Chapter 14Chapter 14Basic CardiologyBasic Cardiology

For EMT’sFor EMT’s

Christopher Salo Christopher Salo

NREMT-P, LPNNREMT-P, LPN

February 13, 2008February 13, 2008

ObjectivesObjectives

Describe the structure and function of the Describe the structure and function of the cardiovascular systemcardiovascular system

Describe EMS care for chest pain patients, Describe EMS care for chest pain patients, including oxygen, aspirin and nitroglycerinincluding oxygen, aspirin and nitroglycerin

Identify some causes of cardiac Identify some causes of cardiac emergenciesemergencies

Quick facts (not Farmer Fun Facts)Quick facts (not Farmer Fun Facts)

The heart beats on average 70 times per The heart beats on average 70 times per minute, 4200 times per hour, 100,000 minute, 4200 times per hour, 100,000 beats per day, 365 Million beats per year, beats per day, 365 Million beats per year, and about 30 Billion beats in an average and about 30 Billion beats in an average lifetime of 80 years.lifetime of 80 years.

The adult heart pumps 7,500 liters of The adult heart pumps 7,500 liters of blood daily.blood daily.

It takes 20 seconds to pump blood to It takes 20 seconds to pump blood to every cell in your body.every cell in your body.

Cardiovascular disease is the number one Cardiovascular disease is the number one cause of death in the U.S., and many cause of death in the U.S., and many times the first indication of this disease is times the first indication of this disease is an acute coronary eventan acute coronary event

Cardiac arrest is the most severe Cardiac arrest is the most severe manifestation of an acute coronary manifestation of an acute coronary syndrome, and with rapid intervention the syndrome, and with rapid intervention the EMT can make the difference between life EMT can make the difference between life and deathand death

Basic Anatomy and PhysiologyBasic Anatomy and Physiology

The cardiovascular system consists of:The cardiovascular system consists of: Heart (The pump)Heart (The pump) Major blood vessels (The hoses)Major blood vessels (The hoses)

Arteries: Aorta, arteries, arterioles Arteries: Aorta, arteries, arterioles Veins: Vena Cava, veins, venules Veins: Vena Cava, veins, venules Capillaries: Nutrient, gas and waste product Capillaries: Nutrient, gas and waste product

exchangeexchange

Blood (The fluid)Blood (The fluid) Cardiac Conduction System (The power)Cardiac Conduction System (The power)

The HeartThe Heart

The heart is simply just a muscle.The heart is simply just a muscle. It has four chambers:It has four chambers:

Left and Right AtriumLeft and Right Atrium Left and Right VentriclesLeft and Right Ventricles

Valves:Valves: Tricuspid and BicuspidTricuspid and Bicuspid Pulmonic and AorticPulmonic and Aortic

Chambers of the heartChambers of the heart

Atria:Atria: Right atrium receives deoxygenated blood from the Right atrium receives deoxygenated blood from the

bodybody Left atrium receives oxygenated blood from the lungsLeft atrium receives oxygenated blood from the lungs

VentriclesVentricles Right ventricle sends deoxygenated blood to the Right ventricle sends deoxygenated blood to the

lungslungs Left ventricle sends oxygenated blood to the bodyLeft ventricle sends oxygenated blood to the body

The left and right sides of the heart are divided The left and right sides of the heart are divided by the septum.by the septum.

Major Vessels of the HeartMajor Vessels of the Heart

Vena Cava: Superior and inferior carry Vena Cava: Superior and inferior carry blood from body to the right atriumblood from body to the right atrium

Pulmonary Artery: Carries blood from right Pulmonary Artery: Carries blood from right ventricle to the lungs for gas exchangeventricle to the lungs for gas exchange

Pulmonary Vein: Carries freshly Pulmonary Vein: Carries freshly oxygenated blood back to the left atriumoxygenated blood back to the left atrium

Aorta: Carries blood from left ventricle out Aorta: Carries blood from left ventricle out to the bodyto the body

ValvesValves

Valves prevent the backflow of blood through Valves prevent the backflow of blood through the systemthe system

Tricuspid and Bicuspid valves on the right and Tricuspid and Bicuspid valves on the right and left between the atria and ventriclesleft between the atria and ventricles

Pulmonic valve between the right ventricle and Pulmonic valve between the right ventricle and pulmonary arterypulmonary artery

Aortic (Mitral) valve between the left ventricle Aortic (Mitral) valve between the left ventricle and the aortaand the aorta

Veins also have valves to prevent backflow of Veins also have valves to prevent backflow of blood. Arteries do not.blood. Arteries do not.

A picture is worth a thousand wordsA picture is worth a thousand words

Cardiac conduction systemCardiac conduction system

Each beat of the heart is actually just muscular Each beat of the heart is actually just muscular contraction in reaction to an electrical impulse contraction in reaction to an electrical impulse created by the heart itself. (Automaticity)created by the heart itself. (Automaticity)

The impulse starts at the Sinoatrial (SA) node The impulse starts at the Sinoatrial (SA) node located in the right atrium and travels through located in the right atrium and travels through the atria, causing them to contract and squeeze the atria, causing them to contract and squeeze the blood into the ventricles. (Atrial Kick)the blood into the ventricles. (Atrial Kick)

The impulse then is held at the Atrioventricular The impulse then is held at the Atrioventricular (AV) node, located between the atria and (AV) node, located between the atria and ventriclesventricles

Cardiac conduction continuedCardiac conduction continued

The impulse is held for a fraction of a second at The impulse is held for a fraction of a second at the AV node to allow the ventricles to fillthe AV node to allow the ventricles to fill

The impulse then travels through the Bundle of The impulse then travels through the Bundle of His to the bundle branches and eventually to the His to the bundle branches and eventually to the Purkinjie fibers in the ventricles.Purkinjie fibers in the ventricles.

The ventricles respond to the impulse by The ventricles respond to the impulse by contracting, causing ventricular systole, and contracting, causing ventricular systole, and forcing the blood out of the ventricles through forcing the blood out of the ventricles through the arteriesthe arteries

Blood flow through the systemBlood flow through the system

Deoxygenated blood enters the right atrium from Deoxygenated blood enters the right atrium from the inferior and superior vena cavathe inferior and superior vena cava

Passes through the tricuspid valve to the right Passes through the tricuspid valve to the right ventricleventricle

Is squeezed through the pulmonic valve and into Is squeezed through the pulmonic valve and into the pulmonary artery to the lungsthe pulmonary artery to the lungs

Gas exchange takes place, becomes Gas exchange takes place, becomes oxygenatedoxygenated

From the lungs into the pulmonary artery and From the lungs into the pulmonary artery and into the left atriuminto the left atrium

Blood flow continuedBlood flow continued

From the left atrium, through the bicuspid valve From the left atrium, through the bicuspid valve into the left ventricleinto the left ventricle

Through the aortic valve and into the aortaThrough the aortic valve and into the aorta The coronary artery, the first small vessel off the The coronary artery, the first small vessel off the

aorta, feeds blood to the heart itselfaorta, feeds blood to the heart itself Oxygenated blood travels through the aorta to Oxygenated blood travels through the aorta to

all the arteries in the body (except the pulmonic all the arteries in the body (except the pulmonic artery)artery)

Arteries become smaller and smaller until they Arteries become smaller and smaller until they become arterioles, the smallest arteriesbecome arterioles, the smallest arteries

Blood flow continuedBlood flow continued

Arterioles connect to capillaries, which are one Arterioles connect to capillaries, which are one cell thick.cell thick.

Cells take oxygen from the blood and rid Cells take oxygen from the blood and rid themselves of waste products at the capillary themselves of waste products at the capillary levellevel

Capillaries connect to venules, the smallest of Capillaries connect to venules, the smallest of the veinsthe veins

Deoxygenated blood travels through larger and Deoxygenated blood travels through larger and larger veins until they reach the vena cava and it larger veins until they reach the vena cava and it starts all over againstarts all over again

Any Questions So Far?Any Questions So Far?Good, now the hard part is overGood, now the hard part is over

Angina PectorisAngina Pectoris

Angina Pectoris: Chest pain, usually brought on by Angina Pectoris: Chest pain, usually brought on by exertion.exertion.

Indicates area of the heart is not perfusing adequately, Indicates area of the heart is not perfusing adequately, causing ischemia.causing ischemia.

Usually lasts 2-15 minutes and may be relieved with rest.Usually lasts 2-15 minutes and may be relieved with rest. Can radiate to neck, arms, jaw, back or shoulders.Can radiate to neck, arms, jaw, back or shoulders. May have cool, clammy skin, diaphoresis, dyspnea, May have cool, clammy skin, diaphoresis, dyspnea,

anxiety, N/Vanxiety, N/V Women, elderly and diabetics may show atypical signs.Women, elderly and diabetics may show atypical signs.

Ventricular FibrillationVentricular Fibrillation

Ventricular Fibrillation- Ventricular Fibrillation- Ventricles simply Ventricles simply quivering.quivering.

Ventricles not squeezing, Ventricles not squeezing, no pulse, no blood flowno pulse, no blood flow

Total disorganized Total disorganized electrical activity in the electrical activity in the heartheart

Early defibrillation is the Early defibrillation is the key!!!key!!!

Ventricular TachycardiaVentricular Tachycardia Ventricular Tachycardia- Ventricular Tachycardia-

Ventricles beating so fast Ventricles beating so fast as to not pump blood as to not pump blood adequatelyadequately

Limited diastolic period, Limited diastolic period, not allowing ventricles to not allowing ventricles to fill enough to provide fill enough to provide adequate cardiac outputadequate cardiac output

Can progress to VF if not Can progress to VF if not treated earlytreated early

May or may not have a May or may not have a pulse, pulse may be pulse, pulse may be rapid, weak and threadyrapid, weak and thready

Defibrillation if pulselessDefibrillation if pulseless

AsystoleAsystole

Asystole- Total Asystole- Total absence of electrical absence of electrical activity in the heart. activity in the heart.

Very low chance of Very low chance of recovery recovery

AED will not allow AED will not allow defibrillationdefibrillation

Perform CPR until Perform CPR until advanced care arrivesadvanced care arrives

Pulseless Electrical ActivityPulseless Electrical Activity

PEA- The heart’s electrical system is firing PEA- The heart’s electrical system is firing in an organized rhythm, but the in an organized rhythm, but the myocardium is not respondingmyocardium is not responding

No response by the muscle means no No response by the muscle means no pulse, therefore, no circulationpulse, therefore, no circulation

Any rhythm seen on monitor that has no Any rhythm seen on monitor that has no pulse is PEApulse is PEA

No defibrillation in cases of PEANo defibrillation in cases of PEA

Signs and Symptoms of cardiac Signs and Symptoms of cardiac compromisecompromise

Squeezing, dull pressure, feeling of heaviness on chest, Squeezing, dull pressure, feeling of heaviness on chest, or sharp, stabbing pain in chest radiating to arm or jawor sharp, stabbing pain in chest radiating to arm or jaw

Sudden onset of perfuse sweatingSudden onset of perfuse sweating Pale skinPale skin DyspneaDyspnea Anxiety, irritabilityAnxiety, irritability Feeling of impending doomFeeling of impending doom Abnormal pulse or BPAbnormal pulse or BP Epigastric painEpigastric pain Nausea or vomitingNausea or vomiting

Case StudyCase Study

You are an EMT-B working for a basic service. You are an EMT-B working for a basic service. You and your partner are enjoying a relaxing You and your partner are enjoying a relaxing afternoon on a warm fall day. The radio afternoon on a warm fall day. The radio screams to life “Unit XYZ, you are needed to screams to life “Unit XYZ, you are needed to respond to 321 Contact Drive for a 58 year old respond to 321 Contact Drive for a 58 year old male with chest pain and shortness of breath”. male with chest pain and shortness of breath”. You scramble to the rig and tear down the road You scramble to the rig and tear down the road with lights and sirens blaring. As you arrive at with lights and sirens blaring. As you arrive at the address, a woman rushes out to meet your the address, a woman rushes out to meet your ambulance, “Please, please, you have to help ambulance, “Please, please, you have to help him. Come on, hurry, I think he is having him. Come on, hurry, I think he is having another heart attack”. another heart attack”.

Now What?Now What?

Scene safe, BSI…..Don’t Forget!!!Scene safe, BSI…..Don’t Forget!!! Scene size up: Number of patients, need for additional Scene size up: Number of patients, need for additional

resources, get ALS rolling if they haven’t been alreadyresources, get ALS rolling if they haven’t been already General impression of patient:General impression of patient:

58 y.o. male, average build, sitting, clutching his chest, breathing 58 y.o. male, average build, sitting, clutching his chest, breathing labored and slightly fastlabored and slightly fast

ABC’sABC’s Seems alert, answers your questionsSeems alert, answers your questions Skin pale and diaphoreticSkin pale and diaphoretic

History of present illnessHistory of present illness SAMPLE history with OPQRSTSAMPLE history with OPQRST

SAMPLE SAMPLE

Signs and Symptoms: Chest pain, trouble breathing. Pt Signs and Symptoms: Chest pain, trouble breathing. Pt clutching chest and labored breathingclutching chest and labored breathing

Allergies: Codine and amoxicillinAllergies: Codine and amoxicillin Medications: ASA, NTG, Lasix, Toprol, GlucophageMedications: ASA, NTG, Lasix, Toprol, Glucophage Past medical history: DM, HTN, AMI x 3, cardiac stentingPast medical history: DM, HTN, AMI x 3, cardiac stenting Last oral intake: Ate lunch about 3 hours agoLast oral intake: Ate lunch about 3 hours ago Events: Was cutting firewood for about an hour and Events: Was cutting firewood for about an hour and

developed the pain, came into the house to rest.developed the pain, came into the house to rest.

OPQRSTOPQRST

Onset- While cutting firewoodOnset- While cutting firewood Provokes/ Palliative- Rest improves pain, Provokes/ Palliative- Rest improves pain,

exertion worsens itexertion worsens it Quality- Sharp, stabbing pain in middle of chest Quality- Sharp, stabbing pain in middle of chest

on left side, feels like my last heart attackon left side, feels like my last heart attack Radiation- Radiates to left shoulder and jawRadiation- Radiates to left shoulder and jaw Severity- 9/10Severity- 9/10 Time- 15 minutes ago, hasn’t stoppedTime- 15 minutes ago, hasn’t stopped

What do we do?What do we do? While you were asking questions, your partner was getting vitals for While you were asking questions, your partner was getting vitals for

you:you: BP 164/96, P 104, R 22 and laboredBP 164/96, P 104, R 22 and labored

You place him on oxygen, NRB @ 12-15LPMYou place him on oxygen, NRB @ 12-15LPM ASSIST him with his Nitroglycerin, but be sure you follow the 5 ASSIST him with his Nitroglycerin, but be sure you follow the 5

rightsrights Right PatientRight Patient Right RouteRight Route Right MedRight Med Right DosageRight Dosage Right timeRight time

If protocols permit, give aspirin, 325mg total. Have patient chew If protocols permit, give aspirin, 325mg total. Have patient chew and swallow. and swallow.

LOAD AND GO!!!LOAD AND GO!!!

Ongoing AssessmentOngoing Assessment

Monitor vital signs, to include a pain scale every 5 Monitor vital signs, to include a pain scale every 5 minutes. Transport to your intercept or the hospital.minutes. Transport to your intercept or the hospital.

How many times can you assist him with his NTG? And How many times can you assist him with his NTG? And how often?how often?

What do you need before he takes any nitro?What do you need before he takes any nitro? What if he doesn’t tolerate the NRB?What if he doesn’t tolerate the NRB? In what position would you transport him?In what position would you transport him? Would you transport code 1 or code 3?Would you transport code 1 or code 3? What if he passes out?What if he passes out? What if he stops breathing?What if he stops breathing? What if his heart stops?What if his heart stops?

Oxygen TherapyOxygen Therapy

Who gets oxygen?Who gets oxygen? How are we going to give it?How are we going to give it? How much are we going to give?How much are we going to give? Who doesn’t get oxygen?Who doesn’t get oxygen? Remember, technically oxygen is a drug, Remember, technically oxygen is a drug,

always chart the response to always chart the response to administration.administration.

Nitroglycerin Nitroglycerin

As EMT-Basics we can ASSIST patients take their As EMT-Basics we can ASSIST patients take their Nitroglycerin tablets or sprays.Nitroglycerin tablets or sprays.

Dosage is 0.3-0.4mg per tab or sprayDosage is 0.3-0.4mg per tab or spray Make sure you follow the 5 rights.Make sure you follow the 5 rights. Make sure the medication isn’t expired.Make sure the medication isn’t expired. Place tablet under the tongue, remind patient not to Place tablet under the tongue, remind patient not to

chew or swallow it, just let it dissolve.chew or swallow it, just let it dissolve. Must have systolic BP over 90 prior to administration.Must have systolic BP over 90 prior to administration. Can be given every 3-5 minutes, up to 3 times provided Can be given every 3-5 minutes, up to 3 times provided

systolic BP is over 90 and patient is not pain free.systolic BP is over 90 and patient is not pain free.

NTG continuedNTG continued

Nitroglycerin is a vasodilator, it works by Nitroglycerin is a vasodilator, it works by opening up the vessels to the heart, allowing opening up the vessels to the heart, allowing more oxygen to get to the ischemic areas that more oxygen to get to the ischemic areas that are causing the pain.are causing the pain.

Pt will most likely develop a headache, possibly Pt will most likely develop a headache, possibly some dizziness.some dizziness.

Contraindicated if BP below 90 systolic, HR Contraindicated if BP below 90 systolic, HR below 50 or above100, suspected head injury, or below 50 or above100, suspected head injury, or if pt has taken “daddy’s little helpers”if pt has taken “daddy’s little helpers”

AspirinAspirin

Aspirin has a rapid acting antiplatelet Aspirin has a rapid acting antiplatelet effect, which helps prevent clot formation.effect, which helps prevent clot formation.

Usual dosage for CP is 160-325mg.Usual dosage for CP is 160-325mg. Chewable “baby” aspirin 81 mg each.Chewable “baby” aspirin 81 mg each. Give 81mg X 4, chew and swallow.Give 81mg X 4, chew and swallow. Contraindications: Already taken ASA or Contraindications: Already taken ASA or

hypersensitivity to ASA.hypersensitivity to ASA.

SummarySummary