EMT Cardiovascular ACS

Transition SeriesTopics for the EMT

TOPICTOPIC

Cardiovascular Emergencies: Chest Pain and Acute Coronary Syndrome

Cardiovascular Emergencies: Chest Pain and Acute Coronary Syndrome

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ObjectivesObjectives

• Discuss the epidemiological profiles of chest pain and ACS.

• Review the pathophysiologic changes that accompany ACS.

• Discuss assessment and strategies for managing a patient with ACS.

• Review cardiac arrest and appropriate arrest management.

IntroductionIntroduction

• ACS refers to any clinical syndrome that adversely affects myocardial activity.

• ACS may be the reason for the call, or an associated finding.

• Due to the dire nature of cardiac events, proper assessment and management are integral to patient survival.

EpidemiologyEpidemiology

• 62 million Americans have cardiovascular disease.

• Chest pain occurs in 7-8 million people annually.

• 1.5 million will suffer a heart attack.• 500,000 will die from a heart attack, with

half of them arresting within one hour of onset.

PathophysiologyPathophysiology

• Atherosclerosis– Intimal damage to blood vessel (damage to

the inside layer of the blood vessel)– Body attempts to repair damage– Fatty streaks develop and smooth muscle

proliferates over injury site– Fibrous caps that form are not stable and may

rupture

The process of artery occlusion (atherosclerosis): (a) The endothelium (inner wall) of the artery is damaged. (b) Fatty streaks begin to form in the damaged vessel walls. (c) Fibrous plaques form, causing further vessel damage and progressive resistance to blood flow. (d) The plaque deposits begin to ulcerate or rupture; platelets aggregate and adhere to the surface of the ruptured plaque, forming clots that may block the artery.


• Acute coronary syndrome manifestations– Angina (stable and unstable)– Myocardial infarction


• Angina pectoris– “Pain in the chest”– Increased workload on the heart– Insufficient blood flow and oxygen– Ischemic cells produce pain

Angina pectoris, or chest pain, results when a coronary artery is blocked, depriving an area of the myocardium of oxygen.


• Angina pectoris– Stable angina

Chest pain of a predictable nature Resolution with nitro or rest is also predictable

– Unstable angina Occurs unexpectedly – not tied to triggers

– Variant angina (Prinzmetal angina) Coronary artery spasm causes the pain from poor

blood flow


• Myocardial infarction– Commonly from coronary artery occlusion– Necrotic core with ischemic borders– Weakens heart muscle and can precipitate

dysrhythmias

Cross section of a myocardial infarction

A heart with normal and infarcted tissue.


• Negative feedback mechanisms– Due to pain and drop in cardiac output– Rate increases, blood vessels constrict, heart

tries to beat harder (sympathetic discharge)

Effects of Myocardial Infarction on Body Systems

AssessmentAssessment

• Clinical picture of ischemia and infarction almost identical

• Most classic findings– Chest pain– Radiation to left arm and jaw– Radiation may also occur to right arm or back– Nausea and vomiting

Both myocardial infarction and less serious angina can present symptoms of severe chest pain. Treat all cases of chest pain as cardiac emergencies.

Symptoms in Women with Cardiac Ischemia or Infarction

Special Considerations in Geriatric Cardiac Events

Emergency Medical CareEmergency Medical Care

• Ensure an open airway• Provide oxygen (high flow)• Administer 160-325 mg aspirin• Assist in administration of nitroglycerin• Position the patient• Arrange for ALS backup or intercept• Ensure rapid and smooth transport to ED

Case StudyCase Study

You respond to the home of a 64-year-old male patient with chest pain. Upon arrival, you find the patient sitting on a chair, grasping at his chest. He looks scared and keeps saying, “My chest hurts so bad, please, please help.”


• Scene Size-Up– Standard precautions taken– Single white male patient, 150 kg weight– NOI is chest pain– Entry and egress from home will be straight

forward– ALS also dual dispatched, still 10 minutes out


• What are some concerns you have based on the scene size-up?


• Primary Assessment Findings– Scene is secured– Pain is “9” on 1-10 scale – Airway patent and breathing is adequate– Chest excursion normal, inspiratory crackles

heard– Central and peripheral pulse present– Patient states he already took 2 of his nitro

pills without relief


• Is this patient a high or low priority? Why?• What are the life threats to this patient?• What emergency care should you provide

based on the primary assessment findings?


The patient further adds that the pain started while he was just watching TV. Although he has had angina before, it was never this strong and it always responded to one dose of nitro prescribed by his doctor.


• Medical History– Hypertension and angina (denies MI)

• Medications– Norvasc and nitro

• Allergies– Sulfa drugs


• Pertinent Secondary Assessment Findings– Pupils equal and reactive to light– Membranes hydrated– Airway patent and breathing adequate– Central and peripheral perfusion good– Inspiratory crackles still noted– Slight nausea, no vomiting


• Pertinent Secondary Assessment Findings– JVD present at 45-degree angle

– SpO2 is 95% on room air, 97% with oxygen

– Chest pain characteristics still the same– Heart rate 113 and irregular, resps 18, B/P

156/90


• What is your field impression at this time?• What would be the next steps in

management you would provide to the patient?


• Care provided:– Patient placed on the cot in semi-Fowler

position– Pulse ox maintained (99%-100%)– Oxygen administered via NRB mask– EKG obtained (Transmit and/or read report to

Medical Control)– After consulting with the ED, aspirin 324 mg

po and nitroglycerin sublingual (0.4 mg) administered


• For each of the following interventions, explain the expected outcome of the intervention:– Placing patient in position of comfort– Applying high-flow oxygen– Administering baby aspirin– Administering sublingual nitro

SummarySummary

• Acute coronary syndromes (angina or infarction) can become life-threatening emergencies in moments.

• The EMT should remain attentive to the patient's condition and any changes in their complaints.

SummarySummary

• Ongoing deterioration suggests infarction, so summoning ALS on each call is warranted.

EMT Cardiovascular ACS

Healthcare

Transcript of EMT Cardiovascular ACS