6. Treat a beta blocker overdose- For cases of beta-blocker poisoning where symptomatic
bradycardia and hypotension are present, high-dose glucagon is considered the first-line
antidote. AGE- atropine, glucagon, epi.
7. Treat chest pain of cardiac origin- ACLS ACS syndromes algorithm.
a. Symptoms suggestive of ischemia or infarction
i.
EMS assessment and care and hospital prep- Assess ABC’s. Be
prepared to provide CPR and Dfib.
1. Administer ASA and consider O2, Nitro, Morphine (fentanyl) if
needed.
2. Obtain 12 lead ECG; if ST elevation- Notify receiving hospital with
transmission or interpretation; note time of onset band first
medical contact.
3. Provide prehospital notification; on arrival, transport to ED/bath lab
per protocol.
4. Notified hospital should mobilize resources to respond to STEMI
5. If considering prehospital fibronolysis, use fibronolytic checklist.
ii.
Concurrent ED/catch lab assessment (<10 min)
1.
2.
3.
4.
5.
6.
8.
Activate STEMI team upon EMS notification
Assess ABC’s give O2 if needed
Establish IV access
Preform brief ; targeted history, physical exam
Review/complete fibrinolytic checklist; check contraindications
Obtain initial cardiac marker levels; complete blood counts and
coag studies
7. Obtain portable chest x-ray (<30 minutes); do not delay transport
to the catch lab
iii.
Immediate ED/catch lab and general treatment
1. If O2 sat <90%, start oxygen at 4 L/min, titration
2. Aspirin 162 to 3254 mg (if not given by EMS)
3. Nitro sublingual or trans lingual
4. Morphine IV if discomfort not relieved by nitro
5. Consider administration of P2Y12 inhibitors
iv.
ECG INTERPRETATION
1. ST elevation or new or presumably new LBBB; strongly suspicious
for injury
a. STart adjunctive therapies as indicated
b. Do not delay reperfusion
c. Time from onset of symptoms less than or equal to 12
hours?
i.
If less than 12 hours, reporfusion goals: therapy
defines by pt and center criteria. FMC- to - balloon
inflation (PCI) goal of less than 90 min. Door to
needle (fibronolysis) goal of 30 min.
d. If greater than 12 hours- troponin elevated or high risk ptconsider early invasive strategy if:
i.
Refractory ischemic chest discomfort
ii.
Recurrent/persistent ST deviation
iii.
VTACH
iv.
Hemodynamically instability
v.
Signs of heart failure
vi.
Start adjunctive therapies- Nitro, Hep as indicated.
2. NON-ST-elevation
a. ST depresssion or dynamic T-wave inversion, transient ST
elevation;strongly suspicious for ischemic and /or high-risk
score (SEE 1D)
b. Normal ECG or no diagnostic changes in ST segment or T
wave; low risk score
i.
Consider admission to ED chest pain unit or to
appropriate bed for further monitoring unit and
possible intervention.
treat unstable Vs stable cardiac treatment:
Unstable cardiac: identify the rhythm and then treat symptomatic bradycardia starting with
medication ( atropine 0.5mg bolus, rpt 3-5 min, max 3mg) ( dopamine 2-20 mcg/kg per min,
titrate to effect taper down slowly) (EPI IV infusion 2-10 mcg per min infusion. Titrate to PT
response) if no response to medication consider base and TCP or synchronized
cardioversion/unsynchronized/defibrillation.
Stable cardiac: pharmacology, pain management, O2, ALS vitals, Nitro, ASA
EMT
Concepts
1. Dyspnea/nocturnal dyspneaa. Dyspnea- Difficult or labored breathing,
b. Nocturnal dyspnea- dyspnea that comes on suddenly in the middle of the night
and may be an ominous sign of left-sided heart failure.
2. Pulseless electrical activity (PEA)- electrical activity is present on ECG but there are no
pulses or BP.
3. Cardiac Dysrhythmias- syncope, diaphoresis, chest pain, pain radiating to back/arm,
palpitations, ALOC,
a. Sinus Tachycardia
b. SInus Bradycardia
c. AFib
d. AFlutter
e. SVT
f. WPW
g. VT
h. VFib
i. Sinus Arrythmis
j. Sinus Exit Block
k. Sinus Arrest
l. Sinus with PAC
m. Paced Atrial
n. NSR with 1st block
o. 2nd degree block type 1
p. 2nd degree block type 2
q. Second degree block 2:1
r. 3rd degree AV block
s. NSR with PJC
t. Junctional
u. Acell junctional
v. Junctional tachy
w. Wandering pacemaker
x. NSR with PVC
y. Idioeventricular
z. Paced Ventricular
4. Cerebrovascular accident (CVA)/Stroke-otherwise known as a stroke. Blood supply to
the areas of the brain are interrupted, by either a hemorrhage or occlusion, causing
ischemia to the brain tissue.
5. Angina/Angina Pectoris-Pain felt in the chest when the supply of oxygen in the heart
doesn’t meet the hearts needs. Stable and unstable.
6. Hypertension (HTN)/Hypotensiona. HTN- High blood pressure, usually a diastolic pressure of greater than 90mmHg
b. Hypotension- Low blood pressure, reads lower than 90 mmHg systolic, 60 mmHg
diastolic.
7. Return of spontaneous circulation (ROSC)- Return of spontaneous circulation is the
resumption of a sustained heart rhythm that perfuses the body after cardiac arrest. It is
commonly associated with significant respiratory effort. Signs include breathing,
coughing, or movement and a palpable pulse or a measurable blood pressure.
8. American Heart Association guidelines (AHA)- Refer to ACLS algorithms for treatment
plan based on pt. 30-2-compressions per 2 breaths.
9. Shockable rhythms and indications for an AED- Shockable rhythms include pulseless
ventricular tachycardia or ventricular fibrillation. Indications for an AED include any
situation where the responder feels as though the pt has no pulse or is not breathing, i.e.
Medical emergencies for unconscious/unresponsive.
10. Pathophysiology of left-sided-heart failure- Left-sided heart failure occurs when the left
ventricle doesn't pump efficiently. This prevents your body from getting enough oxygenrich blood. The blood backs up into your lungs instead, which causes shortness of
breath and a buildup of fluid.
11. Anatomy of the cardiovascular system- three main components: the heart, the blood
vessel and the blood itself. The heart is the system's pump and the blood vessels are
like the delivery routes. Blood can be thought of as a fluid which contains the oxygen
and nutrients the body needs and carries the wastes which need to be removed. Left
and right atrium, left and right ventricle, pericardium, myocardium, endocardium.
12. Pathophysiology of acute coronary syndrome- the inhibition of blood flow to the coronary
arteries due to thrombus, atherosclerosis, coronary artery spasm, arteriosclerosis,
shock, dysrhythmia, PE. Without blood flow to these arteries, the heart cannot function
(pump) properly.
13. Complications of electrical injuries and treatmenta. Complicationsi.
Cardiac arrest due to the electrical effect on the heart.- run it like a code
ii.
Muscle, nerve, and tissue destruction from a current passing through the
body.
iii.
Thermal burns from contact with the electrical source. Treat as burn,
fluids, cover, airway.
iv.
Nerve damage, ALOC.
Skills
1. Differentiate between left sided and right sided heart failure-Systolic: left ventricle can’t
connect completely. Heart won't pump forcefully enough to move blood throughout your
body- heart failure with reduced ejection fraction(HFrEF)-too stretched and weak to
2.
3.
4.
5.
6.
7.
8.
pump. Diastolic: heart isn’t able to relax normally between beats, tissue on the left
ventricle is too stiff to relax. Heart failure with preserved ejection fraction (HFpEF).
Differentiate between types of strokesa. SIchemic stroke- occurs when blood vessels supplying blood to the brain is
obstructed. It accounts for 87% of all strokes.
b. Hemorrhagic stroke- occurs when weakened blood vessel ruptures. The two
types of weakened blood vessels that usually cause this are aneurysms and
arteriovenous malformations. The most common cause of this type of stroke is
uncontrolled HTN.
c. TIA (transient Ischemic Attack)- called “mini stroke”, caused by a serious
temporary clot. A warning, and needs to be taken seriously.
d. Cryptogenic stroke- In most cases, a stroke is caused by a blood clot that blocks
the flow of blood to the brain. In some instances, despite testing, the cause of a
stroke cannot be determined. A stroke of unknown cause is called a “cryptogenic
stroke.”
e. Brain Stem Stroke- When stroke occurs in the brain stem, it can affect both sides
of the body and may leave someone in a ‘locked-in’ state. When a locked-in state
occurs, the patient is generally unable to speak or move below the neck.
Evaluate chest pain without cardiac origin-Gastroesophageal reflux disease (GERD) or
Acid reflux, muscle or bone problems in the chest wall or spine, Lung conditions or
diseases of the pleura, the tissue that cover the lungs, Pulmonary embolism (sharp
pinpoint chest pain), stomach problems (ulcers), stress, anxiety or depression.
Identify cardiogenic shock- Cardiogenic shock is a serious condition that occurs when
your heart cannot pump enough blood and oxygen to the brain, kidneys, and other vital
organs.the most common cause is heart attack.
Identify chest pain not in cardiac origin- Gastroesophageal reflux disease (GERD) or
Acid reflux, muscle or bone problems in the chest wall or spine, Lung conditions or
diseases of the pleura, the tissue that cover the lungs, Pulmonary embolism (sharp
pinpoint chest pain), stomach problems (ulcers), stress, anxiety or depression.
Identify stroke- Sudden numbness or weakness in the face, arm, or leg, especially on
one side of the body. Sudden confusion, trouble speaking, or difficulty understanding
speech. Sudden trouble seeing in one or both eyes. Sudden trouble walking, dizziness,
loss of balance, or lack of coordination. Sudden severe headache with no known cause.
a. F—Face: Ask the person to smile. Does one side of the face droop?
b. A—Arms: Ask the person to raise both arms. Does one arm drift downward?
c. S—Speech: Ask the person to repeat a simple phrase. Is the speech slurred or
strange?
d. T—Time: last time seen normal? If you see any of these signs, transport
emergently.
Administer prescribed cardiac medication-10 rights, make sure there are no
contraindications for med, recheck the doe, med and name on bottle to conform it
matches the pt.
Treat hypotension pt- O2, IV fluid, Vasopressor depending on the severity. Identify and
treat underlying cause of hypotension- treat for the type of shock that the pt has.
9. Treat for return of spontaneous circulation (ROSC)a. Maintain O2 sat of less than or equal to 94%
b. ETCO2 monitor
c. Avoid hyperventilation
d. Treat hypotension-IV/IO bonus, vasopressin infusion, consider treatable causes
e. 12 lead, coronary reperfusion
f. Targeted temp management