S E C T I O N

MEDICAL EMERGENCIES

Chapter 12 Cardiovascular Emergencies

Chapter Overview
After students complete this chapter presentation and the related course work, they will understand the significance and characteristics of cardiovascular emergencies, the pathophysiology, signs, and symptoms of the most common cardiac conditions, the indications, contraindications, and use of automated external defibrillators, and general care of a patient experiencing a cardiac emergency.

Objectives
Cognitive
4-3.1 4-3.2 Describe the structure and function of the cardiovascular system. p. 402 Describe the emergency medical care of the patient experiencing chest pain/discomfort. p. 415 List the indications for automated external defibrillation (AED). p. 419 List the contraindications for automated external defibrillation. p. 421 Define the role of EMT-B in the emergency cardiac care system. p. 402 Explain the impact of age and weight on defibrillation. p. 420 Discuss the position of comfort for patients with various cardiac emergencies. p. 411 Establish the relationship between airway management and the patient with cardiovascular compromise. p. 411 Predict the relationship between the patient experiencing cardiovascular compromise and basic life support. p. 410 Discuss the fundamentals of early defibrillation. p. 422 Explain the rationale for early defibrillation. p. 422 Explain that not all chest pain patients result in cardiac arrest and do not need to be attached to an automated external defibrillator. p. 421 4-3.19 4-3.15 4-3.16 4-3.17 4-3.13 4-3.14 Explain the importance of prehospital ACLS intervention if it is available. p. 430 Explain the importance of urgent transport to a facility with Advanced Cardiac Life Support if it is not available in the prehospital setting. p. 430 Discuss the various types of automated external defibrillators. p. 420 Differentiate between the fully automated and the semiautomated defibrillator. p. 421 Discuss the procedures that must be taken into consideration for standard operations of the various types of automated external defibrillators. p. 421 State the reasons for assuring that the patient is pulseless and apneic when using the automated external defibrillator. p. 421 Discuss the circumstances which may result in inappropriate shocks. p. 421

4-3.3 4-3.4 4-3.5 4-3.6 4-3.7 4-3.8

4-3.18

4-3.9

4-3.20 Explain the considerations for interruption of CPR when using the automated external defibrillator. p. 430 4-3.21 Discuss the advantages and disadvantages of automated external defibrillators. p. 421 4-3.22 Summarize the speed of operation of automated external defibrillation. p. 421 4-3.23 Discuss the use of remote defibrillation through adhesive pads. p. 421 4-3.24 Discuss the special considerations for rhythm monitoring. p. 421

4-3.10 4-3.11 4-3.12

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Objectives, cont.
Cognitive, cont.
4-3.25 List the steps in the operation of the automated external defibrillator. p. 426 4-3.26 Discuss the standard of care that should be used to provide care to a patient with persistent ventricular fibrillation and no available ACLS. p. 427 4-3.27 Discuss the standard of care that should be used to provide care to a patient with recurrent ventricular fibrillation and no available ACLS. p. 427 4-3.28 Differentiate between the single rescuer and multirescuer care with an automated external defibrillator. p. 426 4-3.29 Explain the reason for pulses not being checked between shocks with an automated external defibrillator. p. 423 4-3.30 Discuss the importance of coordinating ACLS trained providers with personnel using automated external defibrillators. p. 427 4-3.31 Discuss the importance of postresuscitation care. p. 427 4-3.35 Discuss the role of the American Heart Association (AHA) in the use of automated external defibrillation. p. 402 4-3.36 Explain the role medical direction plays in the use of automated external defibrillation. p. 424 4-3.37 State the reasons why a case review should be completed following the use of the automated external defibrillator. p. 424 4-3.38 Discuss the components that should be included in a case review. p. 424 4-3.39 Discuss the goal of quality improvement in automated external defibrillation. p. 424 4-3.40 Recognize the need for medical direction of protocols to assist in the emergency medical care of the patient with chest pain. p. 415 4-3.41 List the indications for the use of nitroglycerin. p. 415 4-3.45 Defend the reason for maintenance of automated external defibrillators. p. 423 4-3.46 Explain the rationale for administering nitroglycerin to a patient with chest pain or discomfort. p. 416

Psychomotor
4-3.47 Demonstrate the assessment and emergency medical care of a patient experiencing chest pain/discomfort. p. 413 4-3.48 Demonstrate the application and operation of the automated external defibrillator. p. 426 4-3.49 Demonstrate the maintenance of an automated external defibrillator. p. 423 4-3.50 Demonstrate the assessment and documentation of patient response to the automated external defibrillator. p. 426 4-3.51 Demonstrate the skills necessary to complete the Automated Defibrillator: Operators Shift Checklist. p. 425

4-3.42 State the contraindications and side effects for the use of nitroglycerin. p. 415 4-3.43 Define the function of all controls on an automated external defibrillator, and describe event documentation and battery defibrillator maintenance. p. 420

4-3.32 List the components of postresuscitation care. p. 427 4-3.33 Explain the importance of frequent practice with the automated external defibrillator. p. 424 4-3.34 Discuss the need to complete the Automated Defibrillator: Operators Shift Checklist. p. 425

4-3.52 Perform the steps in facilitating the use of nitroglycerin for chest pain or discomfort. p. 416 4-3.53 Demonstrate the assessment and documentation of patient response to nitroglycerin. p. 416 4-3.54 Practice completing a prehospital care report for patients with cardiac emergencies. p. 418

Affective
4-3.44 Defend the reasons for obtaining initial training in automated external defibrillation and the importance of continuing education. p. 424

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Recommendations
Support Materials
Dry erase board and markers or chalkboard and chalk PowerPoint projector and screen PowerPoint presentation BSI supplies (gloves, mask, goggles, gowns) (minimum of one set per student) Fully and semi-automated AEDs and related equipment for viewing and practice Patient assessment and oxygen administration equipment (stethoscopes, BP cuffs, pen lights, masks, nasal cannulas, oxygen tanks) Local and state statutes, regulations or policies related to automated defibrillation

Teaching Tips
Your knowledge of local protocols for the scope of practice and AED training of EMT-Bs is critical to this chapter. If you are teaching students who will be practicing in the same jurisdiction, obtain and follow local AED procedures, using locally approved equipment. Be advised, however, that many local jurisdictions do not allow EMT-Bs to apply and use AEDs until they have completed additional local training. Be sure your students understand the local requirements for AED authorization. This is a good opportunity to emphasize the importance of maintaining cardiovascular health as an important component of overall physical and mental health. Remember to maintain an appropriate student-to-instructor ratio during all skills sessions. Although there are only two skill drills associated with this chapter, be sure your students are exposed to all activities listed in the psychomotor objective section. Skill scenarios should become increasingly complex as your students gain experience and knowledge. Although it is often best to begin the presentation of an activity simply, be sure to expand the scenario to make a more realistic, beginning-to-end experience once students demonstrate proficiency.

Readings and Preparation

Review all instructional materials, including Emergency Care and Transportation of the Sick and Injured, 9th Edition, Chapter 12, and all related presentation support materials. Review local protocols for AED training and authorization, algorithms for use, and locally approved equipment.

Enhancements
Direct students to visit the Internet at www.emtb.com for online activities. Find out if there are any efforts at the local level to train and equip nontraditional caregivers to provide automated defibrillation. Share this information with your students and suggest involvement as a community outreach project. Contact the local chapter of the American Heart Association for lay and professional literature and other media. See the You Are the EMT video series for coverage of related topics.

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Presentation Overview
Total Time: 8 hours 15 minutes (with enhancements) = 7 hours (minimum presentation) Pre-Lecture I. You are the Provider Notes

Small Group Activity/Discussion

10 minutes

Lecture I. Cardiac Emergencies Notes

Lecture/Discussion

1 hour 45 minutes

II. Assessment of Chest Pain

Notes

Lecture/Discussion

1 hour 10 minutes

III. Heart Surgeries and Pacemakers

Notes

Lecture/Discussion

20 minutes

IV. Cardiac Arrest

Notes

Lecture/Discussion

1 hour

V. Emergency Care for Cardiac Arrest

Notes

Lecture/Discussion

I hour

VI. Skill Drills

A. Administration of Nitroglycerin (Skill Drill 12-1) B. AED and CPR (Skill Drill 12-2) Notes

Demonstration/Group Activity

1 hour 45 minutes

Post-Lecture I. Prep Kit Activities A. Assessment in Action B. Points to Ponder II. Lesson Review III. Assignments IV. Chapter 12 Instructor Keyed Quiz Notes

Small Group/Individual Activity/Discussion Small Group/Individual Activity/Discussion Discussion Lecture Individual Activity

20 minutes 20 minutes 10 minutes 5 minutes 10 minutes

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Lesson Plan
Pre-Lecture
I.You are the Provider
Time: 10 Minutes Small Group Activity/Discussion

Use this activity to motivate students to learn knowledge and skills needed to effectively treat cardiovascular emergencies. The You are the Provider case study is discussed within the PowerPoint presentation for this chapter. The instructor may opt to introduce it at this time before the lecture begins, or may opt to only discuss it within the context of the presentation.

Purpose
This activity will allow the student an opportunity to explore the significance and concerns associated with cardiovascular emergencies.

Instructor Directions
1. Direct students to read the You are the Provider scenario throughout Chapter 12. 2. You may wish to assign students to a partner or a group. Direct them to review the discussion questions at the end of the scenario and prepare a response to each question. Facilitate a class dialogue centered on the discussion questions. 3. You may also use this as an individual assignment and ask students to turn in their comments on a separate piece of paper.

Lesson Plan
Lecture
SLIDE TEXT LECTURE NOTES

Slides 1-15
Chapter Objectives

I. Cardiac
Slides: 1-31

Emergencies

Time: 1 Hour 45 Minutes Lecture/Discussion

Slide 16
Cardiovascular Emergencies Cardiovascular disease (CVD) claimed 931,108 lives in the US during 2001. 2,551 per day Almost two people per minute! CVD accounts for 38.5% of all deaths. One of every 2.6 deaths

A. Cardiovascular emergencies
1. Discuss the American Heart Association statistics listed below: a. Cardiovascular disease (CVD) claimed 931,108 lives in the United States during 2001. i. This equals 2,551 per day. ii. That is almost 2 people per minute! b. CVD accounts for 38.5% of all deaths. i. This is one of every 2.6 deaths.

Slide 17
Blood Flow Through the Heart Figure 12-2

B. Cardiovascular structure and function

1. Blood flow through the heart a. Trace the pathway of blood through the heart, beginning at the vena cava. b. Right side of heart pumps to lungs. c. Left side of heart pumps to body and is more muscular than the right.

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Slide 18
Electrical System of the Heart Figure 12-3

2. Electrical system of the heart a. Heart generates its own impulse at the sinus node. b. Movement of impulse causes first the atria and then the ventricles to contract. 3. Circulation a. b. c. d. Coronary arteries deliver oxygen to the heart. Right coronary artery supplies right side and inferior wall of the heart. Left coronary artery divides into two branches and supplies the left ventricle. Blood supplies to the body i. Aorta (a) Upper supplies both arms (b) Lower branches into the right and left iliac arteries. Later become the femoral arteries. ii. Vena cava (a) Returns blood from veins, organs back through the heart to the lungs for reoxygenation. e. Blood i. Consists of several types of cells and fluid (a) Red blood cells Most numerous and give the blood its color. Carry oxygen to the bodys tissues and remove carbon dioxide. (b) White blood cells Help fight infection (c) Platelets Help the blood to clot

Slide 19
Coronary Arteries Figure 12-4

Slide 20
Blood Flow Figure 12-5 Figure 12-6

Slide 21
Blood Figure 12-7

Slide 22
Cardiac Compromise Chest pain results from ischemia Ischemic heart disease involves decreased blood flow to the heart. If blood flow is not restored, the tissue dies.

C. Cardiac compromise
1. Chest pain related to the heart usually stems from ischemia, or lack of oxygen. 2. Ischemic heart disease involves a decrease in blood flow to one or more portions of the heart muscle. 3. If the blood flow is not restored, the tissue dies.

D. Atherosclerosis
1. Disorder in which calcium and cholesterol build up and form a plaque inside the walls of blood vessels. 2. Can cause complete occlusion or blockage of a coronary artery and other arteries of the body. 3. Fatty material accumulates as a person ages, resulting in narrowing of the lumen (inside diameter of the artery) The inner wall of the artery becomes rough and brittle. A brittle plaque will sometimes develop a crack for unknown reasons. The ragged edge of the crack activates the blood-clotting system. The resulting blood clot will partially or completely block the lumen of the artery. e. Tissues downstream from the blood clot will suffer from ischemia. f. If too much time goes by before blood flow is resumed, the tissues will die. g. This sequence of events is known as acute myocardial infarction (AMI), a classic heart attack. h. Infarction means the death of tissue. i. The death of heart muscle can severely diminish the hearts ability to pump, called cardiac arrest. 4. In the United States, coronary artery disease is the number one cause of death for both men and women. a. b. c. d.

Slide 23
Atherosclerosis Materials build up inside blood vessels. This decreases or obstructs blood flow. Risk factors place a person at risk.

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5. Risk factors are actions or conditions that place a person at higher risk for a myocardial infarction. a. Major controllable risk factors i. Cigarette smoking ii. High blood pressure iii. Elevated cholesterol levels iv. Elevated blood glucose levels (diabetes) v. Lack of exercise vi. Stress b. Major uncontrollable risk factors i. Older age ii. Family history iii. Male sex

Slide 24
Angina Pectoris Pain in chest that occurs when the heart does not receive enough oxygen Typically crushing or squeezing pain Rarely lasts longer than 15 minutes Can be difficult to differentiate from heart attack

E. Angina pectoris
1. Angina pectoris is the pain that occurs when the heart tissues do not get enough oxygen for a brief period of time. 2. It can result from a spasm of the artery, but is most often a symptom of atherosclerotic coronary artery disease. 3. It occurs when the hearts need for oxygen exceeds its supply, usually during physical or emotional stress. 4. Angina pain is typically described as crushing, squeezing, or like somebody is standing on my chest. a. Usually felt in the midchest area under the sternum b. Can radiate to the jaw, the arms (frequently the left arm), the midback, or the epigastrium c. Usually lasts from 3 to 8 minutes but rarely longer than 15 minutes d. May be associated with shortness of breath, nausea, or sweating e. Disappears promptly with rest, supplemental oxygen, or nitroglycerin, all of which increase the supply of oxygen to the heart 5. Although angina does not mean that heart cells are dying, it is a warning that should be taken seriously. 6. Because oxygen supply to the heart is diminished, the electrical system can be compromised and the patient may be at risk for cardiac rhythm problems (arrhythmias). 7. It can be very difficult even for doctors to distinguish between the pain of angina and the pain of heart attack. 8. Assume the worst-case scenario, but reassure the patient that you will be taking good care of him or her.

Slide 25
Heart Attack Acute myocardial infarction (AMI) Pain signals death of cells. Opening the coronary artery within the first hour can prevent damage. Immediate transport is essential.

F. Heart attack
1. The pain of a heart attack signals the actual death of cells in the area of the heart where blood flow is obstructed. a. Once dead, the cells cannot be revived. b. They will turn to scar tissue and become a burden to the beating heart. c. About 30 minutes after blood flow is cut off, some heart muscle cells begin to die. d. After about 2 hours, as many as half of the cells in the area may be dead.

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Slide 26
Signs and Symptoms Sudden onset of weakness, nausea, sweating without obvious cause Chest pain/discomfort Often crushing or squeezing Does not change with each breath Pain in lower jaw, arms, back, abdomen, or neck Sudden arrhythmia with syncope Shortness of breath or dyspnea Pulmonary edema Sudden death

e. After 4 to 6 hours, more than 90% of the cells will be dead. f. Opening the coronary artery with either clot-busting drugs or angioplasty can prevent damage if it is done within the first hour after the onset of symptoms. g. Immediate transport is essential. 2. Signs and symptoms of heart attack a. Sudden onset of weakness, nausea, and sweating without obvious cause b. Chest pain/discomfort that is often crushing or squeezing and does not change with each breath c. Pain in the lower jaw, arms, back, abdomen, or neck d. Sudden arrhythmia with syncope (fainting) e. Shortness of breath or dyspnea f. Pulmonary edema g. Sudden death 3. The pain of heart attack a. The pain of acute myocardial infarction deserves attention. b. It differs from the pain of angina in the following three ways: i. It may or may not be caused by exertion and it can occur at any time. ii. It does not resolve in a few minutes but can last between 30 minutes and several hours. iii. It may or may not be relieved by rest or nitroglycerin. c. Not all patients who are having an AMI experience pain or recognize it. d. About one third of patients never seek medical care. e. Complete a thorough assessment, no matter what the patient says. 4. Consequences of heart attack a. The consequences of acute myocardial infarction can be deadly. b. There are three serious consequences. i. Sudden death ii. Cardiogenic shock iii. Congestive heart failure c. Sudden death i. Approximately 40% of all patients with AMI never reach the hospital. ii. Sudden death usually results from cardiac arrest, a condition in which the heart fails to generate an effective blood flow. iii. The heart may still be twitching. iv. It is using up energy without pumping. v. This abnormality of heart rhythm is a ventricular arrhythmia, known as ventricular fibrillation. (a) Ventricular fibrillation: Disorganized, ineffective quivering of the ventricles. The only way to treat this arrhythmia is to electrically defibrillate (shock) the heart. Defibrillation is highly successful, if begun within a minute or two. (b) If uncorrected, unstable ventricular tachycardia or ventricular fibrillation will eventually lead to asystole, the absence of all heart electrical activity. vi. Other lethal and nonlethal arrhythmias may follow AMI. (a) Premature ventricular contractions (PVCs), or extra beats in the ventricle, are lethal if they occur in the damaged ventricle but harmless if they occur in the nondamaged ventricle. (b) Tachycardia is rapid beating of the heart, 100 beats/min or more. (c) Bradycardia is unusually slow beating of the heart, 60 beats/min or less. (d) Ventricular tachycardia (VT) is rapid heart rhythm, usually 150 to 200 beats/min.

Slide 27
Pain of Heart Attack May or may not be caused by exertion Does not resolve in a few minutes Can last from 30 minutes to several hours May not be relieved by rest or nitroglycerin

Slide 28
Sudden Death 40% of AMI patients do not reach the hospital. Heart may be twitching.

Slide 29
Arrhythmias Figure 12-11

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Slide 30
Cardiogenic Shock Heart lacks power to force blood through the circulatory system. Onset may be immediate or not apparent for 24 hours after AMI.

Slide 31
Congestive Heart Failure CHF occurs when ventricles are damaged. Heart tries to compensate. Increased heart rate Enlarged left ventricle Fluid backs up into lungs or body as heart fails to pump.

d. Cardiogenic shock i. The heart lacks enough power to force the proper volume of blood through the circulatory system. ii. Onset may be immediate or not apparent for 24 hours after AMI. e. Congestive heart failure (CHF) i. CHF occurs when the ventricular heart muscle is so damaged that it can no longer keep up with the return flow of blood from the atria. ii. It can occur any time after a myocardial infarction, heart valve damage, or long-standing high blood pressure. iii. When the muscle can no longer contract effectively, the heart tries other ways to maintain an adequate cardiac output. iv. Two changes in heart function occur. (a) Heart rate increases. (b) The left ventricle enlarges in an effort to increase the amount of blood pumped each minute. v. When these adaptations can no longer make up for the decreased heart functions, congestive heart failure develops. vi. It is called congestive because the lungs become congested with fluid as the heart fails to pump. vii. Blood backs up in the pulmonary veins, increasing the pressure in the lung capillaries. viii. Fluid (mostly water) passes through the walls of the capillary vessels and into the alveoli, a condition called pulmonary edema. ix. Pulmonary edema may occur suddenly, as in AMI, or slowly over months, as in chronic congestive heart failure. x. Sometimes pulmonary edema, in which the patient has pink, frothy sputum and severe dyspnea, is the first sign of AMI. xi. Dependent edema is collection of fluid in the part of the body closest to the ground. May indicate heart disease.

II. Assessment
Slides: 32-51 Lecture/Discussion DOT Ref 4-3-III-A DOT Ref 4-3-III-B DOT Ref 4-3-VI

of Chest Pain

Time: 1 Hour 10 Minutes

Table 12-1: OPQRST Mnemonic for Chest Pain

Slide 32
You are the Provider You are a volunteer EMT-B in a rural area. You are dispatched to an older man complaining of severe chest pain. ALS has been dispatched. You arrive to find the patient clutching his chest. The pain is the worst he has ever had. The patient has nitroglycerin but has not taken it yet.

A. You are the provider

1. Present the following case to the students. a. You are a volunteer fire fighter EMT-B who lives in a rural area. The dispatcher requests that you respond to an older man complaining of severe chest pain. ALS has been dispatched. b. You arrive to find the patient clutching his chest. He says the pain is the worst he has ever had. c. The patient has his own nitroglycerin but has not taken it yet. 2. What is wrong with this patient? a. This patient has angina pectoris and could be having a heart attack.

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Slide 33
You are the Provider (continued) What is wrong with this patient? What must you know before administering any medication? What must you specifically know before assisting a patient with nitroglycerin?

3. As an EMT-B, you can assist a patient with his or her own prescribed nitroglycerin. What must you know before administering any medication? a. You must have an order from medical direction, either online or offline. b. You must have the right medication, the right patient, and the right delivery route. Be sure to check the prescription label to ensure that the medication was prescribed for this patient. 4. What must you specifically know before assisting a patient with nitroglycerin? a. You must obtain the patients blood pressure before administering nitroglycerin. The blood pressure reading must be accurate. An inaccurate blood pressure reading could have detrimental effects on the patient or exacerbate his or her condition. Never estimate the reading.

Slide 34
Scene Size-up Scene size-up General impression Is the patient responsive?

B. Scene size-up
1. Scene safety remains a priority. You must attempt to protect your crew, the patient, and bystanders. 2. Based on the nature of the call and your general impression of the patient, ensure that needed resources are requested. 3. Consider spinal immobilization based on mechanism.

Slide 35
Initial Assessment Chief complaint on responsive patients A chief complaint of chest discomfort, shortness of breath, or dizziness must be taken seriously. Airway and breathing Circulation

C. Initial assessment
1. General impression a. Is the patient responsive? b. Evaluate ABCs. i. Determine if an AED is neededgenerally this should be applied if the patient is pulseless, not breathing, and unresponsive. c. Ascertain chief complaint in responsive patients. i. A chief complaint of chest discomfort, shortness of breath, or dizziness must be taken seriously. ii. Patient may sense impending doom. Speak to these patients in a calm manner. 2. Airway and breathing a. Check for adequate airway and treat appropriately. b. Check for adequacy of breathing i. If breathing is adequate, provide oxygen via nonrebreathing mask at 10 to 15 L /min. ii. If patient does not have adequate respirations, ensure ventilations with 100% oxygen. 3. Circulation a. Determine rate and quality. b. Is it regular or irregular? c. Is it too fast or too slow? d. Assess skin signs and note capillary refill time. 4. Transport decision a. Does the patient have life threats? b. If the patient is stable, transport cardiac patients in the most gentle, stressrelieving manner possible. i. Avoiding the use of lights and siren can help calm the patient. ii. Do not let patient exert or strain him or herself. c. Transport destinations are based on local protocol. Based on patient condition, some consideration should be made to transport the patient to specialty services.

Slide 36
Transport Decision Is the patient a life threat? Stable patients Transport in gentle manner. Avoid lights and siren. Do not let patient exert or strain self. Specialty facilities

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Slide 37
You are the Provider (continued) You obtain a brief history while taking the patients blood pressure. Your partner retrieves the nitroglycerin and obtains permission from medical control. Your partner administers the nitroglycerin. What else can you do at this time?

D. You are the provider (continued)

1. Continue reading the case study presented on the slide. a. You obtain a brief history while taking the patients blood pressure. b. Your partner retrieves the nitroglycerin and obtains permission from medical control. c. Your partner administers the nitroglycerin. d. What else can you do at this time? i. At this time you can also administer baby aspirin and prepare the patient for cardiac monitoring once ALS arrives.

E. Focused history and physical exam

1. SAMPLE history obtains basic information on the patients overall history. a. OPQRST helps you understand the specifics of the patients complaints. b. Medications may give you a clue to the patients past medical historyeven if the patient is unaware of that history. i. Medications that are often prescribed for CHF include furosemide, digoxin, and amiodarone. 2. Focused physical exam, paying close attention to the cardiovascular and respiratory system. a. Look for skin changes. b. Listen to lung sounds, checking for abnormal noises. 3. Baseline vital signs a. Measure and record BOTH systolic and diastolic blood pressure readings. 4. Communication a. Relay all pertinent information to the receiving facility, including patients history, vital signs along with changes, medications, treatments, and pertinent portions of the exam. 5. Interventions a. Aspirin i. Administer according to local protocol. ii. Prevents clots from becoming bigger. iii. Normal dosage is from 162 to 324 mg. b. Nitroglycerin i. Nitroglycerin works in most patients within 5 minutes. ii. Patients take one dose under the tongue if they have angina that does not go away with rest. iii. If the pain is still present after 5 minutes, patients are typically instructed by their doctors to take a second dose. iv. If second dose does not work, most patients are told to take a third dose and then call for EMS. v. If the patient has not taken all three doses, EMT-Bs can help to administer the medication, if allowed by local protocol. vi. Nitroglycerin comes in several forms. (a) Small white pill, placed sublingually (b) Spray, taken sublingually (c) Skin patch, applied to the chest

Slide 38
Focused History and Physical Exam SAMPLE OPQRST Medications are important! Medications often prescribed for CHF: Furosemide Digoxin Amiodarone

Slide 39
Focused Physical Exam Cardiac and respiratory systems Look for skin changes. Lung sounds Baseline vital signs BOTH systolic and diastolic BP readings

Slide 40
Communication Relay history, vital signs, changes, medications, and treatments.

Slide 41
Aspirin Administer according to local protocol. Prevents clots from becoming bigger Normal dosage is from 162 to 324 mg.

Slide 42
Nitroglycerin Forms Pill, spray, skin patch Effects Relaxes blood vessel walls Dilates coronary arteries Reduces workload of heart

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Slide 43
Nitroglycerin Contraindications Systolic blood pressure of less than 100 mm Hg Head injury Maximum dose taken in past hour

Slide 44
Nitroglycerin Potency Nitroglycerin loses potency over time. Especially if exposed to light When nitroglycerin tablets lose potency: May not feel the fizzing sensation May not experience the burning sensation and headache Fizzing only occurs with a potent tablet, not in the spray form.

Slide 45
Assisting With Nitroglycerin (1 of 4) Obtain order from medical direction. Take patients blood pressure.

Slide 46
Assisting With Nitroglycerin (2 of 4) Check that you have right medication, patient, and delivery route. Check expiration date. Find out last dose taken and effects. Be prepared to lay the patient down.

Slide 47
Assisting With Nitroglycerin (3 of 4) Administer tablet or spray under tongue. Have patient keep mouth closed until tablet dissolves or is absorbed.

vii. It has several effects on the circulatory system. (a) Relaxes the muscle of blood vessel walls (b) Dilates coronary arteries (c) Increases blood flow and the supply of oxygen to the heart muscle (d) Decreases the workload of the heart (e) Dilates blood vessels in other parts of the body (f) Sometimes causes low blood pressure and/or a severe headache (g) Can increase or decrease pulse rate viii. Take the patients blood pressure within 5 minutes after each dose. ix. If the systolic blood pressure is less than 100 mm Hg, do not give any more. x. Other contraindications (a) Head injury (b) Maximum prescribed dose (usually three doses) already given in the past hour xi. Nitroglycerin loses potency over time. (a) Occurs especially if exposed to light. (b) When nitroglycerin tablets lose potency, patients may not feel the fizzing sensation when the tablet is placed under their tongue, and may not experience the burning sensation and headache. (c) Fizzing only occurs with a potent tablet, not in the spray form. xii. Do not delay transport to assist with administration of nitroglycerin; give it en route. xiii. Steps in assisting a patient with nitroglycerin (a) Obtain an order from medical control or local protocol. (b) Measure blood pressure. Continue with administration if the systolic blood pressure is greater than 100 mm Hg. (c) Check that you have the right medication, right patient, and right delivery route. (d) Check the expiration date of the nitroglycerin. (e) Question the patient about the last dose taken and its effects. (f) Be prepared to have the patient lie down to prevent fainting. (g) Ask the patient to lift his or her tongue. Place the dose underneath the tongue (Be sure to wear gloves) or have the patient place the dose. (h) Have the patient keep the mouth closed with the tablet under the tongue until the tablet dissolves or is absorbed. (Caution the patient against chewing or swallowing the tablet.) (i) Recheck blood pressure within 5 minutes. (j) Record each medication and time of administration. (k) Reevaluate and note response to medication. (l) May repeat the dose in 3 to 5 minutes, as medical control allows.

Slide 48
Assisting With Nitroglycerin (4 of 4) Recheck blood pressure. Record each activity and time of application. Reevaluate and note response. May repeat dose in 3 to 5 minutes.

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Slide 49
Detailed Physical Exam Perform if time allows. Do not gather information unless: Patients condition is stable Everything else is done

F. Detailed physical exam

1. Perform if time allows. 2. Do not gather information unless patients condition is stable and everything else is done.

Slide 50
Ongoing Assessment Repeat initial assessment. Reassess vital signs every 5 minutes. Monitor closely. If cardiac arrest occurs, begin defibrillation or CPR immediately. Record interventions, instructions from medical control, patients response. Obtain medical control physicians signature.

G. Ongoing assessment
1. Repeat initial assessment to see if patients condition has improved or is deteriorating. 2. Reassess vital signs every 5 minutes or as significant changes occur. 3. Monitor closelysudden cardiac arrest is a risk. 4. If cardiac arrest occurs, begin defibrillation or CPR immediately. a. If AED is immediately available, use it. b. If not, perform CPR until AED arrives. 5. Record all interventions performed, instructions received from medical control, and patients response to all interventions. a. Obtain medical control physicians signature.

Slide 51
You are the Provider (continued) ALS arrives and you report your interventions and vital signs. ALS performs cardiac monitoring and prepares for morphine administration. The patients pain is gone by the time you reach the hospital.

H. You are the provider (continued)

1. ALS arrives and you report your interventions and vital signs. 2. ALS performs cardiac monitoring and prepares for morphine administration. 3. The patients pain is gone by the time you reach the hospital.

Slide 52
Heart Surgeries and Pacemakers Coronary artery bypass graft (CABG) Angioplasty Cardiac pacemaker

III. Heart

Surgeries and Pacemakers

Time: 20 Minutes Slides: 52-54 Lecture/Discussion

A. Over the last 20 years, hundreds of thousands of open-heart operations were performed to bypass damaged segments of coronary arteries in the heart. B. In the coronary artery bypass graft (CABG) operation, a blood vessel from the chest or leg is sewn directly from the aorta to a coronary artery beyond the point of the obstruction.

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C. Another procedure is percutaneous transluminal coronary angioplasty (PTCA) or balloon angioplasty.

1. A tiny balloon is attached to the end of a long tube. 2. The tube is threaded into the narrowed coronary artery and inflated. 3. The balloon is then deflated and the tube and balloon are removed.

D. Patients who have had one of these procedures may or may not have a long scar on the chest. E. Treat chest pain in a patient who has had any of these procedures in the same way you would treat chest pain in patients who have not had heart surgery. F. Some people have cardiac pacemakers.
1. Pacemakers help maintain a regular cardiac rhythm and rate. 2. They are inserted when the electrical system of the heart is so damaged that it cannot function properly. 3. These battery-powered devices deliver an electrical impulse through wires that are in direct contact with the myocardium. 4. The generator typically resembles a silver dollar and is usually placed under the skin in the left upper chest. 5. EMT-Bs normally do not need to be concerned about problems with pacemakers. 6. If a pacemaker does not function properly, the patient may experience syncope, dizziness, or weakness because of an excessively slow heart rate. 7. The pulse ordinarily will be less than 60 beats/min.

Slide 53
Automatic Implantable Cardiac Defibrillators (1 of 2) Maintains a regular heart rhythm and rate Do not place AED patches over pacemaker.

8. A patient with a malfunctioning pacemaker should be promptly transported to the emergency department. 9. When an AED is used, the patches should not be placed directly over the pacemaker.

G. Automatic implantable cardiac defibrillators

1. Some patients who survive ventricular fibrillation cardiac arrests have a small automatic implantable cardiac defibrillator (AICD) placed in their chest. 2. These devices continuously monitor the heart rhythm and deliver shocks as needed. 3. These patients should be treated like all other AMI patients. 4. The electricity from an AICD is so low that it will have no effect on rescuers. 5. Do not place AED patches over the pacemaker.

Slide 54
Automatic Implantable Cardiac Defibrillators (2 of 2) Monitor heart rhythm and deliver shock as needed. Low electricity will not affect rescuers.

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IV. Cardiac
Time: 1 Hour Slides: 55-62

Arrest

Lecture/Discussion

Slide 55
Cardiac Arrest The complete cessation of cardiac activity, either electrical, mechanical, or both.

DOT Ref 4-3-V-A, B, C, F, 1

A. Cardiac arrest
1. The complete cessation of cardiac activity, either electrical, mechanical, or both.

Slide 56
Automated External Defibrillator (AED) AEDs come in various models. Some operator interaction required. A specialized computer recognizes heart rhythms that require defibrillation.

B. Automated external defibrillation

1. The automated portable defibrillator can automatically administer an electrical shock to the heart when needed. 2. AEDs come in different models. a. All models require some operator interaction, such as applying the pads and turning on the machine. b. The operator has to push a button to deliver an electrical shock. c. Most use a computer voice synthesizer to advise the EMT-B what steps to take. d. The vast majority of the AEDs are semiautomated. e. The computer inside the AED recognizes rhythms that require defibrillation, most commonly ventricular fibrillation, and is extremely accurate. f. Shocks may be monophasic or biphasic. 3. Potential problems a. Check the AED daily and exercise the battery as often as the manufacturer recommends to avoid a dead battery. b. If the patient is moving, the computer may be unable to tell the difference between electrical signals from the heart and electrical signals from the arms and chest muscles. i. Apply the AED only to pulseless, unresponsive patients and stay clear of the patient during analysis and shock. c. Most computers identify a regular rhythm faster than 150 to 180 beats/min as ventricular tachycardia, which should be shocked. i. Sometimes, a patient has another heart rhythm that should not be shocked but that is fast enough to confuse the computer. 4. Advantages of AED use Quick delivery of an electrical shock No need for ALS providers to be on the scene Remote, adhesive defibrillator pads, which are safer than paddles Larger pad area than paddles, which means that the transmission of electricity is more efficient 5. Other considerations in using AEDs a. Not all patients in cardiac arrest require electrical shock. b. All patients in cardiac arrest should be analyzed with an AED; some do not have shockable rhythms. c. Asystole (flatline) indicates that no electrical activity remains. d. Pulseless electrical activity usually refers to a state of cardiac arrest despite an organized electrical complex. a. b. c. d.

Slide 57
Potential AED Problems Battery is dead. Patient is moving. Patient is responsive and has a rapid pulse.

Slide 58
AED Advantages ALS providers do not need to be on scene. Remote, adhesive defibrillator pads are used Efficient transmission of electricity

Slide 59
Non-shockable Rhythms Asystole Pulseless electrical activity

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Slide 60
Rationale for Early Defibrillation Early defibrillation is the third link in the chain of survival. A patient in ventricular fibrillation needs to be defibrillated within 2 minutes.

6. Rationale for early defibrillation a. Few patients who experience sudden cardiac arrest outside of a hospital survive unless a rapid sequence of events takes place. b. Links in the chain of survival include: i. Recognition of early warning signs and immediate activation of EMS ii. Immediate CPR iii. Early defibrillation iv. Early advanced care c. Rapid defibrillation has successfully resuscitated many patients in cardiac arrest from ventricular fibrillation. d. Defibrillation works best if it takes place within 2 minutes of the onset of the cardiac arrest. e. CPR prolongs time when defibrillation can be effective. f. Nontraditional rescuers are being trained to use AED. 7. Integrating the AED and CPR a. It is important to work the AED and CPR in sequence. b. Do not touch the patient while the AED is analyzing the heart rhythm and delivering shocks. c. CPR must stop while the AED is performing its job. d. CPR may be stopped for up to 90 seconds if three shocks are necessary. 8. AED maintenance a. Become familiar with the maintenance procedures required for the brand of AED used by your service. b. Read the operators manual. c. Make sure the battery is properly maintained. d. Check your equipment, including your AED, at the beginning of each shift. e. Ask the manufacturer for a checklist of items that should be checked daily, weekly, or less often. f. Report any AED failure that occurs while caring for a patient to the manufacturer and to the U.S. Food and Drug Administration (FDA). g. Be sure to follow local protocol for notifying these organizations. 9. Medical direction a. The medical director should either teach you how to use the AED or approve the written protocol for its use. b. The EMT-B team and your services medical director or quality improvement officer should review each incident in which the AED is used. c. Quality improvement involves both the individuals using AEDs and the responsible EMS system managers. d. Reviews should focus on speed of defibrillation. e. Shocks should be delivered within 1 minute. f. Mandatory continuing education with skill competency review is generally required for EMS providers every 3 to 6 months.

Slide 61
AED Maintenance Read operators manual. Check AED and battery at beginning of each shift. Get a checklist from the manufacturer. Report any failures to the manufacturer and the FDA.

Slide 62
Medical Direction Should approve protocols Should review AED usage Should review speed of defibrillation Should provide review of skills every 3 to 6 months

V. Emergency
Time: 1 Hour Slides: 63-75 Lecture/Discussion DOT Ref 4-3-V-D, E

Care for Cardiac Arrest

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Slide 63
Preparation Make sure the electricity injures no one. Do not defibrillate a patient lying in pooled water. Dry a soaking wet patients chest first. Do not defibrillate a patient who is touching metal. Remove nitroglycerin patches. Shave a hairy patients chest if needed.

A. Preparation
1. Make sure that the electricity from the AED injures no one. 2. Do not defibrillate a patient in pooled water; electricity will diffuse through the pooled water. a. You can defibrillate a wet patient, but dry the patients chest. 3. Do not defibrillate a patient who is touching metal. 4. Carefully remove a nitroglycerin patch from a patients chest and wipe the area with a dry towel before defibrillation to prevent igniting the patch. 5. You may need to shave a hairy patients chest in order for the pads to remain in place.

B. Performing defibrillation
1. Assess responsiveness. 2. Stop CPR if in progress. 3. Check breathing and pulse. 4. If the patient is unresponsive and not breathing adequately, give two slow ventilations.

Slide 64
Using an AED (1 of 8) Assess responsiveness. Stop CPR if in progress. Check breathing and pulse. If patient is unresponsive and not breathing adequately, give two slow ventilations.

Slide 65
Using an AED (2 of 8) If there is a delay in obtaining an AED, have your partner start or resume CPR. If an AED is close at hand, prepare the AED pads. Turn on the machine.

5. If there is a delay in obtaining an AED, have your partner start or resume CPR. 6. If an AED is close at hand, prepare the AED pads. 7. Turn on the machine.

Slide 66
Using an AED (3 of 8) Remove clothing from the patients chest area. Apply pads to the chest. Stop CPR. State aloud, Clear the patient.

8. Remove clothing from the patients chest area. Apply pads to the chest. a. One pad is placed to the right of the breastbone, just below the collarbone. b. One pad is placed on the left chest with the top of the pad 2'' to 3'' below the armpit. 9. Stop CPR. 10. State aloud, Clear the patient. a. Ensure that no one is touching the patient. 11. Push the analyze button, if there is one. 12. Wait for the computer in the AED to determine whether a shockable rhythm is present. 13. At this point, do one of the following: a. If a shock is not needed, go to step 18 (CPR only). b. If a shock is advised, make sure that no one is touching the patient. When the patient and area are clear, push the shock button.

Slide 67
Using an AED (4 of 8) Push the analyze button, if there is one. Wait for the computer. If shock is not needed, start CPR. If shock is advised, make sure that no one is touching the patient. Push the shock button.

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Slide 68
Using an AED (5 of 8) After the shock is delivered, most AEDs will automatically reanalyze the rhythm; if not, push the analyze button again. If the machine advises a shock, deliver a second shock. Reanalyze the rhythm. If the machine advises a shock, deliver a third shock.

14. After the shock is delivered, most AEDs will automatically reanalyze the rhythm; if not, push the analyze button again. 15. If the machine advises a shock, deliver a second shock. 16. Reanalyze the rhythm. 17. If the machine advises a shock, deliver a third shock.

18. Check for a pulse. 19. If the patient has a pulse, check the patients breathing. 20. At this point, do one of the following: a. If the patient is breathing adequately, provide oxygen via nonrebreathing mask and transport. b. If the patient is not breathing adequately: i. Use necessary airway adjuncts and proper positioning of the head and jaw to ensure an open airway. ii. Provide artificial ventilations with high-concentration oxygen. iii. Transport. 21. If the patient has no pulse, perform 1 minute of CPR. 22. Gather additional information on the arrest event. 23. After 1 minute of CPR, make sure no one is touching the patient. Push the analyze button again (as applicable). 24. If necessary, repeat one cycle of up to three stacked shocks. 25. Transport and check with medical control. 26. Continue to support the patient as needed: a. Ventilate until the patient begins to breathe normally. b. Continue CPR if needed.

Slide 69
Using an AED (6 of 8) Check for pulse. If the patient has a pulse, check breathing. If the patient is breathing adequately, provide oxygen via nonrebreathing mask and transport.

Slide 70
Using an AED (7 of 8) If the patient is not breathing adequately, use necessary airway adjuncts and proper positioning to open airway. Provide artificial ventilations with high-concentration oxygen. Transport.

Slide 71
Using an AED (8 of 8) If the patient has no pulse, perform 1 minute of CPR. Gather additional information on the arrest event. After 1 minute of CPR, make sure no one is touching the patient. Push the analyze button again (as applicable). If necessary, repeat one cycle of up to three stacked shocks. Transport and check with medical control. Continue to support the patient as needed.

C. If you are the only rescuer on scene and you have an AED, take the following steps.
1. Perform an initial assessment. a. Assess responsiveness. b. If the patient is responsive, do not apply the AED. 2. Verify that the patient has no pulse and is not breathing (or is breathing with inadequate gasping breaths). 3. If the patient is not breathing or is gasping, give two slow breaths using a BVM device or pocket mask. 4. Expose the patients chest. a. Apply one pad just to the right of the breastbone, just below the collarbone. b. Apply the other pad on the left side of the chest with the top of the pad 2'' to 3'' below the armpit. 5. Turn on the AED. 6. Push the analyze button, if there is one. 7. Deliver up to three shocks, if indicated. 8. Follow your local protocol. If the AED indicates no need for shocks, provide CPR. a. If another person is available who knows CPR, ask for help. He or she can continue CPR while you get the AED and apply it to the patient.

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Slide 72
After AED Shocks Check pulse. No pulse, no shock advised No pulse, shock advised If a patient is breathing independently: Administer oxygen. Check pulse. If a patient has a pulse but breathing is inadequate, assist ventilations.

D. After AED shocks

1. The care of the patient after the AED delivers its shock depends on your local protocols. 2. After the AED protocol is completed, one of the following situations will occur: a. The patient will regain a pulse. b. The patient will have no pulse, and the AED will indicate that no shock is advised. c. The patient will have no pulse, and the AED will indicate that a shock is advised.

Slide 73
Transport Considerations Transport: When patient regains pulse After delivering six to nine shocks After receiving three consecutive no shock advised messages Keep AED attached. Check pulse frequently. Stop ambulance to use an AED.

3. If ALS is not responding to the scene and protocols agree, begin transport when one of the following occurs: a. Patient regains pulse b. Six to nine shocks are delivered c. The machine gives three consecutive messages (separated by 1 minute of CPR) that no shock is advised. 4. Transport considerations a. AEDs cannot analyze rhythm while the vehicle is in motion. b. Do not defibrillate in a moving ambulance. c. Come to a complete stop if more shocks are ordered. 5. Memorize your local protocol for AED use.

Slide 74
Cardiac Arrest During Transport (1 of 2) Check unconscious patients pulse every 30 seconds. If pulse is not present: Stop the vehicle. Perform CPR until AED is available. Analyze rhythm. Deliver shock(s). Continue resuscitation according to local protocol.

E. Cardiac arrest during transport

1. Check the pulse of an unconscious patient at least every 30 seconds while en route. 2. If a pulse is not present, take the following steps or those indicated by local protocol: a. b. c. d. e. Stop the vehicle. If the AED is not immediately ready, perform CPR until it is ready. Analyze rhythm. Deliver a shock, if indicated. Continue resuscitation according to local protocol.

Slide 75
Cardiac Arrest During Transport (2 of 2) If patient becomes unconscious during transport: Check pulse. Stop the vehicle. Perform CPR until AED is availalbe. Analyze rhythm. Deliver up to three shocks. Continue resuscitation according to local protocol.

3. If a conscious patient who is having chest pain becomes unconscious en route, take the following steps: a. b. c. d. e. f. g. Check for a pulse. Stop the vehicle. If the AED is not immediately ready, perform CPR until it is ready. Analyze the rhythm. Deliver up to three shocks, if indicated. Continue resuscitation according to local protocol. If a no shock message is given and no pulse is present, start CPR, then transport.

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F. Always coordinate with ALS according to local protocols.

1. If you have an AED available, do not wait for paramedics to arrive. 2. Notify ALS personnel as soon as you have recognized cardiac arrest. 3. Do not delay defibrillation.

VI. Skill

Drills

Time: 1 Hour 45 Minutes Demonstration/Group Activity

Remember to maintain an adequate instructor-to-student ratio. A ratio of one instructor to six students is recommended by the DOT EMT-B National Standard Curriculum. Also remember that each student is to be evaluated on each skill before completing the course.

Purpose
To allow students an opportunity to observe, practice, and perform patient care skills associated with cardiovascular emergencies.

Materials Needed
1. BSI supplies (gloves, mask, goggles, gowns) (minimum one set per student) 2. AEDs approved for use in local area 3. Patient assessment and oxygen administration supplies 4. Local and state statutes, regulations, or policies related to automated defibrillation.

Instructor Directions
1. Demonstrate each skill, emphasizing any critical points or procedures. 2. Based on the specific skill, assign each student to a partner or team. Provide each partner/team with necessary equipment or materials. 3. Direct students to practice each skill using team members as patients and observers. Closely monitor the practice sessions and provide constructive comments and redirection. 4. As individual students achieve success, conduct skill proficiency exams. Students who fail the exam should be given redirection and the opportunity to practice before being retested.

Skills
A. Administration of Nitroglycerin (Skill Drill 12-1) B. AED and CPR (Skill Drill 12-2)

Emergency Care and Transportation of the Sick and Injured, Ninth Edition

AAOS

Candidate: _____________________________________________________________ Date: __________________________ ID#: _____________________________________________________________________________________________________

Skill Drill 12-1 Administration of Nitroglycerin

Task: Administer nitroglycerin. Performance Observations: The candidate shall be able to correctly administer nitroglycerin. Candidate Directive: Properly administer nitroglycerin. No. Task Steps First Test P 1. Obtain an order from medical direction either online or offline protocol. Take the patients blood pressure. Administer nitroglycerin only if the systolic blood pressure is greater than 100 mm Hg. Check the medication and expiration date. Question the patient about the last dose he or she took and its effects. Make sure that the patient understands the route of administration. Prepare to have the patient lie down to prevent fainting. Ask the patient to lift his or her tongue. Place the tablet or spray the dose underneath the tongue (while wearing gloves), or have the patient do so. Have the patient keep his or her mouth closed with the tablet under the tongue until it is dissolved and absorbed. Caution the patient against chewing or swallowing the tablet. Recheck blood pressure within 5 minutes. Record each medication and the time of administration. Reevaluate the chest pain and repeat treatment if necessary. Retest Evaluation: F Retest P F

2.

3.

4.

Retest Approved By:

Evaluator Comments: _____________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Evaluator Date Retest Evaluator Date

Candidate Comments: _____________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ Candidate Date Retest Candidate Date

Emergency Care and Transportation of the Sick and Injured, Ninth Edition

AAOS

Candidate: _____________________________________________________________ Date: __________________________ ID#: _____________________________________________________________________________________________________

Skill Drill 12-2 AED and CPR

Task: Perform AED and CPR. Performance Observations: The candidate shall be able to correctly perform AED and CPR. Candidate Directive: Properly perform administration of AED and CPR. No. Task Steps First Test P 1. 2. 3. 4. Stop CPR if in progress. Assess responsiveness. Check breathing and pulse. If unresponsive and not breathing adequately, give two slow ventilations. If pulseless, begin CPR. Prepare the AED pads. Turn on the AED; begin narrative if needed. Apply AED pads. Stop CPR. Verbally and visually clear the patient. Push the analyze button if there is one. Wait for the AED to analyze the rhythm. If no shock advised, perform CPR for 1 minute. If shock advised, recheck that all are clear, and push the Shock button. Push the analyze button, if needed, to analyze the rhythm again. Press shock if advised (second shock). Push the analyze button, if needed, to analyze the rhythm again. Press shock if advised (third shock). Check pulse. If pulse is present, check breathing. Gather additional information on the arrest event. If breathing adequately, give oxygen and transport. If not, open airway, ventilate, and transport. If no pulse, perform CPR for 1 minute. Clear the patient, and analyze again. If necessary, repeat one cycle of up to three shocks. Transport and call medical control. Continue to support breathing or perform CPR, as needed. Retest Evaluation: F Retest P F

5. 6.

Retest Approved By:

Evaluator Comments: _____________________________ _________________________________________________ _________________________________________________ _________________________________________________ Evaluator Date _________________________________________________ Retest Evaluator Date

Candidate Comments: _____________________________ __________________________________________________ __________________________________________________ __________________________________________________ Candidate Date __________________________________________________ Retest Candidate Date

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Lesson Plan
Post-Lecture
I. Prep Kit Activities
Time: 40 Minutes Small Group/Individual Activity/Discussion Note: The Prep Kit contains various student-centered end-of-chapter activities designed as enhancement to the instructors presentation. As time permits, these activities may be presented in class. They are also designed to be used as outside/homework activities.

A. Assessment in Action
This activity is designed to assist the student in gaining a further understanding of issues surrounding cardiovascular emergencies. The activity incorporates both critical thinking and application of basic EMT-B knowledge.

Purpose
This activity allows the student an opportunity to analyze an emergency care scenario and develop responses to critical thinking questions.

Instructor Directions
1. Direct students to read the Assessment in Action scenario located in the Prep Kit at the end of Chapter 12. 2. For the quiz questions, direct students to read and individually answer the quiz questions at the end of the scenario. Allow approximately 10 minutes for this part of the activity. Facilitate a class review and dialogue of the answers, allowing students to correct responses as needed. Use the quiz question answers noted below to assist in building this review. Allow approximately 10 minutes for this part of the activity. 3. You may also use these as individual assignments and ask students to turn in their comments on a separate piece of paper.

Answers to Multiple-Choice Questions

1. Answer: A acute myocardial infarction (AMI). The signs and symptoms, past medical history, medications, and events leading to the illness all meet the indications of an AMI. 2. Answer: A angina pectoris. Chest pain for angina pectoris usually does not last for more than 15 minutes. Chest pain for AMI lasts longer then 15 minutes and is not always relieved by nitroglycerin. 3. Answer: B nitroglycerin. In specific situations the EMT-B may assist patients in taking their nitroglycerin. The medication must be prescribed to the patient and must have a current date (cannot be expired). The patient must have a stable blood pressure and it must be approved by medical control online or off line. 4. Answer: D a blockage or occlusion of the coronary artery. The definition of atherosclerosis is a build up of fat in the lumen of the arteries and veins. This build up of fat causes a narrowing that will collect a clot (fibrin), causing a total blockage of blood flow in that artery. 5. Answer: D cardiac arrest. A blocked coronary artery will cause death of the cardiac muscle. If this is not corrected in a reasonable time, the heart will stop. This is called cardiac arrest. 6. Answer: C loss of perfusion (shock). Loss of perfusion or decreased perfusion is the definition of shock. As the body goes into shock the sympathetic nervous system kicks in, causing the peripheral arteries to constrict. This decrease in blood causes the body to look very pale and the skin to be cool to the touch.

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7. Answer: B congestive heart failure (CHF). AMIs can lead to sudden death, cardiogenic shock, and long-term decreased pump ability called congestive heart failure. 8. Answer: A cardiac arrhythmia. Any abnormal heartbeat is defined as a cardiac arrhythmia. 9. AMI pain is not caused by exertion and it does not resolve in a few minutes. Pain of AMI is not relieved after administering nitroglycerin. 10. Blood flows from the right atrium to the right ventricle to the lungs through the pulmonary artery, back from the lungs through the pulmonary vein to the left atrium, to the left ventricle, and out through the aorta to the body. It then moves from the aorta to arteries to arterioles to capillaries, which is where the exchange of oxygen takes place. The blood then continues to venules to veins to the inferior and superior vena cava, and back to the right atrium. 11. Congestive heart failure is a chronic disease of the heart muscle. As the muscle gets older and damaged from lack of oxygen the muscle loses strength. As the heart muscle pump is weakened, blood backs up. In right-sided CHF blood backs up from the right atrium to the body. This causes peripheral edema to the legs (ankles) and sometimes the arms. With left-sided failure the blood backs up into the lungs, causing pulmonary edema. The treatment for minor CHF includes making the patient comfortable and providing oxygen by nasal cannula. More severe CHF will require more attention. High-flow oxygen by a nonrebreathing mask, supporting ventilations with a BVM, and rapid transport will be required. 12. The AED is for treatment of cardiac arrest from ventricular fibrillation. The AED should be turned on and the pads placed on the patients chest. Stop CPR and make sure you are not touching the patient. Push the analyze button, follow the voice directions, and push the shock button if indicated.

B. Points to Ponder
This activity will allow you to help your students probe the more difficult situations that they face. Use this as an opportunity to allow them to express differences of opinion and approach, while directing them to be thorough and decisive in their answers. Encourage challenges.

Purpose
To allow students an opportunity to apply critical thinking analysis to a given case study.

Instructor Directions
1. Direct students to read the Points to Ponder scenario found in the Prep Kit at the end of Chapter 12. 2. You may wish to assign students to a partner or a group and direct them to review the discussion question at the end of the scenario and prepare a response. Allow approximately 10 minutes for this part of the activity. Facilitate a class dialogue centered on the discussion point. Allow approximately 10 minutes for this part of the activity. 3. You may also assign this as an individual assignment and ask students to turn in their comments on a separate piece of paper. 4. Personally review the scenario and discussion question based on your experience and knowledge as an emergency care worker. Develop your own key points for guiding this discussion.

Scenario
You have been dispatched to a report of a patient having chest pain. Upon arrival you find the patient sitting in a chair. She is pale and slightly short of breath. You complete your SAMPLE history and find the patient has a history of hypertension and CHF and had a heart attack 5 years ago. She takes nitroglycerin and hydrochlorothiazide for her blood pressure. The onset of symptoms has been over the last week. The patient has taken her nitroglycerin as prescribed and her chest pain is relieved. You complete a detailed physical exam and find crackles in her lungs. Her ankles are very swollen. You recommend transport to the hospital for treatment. The patient refuses and wants to stay at home. What should you say to this patient? If she refuses treatment, how should you document this?

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Issues
Convincing Patients of the Need for Treatment Right of Refusal Advocating for the Patient Assistance from Medical Control

Discussion
This patient is in CHF (heart failure). If not treated, the patient will soon experience sudden cardiac arrest and possible death. You need to explain this to her and ensure that she understands the consequences of refusing treatment. Talk with her in a calm, respectful manner to convey that you have her best interests in mind. You may need the assistance of medical control to help convince her.

II. Lesson Review

Time: 10 Minutes Discussion Note: Facilitate a review of this lessons major topics using the review questions as direct or overhead questions. Answers are found throughout this lesson plan with IRK references listed for each question. A. Describe the atherosclerotic process and the role that blood clotting mechanisms play in coronary artery occlusion. (Lecture I-C) B. Define angina, its causes, signs and symptoms, and treatment. (Lecture I-D) C. Discuss the time frames in which tissue death occurs in AMI and the time frames in which treatment must occur to prevent damage. (Lecture I-E-1) D. Describe the pain of AMI and how it differs from angina. (Lecture I-E-3) E. Describe the signs and symptoms and physical findings of AMI. (Lecture I-E-2) F. Discuss the three serious consequences of AMI. (Lecture I-E-4) G. What are the steps in approaching a patient with chest pain? (Lecture II-C) H. What are the concerns for EMT-Bs in treating patients with pacemakers or implanted cardiac defibrillators? (Lecture III-F/G) I. What does an automated external defibrillator do? (Lecture IV-B-2) J. What are the potential problems with AED usage? (Lecture IV-B-3) K. Why is early defibrillation important? (Lecture IV-B-6) L. List the general steps in performing automated defibrillation. (Lecture V-B) M. When do you transport a patient who has been defibrillated? (Lecture V-D-4) N. What do you do if a patient with chest pain has a cardiac arrest while en route to the hospital? (Lecture V-E) O. What are the safety and maintenance considerations for AED operators? (Lecture IV-B-8, V-A)

III. Assignments
Time: 5 Minutes Lecture A. Review all materials from this lesson and be prepared for a lesson quiz to be administered (date to be determined by instructor). B. Read Chapter 13: Neurologic Emergencies for the next class session.

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IV. Instructor Keyed Quiz

Time: 10 Minutes Individual Activity 1. Which side of the heart receives oxygenated blood from the lungs? Answer: left p. 402 p. 404 p. 404 2. What is the function of the red blood cell? Answer: carries oxygen in the blood 3. What causes chest pain? Answer: insufficient blood flow through the coronary arteries Answer: atherosclerosis p. 405 p. 408 4. In what condition does plaque build up in the walls of blood vessels? 5. What controllable risk factors place a person at high risk for myocardial infarction? Answer: cigarette smoking, high blood pressure, elevated cholesterol, diabetes, lack of exercise, and stress 6. Typically, how long does the pain from angina last? Answer: 3 to 8 minutes Answer: left Answer: 40% p. 408 p. 409 p. 410 p. 421 p. 408 7. In which ventricle is AMI more prone to occur? 8. What percentage of AMI patients do not reach the hospital due to sudden death? 9. What is the cause of cardiogenic shock? Answer: the heart is unable to pump blood with enough force. 10. What are reasons for error with an AED? Answer: dead battery, applied to a patient with a pulse, applied to a moving patient 11. How long may CPR be stopped to deliver shocks? Answer: 90 seconds p. 423

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Student Quiz
Name: Date: 1. Which side of the heart receives oxygentated blood from the lungs?

2. What is the function of the red blood cell?

3. What causes chest pain?

4. In what condition does plaque build up in the walls of blood vessels?

5. What controllable risk factors place a person at high risk for myocardial infarction?

6. Typically, how long does the pain from angina last?

7. In which ventricle is AMI more prone to occur?

8. What percentage of AMI patients do not reach the hospital due to sudden death?

9. What is the cause of cardiogenic shock?

10. What are reasons for error with an AED?

11. How long may CPR be stopped to deliver shocks?