Transcript Slide 1

EMT Refresher Cardiology
Christina Moore
Halifax EMS
NREMT-P / CCEMT-P
Objectives
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Identify Causes of Chest Pain
Anatomy
Physiology
Pathophysiology
Assessment
Treatment Options
Differentiate key origins of C Px
Why?
• Frequency EMS Calls for Chest Pain?
– In Halifax, ~ 40%
– You?
A Bit of History
• 1960s
30-40% chance of
death days after heart
attack
• Today
6%
Chest Pain
• List Types, sources, etc
Chest Pain - Summary
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Heart Attack (ACS / AMI)
Cardiac Tamponade
Ischemia
Pericarditis
Pulmonary Embolism
Angina (Stable/Unstable)
Tension Pneumothorax
Myocarditis
Shingles
Muscular-skeletal problems
Aortic Dissection
Aortic Aneurysm
Pleurisy
CHF
Esophogeal Rupture
Aortic Stenosis
Mitral Valve Prolaps
Cardiomyopathy
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Cholecystitis
Pancreatitis
Esophogeal tear
Cocaine-indused chest pain
Coronary Spasm (Prinzmetal’s
Angina)
Cardiac Dysrhythmia
Others?
Chest Pain Sorted
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Heart Attack (ACS / AMI)
Cardiac Tamponade
Cardiac Dysrhythmia
Pulmonary Embolism
Tension Pneumothorax
Aortic Dissection
CHF
Esophogeal Rupture
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Cholecystitis
Pancreatitis
Esophogeal tear
Aortic aneurysm
Cocaine-indused chest pain
Coronary Spasm (Prinzmetal’s Angina)
Angina (Stable/Unstable)
Ischemia
Pericarditis
Myocarditis
Shingles
Muscular-skeletal problems
Pleurisy
Aortic Stenosis
Mitral Valve Prolaps
Cardiomyopathy
What tools do we have
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Eyes – inspect
Ears/Stethoscope - auscultate
Hands – palpate
History – personal and familial
Watch – time
EKG 4/12 lead
Phone-a-friend
Medication Administration
Knowledge/skills/experience
Capnography
Lab Tests (bio-markers, chem7, ABG, etc)
X-Ray
Ultrasound
Cardiac Cath
Cardiac Echo
Anatomy
• Go to
http://www.visiblebody.com/start
Goals
- cardiac circulatory system
- cardiac conductive system
- And the other fun stuff
Key Physiology Points
• Cardiac Tissue
– Automaticity
– Conductivity
– Contractility
– Rhythmicity
– Excitability
Physiology Continued
• Gas of Life?
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Nutrients: O2, Sugar
Waste: CO2, H2O
pH: 7.35 – 7.45
Exhaled CO2: 35 – 45 mmHg
What Happens to Tissue when WRONG
Pathophysiology
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What happens when it goes wrong
No O2, dirty combustion & bad byproducts
No Sugar – see above
Too Many bad byproducts
– Expanding field of injury
• No O2 & No Sugar - dying
Pathophysiology Measured
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Pain
Blood Sugars
Capnography
Blood pH
SpO2
Troponin/bio-markers
Urine
Pathophysology Observed
•SHOCK
Case Study
• 63 yof, teeth/jaw pain and a “tight neck”,
sweating
• Initial Observations
• From Across the Room
Case Study
• Initial Life-Threatening Diagnoses/Interventions
• Differentiate?
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Heart Attack (ACS / AMI)
Cardiac Tamponade
Cardiac Dysrhythmia
Pulmonary Embolism
Tension Pneumothorax
Aortic Dissection
CHF
Esophogeal Rupture
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Cholecystitis
Pancreatitis
Esophogeal tear
Aortic aneurysm
Cocaine-indused chest pain
Coronary Spasm (Prinzmetal’s Angina)
Angina (Stable/Unstable)
Ischemia
Pericarditis
Myocarditis
Shingles
Muscular-skeletal problems
Pleurisy
Aortic Stenosis
Mitral Valve Prolaps
Cardiomyopathy
Assessment
• SAMPLER
• OPQRST
• Diagnostics
– EKG 4 & 12 lead
EMS Treatment
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Oxygen
Aspirin
Nitroglycerin (NTG)
IV – 2 lines preferred
STEMI Alert
Paramedic Request
Rapid Transport to Cath Lab
Oxygen
• Per American Heart Assoc, 2010
Guidelines:
• 2-6 lpm O2 via Nasal Cannula
• Titrate to SpO2 approx 96% (not 100%)
• Why?
Aspirin
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Class of Medication
Mechanism of Action
Indications
Contra-Indications
Dosing?
Dude, Dose, Delivery, Date, Document
Nitroglycerin
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Class of Medication
Mechanism of Action
Indications
Contra-Indications
Dosing?
Dude, Dose, Delivery, Date, Document
EKG
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Mechanism of Action
Indications
Contra-Indications
Dude,Date, Document
Case Study
STEMI Alert
• When 12-lead EKG prints
* * * ACUTE MI * * *
• When you have confirmation from medic
• When you have transmitted & confirmed
STEMI Alert
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DHMC Zone 2
Valid reason to call DHART Helicopter
“Drip & Ship” via Critical Access Hospital
Timed process from:
– 911 to “Balloon”
– EMS to Balloon
– Door to Balloon
• Goals: 90 minutes
Next Steps
• One link in a many link chain
• Paramedic Interventions
– Pain Control
– IV Beta Blocker
• ER Interventions
– IV Heparin Bolus, Hep drip
– IV Fibrinolytic
– IV NTG
• Cath Lab
Cardiac Circulation
Cardiac Cath
• YouTube
http://www.youtube.com/watch?v=3Z2DaU0GBAE&feature=feedf_more
Acute Coronary Syndrome
• Questions/Discussion on ACS?
• Let’s do the next one
Induced Hypothermia
• What happens to pissed off tissue?
• Sprained Ankle…
– Swelling
– Pain
• Treatment
– RICE: Rest, Ice, Compression, Elevation
Induced Hypothermia
• Compartment Syndrome?
• What is it?
• Where can it happen?
Induced Hypothermia
• CPR – with return of spontaneous
circulation
• Pt’s mental state deteriorated
• Induce hypothermia with cold (4d C) IV
fluids
• Keep chilled and “medical coma” for 3
days
Future of Hypothermia
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Trauma?
Strokes?
Kids?
Lots of potential… lots of unanswered
questions
Other “Chest Pain”
• Chest Pain with Respiratory Distress
– Tension Pneumothorax
– Pulmonary Embolism
– Esophogeal Rupture
– Acute Pulmonary Edema / CHF
Tension Pneumothorax
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History?
Progressive deterioration
Pressure on the heart/great vessels
Disrupting blood flow
Tension Pneumothorax
• Assessment
– Chest Discomfort
– Severe Respiratory Distress
– Decreased or absent breath sounds on
affected side
• Obstructive Shock
• Treatment?
Tension Pneumothorax
• Decompression
– Paramedic – large needle to chest
– MD/PA – large tube in chest
• Field Treatment:
– Rapid transport,
– high flow O2,
– Intercept
Pulmonary Embolism (PE)
• Cause?
– Blood clot in an artery in the lungs
– Often starts somewhere else, travels through
heart to lungs and lodges in there
– If <30% impact, few symptoms unless…
• COPD, etc
PE
• Assessment
– Chest Pain
– Tachypnea (96%)
– SoB (82%)
– Chest Pain (49%)
– Cough (20%)
– Hemoptysis (7%)
• EKG – Sinus Tachycardia
PE
• History / Risk Factors
• Young women who smoke and use birth
control
• Deep Vein Thrombosis (DVT)
– Traveller’s Syndrome
– Leg Cramps
PE Diagnostic
• In Field: History, Assessment
• In ED:
– CTA (CT-angiogram)
– D-Dimer
– X-Ray
• Treatment
– Thrombolytics \ anticoagulantion therapy
Esophogeal Rupture
• Often iatrogenic
– Post surgical, post procedural
• Swallowed foreign object (caustic, sharp,
etc)
• BFT , Penetrating Trauma
• Forceful vomitting
Esophogeal Rupture
• Assessment: History
• Treatment: Supportive
CHF
• Pump Failure
– Brian Richard’s Drawing
CHF
• Assessment
• Management
– V.S., EKG, Lung Sounds
• CPAP
• Treat shock/symptoms
Other Chest Pain
• Chest Discomfort with Altered Vital Signs
– Cardiac Dysrhythmia
– Aortic Aneurysm \ Dissection
– Pericardial Tamponade
– Acute Coronary Syndrom (covered)
Other Chest Pain
• Unstable Angina
• Coronary Spasm / Prinzmetal Angina
• Cocaine-Induced Chest Pain
Other Chest Pain
• Chest Pain due to Infection
– Pericaditis
– Myocarditis
• Simple Pneumothorax
Other Chest Pain
• Intra-abdominal Causes of Chest
Discomfort
– Cholecystitis
– Pancreatitis
– Esophogeal Tear
• Neurological Causes of Chest Pain
– Thoracic Outlet Syndrome (pg 205)
– Herpes Zoster (Shingles)
Others - continued
• Other Pulmonary Causes
– Pneumonitis
– Pleurisy
• Heart-related Causes
– Aortic Stenosis
– Mitral Valve Prolapse
– Cardiomyopathy
Others – Continued
• Did we miss some?
– YES
Objectives Reviewed
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Identify Causes of Chest Pain
Anatomy
Physiology
Pathophysiology
Assessment
Treatment Options
Differentiate key origins of C Px