McCann Paramedic Program: Cardiology Lecture 3-Treatment of Cardiovascular Emergencies

1. Cardiovascular Emergencies
Part III
Dale A. LeCrone Sr NRP
Instructor

3. • Defibrillation
• Surge of electric energy is delivered to
the heart
• Current depolarizes hearts muscle cells.
• When cells repolarize after the shock,
they should respond to an impulse from
SA node.
• Needs to be done as soon as possible
for:
• Ventricular fibrillation
• Pulseless ventricular tachycardia
• Not useful in asystole

4. • Manual defibrillation
• Automated external defibrillator (AED): interprets cardiac rhythm
• Manual defibrillation: paramedic interprets cardiac rhythm
• Switch an AED to manual mode when:
• All electrical therapy functions are needed.
• Patient is in cardiac arrest.

5. • Manual defibrillation (cont’d)
• Follow safety measures.
• Make sure no one is touching the patient.
• Do not defibrillate a patient in pooled water.
• Do not defibrillate a patient who is touching metal.
• If implanted pacemaker or internal defibrillator, place the pad below, or in anterior and
posterior positions.

6. • To perform manual defibrillation:
• Attach pads to the patient’s chest.
• Dry the chest if necessary.
• Check the instructions.
• Set energy level to 200 J.
• Charge the defibrillator.
• Apply a conductive gel and apply pressure.

7. • To perform manual defibrillation (cont’d):
• Follow recommended placement.
• Position the negative pad right of the upper part of the sternum and the
positive pad just below.
• Clear the area.
• Discharge the defibrillator.

8. • To perform manual defibrillation (cont’d):
• Contraction of the chest will be evident.
• Resume CPR immediately and continue for
2 minutes/5 cycles before checking pulse.
• If the rhythm does not require a shock and there is a pulse, check the
breathing.

9. • Inspect defibrillator, checking:
• Defibrillation pads
• Cables and connectors
• Power supply
• Monitor
• ECG
• Recorder
• Ancillary supplies

10. • Patients who do not regain a pulse on the scene usually do not
survive.
• Transport when one of the following occurs:
• The patient regains a pulse.
• Six to nine shocks have been delivered.
• Defibrillator gives three consecutive messages that no shock is advised.

11. • Automated external defibrillator (AED)
• Charge pads and deliver countershocks.
• Semiautomated AED prompts rescuer.
• If you witness cardiac arrest, attach AED as soon as available.
• If not witnessed, perform five cycles of CPR first.

12. • AED (cont’d)
• After AED protocol:
• Pulse is regained
• No pulse regained and AED indicates no shock
• No pulse regained and AED indicates shock is advised

13. • Cardiac arrest during transport
• If pulse is not present:
• Stop vehicle.
• If defibrillator is not ready, perform CPR.
• Analyze the rhythm.
• Deliver one shock and resume CPR.
• Continue resuscitation.

14. • Cardiac arrest during transport (cont’d)
• If adult patient loses consciousness:
• Check for a pulse.
• Stop the vehicle.
• If defibrillator is not ready, perform CPR.
• Analyze the rhythm.
• Deliver one shock and resume CPR.
• Continue resuscitation.

15. • Synchronized cardioversion: use of the defibrillator to terminate
hemodynamically unstable tachydysrhythmias.
• Involves energy delivery at peak of R wave
• Increases probability of depolarizing myocytes
• Allows SA to resume pacemaker function

16. • Synchronized cardioversion (cont’d)
• Performed just as defibrillation except the user selects the synchronize setting
first.
• Done only with severely impaired CO
• When done on a conscious patient, he or she must be sedated.

17. • Artificial pacemakers deliver
repetitive electric currents to the
heart.
• Passes through the skin across the
heart
• Pacer is set for a specific rate
• Energy is increased until heart
responds

18. • Several applications in prehospital care:
• Interhospital transfer needing pacemaker implantation
• Artificial pacemaker failure
• Bradydysrhythmias or blocks associated with severely reduced CO

19. • Must increase heart rate and improve CO.
• Support airway and breathing, then:
• Establish IV line with normal saline.
• Administer atropine.
• If no response to atropine, begin TCP immediately.
• If unsuccessful, consider a sympathomimetic drug.
• Transport to a hospital.

21. • Decide on seriousness of symptoms.
• Unstable tachycardia:
• Chest pain
• Dyspnea
• Hypotension
• Altered mental status

22. • Decide if signs and symptoms indicate tachycardia or another
condition.
• Rates of 150 beats/min rarely cause serious signs of tachycardia.
• Slowing heart rate of patient compensating for a medical condition may be
fatal.

23. • If unstable signs and symptoms result from tachycardia, cardioversion
is needed.
• If signs and symptoms are mild, slower but safer treatment is
recommended.
• Determine origin or pacemaker site of rhythm.

24. • In SVTs, attempt to
stimulate vagus nerve.
• Carotid sinus massage
• Have patient bear down
against a closed glottis.
© Jones & Bartlett Learning. Courtesy of MIEMSS.
© Jones & Bartlett Learning. Courtesy of MIEMSS.

25. • Never massage
both carotid
arteries
simultaneously.
• May cause
significant
bradycardia or
asystole

26. • Consider patient’s history.
• Patients at risk of thromboembolism include:
• Advanced age
• Coronary artery disease
• High cholesterol
• If successful, transport anyway.

27. • Administer adenosine.
• 6 mg, by rapid IV push
• Insert syringe of adenosine and syringe of at least 20 mL of normal saline
solution.
• Be prepared for a short run of asystole.

28. • Administer adenosine (cont’d).
• If first dose is unsuccessful, administer again.
• If still unsuccessful, transport immediately.
• If patient becomes unstable, move to cardioversion algorithm.
• If the rhythm is ventricular and patient is stable, transport to the hospital.

30. • Warnings of cardiac arrest:
• Atherosclerosis
• Underlying cardiac disease
• Electrocution, drowning, or other trauma
• Cardiac arrest management requires a systematic approach that is
rehearsed.

31. • CPR should now be initiated prior to airway and breathing
assessment.
• Concentrate on high-quality compressions.
• Avoid excessive volume and inflation pressure.
• Keep compressions smooth, regular, and uninterrupted.

32. • Maintain compression for
at least half the
compression-release cycle.
• Avoid jerky compressions.
• Keep shoulders over
patient’s sternum, keep
elbows straight.
• Maintain proper hand
position.
• Rotate compressors every
2 minutes.

33. • Single rescuer: give 30 compressions and
2 ventilations at rate of at least 100 per minute.
• Do not interrupt CPR compressions except for:
• Advanced airway placement
• Defibrillation
• Moving the patient
• Do not stop for more than 10 seconds.

34. • Minimally interrupted
chest compression
• Use of adjunctive
equipment
• Cardiac monitoring for
dysrhythmia
• Establishment and
maintenance of IV
• Use of definitive therapy
to:
• Prevent cardiac arrest
• Establish an effective
cardiac rhythm and
circulation.
• Stabilize patient’s condition.

35. • Administer hypothermia therapy for patients in a coma after return of
spontaneous circulation.
• Transport to an appropriate facility.
• Monitor closely.

36. • As you approach the scene, bring:
• Defibrillator
• Portable oxygen cylinder
• Jump kit with airway management equipment
• Intubation kit
• IV equipment
• Drug box
• If alone, do not take time to carry everything.

37. • Assess circulation.
• If no pulse, start CPR.
• Second paramedic should
attach defibrillator.
• After 2 minutes, proceed.
• Assess responsiveness.
• If not responsive:
• Open airway and assess
breathing.
• If not breathing:
• Give two slow breaths
using a bag-mask or
barrier device.

38. • Check pulse and rhythm on
monitor.
• If ventricular fibrillation or
tachycardia is present:
• Follow algorithm.
• If not present, resume CPR.
• If still in cardiac arrest, may
be:
• Ventricular fibrillation or
tachycardia
• PEA
• Asystole

40. • Address CAB issues.
• Begin CPR and attach
defibrillator.
• Confirm ventricular
fibrillation or tachycardia.
• Confirm absence of pulse.
• Resume CPR.
• Clear patient and then
defibrillate.
• Biphasic: 120 to 200 J
• Monophasic: 360 J
• Resume CPR after
discharge.

41. • On monitor:
• Identify rhythm.
• No pulse: move to asystole-
PEA pathway.
• Pulse: move to appropriate
algorithm.
• If ventricular fibrillation or
tachycardia: resume CPR.
• Clear the patient, then
defibrillate.
• Resume CPR.
• Insert advanced airway if
airway is not adequate.

42. • Start IV line.
• If unable, establish IO
access until IV is
established.
• Administer a vasopressor
drug.
• Epinephrine
• Vasopressin
• At end of 2 minutes of CPR,
check for circulation and
rhythm.
• If ventricular fibrillation or
tachycardia, resume CPR.
• Clear the patient, then
defibrillate.

43. • Resume CPR for 2 minutes.
• Consider an
antidysrhythmic
medication.
• After CPR, check for
circulation and rhythm on
monitor.
• If ventricular fibrillation or
tachycardia:
• Resume CPR.
• Clear patient and
defibrillate.
• Resume CPR for 2 minutes.
• If still present, consider
transport.

45. • If spontaneous circulation returns:
• Assess vital signs.
• Support airway and breathing, as necessary.
• Provide medications as indicated.
• Consider hypothermia protocol and transport to appropriate center.

46. • Organized cardiac rhythm not accompanied by a detectable pulse
• Heart beat so weak from:
• Cardiogenic or hypovolemic shock
• Cardiac tamponade
• Massive pulmonary embolism
• Electrolyte imbalance disturbances
• Drug overdose

47. • Resume CPR.
• Insert an advanced airway
if airway is not adequate.
• Start an IV line.
• If access cannot be
established, consider IO
access.
• Administer a vasopressor
drug.
• At end of CPR, check
circulation and rhythm.
• If PEA still present:
• Continue CPR.
• Search for causes.

48. • Flat line may or may not be asystole.
• Rule out other causes:
• Leads not attached to patient or monitor
• Incorrect monitor setting
• Very-low-voltage ventricular fibrillation
• True asystole

49. • Resume CPR.
• Check for other causes of
flat line.
• Switch to another lead to
detect low-voltage
fibrillation.
• Insert an advanced airway
if airway is not adequate.
• Start an IV line.
• If unable to establish,
consider IO access.
• Administer a vasopressor
drug.
• Epinephrine
• Vasopressin

50. • At end of 2 minutes of CPR,
check for circulation and
rhythm.
• If asystole is still present:
• Resume CPR.
• Search for/treat possible
causes.
• Consider termination of
resuscitation.

51. • Heart rate should be stabilized.
• Stabilize cardiac rhythm.
• If ventricular fibrillation or ventricular tachycardia, consider antidysrhythmic
drug.
• If severe bradycardia, atropine or TCP may be necessary.

52. • Lessen effects on the brain:
• Correct marked hypotension.
• Avoid tracheal suctioning in an intubated patient.
• Consider elevating the patient’s head.
• If effective rhythm is restored, transport.
• If comatose, begin hypothermia treatment.

53. • In the past, once CPR was started, it had to continue until a physician
pronounced death.
• In some jurisdictions, pronouncement of death may be permitted by a
paramedic.

54. • Coronary artery disease (CAD) is the most common form of heart
disease.
• If coronary arteries are blocked, cardiac muscle will be deprived of
oxygen (ischemia).
• If not restored, area will die (undergo infarction).

55. • Atherosclerosis
• Affects inner lining of aorta and cerebral and coronary blood vessels
• Leads to narrowing and blood flow reduction
• Area provides a locus for the formation of a fixed blood clot (thrombus)
• May cause arteriorsclerosis