Home | Index | Next                     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

 

 

Associated signs and symptoms

 

·          nausea

·          belching

·          may be relieved by antacids

 

 

Field management

 

·        BLS procedures

·          High flow O2 by mask

·          Reassure the patient and have them rest

·          Fowler’s position if not hypotension

·          Patient assisted nitroglycerin if 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 not relieved by nitroglycerin by nitroglycerin and no signs of hypovolemia

 

 

INITIAL ASSESSMENT AND FOCUSED HISTORY AND DETAILTED PHYSICAL EXAMINATION  OF CHEST PAIN

 

Initial Assessment

1).  Assess environment:  (may need to manipulate the environment)

 

·        Safety of rescuers and environment

  • Environmental factors

Patient location (home, street, convalescent, etc.)

Weapons (may indicate trauma mechanism)

Medications (may offer clues to past medical history)

Witnesses (may help to explain circumstances)

 

 

 

2).  Airway  (determine responsiveness and patency of airway)

  • Patients may be altered or unconscious and unable to maintain or protect their airway
  • Introduce self to patient
  • Obtain patient’s name and age

·        Determine LOC:  day/time/place

 

 

 

3).  Breathing:  assess rate, rhythm, and tidal volume

  • Is the breathing labored or unlabored

·        If labored, place the patient on oxygen

 

 

4).  Circulation:    

 

a).  Palpate for pulse noting: rate/rhythm/quality

b).  Check capillary refill

 

  • Increased heart rate may be a compensatory mechanism
  • Decreased heart rate may be a protective mechanism
  • Character of the pulse (weak or strong) is an indicator of the pressure and volume within the arteries
  • Location of pulses can help to estimate blood pressure, generally:

     

Radial pulse not palpable if BP <80mm/hg

Femoral pulse not palpable if BP <70mm/hg

Carotid pulse not palpable if BP <60mm/hg

 

  • Skin-pale, cool, moist skin and delayed capillary refill due to peripheral vasoconstriction

·                                 Cyanosis indicates a lack of oxygenated blood

 

 

5). Skin signs:  assess color, temperature and moisture

  • Pale, cool, moist skin and delayed capillary refill are due to peripheral vasoconstriction
  • Cyanosis indicates lack of oxygenated blood

·        If signs of poor perfusion, consider placing patient supine

 

6).  Assess neurological status:  assess level of consciousness                

       (Glasgow Coma Score) and neuro deficits

·        Restlessness, agitation, and lethargy may be due to hypoxia and decreased cerebral perfusion.

·        Unconsciousness or coma due to prolonged hypoxia and cell death

 

 
 
 

 

 

 

 

 

 

 

 

7). Determine Chief Complaint
 
 

 


Focused History and Detailed Physical Examination

 

 

1).  Elicit history of chief complaint or problem  (PQRST)

·        Pain assessment

·          P - provoking/palliating factors

·          Q - quality of the pain

·          R – radiation/region/reoccurrence

·          S - severity of the pain

·          T - time (duration) of the pain

·        Associated symptoms

·          nausea

·          vomiting

·          weakness

·          syncope

 

2).  Elicit personal history (HAM)

  • H   medical history/under a doctors care
  • A   allergies/age

·      M   medications-current over the counter and prescription                                              
 
 

 

 

 

 

 

 

 

3). Vital Signs

  • Hypotension may result from poor cardiac output or dysrhythmias
  • Cardiac dysrhythmias can cause shock or be a complication of shock due to hypoxia, acidosis, and a increase in circulating catecholamines
 
 

 

 

 

 

 

 

 

4). Special Questions

  • Ask questions specific to chief complaint
 
 

 

 

 

 

 

5).  Pertinent Body Check:

  • Medical:     perform body check pertinent to chief complaint

 

 
 
 

 

 

 

 

 

 


Head to Toe Examination:

 

Specific for Cardiovascular Complaints:

 

·          Assess for abnormal lung sounds:

·          rales - pulmonary edema due to pump failure; fluid overload due to fluid challenges

·          wheezes - bronchoconstriction due to fluid in the alveoli

·          Assess for pedal edema

·          Assess for JVD

 

Golden Rule:

It is impossible to accurately differentiate between the causes of chest pain in the field, therefore,  all chest pain, regardless of suspected cause, must be fully assessed and treated.      
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