Cardiac Emergencies Brownbag as delivered to the Cisco ERT

1. Cardiac Emergencies &
Oxygen Assistance
Rakesh Bharania, EMT-B
We gotta go to Cisco … again!
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2. Agenda
 You Are Key!
 Heart Overview
 Cardiac Emergencies
 ERT Cardiac protocols
 Oxygen assistance
 PulsePoint
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3. The Key To
Survival
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4. Cardiac Chain Of Survival
Early Early Early Early
911 CPR Defibrillation Advanced
Care
But all this starts with you
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5. First responders make the difference!
 Cisco ERT can be the difference between life and death in a
cardiac emergency.
 The numbers prove it.
 Trained bystanders save as many people as ALS paramedics do,
and send more home with intact brain function
 Why? Time!
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6. Real-world examples
 Seattle, WA: CPR training is widespread and EMS response
and time to defibrillation is short, the survival rate for witnessed
VFib cardiac arrest is about 30%.
 New York City: few victims receive bystander CPR and time to
EMS response and defibrillation is longer, survival from sudden
VFib cardiac arrest averages 1–2%
 Security guards at O’Hare Airport (Chicago), Las Vegas Casinos
achieve a survival rate of 50-74%!
 Since AED deployment, Cisco ERT has a 100%
success rate (3 for 3)
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7. CPR and AED use is recommended for both traditional and non-
traditional public safety responders - this is a Class I
recommendation.
AED Programs should be implemented in sites where there is a
high likelihood of witnessed cardiac arrest. - this is a Class I
recommendation
2005 AHA CPR/ECC Guidelines (reaffirmed in 2010 CPR/ECC)
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8. The Heart
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9. Basic Anatomy
 About the size of your fist
 100k beats / day
 2000 gal. blood pumped / day
 Four chambers:
> two atria (top)
> two ventricles (bottom)
 Four one-way valves:
> Tricuspid
> Pulmonary
> Mitral
> Aortic
 Two coronary arteries supply
the heart muscle itself (not shown)
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10. The Heart’s Electrical System
 The sinoatrial (SA) node is the heart’s
“natural pacemaker”
 Electrical impulses travel
to the atrioventricular (AV)
node.
 Through the Bundle of His
 Signal splits down the
left and right bundle
branches
 Normal adult rate:
60-100/min,
can vary due to stress,
physical activity,
hormonal changes
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11. The Heartbeat - Diastole
 Diastole – atria pumping
 SA node sends an electrical
signal – atrial contraction
 Tricuspid and Mitral valves
open, filling the ventricles
 Pulmonary and Aortic valves are
closed
 This is the longer of the two phases of
a heartbeat
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12. The Heartbeat - Systole
 Systole – ventricles pumping
 Electrical impulse arrives at the AV node
and travels down to the two bundle
branches causing ventricular contraction
 Pulmonary and Aortic valves are
opened, blood forced out to
the lungs for oxygen, and
to the rest of the body
 Tricuspid and Mitral valves
closed, preventing backflow
 This is the shorter of the two phases of
a heartbeat
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13. Cardiac
Emergencies
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14. Cardiac Emergencies
 Heart disease the #1 cause of death for Americans.
 We’ll talk about the most common cardiac emergencies you may
be faced with.
> Heart Attacks
> Sudden Cardiac Arrest
Remember: While not all chest pain/discomfort is cardiac, all chest
pain calls should be treated as such!
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15. Heart Attacks
 A heart attack (myocardial
infarction or MI) occurs
when the heart’s oxygen
supply is blocked &
heart muscle is damaged
(infarction)
 Caused by plaque buildup
in the coronary arteries
 When plaque ruptures, platelets
form clots around the plaque
 This can restrict blood to
distal portions of the heart
 Drugs: asprin, thrombolytics
“clot busters”, vasodilators
such as nitroglycerin
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16. Heart Attacks – Typical Signs/Symptoms
 Chest discomfort. Most heart attacks involve discomfort in the
center of the chest that lasts more than a few minutes, or that goes
away and comes back. It can feel like uncomfortable pressure,
squeezing, fullness or pain.
 Discomfort in other areas of the upper body. Symptoms can
include pain or discomfort in one or both arms, the back, neck, jaw
or stomach.
 Shortness of breath. This feeling often comes along with chest
discomfort. But it can occur before the chest discomfort.
 Other signs: These may include breaking out in a cold sweat,
nausea or lightheadedness, denial
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17. Heart Attacks – Women
 “Atypical presentations are typical for women.”
 Chest pain is not as common a symptom of a heart attack in
women as it is in men (43% reported no chest pain/pressure)
 Women are more prone to experience so-called “atypical”
symptoms than men before and during a heart attack
 Such symptoms include (but are not limited to):
Back, neck, or jaw pain
Nausea
Vomiting
Indigestion
Weakness
Fatigue
Dizziness
Lightheadedness
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18. Sudden Cardiac Arrest - Overview
 Sudden Cardiac Arrest != Heart Attack.
 SCA = electrical problem
 MI = plumbing problem
 It is the largest cause of natural
death in the U.S., causing about
250,000 adult deaths each year
 SCA occurs most frequently
in adults mid-30s to mid-40s, and
affects men twice
as often as it does women
 We worry about two rhythms,
ventricular tachycardia (VTach), and
ventricular fibrillation (VFib)
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19. Sudden Cardiac Arrest –
Signs/Symptoms
 Patients will suddenly lose consciousness, without any prior
warning.
 No breathing (there may be ineffective breathing motions, however
– “agonal breathing” – does not count as breathing)
 No pulse
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20. ECGs in one slide
 Electrocardiograms (ECG/EKG) record electrical activity of the
heart.
 Does not automatically correspond to physical action of the heart.
 Normal Sinus Rhythm includes a P wave, a QRS Complex
and a T wave.
 P = current for atrial contraction
 QRS = current for ventricular
contraction
 T = ventricular repolarization
(atrial repolaraization is hidden
by QRS)
 The ECG is so familiar to the
general population that it is
part of the logo of many
medical organizations,
representing the technical side of medicine
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21. Ventricular Tachycardia
 Ventricular Tachycardia is
a rapid ventricular
rhythm
 Heart rate 140-250 but
ineffective perfusion Normal Sinus Rhythm
 Can degrade to VFib
 Treated with: Valsalva
maneuvers,
anti-arrhythmic drugs
(Rakesh’s favorite:
adenosine),
cardioversion
 Pulseless VTach is
shockable by an AED
(not all VTach is pulseless)
Two examples of VTach
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22. Ventricular Tachycardia
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23. Sudden Cardiac Arrest - VFib
 Ventricular Fibrillation
occurs when the heart’s
electrical activity loses
all coordination
 Pulseless, no BP Normal Sinus Rhythm
 Respiration will
stop, unconsciousness will
occur
 Asystole (and death)
will result unless treated
 This is the most
common cardiac
arrest rhythm
Two examples of VFib
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24. Defibrillation
for Everyone!
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25. Defibrillation Facts
 90% of adults successfully resuscitated from non-traumatic cardiac
arrest were in VFib
 The success of defibrillation is directly related to the time to
defibrillation
 Chances of successful defibrillation of pulseless VTach or VFib is
70-80% at time zero. Each minute that passes, chances of
successful defibrillation decreases between 2-10%
 Ten minutes after the event, chances of survival is near zero
 Defibrillation does not “restart” a stopped heart (asystole),
regardless of what the movies show
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26. Medtronic Lifepak CR Plus AED
 Fully automated.
 Can detect shockable rhythms
 Delivers a “biphasic” shock. Accommodates patient
impedance
 Pads are compatible with
Medtronic ALS ECG monitors
 20 minutes ECG record time
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27. Cardiac Science PowerHeartAED G3
 Fully automated.
 Biphasic, adjusts for patient
 “Rescue Ready” indicator
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28. Updated AHA AED Behavior
 1 shock followed by immediate CPR
 After two min. of CPR, second shock delivered if needed.
 No more “stacked shocks.” Most biphasic AEDs convert Vf in one
shock.
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29. So who’s got ‘em?
 ERT Leads
 Mobile SAS Officers/Supervisors and SAS Coordinators
 Cisco NERV disaster response trucks
 Wall mounted in EBC/CBC & Fitness Center Locations
 Wall mounted, one unit per building (typically first floor breakroom)
 Cisco RTP and SJ Saves!!!
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30. So what about CPR?
 CPR supports the patient but cannot reverse cardiac arrest.
 It’s still needed to buy the time between arrest onset and
defibrillation.
 So, it’s still important. AHA: Re-emphasis on CPR. (C-A-B)
 CPR is a hard skill for even those who do it all the time
(paramedics, ER doctors, etc.)
 Chest compressions often done too shallowly. Rate at least
100/min, Push hard, push fast.
 Done properly, cartilage damage or rib breaking is common
 Chest compressions can be done w/o breaths if unwilling or able to
perform them!
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31. Emergency
Protocols
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32. ERT Chest Pain protocol
 Ensure 911 / BSI / Scene Safety
 Have someone retrieve AED
 Position of comfort, reassure patient
 Assess vital signs, SAMPLE &
OPQRST history
 Oxygen (if available, and trained
to do so) @ 15 lpm/NRB (preferred)
or 6 lpm/cannula
 Aspirin if asked by 911 and readily available.
(325 mg – 4 x 81mg baby aspirin, chewed)
 Be prepared to initiate CPR / AED
if patient goes unresponsive
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33. ERT Cardiac Arrest Protocol
 Ensure 911 / BSI / Scene Safety
 Have someone retrieve AED
 Confirm unresponsiveness
“Are you OK?”
 If there is no breathing or only
agonal breathing, immediately give
30 compressions. Rate = 100/min
 Open airway (head-tilt, chin lift)
and deliver two rescue breaths.
 Perform CPR cycles of 30:2 until AED or EMS
 If CPR in progress, 3rd person can setup & attach pads.
 Deliver AED shock as soon as possible.
 Recheck for breathing after every five cycles of CPR. Continue
if needed.
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34. Oxygen
Assistance
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35. Oxygen Assistance
Without a “patent” airway, regardless of any other emergency, the
patient will not survive.
Cisco ERT Protocol (2011): Non-EMT ERT members may assist
an oxygen-equipped ERT member with Oxygen
What this means: YOU can setup oxygen for
an ERT EMT, but you cannot actually apply
the oxygen to a patient.
OXYGEN SAFETY:
No smoking
Contents under pressure (don’t
open w/o a regulator on the tank)
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36. Oxygen Delivery
Room air – 21% Oxygen however, we can deliver higher levels of
oxygen when required…
Non-Rebreather Mask (NRB) – 60-100% Oxygen at 10-15 lpm.
Preferred method of O2 delivery pre-hospital. Used on distressed
or other serious patients.
Nasal Cannula – 24-44% Oxygen at 1-6 lpm. Common for long
term O2 therapy, but not really good for pre-hospital. Used when
patient won’t tolerate NRB or as a comfort measure.
Bag-Valve Mask – assists a patient who is breathing
too slowly or not at all. Can be connected to
O2 @ 15 lpm, 100% O2 delivery. Best used with
an airway adjunct. Preferred over a pocket-mask
Oxygen Bear – provides “blow-by” oxygen for
pediatric patients who won’t tolerate mask.
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37. Airway Adjuncts
If a patient is unable to manage their own airway due to altered
mental status, trauma, etc. Trained persons (EMTs, etc.) are
permitted to use two different types of “airway adjuncts” to help
manage a patient’s airway.
Oropharyngeal Airways (OPA) are “hook-like” devices
that are inserted into a person’s mouth to keep the
tongue and epiglottis clear. Can only be used
on patients without a gag-reflex.
Nasopharyngeal Airways (NPA) are trumpet-like tubes
that are inserted into one of a patient’s nostrils. Can
be used on conscious or semi-conscious patients.
Each adjunct has its primary uses and contraindications.
Neither is considered a “definitive” airway – patient
could still aspirate. Intubation “secures” the airway,
but is a paramedic skill.
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38. PulsePoint
Location-aware public CPR/AED alert app for Apple iPhone & Android
www.firedepartment.mobi
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39. Now that we have AEDs & O2 how about a pony?
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