cardiology part 2
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CardiologyCardiology
Part 2: Assessment Part 2: Assessment and Management of and Management of the Cardiovascular the Cardiovascular
PatientPatient
SectionsSections
Assessment of the Cardiovascular Patient
Management of Cardiovascular Emergencies
Managing Specific Cardiovascular Emergencies
Assessment of the Cardiovascular Patient
Management of Cardiovascular Emergencies
Managing Specific Cardiovascular Emergencies
Scene Size-up and Initial Assessment Determine scene safety. Determine level of responsiveness. Airway. Breathing:
Note breath sounds indicative of cardiovascular problems.
Circulation: Note color, temperature, turgor, moisture, mobility,
edema.
Treat life-threatening problems.
Scene Size-up and Initial Assessment Determine scene safety. Determine level of responsiveness. Airway. Breathing:
Note breath sounds indicative of cardiovascular problems.
Circulation: Note color, temperature, turgor, moisture, mobility,
edema.
Treat life-threatening problems.
Assessment of the Assessment of the Cardiovascular Cardiovascular
PatientPatient
Focused History Common Symptoms
Chest Pain• OPQRST History of Pain
Dyspnea• Onset• Duration• Provocation/palliation• Orthopnea
Cough
Focused History Common Symptoms
Chest Pain• OPQRST History of Pain
Dyspnea• Onset• Duration• Provocation/palliation• Orthopnea
Cough
Assessment of the Assessment of the Cardiovascular Cardiovascular
PatientPatient
Other Signs and Symptoms Level of
consciousness Diaphoresis Restlessness and
anxiety Feeling of impending
doom Nausea and/or
vomiting Fatigue Palpitations
Other Signs and Symptoms Level of
consciousness Diaphoresis Restlessness and
anxiety Feeling of impending
doom Nausea and/or
vomiting Fatigue Palpitations
Assessment of the Assessment of the Cardiovascular Cardiovascular
PatientPatient Other Signs and
Symptoms Edema Headache Syncope Behavioral change Anguished facial
expression Activity limitations Trauma
Other Signs and Symptoms Edema Headache Syncope Behavioral change Anguished facial
expression Activity limitations Trauma
Allergies Medications
Nitroglycerin, propranolol, digitalis, diuretics, antihypertensives, antidysrhythmics, lipid-lowering agents
Nonprescription drugs• Cocaine
• Antihistamines
• Alcohol
Allergies Medications
Nitroglycerin, propranolol, digitalis, diuretics, antihypertensives, antidysrhythmics, lipid-lowering agents
Nonprescription drugs• Cocaine
• Antihistamines
• Alcohol
Assessment of the Assessment of the Cardiovascular Cardiovascular
PatientPatient
Past Medical History Cardiac history Heart problems Other medical problems Family cardiac history Modifiable risk factors for heart disease (smoking, etc.)
Last Oral Intake Caffeinated beverages
Events Preceding the Incident Stress, strenuous or sexual activity
Past Medical History Cardiac history Heart problems Other medical problems Family cardiac history Modifiable risk factors for heart disease (smoking, etc.)
Last Oral Intake Caffeinated beverages
Events Preceding the Incident Stress, strenuous or sexual activity
Assessment of the Assessment of the Cardiovascular Cardiovascular
PatientPatient
Physical Examination Inspection
Tracheal position
Thorax Epigastrium
Physical Examination Inspection
Tracheal position
Thorax Epigastrium
Assessment of the Assessment of the Cardiovascular Cardiovascular
PatientPatient
Auscultation Breath
Sounds• Adventitious
Sounds
Heart Sounds• Normal
• Abnormal
Auscultation Breath
Sounds• Adventitious
Sounds
Heart Sounds• Normal
• Abnormal
Assessment of the Assessment of the Cardiovascular Cardiovascular
PatientPatient
Auscultation Carotid
Artery Bruit
Auscultation Carotid
Artery Bruit
Assessment of the Assessment of the Cardiovascular Cardiovascular
PatientPatient
Palpation Pulse Thorax
• Crepitus
• Chest Wall Tenderness
Epigastrium
Palpation Pulse Thorax
• Crepitus
• Chest Wall Tenderness
Epigastrium
Assessment of the Assessment of the Cardiovascular Cardiovascular
PatientPatient
Basic Life Support Advanced Life Support
ECG Monitoring Vagal Maneuvers Precordial Thump Pharmacological Management Defibrillation Synchronized Cardioversion Transcutaneous Cardiac Pacing Diagnostic (12-Lead) ECG
Basic Life Support Advanced Life Support
ECG Monitoring Vagal Maneuvers Precordial Thump Pharmacological Management Defibrillation Synchronized Cardioversion Transcutaneous Cardiac Pacing Diagnostic (12-Lead) ECG
Management of Management of Cardiovascular Cardiovascular EmergenciesEmergencies
Monitoring ECG in the Field Parts of the
Defibrillator Monitoring
Leads Lead II, MCL1 “Quick-Look”
Paddles
Monitoring ECG in the Field Parts of the
Defibrillator Monitoring
Leads Lead II, MCL1 “Quick-Look”
Paddles
Management of Management of Cardiovascular Cardiovascular EmergenciesEmergencies
ECG MonitoringECG Monitoring
ECG MonitoringECG Monitoring
ECG MonitoringECG Monitoring
ECG MonitoringECG Monitoring
ECG MonitoringECG Monitoring
ECG MonitoringECG Monitoring
ECG MonitoringECG Monitoring
ECG MonitoringECG Monitoring
Monitoring ECG in the Field Causes of Poor Signals
Excessive hair, loose or dislodged electrode Dried conductive gel, poor placement, diaphoresis Patient movement or muscle tremor Broken patient cable or lead wire Low battery Faulty grounding Faulty monitor
Monitoring ECG in the Field Causes of Poor Signals
Excessive hair, loose or dislodged electrode Dried conductive gel, poor placement, diaphoresis Patient movement or muscle tremor Broken patient cable or lead wire Low battery Faulty grounding Faulty monitor
Management of Management of Cardiovascular Cardiovascular EmergenciesEmergencies
Vagal Maneuvers Indication
Stable patient with symptomatic tachycardia
Maneuvers Valsalva maneuvers Coughing Carotid Sinus Massage
• Avoid in patients with a history of cerebrovascular or carotid artery disease, or patients with carotid bruits.
Vagal Maneuvers Indication
Stable patient with symptomatic tachycardia
Maneuvers Valsalva maneuvers Coughing Carotid Sinus Massage
• Avoid in patients with a history of cerebrovascular or carotid artery disease, or patients with carotid bruits.
Management of Management of Cardiovascular Cardiovascular EmergenciesEmergencies
Precordial Thump Indication
Pulseless patient who has a witnessed arrest.
Most effective when performed immediately after onset of VF.
Not used in pediatric patients.
Technique
Precordial Thump Indication
Pulseless patient who has a witnessed arrest.
Most effective when performed immediately after onset of VF.
Not used in pediatric patients.
Technique
Management of Management of Cardiovascular Cardiovascular EmergenciesEmergencies
Pharmacological Management Antidysrhythmics
Atropine Sulfate Lidocaine Procainamide Bretylium Adenosine Amiodarone Verapamil
Pharmacological Management Antidysrhythmics
Atropine Sulfate Lidocaine Procainamide Bretylium Adenosine Amiodarone Verapamil
Management of Management of Cardiovascular Cardiovascular EmergenciesEmergencies
Sympathomimetic Agents Epinephrine Norepinephrine Isoproterenol Dopamine Dobutamine Vasopressin
Drugs Used for Myocardial Ischemia Oxygen Nitrous Oxide Nitroglycerin Morphine Sulfate Nalbuphine
Sympathomimetic Agents Epinephrine Norepinephrine Isoproterenol Dopamine Dobutamine Vasopressin
Drugs Used for Myocardial Ischemia Oxygen Nitrous Oxide Nitroglycerin Morphine Sulfate Nalbuphine
Management of Management of Cardiovascular Cardiovascular EmergenciesEmergencies
Thrombolytic Agents Aspirin Alteplase Relteplase
Other Prehospital Drugs Furosemide Diazepam Promethazine Sodium Nitroprusside
Thrombolytic Agents Aspirin Alteplase Relteplase
Other Prehospital Drugs Furosemide Diazepam Promethazine Sodium Nitroprusside
Management of Management of Cardiovascular Cardiovascular EmergenciesEmergencies
Drugs Infrequently Used in the Prehospital Setting Digitalis Beta Blockers
• Propranolol, metaprolol, labetalol
Calcium Channel Blockers• Verapamil, nifedipine, diltiazem
Alkalinizing Agents• Sodium bicarbonate
Drugs Infrequently Used in the Prehospital Setting Digitalis Beta Blockers
• Propranolol, metaprolol, labetalol
Calcium Channel Blockers• Verapamil, nifedipine, diltiazem
Alkalinizing Agents• Sodium bicarbonate
Management of Management of Cardiovascular Cardiovascular EmergenciesEmergencies
Defibrillation Chest Wall Resistance
Paddle pressure, paddle–skin interface, paddle surface area, number of previous countershocks, and inspiratory vs. expiratory phase at time of shock
Success of Defibrillation Time until VF Condition of the myocardium Heart size and body weight Previous countershocks Proper paddle size, placement, interface, and pressure Properly functioning defibrillator
Defibrillation Chest Wall Resistance
Paddle pressure, paddle–skin interface, paddle surface area, number of previous countershocks, and inspiratory vs. expiratory phase at time of shock
Success of Defibrillation Time until VF Condition of the myocardium Heart size and body weight Previous countershocks Proper paddle size, placement, interface, and pressure Properly functioning defibrillator
Management of Management of Cardiovascular Cardiovascular EmergenciesEmergencies
DefibrillationDefibrillation
DefibrillationDefibrillation
DefibrillationDefibrillation
DefibrillationDefibrillation
DefibrillationDefibrillation
DefibrillationDefibrillation
DefibrillationDefibrillation
Emergency Synchronized Cardioversion Indications
Unstable, tachycardic patient• Perfusing VT
• PSVT
• Rapid atrial fibrillation
• 2:1 atrial flutter
Emergency Synchronized Cardioversion Indications
Unstable, tachycardic patient• Perfusing VT
• PSVT
• Rapid atrial fibrillation
• 2:1 atrial flutter
Management of Management of Cardiovascular Cardiovascular EmergenciesEmergencies
Procedure Similar to
defibrillation. Premedicate the
patient whenever possible.
Turn on the synchronizer.
Hold discharge buttons until countershock administered.
Procedure Similar to
defibrillation. Premedicate the
patient whenever possible.
Turn on the synchronizer.
Hold discharge buttons until countershock administered.
Management of Management of Cardiovascular Cardiovascular EmergenciesEmergencies
ManagemenManagement of t of
CardiovasculCardiovascular ar
EmergenciesEmergencies
Transcutaneous Cardiac Pacing Indications
Symptomatic, unstable patients who do not respond to pharmacological therapy• Symptomatic bradycardias with high-degree AV blocks.
• Atrial fibrillation with a slow ventricular response.
• Other significant bradycardias, including asystole.
Transcutaneous Cardiac Pacing Indications
Symptomatic, unstable patients who do not respond to pharmacological therapy• Symptomatic bradycardias with high-degree AV blocks.
• Atrial fibrillation with a slow ventricular response.
• Other significant bradycardias, including asystole.
Management of Management of Cardiovascular Cardiovascular EmergenciesEmergencies
External External Cardiac Cardiac PacingPacing
External Cardiac External Cardiac PacingPacing
External Cardiac External Cardiac PacingPacing
External Cardiac External Cardiac PacingPacing
External Cardiac External Cardiac PacingPacing
External Cardiac External Cardiac PacingPacing
External Cardiac External Cardiac PacingPacing
Carotid Sinus Massage Indications
Paroxysmal supraventricular tachycardia in a stable patient.
Complications Do not use in patients with a history of cerebrovascular or
carotid artery disease. Do not use in patients having carotid bruits. Asystole, PVCs, VT, and VF may occur. Patient may experience bradycardia, nausea, and vomiting.
Support and Communication
Carotid Sinus Massage Indications
Paroxysmal supraventricular tachycardia in a stable patient.
Complications Do not use in patients with a history of cerebrovascular or
carotid artery disease. Do not use in patients having carotid bruits. Asystole, PVCs, VT, and VF may occur. Patient may experience bradycardia, nausea, and vomiting.
Support and Communication
Management of Management of Cardiovascular Cardiovascular EmergenciesEmergencies
Carotid Sinus Carotid Sinus MassageMassage
Carotid Sinus Carotid Sinus MassageMassage
Carotid Sinus Carotid Sinus MassageMassage
Carotid Carotid Sinus Sinus
MassageMassage
Carotid Sinus Carotid Sinus MassageMassage
Carotid Sinus Carotid Sinus MassageMassage
Carotid Sinus Carotid Sinus MassageMassage
Carotid Sinus Carotid Sinus MassageMassage
Angina Pectoris Myocardial Infarction Heart Failure Cardiac Tamponade Hypertensive Emergencies Cardiogenic Shock Cardiac Arrest Peripheral Vascular and Other
Cardiovascular Emergencies
Angina Pectoris Myocardial Infarction Heart Failure Cardiac Tamponade Hypertensive Emergencies Cardiogenic Shock Cardiac Arrest Peripheral Vascular and Other
Cardiovascular Emergencies
Managing Specific Managing Specific Cardiovascular Cardiovascular EmergenciesEmergencies
Angina PectorisAngina Pectoris Epidemiology & Pathophysiology
Pathophysiology Angina occurs when the heart’s demand for oxygen
exceeds the blood’s oxygen supply. Commonly caused by artherosclerosis. May also result from spasm of the coronary arteries
(Prinzmetal’s angina). Stable vs. Unstable Angina Disease Progression Spectrum of coronary artery disease best
referred to as acute coronary syndrome
Epidemiology & Pathophysiology Pathophysiology
Angina occurs when the heart’s demand for oxygen exceeds the blood’s oxygen supply.
Commonly caused by artherosclerosis. May also result from spasm of the coronary arteries
(Prinzmetal’s angina). Stable vs. Unstable Angina Disease Progression Spectrum of coronary artery disease best
referred to as acute coronary syndrome
Angina PectorisAngina Pectoris Causes of Chest Pain
Cardiovascular, including acute coronary syndrome, pericarditis, or thoracic dissection of the aorta
Respiratory, including pulmonary embolism, pneumothorax, pneumonia, and pleural irritation
Gastrointestinal, including cholecystitis, pancreatitis, hiatal hernia, esophageal disease, gastroesophageal reflux, peptic ulcer disease, and dyspepsia
Musculoskeletal, including chest wall syndrome, costochondritis, acromioclavicular disease, herpes zoster, chest wall trauma, and chest wall tumors
Causes of Chest Pain Cardiovascular, including acute coronary syndrome,
pericarditis, or thoracic dissection of the aorta Respiratory, including pulmonary embolism,
pneumothorax, pneumonia, and pleural irritation Gastrointestinal, including cholecystitis, pancreatitis,
hiatal hernia, esophageal disease, gastroesophageal reflux, peptic ulcer disease, and dyspepsia
Musculoskeletal, including chest wall syndrome, costochondritis, acromioclavicular disease, herpes zoster, chest wall trauma, and chest wall tumors
Angina PectorisAngina Pectoris Field Assessment
Signs of Shock Chest Discomfort
Typically sudden onset, which may radiate or be localized to the chest.
Patient often denies chest pain. Duration
Episodes last 3–5 minutes. Pain relieved with rest and/or nitroglycerin.
Field Assessment Signs of Shock Chest Discomfort
Typically sudden onset, which may radiate or be localized to the chest.
Patient often denies chest pain. Duration
Episodes last 3–5 minutes. Pain relieved with rest and/or nitroglycerin.
Angina PectorisAngina Pectoris Breathing History
Past episodes of angina:• Episodes of angina that are increasing in frequency,
duration, or severity are significant.
ECG Do not delay scene time. 12-Lead ECG preferred:
• Angina typically causes nonspecific ST changes.
Breathing History
Past episodes of angina:• Episodes of angina that are increasing in frequency,
duration, or severity are significant.
ECG Do not delay scene time. 12-Lead ECG preferred:
• Angina typically causes nonspecific ST changes.
Angina PectorisAngina Pectoris Management
Relieve anxiety: Place the patient in a position of physical and emotional
comfort. Administer oxygen. Establish IV access. Monitor ECG. Consider medication administration:
Nitroglycerin tablets or spray Nifedipine or other calcium channel blockers Morphine sulfate
Management Relieve anxiety:
Place the patient in a position of physical and emotional comfort.
Administer oxygen. Establish IV access. Monitor ECG. Consider medication administration:
Nitroglycerin tablets or spray Nifedipine or other calcium channel blockers Morphine sulfate
Angina PectorisAngina Pectoris Special Considerations
Patients with new-onset or crescendo angina often require hospitalization.
Symptoms not relieved by rest, nitroglycerin, and oxygen may indicate an overall worsening of the disease or the early stages of a myocardial infarction.
Patients may refuse transport after pain is relieved, even though the underlying problem is not addressed.
Special Considerations Patients with new-onset or crescendo angina often
require hospitalization. Symptoms not relieved by rest, nitroglycerin, and
oxygen may indicate an overall worsening of the disease or the early stages of a myocardial infarction.
Patients may refuse transport after pain is relieved, even though the underlying problem is not addressed.
Myocardial Myocardial InfarctionInfarction Pathophysiology
Death and necrosis of heart muscle due to inadequate oxygen supply. Causes may include
occlusion, spasm, microemboli, acute volume overload, hypotension, acute respiratory failure, and trauma.
Location and size dependent on the vessel involved.
Pathophysiology Death and necrosis of
heart muscle due to inadequate oxygen supply. Causes may include
occlusion, spasm, microemboli, acute volume overload, hypotension, acute respiratory failure, and trauma.
Location and size dependent on the vessel involved.
Myocardial Myocardial InfarctionInfarction Transmural vs. Subendocardial MIs.
Effects of a Myocardial Infarction Dysrhythmias Heart Failure Ventricular Aneurysm
Goals of Treatment Pain Relief Reperfusion
Transmural vs. Subendocardial MIs. Effects of a Myocardial Infarction
Dysrhythmias Heart Failure Ventricular Aneurysm
Goals of Treatment Pain Relief Reperfusion
Myocardial Myocardial InfarctionInfarction Field Assessment
Breathing Signs of Shock Chief Complaint
Typically related to chest pain. Evaluate using OPQRST:
• Discomfort > 30 minutes.• Radiation to arms, neck, back, or epigastric region.
Patients may minimize symptoms. Feelings of “impending doom.”
Field Assessment Breathing Signs of Shock Chief Complaint
Typically related to chest pain. Evaluate using OPQRST:
• Discomfort > 30 minutes.• Radiation to arms, neck, back, or epigastric region.
Patients may minimize symptoms. Feelings of “impending doom.”
Myocardial Myocardial InfarctionInfarction Other Symptoms
Nausea and vomiting Diaphoresis
Myocardial Infarctions & the ECG Diagnostic ECGs:
• 12-lead ECGs• S-T segment• Pathological Q waves
Dysrhythmias:• Asystole, PEA, VF, VT.• Dysrhythmias are the leading cause of death in MI.
Other Symptoms Nausea and vomiting Diaphoresis
Myocardial Infarctions & the ECG Diagnostic ECGs:
• 12-lead ECGs• S-T segment• Pathological Q waves
Dysrhythmias:• Asystole, PEA, VF, VT.• Dysrhythmias are the leading cause of death in MI.
Myocardial Myocardial InfarctionInfarction Reperfusion Screening
Reperfusion of ischemic/injured tissue. Time from onset to treatment < 6 hours. Absence of history that would exclude
thrombolytics.
Transport Rapid transport indicated when acute MI suspected
Reperfusion Screening Reperfusion of ischemic/injured tissue. Time from onset to treatment < 6 hours. Absence of history that would exclude
thrombolytics.
Transport Rapid transport indicated when acute MI suspected
Myocardial Myocardial InfarctionInfarction Management
Prehospital Administer oxygen. Establish IV access. Consider medication administration:
• Aspirin• Morphine sulfate• Promethazine• Nitroglycerin• Nitrous oxide• Nubain• Antiarrhythmia medication as indicated
Management Prehospital
Administer oxygen. Establish IV access. Consider medication administration:
• Aspirin• Morphine sulfate• Promethazine• Nitroglycerin• Nitrous oxide• Nubain• Antiarrhythmia medication as indicated
Myocardial Myocardial InfarctionInfarction Monitor ECG.
Rapid transport as indicated. Avoid patient refusals if possible. Identify candidates for thrombolytic therapy.
In-Hospital: Diagnostic ECGs. Enzyme levels. Risk assessment. Treatment:
• Cardiac catheterization, PTCA, and CABG.
Monitor ECG. Rapid transport as indicated. Avoid patient refusals if possible. Identify candidates for thrombolytic therapy.
In-Hospital: Diagnostic ECGs. Enzyme levels. Risk assessment. Treatment:
• Cardiac catheterization, PTCA, and CABG.
MyocardiMyocardial al
InfarctioInfarctionn
Heart FailureHeart Failure
Left Ventricular Failure Pathophysiology
Results in increased back pressure into the pulmonary circulation.
Left Ventricular Failure Pathophysiology
Results in increased back pressure into the pulmonary circulation.
Heart FailureHeart Failure
Right Ventricular Failure Pathophysiology
Results in increased back pressure into the systemic venous circulation.
Pulmonary Embolism
Right Ventricular Failure Pathophysiology
Results in increased back pressure into the systemic venous circulation.
Pulmonary Embolism
Heart FailureHeart Failure
Congestive Heart Failure Pathophysiology
Reduction in the heart’s stroke volume causes fluid overload throughout the body’s other tissues.
Manifestation
Congestive Heart Failure Pathophysiology
Reduction in the heart’s stroke volume causes fluid overload throughout the body’s other tissues.
Manifestation
Heart FailureHeart Failure Field Assessment
Pulmonary Edema: Cough with copious amounts of clear or pink-tinged
sputum. Labored breathing, especially with exertion. Abnormal breath sounds, including rales, rhonchi, and
wheezes. Pulsus paradoxus and pulsus alternans.
Paroxysmal Nocturnal Dyspnea (PND) Medications:
Diuretics. Medications to increase cardiac contractile force. Home oxygen.
Field Assessment Pulmonary Edema:
Cough with copious amounts of clear or pink-tinged sputum.
Labored breathing, especially with exertion. Abnormal breath sounds, including rales, rhonchi, and
wheezes. Pulsus paradoxus and pulsus alternans.
Paroxysmal Nocturnal Dyspnea (PND) Medications:
Diuretics. Medications to increase cardiac contractile force. Home oxygen.
Heart FailureHeart Failure Mental Status
Mental status changes indicate impending respiratory failure.
Breathing Signs of labored breathing. Tripod positioning. “Number of pillows.”
Skin Color changes. Peripheral and/or sacral edema.
Mental Status Mental status changes indicate impending respiratory
failure.
Breathing Signs of labored breathing. Tripod positioning. “Number of pillows.”
Skin Color changes. Peripheral and/or sacral edema.
Heart FailureHeart Failure
Management General management:
Avoid supine positioning. Avoid exertion such as standing or walking.
Maintain the airway. Administer oxygen. Establish IV access.
Limit fluid administration.
Management General management:
Avoid supine positioning. Avoid exertion such as standing or walking.
Maintain the airway. Administer oxygen. Establish IV access.
Limit fluid administration.
Heart FailureHeart Failure Monitor ECG. Consider medication administration:
Morphine Nitroglycerine Lasix Dopamine/dobutamine Promethazine Nitrous oxide
Avoid patient refusals if at all possible.
Monitor ECG. Consider medication administration:
Morphine Nitroglycerine Lasix Dopamine/dobutamine Promethazine Nitrous oxide
Avoid patient refusals if at all possible.
Cardiac Cardiac TamponadeTamponade Epidemiology & Pathophysiology
Pathophysiology Result of fluid accumulation between visceral pericardium
and parietal pericardium. Increased intrapericardial pressure impairs diastolic
filling. Typically worsens progressively until corrected.
Epidemiology Acute onset typically the result of trauma or MI. Benign presentations may be caused by cancer,
pericarditis, renal disease, and hypothyroidism.
Epidemiology & Pathophysiology Pathophysiology
Result of fluid accumulation between visceral pericardium and parietal pericardium.
Increased intrapericardial pressure impairs diastolic filling.
Typically worsens progressively until corrected.
Epidemiology Acute onset typically the result of trauma or MI. Benign presentations may be caused by cancer,
pericarditis, renal disease, and hypothyroidism.
Cardiac Cardiac TamponadeTamponade Field Assessment
Patient History Determine precipitating causes. Patient relates a history of dyspnea and orthopnea.
Exam Rapid, weak pulse Decreasing systolic pressure Narrowing pulse pressures Pulsus paradoxus Faint, muffled heart sounds Electrical alternans
Field Assessment Patient History
Determine precipitating causes. Patient relates a history of dyspnea and orthopnea.
Exam Rapid, weak pulse Decreasing systolic pressure Narrowing pulse pressures Pulsus paradoxus Faint, muffled heart sounds Electrical alternans
Cardiac Cardiac TamponadeTamponade Management
Maintain airway. Administer oxygen. Establish IV access. Consider medication administration:
Morphine sulfate Nitrous oxide Furosemide Dopamine/dobutamine
Management Maintain airway. Administer oxygen. Establish IV access. Consider medication administration:
Morphine sulfate Nitrous oxide Furosemide Dopamine/dobutamine
Cardiac Cardiac TamponadeTamponade Rapid Transport
Pericardiocentisis Pericardiocentisis is the definitive treatment. Insertion of a cardiac needle and aspiration of fluid
from the pericardium. Procedure should be performed only if allowed by
local protocol. Procedure should be performed only by personnel
adequately trained in the procedure.
Rapid Transport Pericardiocentisis
Pericardiocentisis is the definitive treatment. Insertion of a cardiac needle and aspiration of fluid
from the pericardium. Procedure should be performed only if allowed by
local protocol. Procedure should be performed only by personnel
adequately trained in the procedure.
Hypertensive Hypertensive EmergenciesEmergencies
Hypertensive Emergency Causes
Typically occurs only in patients with a history of HTN. Primary cause is noncompliance with prescribed
antihypertensive medications. Also occurs with toxemia of pregnancy.
Risk Factors Age-related factors Race-related factors
Hypertensive Emergency Causes
Typically occurs only in patients with a history of HTN. Primary cause is noncompliance with prescribed
antihypertensive medications. Also occurs with toxemia of pregnancy.
Risk Factors Age-related factors Race-related factors
Hypertensive Hypertensive EmergenciesEmergencies
Field Assessment Initial Assessment
Alterations in mental state
Signs & Symptoms Headache accompanied by nausea and/or vomiting Blurred vision Shortness of breath Epistaxis Vertigo Tinnitus
Field Assessment Initial Assessment
Alterations in mental state
Signs & Symptoms Headache accompanied by nausea and/or vomiting Blurred vision Shortness of breath Epistaxis Vertigo Tinnitus
Hypertensive Hypertensive EmergenciesEmergencies
History Known history of hypertension Compliance with medications
Exam BP > 160/90 Signs of left ventricular failure Strong, bounding pulse Abnormal skin color, temperature, and condition Presence of edema
History Known history of hypertension Compliance with medications
Exam BP > 160/90 Signs of left ventricular failure Strong, bounding pulse Abnormal skin color, temperature, and condition Presence of edema
Hypertensive Hypertensive EmergenciesEmergencies
Management Maintain airway. Administer oxygen. Establish IV access. Consider medication administration:
Morphine sulfate Furosemide Nitroglycerin Sodium nitroprusside Labetalol
Management Maintain airway. Administer oxygen. Establish IV access. Consider medication administration:
Morphine sulfate Furosemide Nitroglycerin Sodium nitroprusside Labetalol
Cardiogenic ShockCardiogenic Shock Pathophysiology
General Inability of the heart to meet the body’s metabolic needs. Often remains after correction of other problems. Severe form of pump failure. High mortality rate.
Causes Tension pneumothorax and cardiac tamponade. Impaired ventricular emptying. Impaired myocardial contractility. Trauma.
Pathophysiology General
Inability of the heart to meet the body’s metabolic needs. Often remains after correction of other problems. Severe form of pump failure. High mortality rate.
Causes Tension pneumothorax and cardiac tamponade. Impaired ventricular emptying. Impaired myocardial contractility. Trauma.
Cardiogenic ShockCardiogenic Shock Field Assessment
Initial Assessment Chief Complaint
Chief complaint is typically chest pain, shortness of breath, unconsciousness, or altered mental state.
Onset may be acute or progressive. History
History of recent MI or chest pain episode. Presence of shock in the absence of trauma.
Field Assessment Initial Assessment Chief Complaint
Chief complaint is typically chest pain, shortness of breath, unconsciousness, or altered mental state.
Onset may be acute or progressive. History
History of recent MI or chest pain episode. Presence of shock in the absence of trauma.
Cardiogenic ShockCardiogenic Shock Mental Status
Restlessness progressing to confusion Airway and Breathing
Dyspnea, labored breathing, and cough PND, tripod position, accessory muscle retraction, and
adventitious lung sounds ECG
Tachycardia and atrial dysrhythmias Circulation
Hypotension Cool, clammy skin
Mental Status Restlessness progressing to confusion
Airway and Breathing Dyspnea, labored breathing, and cough PND, tripod position, accessory muscle retraction, and
adventitious lung sounds ECG
Tachycardia and atrial dysrhythmias Circulation
Hypotension Cool, clammy skin
Cardiogenic ShockCardiogenic Shock
Management Maintain airway. Administer oxygen Identify and treat underlying problem. Establish IV access. Consider medication administration:
Vasopressors Other meds
Management Maintain airway. Administer oxygen Identify and treat underlying problem. Establish IV access. Consider medication administration:
Vasopressors Other meds
CardiogeCardiogenic Shocknic Shock
Cardiac ArrestCardiac Arrest Sudden Death
Causes Electrolyte or acid–base imbalances Electrocution Drug intoxication Hypoxia Hypothermia Pulmonary embolism Stroke Drowning Trauma End-stage renal disease and hyperkalemia
Sudden Death Causes
Electrolyte or acid–base imbalances Electrocution Drug intoxication Hypoxia Hypothermia Pulmonary embolism Stroke Drowning Trauma End-stage renal disease and hyperkalemia
Cardiac ArrestCardiac Arrest Field Assessment
Initial Assessment Unresponsive, apneic, pulseless patient
ECG Dysrhythmias
History Prearrest events Bystander CPR “Down time”
Field Assessment Initial Assessment
Unresponsive, apneic, pulseless patient ECG
Dysrhythmias History
Prearrest events Bystander CPR “Down time”
Cardiac ArrestCardiac Arrest Management
Resuscitation Return of Spontaneous Circulation Survival Role of Basic Life Support General Guidelines
Manage specific dysrhythmias. CPR. Advanced airway management. Establish IV access.
Management Resuscitation Return of Spontaneous Circulation Survival Role of Basic Life Support General Guidelines
Manage specific dysrhythmias. CPR. Advanced airway management. Establish IV access.
Cardiac Cardiac Arrest Arrest
ManagemeManagementnt
Cardiac Cardiac Arrest Arrest
ManagemeManagementnt
Cardiac Cardiac Arrest Arrest
ManagemeManagementnt
Cardiac ArrestCardiac Arrest Postresuscitation Management
Manage dysrhythmias and problems as presented. Be alert for PEA. Transport rapidly:
• Take care to protect intubation and IV access.
Withholding Resuscitation Rigor mortis Dependent lividity Decapitation, decomposition, incineration Valid advanced directive
Postresuscitation Management Manage dysrhythmias and problems as presented. Be alert for PEA. Transport rapidly:
• Take care to protect intubation and IV access.
Withholding Resuscitation Rigor mortis Dependent lividity Decapitation, decomposition, incineration Valid advanced directive
Cardiac ArrestCardiac Arrest Terminating Resuscitation
Indications for termination of resuscitation• Patient over 18 years old.• Cause is presumed cardiac in origin.• Successful endotracheal intubation.• ACLS standards applied throughout the arrest.• On-scene effort > 25 minutes, or four rounds of drug
therapy.• ECG remains asystolic or agonal.• Blunt trauma victims presenting with or developing
asystole.
Terminating Resuscitation Indications for termination of resuscitation
• Patient over 18 years old.• Cause is presumed cardiac in origin.• Successful endotracheal intubation.• ACLS standards applied throughout the arrest.• On-scene effort > 25 minutes, or four rounds of drug
therapy.• ECG remains asystolic or agonal.• Blunt trauma victims presenting with or developing
asystole.
Cardiac ArrestCardiac Arrest Terminating Resuscitation
Contraindications to termination of resuscitation:• Patient under 18 years old.• Arrest is of a treatable cause.• Present or recurring VF/VT.• Transient return of a pulse.• Signs of neurological viability.• Witnessed arrest.• Family or others opposed to termination of resuscitation.
Always follow local protocols related to termination of resuscitation.
Support the family or others after termination of resuscitation.
Coordinate with law enforcement as required.
Terminating Resuscitation Contraindications to termination of resuscitation:
• Patient under 18 years old.• Arrest is of a treatable cause.• Present or recurring VF/VT.• Transient return of a pulse.• Signs of neurological viability.• Witnessed arrest.• Family or others opposed to termination of resuscitation.
Always follow local protocols related to termination of resuscitation.
Support the family or others after termination of resuscitation.
Coordinate with law enforcement as required.
BradycardiBradycardia a
AlgorithmAlgorithm
TachycarTachycardia dia
AlgorithAlgorithmm
Atherosclerosis Pathophysiology
Progressive degenerative disease of the medium-sized and large arteries.
Results from the buildup of fats on the interior of the artery.
Fatty buildup results in plaques and eventual stenosis of the artery.
Arteriosclerosis Claudication
Atherosclerosis Pathophysiology
Progressive degenerative disease of the medium-sized and large arteries.
Results from the buildup of fats on the interior of the artery.
Fatty buildup results in plaques and eventual stenosis of the artery.
Arteriosclerosis Claudication
Peripheral Vascular and Peripheral Vascular and Other Cardiovascular Other Cardiovascular
EmergenciesEmergencies
Aneurysm Pathophysiology
Ballooning of an arterial wall, usually the aorta, that results from a weakness or defect in the wall
Types Atherosclerotic Dissecting Infectious Congenital Traumatic
Aneurysm Pathophysiology
Ballooning of an arterial wall, usually the aorta, that results from a weakness or defect in the wall
Types Atherosclerotic Dissecting Infectious Congenital Traumatic
Peripheral Vascular and Peripheral Vascular and Other Cardiovascular Other Cardiovascular
EmergenciesEmergencies
Abdominal Aortic Aneurysm Often the result
of atherosclerosis
Signs and symptoms• Abdominal pain
• Back/flank pain
• Hypotension
• Urge to defecate
Abdominal Aortic Aneurysm Often the result
of atherosclerosis
Signs and symptoms• Abdominal pain
• Back/flank pain
• Hypotension
• Urge to defecate
Peripheral Vascular and Peripheral Vascular and Other Cardiovascular Other Cardiovascular
EmergenciesEmergencies
Dissecting Aortic Aneurysm Caused by degenerative changes in the smooth
muscle and elastic tissue. Blood gets between and separates the wall of the
aorta. Can extend throughout the aorta and into
associated vessels.
Dissecting Aortic Aneurysm Caused by degenerative changes in the smooth
muscle and elastic tissue. Blood gets between and separates the wall of the
aorta. Can extend throughout the aorta and into
associated vessels.
Peripheral Vascular and Peripheral Vascular and Other Cardiovascular Other Cardiovascular
EmergenciesEmergencies
Acute Pulmonary Embolism Pathophysiology
Blockage of a pulmonary artery by a blood clot or other particle.
The area served by the pulmonary artery fails. Signs and Symptoms
Dependent upon size and location of the blockage. Onset of severe, unexplained dyspnea. History of recent lengthy immobilization.
Acute Pulmonary Embolism Pathophysiology
Blockage of a pulmonary artery by a blood clot or other particle.
The area served by the pulmonary artery fails. Signs and Symptoms
Dependent upon size and location of the blockage. Onset of severe, unexplained dyspnea. History of recent lengthy immobilization.
Peripheral Vascular and Peripheral Vascular and Other Cardiovascular Other Cardiovascular
EmergenciesEmergencies
Acute Arterial Occlusion Pathophysiology
Sudden occlusion of arterial blood flow due to trauma, thrombosis, tumor, embolus, or idiopathic means.
Frequently involves the abdomen or extremities.
Vasculitis Pathophysiology
Inflammation of the blood vessels. Commonly stems from rheumatic diseases and
syndromes.
Acute Arterial Occlusion Pathophysiology
Sudden occlusion of arterial blood flow due to trauma, thrombosis, tumor, embolus, or idiopathic means.
Frequently involves the abdomen or extremities.
Vasculitis Pathophysiology
Inflammation of the blood vessels. Commonly stems from rheumatic diseases and
syndromes.
Peripheral Vascular and Peripheral Vascular and Other Cardiovascular Other Cardiovascular
EmergenciesEmergencies
Noncritical Peripheral Vascular Conditions Peripheral Arterial Atherosclerotic Disease
Can be acute or chronic. Often associated with diabetes. Extremities exhibit pain, coldness, numbness, and pallor.
Deep Venous Thrombosis Blood clot in a vein. Typically occurs in the larger veins of the thigh and calf. Swelling, pain, and tenderness, with warm, red skin.
Varicose Veins Dilated superficial veins, common with pregnancy and
obesity.
Noncritical Peripheral Vascular Conditions Peripheral Arterial Atherosclerotic Disease
Can be acute or chronic. Often associated with diabetes. Extremities exhibit pain, coldness, numbness, and pallor.
Deep Venous Thrombosis Blood clot in a vein. Typically occurs in the larger veins of the thigh and calf. Swelling, pain, and tenderness, with warm, red skin.
Varicose Veins Dilated superficial veins, common with pregnancy and
obesity.
Peripheral Vascular and Peripheral Vascular and Other Cardiovascular Other Cardiovascular
EmergenciesEmergencies
General Assessment and Management of Vascular Disorders Assessment
Initial Assessment Circulatory Assessment
• Pallor• Pain• Pulselessness• Paralysis• Paresthesia
General Assessment and Management of Vascular Disorders Assessment
Initial Assessment Circulatory Assessment
• Pallor• Pain• Pulselessness• Paralysis• Paresthesia
Peripheral Vascular and Peripheral Vascular and Other Cardiovascular Other Cardiovascular
EmergenciesEmergencies
Chief Complaint• OPQRST
Physical Exam• Prior history of vascular problems• Differences in pulses or blood pressures
Management Maintain the airway. Administer oxygen if respiratory distress or signs of
hypoperfusion present. Consider administration of analgesics. Transport rapidly if signs of hypoperfusion present.
Chief Complaint• OPQRST
Physical Exam• Prior history of vascular problems• Differences in pulses or blood pressures
Management Maintain the airway. Administer oxygen if respiratory distress or signs of
hypoperfusion present. Consider administration of analgesics. Transport rapidly if signs of hypoperfusion present.
Peripheral Vascular and Peripheral Vascular and Other Cardiovascular Other Cardiovascular
EmergenciesEmergencies
CardiologyCardiology
Assessment of the Cardiovascular Patient
Management of Cardiovascular Emergencies
Management of Specific Cardiovascular Emergencies
Assessment of the Cardiovascular Patient
Management of Cardiovascular Emergencies
Management of Specific Cardiovascular Emergencies