Nitroglycerin is the mainstay treatment for angina pectoris

Part 2: Assessment and
Management of the
Cardiovascular Patient

Sections
 Assessment of the
 Management of Cardiovascular
Emergencies
 Managing Specific
Cardiovascular Emergencies

Assessment of the
 Scene Size-up and Initial Assessment
 Determine scene safety.
 Determine level of responsiveness.
 Airway.
 Breathing:
 Note breath sounds indicative of cardiovascular
problems.
 Circulation:
 Note color, temperature, turgor, moisture, mobility,
edema.
 Treat life-threatening problems.

Assessment of the
 Focused History
 Common Symptoms
 Chest Pain
• OPQRST History of Pain
 Dyspnea
• Onset
• Duration
• Provocation/palliation
• Orthopnea
 Cough

Assessment of the
 Other Signs and  Other Signs and
Symptoms Symptoms
 Level of  Edema
consciousness  Headache
 Diaphoresis
 Syncope
 Restlessness and
anxiety  Behavioral change
 Feeling of impending  Anguished facial
doom expression
 Nausea and/or  Activity limitations
vomiting  Trauma
 Fatigue
 Palpitations

Assessment of the
 Allergies
 Medications
 Nitroglycerin, propranolol, digitalis, diuretics,
antihypertensives, antidysrhythmics, lipid-lowering
agents
 Nonprescription drugs
• Cocaine
• Antihistamines
• Alcohol

Assessment of the
 Past Medical History
 Cardiac history
 Heart problems
 Other medical problems
 Family cardiac history
 Modifiable risk factors for heart disease (smoking, etc.)
 Last Oral Intake
 Caffeinated beverages
 Events Preceding the Incident
 Stress, strenuous or sexual activity

Assessment of the
 Physical
Examination
 Inspection
 Tracheal
position
 Thorax
 Epigastrium

Assessment of the
 Auscultation
 Breath
Sounds
• Adventitious
Sounds
 Heart Sounds
• Normal
• Abnormal

Assessment of the
 Auscultation
 Carotid
Artery Bruit

Assessment of the
 Palpation
 Pulse
 Thorax
• Crepitus
• Chest Wall
Tenderness
 Epigastrium

Management of Cardiovascular
Emergencies

 Basic Life Support
 Advanced Life Support
 ECG Monitoring
 Vagal Maneuvers
 Precordial Thump
 Pharmacological Management
 Defibrillation
 Synchronized Cardioversion
 Transcutaneous Cardiac Pacing
 Diagnostic (12-Lead) ECG

Emergencies
 Monitoring
ECG in the
Field
 Parts of the
Defibrillator
 Monitoring
Leads
 Lead II, MCL1
 “Quick-Look”
Paddles

Emergencies

 Monitoring ECG in the Field
 Causes of Poor Signals
 Excessive hair, loose or dislodged electrode
 Dried conductive gel, poor placement, diaphoresis
 Patient movement or muscle tremor
 Broken patient cable or lead wire
 Low battery
 Faulty grounding
 Faulty monitor

Emergencies

 Vagal Maneuvers
 Indication
 Stable patient with symptomatic tachycardia
 Maneuvers
 Valsalva maneuvers
 Coughing
 Carotid Sinus Massage
• Avoid in patients with a history of cerebrovascular or
carotid artery disease, or patients with carotid bruits.

Emergencies
 Precordial
Thump
 Indication
 Pulseless patient who
has a witnessed
arrest.
 Most effective when
performed
immediately after
onset of VF.
 Not used in pediatric
patients.
 Technique

Emergencies

 Pharmacological Management
 Antidysrhythmics
 Atropine Sulfate
 Lidocaine
 Procainamide
 Bretylium
 Adenosine
 Amiodarone
 Verapamil

Emergencies
 Sympathomimetic Agents
 Epinephrine
 Norepinephrine
 Isoproterenol
 Dopamine
 Dobutamine
 Vasopressin
 Drugs Used for Myocardial Ischemia
 Oxygen
 Nitrous Oxide
 Nitroglycerin
 Morphine Sulfate
 Nalbuphine

Emergencies

 Thrombolytic Agents
 Aspirin
 Alteplase
 Relteplase
 Other Prehospital Drugs
 Furosemide
 Diazepam
 Promethazine
 Sodium Nitroprusside

Emergencies
 Drugs Infrequently Used in the Prehospital
Setting
 Digitalis
 Beta Blockers
• Propranolol, metaprolol, labetalol
 Calcium Channel Blockers
• Verapamil, nifedipine, diltiazem
 Alkalinizing Agents
• Sodium bicarbonate

Emergencies

 Defibrillation
 Chest Wall Resistance
 Paddle pressure, paddle–skin interface, paddle surface
area, number of previous countershocks, and inspiratory
vs. expiratory phase at time of shock
 Success of Defibrillation
 Time until VF
 Condition of the myocardium
 Heart size and body weight
 Previous countershocks
 Proper paddle size, placement, interface, and pressure
 Properly functioning defibrillator

Emergencies

 Emergency Synchronized
Cardioversion
 Indications
 Unstable, tachycardic patient
• Perfusing VT
• PSVT
• Rapid atrial fibrillation
• 2:1 atrial flutter

Emergencies
 Procedure
 Similar to
defibrillation.
 Premedicate the
patient
whenever
possible.
 Turn on the
synchronizer.
 Hold discharge
buttons until
countershock
administered.

Management of
Cardiovascular
Emergencies

Emergencies

 Transcutaneous Cardiac Pacing
 Indications
 Symptomatic, unstable patients who do not respond
to pharmacological therapy
• Symptomatic bradycardias with high-degree AV blocks.
• Atrial fibrillation with a slow ventricular response.
• Other significant bradycardias, including asystole.

Emergencies
 Carotid Sinus Massage
 Indications
 Paroxysmal supraventricular tachycardia in a stable
patient.
 Complications
 Do not use in patients with a history of cerebrovascular or
carotid artery disease.
 Do not use in patients having carotid bruits.
 Asystole, PVCs, VT, and VF may occur.
 Patient may experience bradycardia, nausea, and
vomiting.

 Support and Communication

Managing Specific

 Angina Pectoris
 Myocardial Infarction
 Heart Failure
 Cardiac Tamponade
 Hypertensive Emergencies
 Cardiogenic Shock
 Cardiac Arrest
 Peripheral Vascular and Other

Angina Pectoris
 Epidemiology & Pathophysiology
 Pathophysiology
 Angina occurs when the heart’s demand for oxygen
exceeds the blood’s oxygen supply.
 Commonly caused by artherosclerosis.
 May also result from spasm of the coronary arteries
(Prinzmetal’s angina).
 Stable vs. Unstable Angina
 Disease Progression
 Spectrum of coronary artery disease best
referred to as acute coronary syndrome

Angina Pectoris
 Causes of Chest Pain
 Cardiovascular, including acute coronary syndrome,
pericarditis, or thoracic dissection of the aorta
 Respiratory, including pulmonary embolism,
pneumothorax, pneumonia, and pleural irritation
 Gastrointestinal, including cholecystitis, pancreatitis,
hiatal hernia, esophageal disease, gastroesophageal
reflux, peptic ulcer disease, and dyspepsia
 Musculoskeletal, including chest wall syndrome,
costochondritis, acromioclavicular disease, herpes
zoster, chest wall trauma, and chest wall tumors

Angina Pectoris
 Field Assessment
 Signs of Shock
 Chest Discomfort
 Typically sudden onset, which may radiate or be
localized to the chest.
 Patient often denies chest pain.
 Duration
 Episodes last 3–5 minutes.
 Pain relieved with rest and/or nitroglycerin.

Angina Pectoris
 Breathing
 History
 Past episodes of angina:
• Episodes of angina that are increasing in frequency,
duration, or severity are significant.
 ECG
 Do not delay scene time.
 12-Lead ECG preferred:
• Angina typically causes nonspecific ST changes.

Angina Pectoris
 Management
 Relieve anxiety:
 Place the patient in a position of physical and emotional
comfort.
 Administer oxygen.
 Establish IV access.
 Monitor ECG.
 Consider medication administration:
 Nitroglycerin tablets or spray
 Nifedipine or other calcium channel blockers
 Morphine sulfate

Angina Pectoris
 Special Considerations
 Patients with new-onset or crescendo angina often
require hospitalization.
 Symptoms not relieved by rest, nitroglycerin, and
oxygen may indicate an overall worsening of the
disease or the early stages of a myocardial
infarction.
 Patients may refuse transport after pain is relieved,
even though the underlying problem is not
addressed.

Myocardial Infarction
 Pathophysiology
 Death and necrosis of
heart muscle due to
inadequate oxygen
supply.
 Causes may include
occlusion, spasm,
microemboli, acute
volume overload,
hypotension, acute
respiratory failure,
and trauma.
 Location and size
dependent on the
vessel involved.

 Transmural vs. Subendocardial MIs.
 Effects of a Myocardial Infarction
 Dysrhythmias
 Heart Failure
 Ventricular Aneurysm
 Goals of Treatment
 Pain Relief
 Reperfusion

 Breathing
 Signs of Shock
 Chief Complaint
 Typically related to chest pain.
 Evaluate using OPQRST:
• Discomfort > 30 minutes.
• Radiation to arms, neck, back, or epigastric region.
 Patients may minimize symptoms.
 Feelings of “impending doom.”

 Other Symptoms
 Nausea and vomiting
 Diaphoresis
 Myocardial Infarctions & the ECG
 Diagnostic ECGs:
• 12-lead ECGs
• S-T segment
• Pathological Q waves
 Dysrhythmias:
• Asystole, PEA, VF, VT.
• Dysrhythmias are the leading cause of death in MI.

 Reperfusion Screening
 Reperfusion of ischemic/injured tissue.
 Time from onset to treatment < 6 hours.
 Absence of history that would exclude
thrombolytics.
 Transport
 Rapid transport indicated when acute MI suspected

 Management
 Prehospital
 Administer oxygen.
 Establish IV access.
 Consider medication administration:
• Aspirin
• Morphine sulfate
• Promethazine
• Nitroglycerin
• Nitrous oxide
• Nubain
• Antiarrhythmia medication as indicated

 Monitor ECG.
 Rapid transport as indicated.
 Avoid patient refusals if possible.
 Identify candidates for thrombolytic therapy.
 In-Hospital:
 Diagnostic ECGs.
 Enzyme levels.
 Risk assessment.
 Treatment:
• Cardiac catheterization, PTCA, and CABG.

Heart Failure
 Left
Ventricular
Failure
 Pathophysiology
 Results in
increased back
pressure into
the pulmonary
circulation.

Heart Failure
 Right
Ventricular
Failure
 Pathophysiology
 Results in
increased back
pressure into the
systemic venous
circulation.
 Pulmonary
Embolism

Heart Failure
 Congestive Heart Failure
 Pathophysiology
 Reduction in the heart’s stroke volume causes fluid
overload throughout the body’s other tissues.
 Manifestation

Heart Failure
 Pulmonary Edema:
 Cough with copious amounts of clear or pink-tinged
sputum.
 Labored breathing, especially with exertion.
 Abnormal breath sounds, including rales, rhonchi, and
wheezes.
 Pulsus paradoxus and pulsus alternans.
 Paroxysmal Nocturnal Dyspnea (PND)
 Medications:
 Diuretics.
 Medications to increase cardiac contractile force.
 Home oxygen.

Heart Failure
 Mental Status
 Mental status changes indicate impending respiratory
failure.
 Breathing
 Signs of labored breathing.
 Tripod positioning.
 “Number of pillows.”
 Skin
 Color changes.
 Peripheral and/or sacral edema.

Heart Failure
 Management
 General management:
 Avoid supine positioning.
 Avoid exertion such as standing or walking.
 Maintain the airway.
 Limit fluid administration.

Heart Failure
 Monitor ECG.
 Morphine
 Nitroglycerine
 Lasix
 Dopamine/dobutamine
 Promethazine
 Nitrous oxide
 Avoid patient refusals if at all possible.

Cardiac Tamponade
 Epidemiology & Pathophysiology
 Pathophysiology
 Result of fluid accumulation between visceral pericardium
and parietal pericardium.
 Increased intrapericardial pressure impairs diastolic
filling.
 Typically worsens progressively until corrected.
 Epidemiology
 Acute onset typically the result of trauma or MI.
 Benign presentations may be caused by cancer,
pericarditis, renal disease, and hypothyroidism.

Cardiac Tamponade
 Patient History
 Determine precipitating causes.
 Patient relates a history of dyspnea and orthopnea.
 Exam
 Rapid, weak pulse
 Decreasing systolic pressure
 Narrowing pulse pressures
 Pulsus paradoxus
 Faint, muffled heart sounds
 Electrical alternans

Cardiac Tamponade
 Management
 Maintain airway.
 Nitrous oxide
 Furosemide
 Dopamine/dobutamine

Cardiac Tamponade
 Rapid Transport
 Pericardiocentisis
 Pericardiocentisis is the definitive treatment.
 Insertion of a cardiac needle and aspiration of fluid
from the pericardium.
 Procedure should be performed only if allowed by
local protocol.
 Procedure should be performed only by personnel
adequately trained in the procedure.

Hypertensive
Emergencies
 Hypertensive Emergency
 Causes
 Typically occurs only in patients with a history of HTN.
 Primary cause is noncompliance with prescribed
antihypertensive medications.
 Also occurs with toxemia of pregnancy.
 Risk Factors
 Age-related factors
 Race-related factors

Hypertensive
Emergencies
 Initial Assessment
 Alterations in mental state
 Signs & Symptoms
 Headache accompanied by nausea and/or vomiting
 Blurred vision
 Shortness of breath
 Epistaxis
 Vertigo
 Tinnitus

Hypertensive
Emergencies
 History
 Known history of hypertension
 Compliance with medications
 Exam
 BP > 160/90
 Signs of left ventricular failure
 Strong, bounding pulse
 Abnormal skin color, temperature, and condition
 Presence of edema

Hypertensive
Emergencies
 Management
 Furosemide
 Nitroglycerin
 Sodium nitroprusside
 Labetalol

Cardiogenic Shock
 Pathophysiology
 General
 Inability of the heart to meet the body’s metabolic needs.
 Often remains after correction of other problems.
 Severe form of pump failure.
 High mortality rate.
 Causes
 Tension pneumothorax and cardiac tamponade.
 Impaired ventricular emptying.
 Impaired myocardial contractility.
 Trauma.

Cardiogenic Shock
 Chief Complaint
 Chief complaint is typically chest pain, shortness of
breath, unconsciousness, or altered mental state.
 Onset may be acute or progressive.
 History
 History of recent MI or chest pain episode.
 Presence of shock in the absence of trauma.

Cardiogenic Shock
 Mental Status
 Restlessness progressing to confusion
 Airway and Breathing
 Dyspnea, labored breathing, and cough
 PND, tripod position, accessory muscle retraction, and
adventitious lung sounds
 ECG
 Tachycardia and atrial dysrhythmias
 Circulation
 Hypotension
 Cool, clammy skin

Cardiogenic Shock
 Management
 Administer oxygen
 Identify and treat underlying problem.
 Vasopressors
 Other meds

Cardiac Arrest
 Sudden Death
 Causes
 Electrolyte or acid–base imbalances
 Electrocution
 Drug intoxication
 Hypoxia
 Hypothermia
 Pulmonary embolism
 Stroke
 Drowning
 Trauma
 End-stage renal disease and hyperkalemia

Cardiac Arrest
 Unresponsive, apneic, pulseless patient
 ECG
 Dysrhythmias
 History
 Prearrest events
 Bystander CPR
 “Down time”

Cardiac Arrest
 Management
 Resuscitation
 Return of Spontaneous Circulation
 Survival
 Role of Basic Life Support
 General Guidelines
 Manage specific dysrhythmias.
 CPR.
 Advanced airway management.
 Establish IV access.

Cardiac Arrest
 Postresuscitation Management
 Manage dysrhythmias and problems as presented.
 Be alert for PEA.
 Transport rapidly:
• Take care to protect intubation and IV access.
 Withholding Resuscitation
 Rigor mortis
 Dependent lividity
 Decapitation, decomposition, incineration
 Valid advanced directive

Cardiac Arrest
 Terminating Resuscitation
 Indications for termination of resuscitation
• Patient over 18 years old.
• Cause is presumed cardiac in origin.
• Successful endotracheal intubation.
• ACLS standards applied throughout the arrest.
• On-scene effort > 25 minutes, or four rounds of drug
therapy.
• ECG remains asystolic or agonal.
• Blunt trauma victims presenting with or developing
asystole.

Cardiac Arrest
 Terminating Resuscitation
 Contraindications to termination of resuscitation:
• Patient under 18 years old.
• Arrest is of a treatable cause.
• Present or recurring VF/VT.
• Transient return of a pulse.
• Signs of neurological viability.
• Witnessed arrest.
• Family or others opposed to termination of resuscitation.
 Always follow local protocols related to termination of
resuscitation.
 Support the family or others after termination of
resuscitation.
 Coordinate with law enforcement as required.

Peripheral Vascular and Other
 Atherosclerosis
 Pathophysiology
 Progressive degenerative disease of the medium-sized
and large arteries.
 Results from the buildup of fats on the interior of the
artery.
 Fatty buildup results in plaques and eventual stenosis of
the artery.
 Arteriosclerosis
 Claudication

 Aneurysm
 Pathophysiology
 Ballooning of an arterial wall, usually the aorta, that
results from a weakness or defect in the wall
 Types
 Atherosclerotic
 Dissecting
 Infectious
 Congenital
 Traumatic

 Abdominal
Aortic
Aneurysm
 Often the result
of
atherosclerosis
 Signs and
symptoms
• Abdominal pain
• Back/flank pain
• Hypotension
• Urge to
defecate

 Dissecting Aortic Aneurysm
 Caused by degenerative changes in the smooth
muscle and elastic tissue.
 Blood gets between and separates the wall of the
aorta.
 Can extend throughout the aorta and into
associated vessels.

 Acute Pulmonary Embolism
 Pathophysiology
 Blockage of a pulmonary artery by a blood clot or
other particle.
 The area served by the pulmonary artery fails.
 Signs and Symptoms
 Dependent upon size and location of the blockage.
 Onset of severe, unexplained dyspnea.
 History of recent lengthy immobilization.

 Acute Arterial Occlusion
 Pathophysiology
 Sudden occlusion of arterial blood flow due to trauma,
thrombosis, tumor, embolus, or idiopathic means.
 Frequently involves the abdomen or extremities.

 Vasculitis
 Pathophysiology
 Inflammation of the blood vessels.
 Commonly stems from rheumatic diseases and
syndromes.

 Noncritical Peripheral Vascular
Conditions
 Peripheral Arterial Atherosclerotic Disease
 Can be acute or chronic.
 Often associated with diabetes.
 Extremities exhibit pain, coldness, numbness, and pallor.
 Deep Venous Thrombosis
 Blood clot in a vein.
 Typically occurs in the larger veins of the thigh and calf.
 Swelling, pain, and tenderness, with warm, red skin.
 Varicose Veins
 Dilated superficial veins, common with pregnancy and
obesity.

 General Assessment and
Management of Vascular
Disorders
 Assessment
 Initial Assessment
 Circulatory Assessment
• Pallor
• Pain
• Pulselessness
• Paralysis
• Paresthesia

 Chief Complaint
• OPQRST
 Physical Exam
• Prior history of vascular problems
• Differences in pulses or blood pressures
 Management
 Maintain the airway.
 Administer oxygen if respiratory distress or signs of
hypoperfusion present.
 Consider administration of analgesics.
 Transport rapidly if signs of hypoperfusion present.

Cardiology
 Assessment of the Cardiovascular
Patient
 Management of Cardiovascular
Emergencies
 Management of Specific

Nitroglycerin is the mainstay treatment for angina pectoris

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