CARDIOVASCULAR SYSTEM

600,000 People Die Annually of Cardiovascular Disease. Half of Those Deaths Occur Outside the Hospital Setting, and Half of Those Deaths Are the Result of “Sudden Death.” Sudden Death is the First Sign of Cardiovascular Disease in Half of Those Patients.

CARDIOVASCULAR SYSTEM

The Best Chance of Survival From “Sudden Death” is CPR and Early, Rapid Defibrillation

CARDIOVASCULAR SYSTEM

Affective Objective

• Know How & Why to Defend Training & Continuing Education In CPR & Use of an AED

• Know When & When Not to Administer Nitroglycerin for Chest Pain & Discomfort

CARDIOVASCULAR SYSTEM

• Circulatory System Components

– Heart

– Arteries & Arterioles

– Veins & Venules

– Capillaries

– Blood

CARDIOVASCULAR SYSTEM

• Heart

– Atrium

• Right – Receives Blood From Body

• Left – Receives Blood From Lungs

– Ventricle

• Pumps to Lungs

• Pumps to Body

CARDIOVASCULAR SYSTEM

• Conductive System

– Myocardium

• Muscle & Heart

– Contract & Conduct

– Produces Electrical Impulses

• Only Muscle Able to Produce it’s Own Electrical Stimulation

CARDIOVASCULAR SYSTEM

• This Slide Is On a Need To Know Basis

– You Don’t Need to Know It

CARDIOVASCULAR SYSTEM

• Arteries

– Carry Blood Away From Heart

• Major Arteries

– Coronary Arteries

• Supplies Blood to Heart Muscle

– Aorta

• Largest Artery, Originates at Heart, Protected by Spine Thru Abdominal Cavity

• Splits at Level of Naval Into Iliac Arteries

CARDIOVASCULAR SYSTEM

• Arteries

– Pulmonary Artery

• From Right Ventricle, Carries O2 Poor Blood

– Carotids

• Supplies Head & Neck

– Femoral

• Supply Legs, Palpated in Groin

CARDIOVASCULAR SYSTEM

• Arteries

– Radial

• Lower Arm, Follows Radius, Thumb Side

– Brachial

• Upper Arm, Follows Humerus Between Bicep & Tricep Muscles, Used For BP

– Posterior Tibial

• Posterior Medial Malleolus – Back, Inside Ankle

– Dorsalis Pedis

• Anterior Foot

CARDIOVASCULAR SYSTEM

• Arterioles

– Smallest Arteries

• Capillaries

– Tiniest Vessels

• Connects Arterioles & Venules

• Nutrient & Gas Exchange at Cell Level

• Venules

– Smallest Veins

CARDIOVASCULAR SYSTEM

• Veins

– Carries Blood Back to the Heart

– Pulmonary Vein

• Carries O2 Rich Blood From Lungs to Left Atrium

– Venae Cava

• Superior & Inferior

• From Body to Right Atrium

CARDIOVASCULAR SYSTEM

• Blood Composition

• Red Blood Cells

– Oxygen to Organs

– CO2 from Organs

– Gives Color

• White Blood Cells

– Fights Infection

• Plasma

– Fluid Carries Blood

• Platelets - Clotting

PHYSIOLOGY

• Pulse

– Left Ventricle Contracts

– Systolic BP

– Pulse Palpated Where Artery is Close to Skin Surface

PHYSIOLOGY

• Peripheral Pulses

– Radial

– Brachial

– Posterior Tibial

– Dorsalis Pedis

• Central Pulses

– Carotid

– Femoral

PHYSIOLOGY

• Blood Pressure

– Systolic

• Pressure Exerted on Walls of Artery When Left Ventricle Contracts

– Diastolic

• Pressure Exerted on Walls of Artery When Left Ventricle Relaxes

PHYSIOLOGY

• Inadequate Circulation

• Profound Depression of the Vital Processes

• Signs & Symptoms

– Pale, Cyanotic, Cool Clammy Skin, Rapid Weak Pulse, Rapid Shallow Breathing, Restlessness, Anxiety, Mental Dullness, Nausea, Vomiting, Reduction in Blood Volume, Subnormal Temperature, Low or Decreasing BP

What is a Heart Attack ?

CARDIAC COMPRIMISE

CONGESTIVE HEART FAILURE – CHF

• Poor Pump That Backs-up Fluid

• Right Sided Failure • Left Sided Failure

– JVD - Lungs / Breathing

– Unexplained Weight Gain - Dependent Edema

– é Urinary Output (Night) - Sleepless

CARDIAC COMPRIMISE

CONGESTIVE HEART FAILURE – CHF

PULMONARY EDEMA

• Fluid Backing Up In the Lungs

• Usually Starts In the Bases

• Gradually Fills Lungs

• The Patient Is Drowning

CARDIAC COMPRIMISE

• CHF Medication Examples

– Digoxin, Lanoxin (Cardiac Glycosides)

• Actions – Slows Heart Rate, Increases Filling Volume & Contraction, Greater Velocity

– “Pril’s”, Vasotec, Prinivil (ACE Inhibitors)

• BP Regulation

– Lasix, Furosemide, Bumex (Diuretics)

• Removes Salt – Water Follows Salt

CARDIAC COMPRIMISE

• Chest Pain, Dull, Squeezing, Tight, Heavy, Pressure

• Commonly Radiates – Left Arm, Neck, Jaw, Upper Back

• Sudden Onset of Sweating

• Difficulty Breathing

CARDIAC COMPRIMISE

• Anxiety, Irritability, Impending Doom

• Epigastric Pain, Nausea, Vomiting

• Palpitations / Fluttering

• Abnormal Pulse or BP

– Tachycardia (Above 100 Beats per Minute)

– Bradycardia (Below 60 Beats per Minute)

EMERGENCY CARE

• If Unresponsive & Pulse is Absent

– Start CPR, Use AED

– Use Pediatric Pads On Small Children

• Responsive with Known Cardiac History

– Perform Initial Assessment

– Perform Focused History & Physical Exam

– Place Patient in Position of Comfort

EMERGENCY CARE

• Chest Pain / Discomfort

– Treat as Cardiac

– Apply O2

– Assess Baseline Vitals

• Questions

– O, P, Q, R, S, T

– S, A, M, P, L, E

• Prescribed NTG ?

EMERGENCY CARE

• Does the Patient Have Nitroglycerin?

– Is It Prescribed By a Doctor For the Patient?

– Does the Patient Have His Nitro With Him/Her

EMERGENCY CARE

• BP Must Be Above 100 Systolic to Use NTG!!!

– May Assist With 1 Dose

– Reassess Patient and Vital Signs

• BP Must Remain Above 100 Systolic to Continue w/ NTG

– Contact Medical Command

– Normal Dose of NTG is 1 Every 3-5 Minutes, Maximum of 3 Tablets or Sprays

NITROGLYCERIN

• Generic Name – Nitroglycerin

• Trade Name – Nitrostat

• Medication Forms – EMT Can Assist

– Tablet

– Spray – 1 Spray = 1 Tablet

• Forms – EMT Can Not Assist

– Patch

– Ointment / Paste

NITROGLYCERIN

• Contraindications

– Hypotension – BP ê 100 mmHg Systolic

– Head Injury

– Infants & Children

– Patient Has Already Taken Maximum Dose

– Men Taking Viagra or Other E.D. Meds

• Max Dose

– 3 Tablets or Sprays

NITROGLYCERIN

• Actions

– Relaxes / Dilates Coronary Arteries

• Perhaps Allowing More Blood Past Blockage

– Decreases the Workload of Heart

– Dilates All Blood Vessels

• Side Effects

– Hypotension

– Headache

– Pulse Rate Changes

NITROGLYCERIN

• Administration

– Obtain Medical Direction

• Verbal Via Phone or Radio

• Written Standing Order

– Perform Focused Assessment

– Baseline Vitals – BP Must Be é 100 Systolic

– Command

– Assure Right Med, Pt, Route & Patient is Alert

– Check Expiration Date of Nitro Container

NITROGLYCERIN

• The Four Rights

– Right Patient?

– Right Drug?

– Right Dose?

– Right Route?

NITROGLYCERIN

• Administration (Cont.)

– Question Patient

• Did He Take Any Already, How Many

• Confirm Route Prescribed

– Wear Gloves

– Ask Patient to Lift Tongue

– 1 Tablet or Spray Sublingual

– Close Mouth

– Do Not Swallow – Allow to Dissolve

NITROGLYCERIN

• Administration (Cont.)

– Recheck BP Within 2 Minutes

– Record All Activities and Times

– Reassess Patient

• Effect On Pain Relief ?

• Headache ?

• Dizzy ?

• Seek Your Medical Direction Before Re-Administering

Statewide BLS Protocol
Chest Pain with NTG

• Criteria:

• A. Chest pain of possible cardiac origin. May include:

– 1. Retrosternal chest heaviness/pressure/pain

– 2. Radiation of pain to neck, arms or jaw

– 3. Associated SOB, nausea/vomiting or sweating

– 4. Possibly worsened by exertion

– 5. Patient over 30 y/o

– 6. Patient with history of recent cocaine use

Statewide BLS Protocol
Chest Pain with NTG

• Exclusion Criteria:

• A. Chest pain, probably not cardiac origin.

– 1. May include:

• a. Pleuritic chest pain- worsens with deep breath or bending/turning.

• b. Patient less than 30 y/o

– 2. If associated with shortness of breath, follow Shortness of Breath protocol #421

Statewide BLS Protocol
Chest Pain with NTG

· Know the Chest Pain Protocol

Statewide BLS Protocol
Chest Pain with NTG

• 7. Contact medical command if EMT has assisted with nitroglycerin. 7

Statewide BLS Protocol
Chest Pain with NTG

• Notes

– 2. An EMT may assist with the medication ONE TIME ONLY prior to contacting Medical Command. Any subsequent administration requires direction from a medical command physician.

Statewide BLS Protocol
Chest Pain with NTG

• Notes

– 6. Nitroglycerine use may lead to severe, and possibly fatal, hypotension when given within 24-48 hours after a patient has used drugs that treat erectile dysfunction (phosphoodiesterase inhibitors). Nitroglycerine should not be given within 24 hours of taking Viagra (sildenafil) or Levitra (vardenafil) or within 48 hours of taking Cialis (tadalafil).

Statewide BLS Protocol
Chest Pain with NTG

• Notes

– 7. If unable to contact medical command, may repeat nitroglycerin one time 5 minutes after initial dose as long as systolic blood pressure is > 100 prior to second dose.

EMERGENCY CARE

• OK, Let’s Finish Emergency Care Of Responsive Patient With Chest Pain.

• If the Patient Does Not Have NTG, Either Prescribed or In Possession of, Do the Focused Assessment

• Transport

• Prefer a Quiet Transport – Why ?

BASIC LIFE SUPPORT

• Not All Chest Pain Turns Into Cardiac Arrest

• Not All Chest Pain Is Cardiac In Nature

• But if it Looks Like a Duck, Sounds Like a Duck & Swims Like a Duck, Treat it Like a Cardiac Problem

BASIC LIFE SUPPORT

• CPR

– 1 Rescuer CPR is Rare For an EMT On Duty

– 2 Rescuer CPR is Common - Practice

– Push Hard, Push Fast, Allow Full Recoil

• 30 Compressions In 23 Seconds

– Witnessed Arrest w/ AED – Shock Immediately

– Unwitnessed Arrest – 2 Minutes CPR B4 Shock

• Bystander CPR On AED Arrival Equals 2 Minutes

BASIC LIFE SUPPORT

• Besides CPR the EMT Must Be Proficient In:

– AED

– When to Request ALS Assist

– BVM w/ O2

– O2 Powered Ventilatory Devices

– Techniques in Lifting & Moving

– Suctioning

– Airway Adjuncts

– BSI

– Interviewing & Communications

BASIC LIFE SUPPORT

• AED

• Early Defibrillation Results in Saves

• Chain of Survival

– Early Access

– Early CPR

– Early Defibrillation

– Early ACLS

BASIC LIFE SUPPORT

• Types

– Automated

• Turn On Power

– Semi-Automated

• Turn On

• Analyze

• Shock

– Biphasic vs. Monophasic

BASIC LIFE SUPPORT

• Attach AED to Unresponsive, Pulseless, Non-Breathing Patients Only (age & weight appropriate)

• Light Up the Right Patient

• Machines & Humans Can Make Mistakes

BASIC LIFE SUPPORT

• AED Operation

– BSI, Scene Safe ?

– Initial Assessment

– Stop CPR if Being Preformed

– Verify Apnea & Pulselessness

– Resume CPR Until Device is Prepared

– Place Pads On Patient & Connect to Device

– Turn On Power

BASIC LIFE SUPPORT

• AED Operation

– Stop CPR

– Clear Everyone During Analysis & Shock

• Stop CPR & Ventilations

• Defibrillation More Beneficial

– Push Analyze

– If Shock Is Advised

• Wait For Device to Charge

BASIC LIFE SUPPORT

• AED Operation – Follow Machine’s Orders

– Resume CPR For 2 Minutes

• Check Pulse to Confirm Effectiveness

– Re-Analyze

– Shock If Indicated

– Continue Unless Patient Begins to Move

– Continue Until ALS Arrives

– Transport After 3 Shocks

– Provide Shocks During Transport if Indicated

BASIC LIFE SUPPORT

AED SOP

• Transport the Patient if:

– Patient Regains Pulse or Movement

– 3 Shocks Are Delivered

– 3 Consecutive “No Shock Indicated” Messages

• Separated by 2 Minutes of CPR

BASIC LIFE SUPPORT

AED SOP

– If Patient Begins to Move

• Check For Breathing – Continue Ventilating

• Monitor Pulse Frequently

BASIC LIFE SUPPORT

• 1 EMT Operates AED – 1 EMT Does CPR

• Defibrillation Is a High Priority

– Don’t Do Anything to Delay Analysis

• Avoid All Contact During Analysis

• Clear the Patient – Analysis & Shock

– “I’m Clear, You’re Clear, We Are All Clear!!!”

– LOUD and CLEAR

BASIC LIFE SUPPORT

• AED Pediatric Considerations

– Airway Airway Airway

– AED Contraindicated > 1Year of Age

– Pediatric Pads 1 to 8 Years Old

• Attenuator

• Puberty – Underarm Hair Boys, Breast Development Girls

– Adult Pads Can Not Touch

• Anterior / Posterior Placement

• Adult Pads on Peds But No Peds Pads On Adults!!!

BASIC LIFE SUPPORT

• AED Operation

– Safety

• Do Not Use In Water

• Move to Dry Location or Surface

• Dry Chest / Path Between Pads

• Do Not Touch Any Metal the Patient May Be In Contact With

• AED May Not Analyze Correctly in Moving Ambulance

• Defibrillation is Dangerous in Moving Ambulance