Cardiac

1
Cardiac Nervous SystemReview of Emergencies

• ECRN Mod III CE 2010
• Condell Medical Center EMS System
• Prepared by FF/PMD Michael Mounts
• Lake Forest Fire Department
• Reviewed/revised by Dr. Kent Bailey, EMS Medical
  Director

2
Objectives

• Identify components of the nervous system
• Identify signs and symptoms of a patient with a
  CVA
• Identify assessment field treatment of patient
  with a CVA
• Identify anatomy and physiology of the
  cardio-pulmonary system
• Identify signs and symptoms of a patient with ACS
  
• Identify field treatment of patient with ACS

3
Objectives cont.

• Discuss situations for using the RAD 57 tool
• Identify patient care based on RAD 57 readings
• Review documentation components for discussed
  conditions
• Identify a variety of ECG rhythm strips
• Review Region X SOPs for various emergencies
  discussed

4
Components of the CNS

• Brain - 3 major structures
• Cerebrum
• largest element of nervous system
• occupies most of cranium
• highest functional portion of brain
• center of conscious thought, personality, speech,
  motor control, and visual, auditory, tactile
  perception
• Cerebellum
• fine tunes motor control, allows smooth motion
  from one position to another
• responsible for balance maintenance of muscle
  tone

5
Components of the CNS cont.

• Brainstem
• central processing center communication junction
• midbrain
• hypothalamus
• controls much of endocrine function, vomiting
  reflex, hunger, thirst, kidney function, body
  temperature

6
Components of the CNS cont.

• Brainstem cont.
• pons
• medulla oblongata
• respiratory center (depth, rate, rhythm)
• cardiac center (rate strength of cardiac
  contractions)
• vasomotor center (control of distribution of
  blood and maintenance of blood pressure)

7
Cross-section of the brain
skull
In order
periosteum
1. Skull bone 2. Periosteum of the
skull 3. Dura 4. Arachnoid 5. Subarachnoid
space 6. Pia mater
dura
8
CNS Circulation

• 4 major arterial vessels
• Capillaries unique
• walls thicker so they are less permeable
• protected environment via the blood-brain barrier
• Cerebral perfusion
• changes in ICP are met with compensatory changes
  in blood pressure

9
Cerebral Perfusion Pressure

• Intracranial pressure - pressure within cranium
• pressures within cranium create a natural
  resistance to control the amount of cerebral
  blood flow
• blood flow to the brain remains adequate as long
  as pressures within the cranium are appropriate
• 3 major cranial contents
• ?brain, ?blood, ?cerebrospinal fluid
• Any changes in one of the 3 cranial contents is
  at the sacrifice to one of the others
• When ICP rises, the body increases the BP to
  maintain the cerebral perfusion (Cushing reflex)

10
Brain Function By Region

• Frontal Lobe - reasoning, planning, parts of
  speech, movement, emotions, and problem solving
• Parietal Lobe - movement, orientation,
  recognition, perception of stimuli
• Occipital Lobe - visual processing
• Temporal Lobe - perception and recognition of
  auditory stimuli, memory, and speech
• Cerebellum - regulation and coordination of
  movement, posture, and balance
• Brain stem - breathing, heartbeat, and blood
  pressure

11
Remember

• Wernickes Area
• Controls speech comprehension
• Brocas Area
• Controls speech production
• Both on left side of brain
• If either of the above speech
• areas are noted to be affected,
• see if right sided weakness
• is also present
• Speech and motor problems will be reflected on
  opposite sides of the body

12
Left vs. Right

• This theory of the structure and functions of the
  mind suggests that the two different sides of the
  brain control two different modes of thinking.
  It also suggests that each of us prefers one mode
  over the other.

Left Brain Logical Sequential Rational Analytical
Objective Looks at parts
Right Brain Random Intuitive HolisticSynthesizin
g Subjective Looks at wholes
13
Left vs. Right cont.
Note Notice how Broca Wernickes area are on
Left side Hearing difference Speech on Left
vs. Music on Right
14
CVA Signs and Symptoms

• Trouble with walking, sudden dizziness, loss of
  balance or loss of coordination.
• Trouble with speaking and/or understanding,
  confusion, slurred words or be unable to find the
  right words to explain what is happening
  (aphasia).
• Paralysis or numbness on one side of the body or
  face.
• Trouble with seeing in one or both eyes. Sudden
  blurred or blackened vision, or seeing double.
• Headache a sudden, severe "bolt out of the blue"
  headache which may be accompanied by vomiting,
  dizziness or altered consciousness.

15
What to do

• Initial assessment
• AVPU, ABCs, life threats, etc.
• Sample history
• Vitals
• Pupils
• Glasgow
• Time of onset VERY important!
• F.A.S.T. or Cincinnati Stroke Scale
• Remember you only need to have one of these
  signs for positive CVA identification.

16
Cincinnati Stroke Scale or FAST

• F look for facial drooping
• Have patient smile large enough to see teeth
• A check for arm drift
• Patient holds hands out in front for 10 seconds
  with eyes closed, palms up
• S check for slurred speech
• T teach patients to call 911 time is
  essential

17
Facial Drooping

• Ask the patient to smile real big and show you
  their teeth
• Best way to see if a droop is present

18
Arm Drift

• Demonstrate first and then have patient hold
  their hands out in front, palms up, for 10 seconds

19
Clarity of Speech

• Most likely youll know by now if there is a
  speech problem
• Can have the patient repeat after you any words
  or a sentence you give them
• You cant teach an old dog new tricks

20
7 DS Of Stroke Care

• Detection of signs and symptoms
• Dispatch advise to call 911
• Delivery to the appropriate facility
• Door emergent triage in the ED
• Data appropriate tests
• Decision to administer a fibrinolytic or not
• Drug must administer the fibrinolytic within 3
  hours of onset of symptoms

21

• Intracranial Hemorrhages
• Epidural rapid onset, traumatic
• Arterial bleed
• Headache
• Nausea/vomiting
• Seizures
• Focal neurologic deficits (aphasia, weakness,
  numbness)
• Subdural slower onset, traumatic
• Venous bleed
• Symptoms are often vague
• Usually altered mental status
• Seen more often in elderly brain atrophy
  stretches the veins, making them more likely to
  tear in trauma
• Note - White area is bleeding

22

• Intracranial Hemorrhages
• Subarachnoid sudden onset
• Usually from berry aneurysm rupture from the base
  of the brain bleeding around the brain (mixed
  with the CSF)
• Usual spontaneous, non-traumatic
• Sudden severe headache
• Vertigo
• Light sensitivity
• Often altered mental status
• Intraparenchymal (inside brain tissue)
• Traumatic bleed or spontaneous rupture of AVM
  (arteriovenous malformation)

23
Region X EMS Protocol Stroke Brain Attack
24
Cardio-Pulmonary AP

• We need to know what is being affected and how
  that is shown as sign and/or symptoms
• Knowing the following general AP will assist in
  assessment
• Veins
• Arteries
• Other tissues

25
Cardiac AP review
26
Coronary Circulation

• Coronary arteries and veins
• Myocardium extracts the largest amount of oxygen
  as blood moves into general circulation
• Oxygen uptake by the myocardium can only improve
  by increasing blood flow through the coronary
  arteries
• If the coronary arteries are blocked, they must
  be reopened if circulation is going to be
  restored to that area of tissue supplied

27
The Electrical Conduction System

• SA Node
• AV Node
• Bundle of HIS
• Purkinje Fibers

28
The Electrical Conduction System cont.

• SA node Fastest rate of automaticity
  automaticity. Primary pacemaker of the heart.
  Rate 60 to 100 bpm
• AV node Has a delay which allows for atrial
  contraction and a more filling of the ventricles.
  Rate 40-60 bpm (if not driven by the rate above)
• Bundle of His Has the ability to self-initiate
  electrical activity Rate 40-60 bpm
• Purkinje Fibers Network of fibers that carry
  electrical impulses directly to ventricular
  muscle. Rate 20-40 bpm (if not driven by the
  rate above)

29
The Electrical Conduction System in motion
30
Electrocardiogram (ECG/EKG)

• Its name is made of 3 different parts
• electro, because it is related to electrical
  activity
• cardio, Greek for heart
• gram, a Greek root meaning "to write"

31
12-Lead Electrodes

• A lead is a tracing of the electrical activity
  between 2 electrodes
• Leads view the heart from the front of the body
• Top, bottom, right, and left side of heart
• Leads view the heart as if it were sliced in half
  horizontally
• Front, back, right, and left sides of heart
• Each lead has a positive and a negative electrode

32
12-lead ECG

• A 12-lead ECG is made up of a tracing of the
  electrical activity of the heart from 12
  different points of view. The point of view comes
  from the location of the positive electrode of
  each lead. The positioning of these electrodes is
  broken down into 3 categories
• The limb leads (lead I, II III)
• The augmented leads (aVR, aVL aVF)
• The precordial/chest leads (V1, V2, V3, V4, V5,V6)

33
Standard 12-Lead EKG

• Six limb leads
• Leads I, II, III, aVR, aVL, aVF
• Six chest leads (precordial leads)
• V1, V2, V3, V4, V5, V6
• Information from 12 leads obtained from the
  attachment of only 10 electrodes

34
Contiguous ECG Leads

• EKG changes are significant when they are seen in
  at least two contiguous leads
• Two leads are contiguous if they look at the same
  area of the heart or they are numerically
  consecutive chest leads

35
12-Lead Electrode Placement
36
Lateral Wall MI I, aVL, V5, V6
Source The 12-Lead ECG in Acute Coronary
Syndromes, MosbyJems, 2006.
37
Complications of Lateral Wall MI

• I, aVL, V5,V6
• Complications arise due to the conduction
  components that are in the septum
• Conduction dysrhythmias most common
• Second degree Type II classical
• 3rd degree complete heart block
• Bundle branch blocks
• Monitor patient closely for these blocks
• 2nd degree Type II and 3rd degree are serious
  dysrhythmias that need to be treated aggressively
  with TCP

38
Inferior Wall MI II, III, aVF
Source The 12-Lead ECG in Acute Coronary
Syndromes, MosbyJems, 2006.
39
Complications of Inferior Wall MI

• II, III, aVF
• 40 of patients with inferior MIs have right
  ventricular infarcts
• In the presence of a right ventricular infarct,
  there is a high likeliness of both ventricles
  being damaged
• Contraction capabilities will be negatively
  affected
• Patients may present hypotensive
• Nitrates and Morphine alone will dilate blood
  vessels worsening hypotension
• Under Medical Control direction patients are
  often treated with a fluid challenge with the
  nitrates
• 1st degree heart block and Second degree Type I
  Wenckebach most common heart blocks

40
Septal MI V1 and V2
Source The 12-Lead ECG in Acute Coronary
Syndromes, MosbyJems, 2006.
41
Complications of Septal Wall MI

• V1 and V2
• Significant amount of conduction components are
  in the septal area
• Patient predisposed to dysrhythmias
• Second degree Type II classical
• 3rd degree heart block
• Bundle branch block
• Lethal heart blocks treated aggressively - TCP
• Rare to have a septal MI alone
• Common to have anterior or lateral involvement
  along with septal area

42
Anterior Wall MI V3, V4
Source The 12-Lead ECG in Acute Coronary
Syndromes, MosbyJems, 2006.
43
Complications of Anterior Wall MI

• V3, V4
• Known as the widowmaker due to the potential
  for a massive area of infarction from blockage of
  the large amount of myocardium supplied by the
  LAD (left anterior descending artery)
• Often the septal or lateral walls are also
  involved
• Watch for lethal ventricular dysrhythmias and
  cardiogenic shock
• Second degree Type II and 3rd degree heart block
  are more common than other blocks

44
Anterior Wall MI cont.

• Early death within a few days often from CHF
• Massive area of ventricular tissue infarcted if
  LAD totally occluded
• Important to obtain history of recent MI
  diagnosis and hospital discharge
• Increased incidence of ventricular tachycardia
  (VT) and ventricular fibrillation (VF) up to 1 -2
  weeks post acute anterior MI

45
Posterior MI Reciprocal Changes ST Depression
V1, V2, V3, poss V4
Source The 12-Lead ECG in Acute Coronary
Syndromes, MosbyJems, 2006.
46
Atypical Presentation in the Elderly

• Most frequent symptoms of acute MI
• Shortness of breath
• Fatigue and weakness (I just dont feel well)
• Abdominal or epigastric discomfort
• Often have preexisting conditions making this an
  already vulnerable population
• Hypertension
• CHF
• Previous AMI
• Likely to delay seeking treatment

47
Atypical Presentation in Women

• Discomfort described as
• Aching
• Tightness
• Pressure
• Sharpness
• Burning
• Fullness
• Tingling
• Often have no actual chest pain to offer as a
  complaint. Often the pain is in the back,
  shoulders, or neck

• Frequent acute symptoms
• Shortness of breath
• Weakness
• Unusual fatigue
• Cold sweats
• Dizziness
• Nausea/vomiting

48
Atypical Presentation in the Patient With Diabetes

• Atypical presentation due to autonomic
  dysfunction
• Common signs/symptoms
• Generalized weakness
• Generalized feeling of not being well
• Syncope
• Lightheadedness
• Change in mental status

49
Remember

• Watch out for the triple threat
• Elderly
• Female
• Diabetic history
• How many elderly women with diabetes do you see
  in your facility?
• Probably lots!!!

50
Using Region X Cardiac SOPs

• Care is initiated for all patients based on
  physical assessment
• A pediatric patient is considered under the age
  of 16 (15 and less)
• EMS is not to delay care to contact Medical
  Control call after care initiated
• But, prompt communication is encouraged

51
Region X Cardiac SOPs cont.

• Obtaining a history and performing an assessment
  can often provide valuable information
• Consider underlying causes for all situations
• In the cardiac SOPs, think of the 6 Hs and 5
  Ts as possible causes of the problem as you
  progress through assessment treatment for the
  patient

52
6 Hs

• Hypovolemia
• Hypoxia
• Hydrogen ion acidosis
• Hyper/hypokalemia (high/low potassium levels)
• Hypothermia
• Hypoglycemia

• Give fluids (20 ml/kg)
• Provide supplemental O2
• Ventilate to blow off CO2
• Difficult to determine in the field consider in
  diabetic ketoacidosis renal dialysis
• Attempt rewarming
• Check blood glucose on all altered mental status
  pts

53
5 Ts

• Think out of the box
• Check for JVD, ? B/P
• Check for JVD, ? B/P, absent/decreased breath
  sounds, difficulty bagging
• Obtain 12 lead when applicable good history
  taking to lead to suspicions (travel, surgery,
  immobility)
• What is history of current status?

• Toxins (overdose)
• Tamponade, cardiac
• Tension pneumothorax
• Thrombosis, coronary (ACS) or Thrombosis,
  pulmonary (embolism)
• Trauma

54
Region X Protocol Acute Coronary Syndrome
55
Assessment for CO Exposure

• EMS may be summoned to monitor the air quality
  for the presence of carbon monoxide
• Airborne CO meters are used and documentation
  made whether there is a need for patient
  transport or not
• A more immediate concern is the level of CO in
  the patients blood
• RAD 57 monitors are a non-invasive tool that
  allows results in less than 30 seconds
• Rapid diagnosis leads to rapid and appropriate
  treatment

56
Signs and Symptoms CO Poisoning

• Carboxyhemoglobin levels of lt15 20
• Mild severity
• Headache
• Nausea and vomiting
• Dizziness
• Blurred vision

57
Signs and Symptoms CO Poisoning

• Carboxyhemoglobin levels of 21 40
• Moderate severity
• Confusion
• Syncope
• Chest pain
• Dyspnea
• Tachycardia
• Tachypnea
• Weakness

58
Signs and Symptoms CO Poisoning

• Carboxyhemoglobin levels of 41 - 59
• Severe
• Dysrhythmias
• Hypotension
• Cardiac ischemia
• Palpitations
• Respiratory arrest
• Pulmonary edema
• Seizures
• Coma
• Cardiac arrest

59
Signs and Symptoms CO Poisoning

• Carboxyhemoglobin levels of gt60
• Fatal
• Cherry red skin is not listed as a sign
• An unreliable finding

60
Increased Risks

• Health and activity levels can increase the risk
  of signs and symptoms at lower concentrations of
  CO
• Infants
• Women who are pregnant
• Fetus at greatest risk because fetal hemoglobin
  has a greater affinity for oxygen and CO compared
  to adult hemoglobin
• Elderly
• Physical conditions that limit the bodys ability
  to use oxygen
• Emphysema, asthma
• Heart disease
• Physical conditions with decreased O2 carrying
  capacity
• Anemia iron-deficiency sickle cell

61
Patient Assessment Tools

• Continuously monitor SpO2 and SpCO levels
• Remember that SpO2 may be falsely normal
• If EMS has a CO-oximeter (ie Rad 57), EMS will
  report the findings to the ED staff
• Generally, results gt3 indicate suspicion for CO
  exposure in non-smoker
• Cardiac monitor
• 12 lead EKG obtained and transmitted to ED

62
Pulse Oximetry

• Device to analyze infrared signals
• Measures the percentage of oxygenated hemoglobin
  (saturated Hgb)
• Can mistake carboxyhemoglobin for oxyhemoglobin
  and give a false normal level of oxyhemoglobin
• Never rely just on the pulse oximetry reading
  always correlate with clinical assessment

63
Pulse CO-oximeter Device (ie RAD 57)

• Hand-held device
• Attaches to a finger tip similar to pulse ox
  device
• Most commonly measured gases in commercial
  devices include
• Carbon monoxide (SpCO)
• Oxygen (SpO2)
• Methemoglobin (SpMet)
• Other combustible gases
• Without the device, need to draw a venous sample
  of blood to test for CO levels

64
Pulse CO-oximeter Tool

• Firefighters have an increased exposure risk
• Active firefighting
• Inhaled products of combustion in structure fire
• Inhaled exhaust from vehicles and power tools
• Rehab operations more efficient when firefighter
  can be screened at the scene and released back
  to duty
• Pulse rate, oxygen saturation, carboxyhemoglobin
  level evaluated

65
Treatment CO Poisoning

• Increasing the concentration of inhaled oxygen
  can help minimize the binding of CO to hemoglobin
• Some CO may be displaced from hemoglobin when the
  patient increases their inhaled oxygen
  concentrations
• Treatment begins with high index of suspicion and
  removal to a safer environment
• Immediately begin 100 O2 delivery

66
Treatment CO Poisoning

• Some guidelines indicate to initiate treatment
  when SpCO levels exceed 10 some at 12
• Treatment levels vary significantly
• If you do not have a CO-oximeter to use, maintain
  a heightened level of suspicion and base
  treatment on symptoms
• Monitor for complications related to CO exposure
• Seizures
• Cardiac dysrhythmias
• Cardiac ischemia

67
CO Poisoning and CPAP

• CPAP could assist in fully oxygenating hemoglobin
• If considered, EMS must call Medical Control for
  permission to use CPAP
• ECRN will obtain report with patient information
• ECRN must discuss with ED MD to obtain order to
  use CPAP in the field

68
Region X SOP CO / Smoke Inh
69
Additions to CO / Smoke Inhalation SOP

• SpCO levels lt 5 3 - not treatment
• SpCO levels 5 with symptoms 4
• 100 O2 ED evaluation
• SpCO levels 10
• 100 O2 ED evaluation
• SpCO levels 25
• 100 O2 ED evaluation
• Consider hyperbaric chamber
• Footnotes see next page

70
Key Comments of CO / Smoke Inhalation SOP

• 2. Do not rely on pulse oximetry to indicate
  degree of hypoxia with CO exposure and consider
  cyanide poisoning in presence of smoke / fire
  situations. See Carbon Monoxide/Smoke Inhalation
  SOP.
• 3. A normal SpCO level does not negate the need
  for further management of the symptomatic patient
  as other diagnoses may still be present.
• 4. 5 Mild headache
• 6-10 Mild headache, shortness of breath with
  exertion
• 11-20 Moderate headache, shortness of breath
• 21-30 Worsening headache, nausea, dizziness,
  fatigue
• 31-40 Severe headache, vomiting, vertigo,
  altered judgment
• 41-50 Confusion, syncope, tachycardia
• 51-60 Seizures, shock, apnea, coma
• NOTE If indicated, consider conscious sedation
  intubation.
• Consider cyanide poisoning in presence of
  smoke/fire situations.

71
Case 1

• 45 year-old patient who complains of chest
  heaviness lightheadedness
• VS 90/56 P 86 R - 22
• Is there ST elevation (EKG next slide)
• If so, where?
• What are you going to do for this patient?

72
Case 1 ST ElevationV2 V5
73
Case 2

• Patients spouse called EMS
• Patient dropping silverware at lunch, unable to
  sit up straight, unable to complete sentences
• Vital signs 170/110 P 64 R 16 GCS -14
• EKG monitor below

74
Case 2

• What is your impression?
• What is the cardiac rhythm?
• Atrial fibrillation
• How does this rhythm relate to any impressions?
• What assessments need to be done?
• Blood sugar level for all patients with altered
  level of consciousness
• Cincinnati stroke scale

75
Case 2

• Cincinnati stroke scale
• Ask the patient to smile real big showing you
  their teeth
• Ask the patient to put their hands out in front,
  palms up, and close their eyes
• Hold the position for 10 seconds
• Ask the patient to repeat a saying
• You cant teach an old dog new tricks

76
Case 2

• Whats the most important question to ask the
  patient?
• When did the symptoms begin?

77
Case 3

• 58 year-old male patient who complains of chest
  pain radiating down the left arm after working
  out in the gym
• VS 110/72 P 100 R - 18
• Is there ST elevation (EKG next slide)
• If so, where?
• What are you going to do for this patient?

78
Case 3 ST Elevation II, III, aVF
79
Case 4

• 36 year-old patient who passed out standing in
  line at a bank
• VS 128/78 P 80 R - 20
• Is there ST elevation (EKG next slide)
• If so, where?
• What are you going to do for this patient?

80
Case 4 ST elevation II, III, aVF
81
Case 5

• Received call from a 10 year-old child that he
  could not wake up his mother. On arrival the 34
  year-old female was unconscious with signs of
  seizure activity. 2 other children are in the
  home.
• What are your general impressions/suspicions?
• What is included in your assessment?
• What is your treatment?

82
Case 5

• Upon scene arrival, a faint odor of exhaust was
  noted
• Evaluate the patient for normal reasons of
  altered level of consciousness including history
  of seizure disorder and suicide attempt
• After 5 minutes on scene, rescue personnel began
  complaining of headache
• A car was found running in the garage directly
  under the bedroom/bathroom

83
Bibliography

• Various on-line photos
• eHow.com
• Previous EMS CE packets
• 2006 Condell CE Module
• February 2009 Condell CE
• February LFFD CE add-on (Jon Bardi)
• CMC SOP pages