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CARDIOVASCULAR
EMERGENCIES
INTRODUCTION
Optimal patient care requires that the
EMT-I understands the causes and management of patients with cardiovascular
emergencies. The following topics will
be discussed during this lesson:
·
Causes of
chest pain
·
Sign/symptoms
of acute cardiovascular problems
·
Field
treatment of acute cardiovascular problems
·
Assessment
of patients with chest pain
·
Complications
of acute myocardial infarction
LESSON
OBJECTIVES
At the end this lesson the participants
will be able to:
1. Verbalize
possible causes of chest pain related to the following systems - myocardial,
vascular, pulmonary, and gastrointestinal.
2. State the pathophysiology,
signs and symptoms, and field management of angina.
3. Discuss the pathophysiology, signs and symptoms, and field management of myocardial infarction.
4. State four complications
of acute myocardial infarction
5.
Verbalize the pathophysiology, signs and symptoms, and field management
of dissecting aortic aneurysm.
6. Discuss the
pathophysiology, signs and symptoms, and field management of pulmonary causes
of chest pain.
7. Verbalize the
pathophysiology, signs and symptoms, and field management of gastritis.
8. Discuss the
pathophysiology, signs and symptoms, and field management of esophagitis.
9. Verbalize the
pathophysiology, signs and symptoms, and field management of hiatal hernia.
10. Understand
the PQRST assessment for chest pain.
11. Discuss
the transport decisions relative to chest pain patients
12. Demonstrate
understand of the use of patient assisted nitroglycerin.
SKILLS
Patient assisted medication: nitroglycerin
KEY
VOCABULARY
·
A.M.I. -
abbreviation for acute myocardial infarction
·
Atherosclerosis
- plaque formation on the inside of arteries that causes narrowing
·
Dysrythmia
- an abnormal heart rhythm
·
Hemoptysis
- coughing bloody sputum
·
S.O.B. -
abbreviation for “short of breath”
·
Ventricular
Fibrillation - a lethal heart rhythm
·
N.T.G. -
abbreviation for nitroglycerin, a medication used to relieve chest pain
KEY
CONCEPTS
The following section provides
information and space for taking notes on the key concepts discussed by the
instructor:
PATHOPHYSIOLOGY, SIGNS AND SYMPTOMS, AND
FIELD MANAGEMENT OF CHEST PAIN
Possible Causes of Chest Pain
|
·
Myocardial ·
angina ·
acute
myocardial infection ·
Vascular ·
dissecting
aneurysm ·
Pulmonary ·
pulmonary
embolus ·
pneumonia ·
pleurisy ·
GI Tract ·
gastritis ·
esophagitis |
MYOCARDIAL CAUSES OF CHEST PAIN
Angina
|
Pathophysiology ·
Chest
pain caused when the oxygen demand is greater than the supply. ·
Usually
results from narrowing of the coronary arteries. |
|
Signs and symptoms ·
P - Provoked by exertion or exercise,
activity, stress (relieved by
rest) ·
Q - Pressure, heaviness, tightness,
sharp ·
R - Substernal, may radiate to jaw,
neck, shoulder, and arm ·
S -
Severity varies (mild to moderate) ·
T - Time less than 30 minutes (usually
less than 10-15 minutes) |
|
Field management ·
BLS procedures ·
High flow
O2 by mask ·
Reassure
the patient and have them rest ·
Position
of Comfort ·
Patient
assisted nitroglycerin if systolic B.P. > 100 ·
Recheck
vital signs after patient administered nitroglycerin and every 5 minutes ·
Assist
with ALS procedures ·
ALS
procedures ·
Venous
access (saline lock) ·
Monitor ·
Nitroglycerin
sublingual spray ·
Lidocaine
if ventricular dysrhythmias ·
Morphine
for pain unrelieved by nitroglycerin |
Acute Myocardial Infarction
|
Pathophysiology ·
Myocardial
tissue destruction caused by interruption of blood flow through the coronary
arteries |
|
Signs and symptomssIgSiS ·
P -
Often unprovoked (may follow exercise, stress, activity) ·
Q - Pain varies (epigastric,
indigestion, crushing, pressure, heaviness, or absent)
·
R - Substernal, epigastric, often radiates
to the neck, arm, shoulder, or
jaw ·
S - Severity varies (moderate to severe) ·
T - Pain lasting more than 30 minutes is
significant |
|
Associated Sign/Symptoms ·
Nausea
and vomiting ·
Pale,
cool, moist skin ·
Hypotension ·
Irregular
pulse ·
Shortness
of breath ·
Syncope |
|
Field management ·
BLS
procedures ·
High flow
O2 by mask ·
Reassure
the patient and have them rest ·
Position
of Comfort ·
Patient assisted
nitroglycerin if systolic B.P. is >100 ·
Recheck
vital signs after patient assisted nitroglycerin and every 5 minutes ·
Assist
with ALS procedures ·
ALS
procedures ·
Venous
access (saline lock) ·
Monitor ·
Nitroglycerin
sublingual spray ·
Lidocaine
if ventricular dysrhythmias ·
Morphine
if pain unrelieved by nitroglycerin |
Complications of Acute Myocardial
Infarction
|
·
Sudden
Death ·
Usually
from ventricular fibrillation in the first 2 hours after the onset of
symptoms ·
Dysrhythmias
·
Ventricular
fibrillation is the most common complication following an MI, however, many
other dysrhythmias are frequently seen ·
Cardiogenic
Shock ·
Pump
failure resulting from a large area of the myocardium being destroyed
(discussed in the “Shock” lecture) ·
Congestive
Heart Failure ·
Left
heart failure that results in a back-up of blood returning from the lungs
(pulmonary edema) (discussed in the “Respiratory Emergencies” lecture) |
VASCULAR CAUSES OF CHEST PAIN
Aneurysm
|
Pathophysiology ·
A defective
area in the artery (usually the aorta) allows blood to accumulate between the
layers of the vessel. As the vessel
is separating (dissecting) the balloon-like effect causes pain and
obstruction to blood flow. The vessel
will eventually rupture which leads to rapid deterioration and is often
fatal. |
|
Signs
and symptoms ·
P - often provoked by lifting or
straining ·
Q - pain is commonly described as
shearing, knife-like, hot, or
tearing ·
R - anterior chest and radiates to the
back ·
S - very severe ·
T - usually sudden onset lasting minutes
to hours |
|
Associated signs and symptoms: ·
unequal
pulses (radial or femoral) ·
unequal
blood pressure ·
nausea,
vomiting ·
restlessness
and agitation ·
pale,
cool, moist skin |
|
Field management ·
BLS
procedures ·
High flow
O2 by mask ·
Reassurance
and rest ·
Trendelenburg
position if hypotensive ·
Nitroglycerin
is avoided because it may increase the arterial dissection ·
Recheck
vital signs approximately every 5 minutes ·
Rapid
transport ·
Assist
with ALS procedures |
|
·
ALS
procedures ·
Venous
access (large bore) ·
Monitor ·
Morphine
if not hypotension ·
Dopamine
if hypotensive |
PULMONARY CAUSES OF CHEST PAIN
|
Pathophysiology ·
Pleuritic
chest pain is caused when the pleural lining becomes inflamed. Pleurisy and pneumonia are common causes ·
Pulmonary
embolus is caused by an obstruction in the blood flow to the pulmonary
arteries. Patients with pulmonary embolism
always complain of shortness of breath but not always chest pain. ·
(Pneumonia
and pulmonary embolus are discussed in the “Respiratory Emergencies” lecture) |
|
Signs and symptoms ·
P - may be preceded by U.R.I., surgery,
prolonged bed rest, certain
medications (depends on the cause) ·
Q - pain increases with respiration
(usually on inspiration) ·
R - may radiate to the back or abdomen ·
S - moderate to severe ·
T - sudden or gradual onset depending on
the cause |
|
GOLDEN RULE: Patients with primary pulmonary
problems may have a chief complaint of chest pain or shortness of breath or both. It is impossible to distinguish hyperventilation syndrome from
dyspnea and anxiety in the field. All
shortness of breath MUST be thoroughly assessed and appropriately treated! |
|
|
|
Field management ·
BLS
procedures ·
High flow
O2 by mask ·
Reassure
the patient ·
Position
of Comfort ·
Recheck
vital signs approximately every 5 minutes ·
Assist
with ALS procedures ·
ALS
procedures ·
Venous access
(saline lock) ·
Monitor ·
Nitroglycerin
is not generally used if there is a strong suspicion of pleuritic pain. If the etiology is unclear nitroglycerin
may be given to assist with the differential diagnosis |
|
GASTROINTESTINAL CAUSES OF CHEST PAIN
Gastritis and Esophagitis
|
Pathophysiology ·
Inflammation
of the lining of the stomach and/or esophagus increases gastric acid
secretion, usually with stress alcohol consumption and medications. |
|
Signs and symptoms ·
P - pain may follow consumption of
irritating foods and is usually
relieved by antacids or bland foods ·
Q - burning, constant pain in the
epigastric area ·
R - radiates to chest ·
S - mild to moderate ·
T - duration varies |
|
Associated signs and symptoms ·
belching ·
nausea ·
indigestion ·
blood
streaked emesis |
|
Field management ·
BLS
procedures ·
High flow
O2 by mask ·
Reassure
the patient and have them rest ·
Position
of Comfort ·
Patient
assisted nitroglycerin if systolic B.P. >100 ·
Recheck
vital signs approximately every 5 minutes ·
Assist with
ALS procedures ·
ALS
procedures ·
Venous
access (saline lock) ·
Monitor ·
Nitroglycerin
if systolic B.P. >100 ·
Lidocaine
if ventricular dysrhythmias ·
Morphine
for severe pain if systolic B.P. >100 and no signs of hypovolemia |
Hiatal Hernia
|
Pathophysiology ·
Herniation
of a portion of the stomach and the esophagus through the diaphragmatic
opening |
|
Signs and symptoms ·
P - usually worse when laying down and
somewhat better when sitting ·
Q - burning, fullness, heartburn ·
R - epigastric, substernal, and
radiating to the chest ·
S - moderate ·
T - varies |