Cardiac Emergencies - Angina Pectoris Review

1 Angina Pectoris Review. • Occurs when the hearts blood supply is exceeded by the oxygen demands. • Typically occurs during exertion (Stable Angina) however can occur at rest (Unstable Angina) • Prinzmental’s Angina – spasm of the coronary arteries lead to inadequate blood flow to the myocardium • Stable Angina - Usually responds well to treatment • Unstable Angina – typically does not respond well to treatment and usually indicates that the atherosclerotic disease is progressing. • Angina is usually progressive in nature and although the pain may resolve, episodes will generally increase in frequency and intensity Assessment of Angina. • Patient most often C/O chest discomfort or pain (Some will state that it feels like their typical angina) ( Pressure, Heaviness, non-reproducible ) OPQRST HX • Can Radiate or remain midsternal • Sometime epigastric pain can accompany the chest pain • Often episodes last 3-5 minutes but can exceed this amount of time • Patients with a history may self administer nitro and often have relief with rest (Stable) • Assess for JVD ( Place patient at 45 degree angle) • Assess legs and ankles for peripheral edema (Note pitting edema) • May have laboured breathing (Full auscultation required) • Pale, cool, diaphoretic skin • Possibly have elevated blood pressure during the episode (due to pain) returns to normal after the event • Obtain an in-depth history both SAMPLE and pain • Obtain full set of vitals including ECG and 12 lead ( ST Depression is most common) Symptoms of Angina May Include: • Pain or discomfort in the chest or surrounding areas (arm, shoulder, back, neck, or jaw) • SOB • Tiredness/Fatigue • Nausea • Sweating • Weakness Questions used to determine if pain is Cardiac: • OPQRST • Ask the patient if the pain changes with positioning, palpation, deep inspiration, exertion • Ask the patient to describe the pain, DO NOT give examples if possible, as the patient likely will just pick a word you have given • Ask if the pain travels anywhere, or if they can feel it somewhere else • Ask the patient to rate there pain on a scale from 1-10, 1 being very little pain and 10 being the most pain they have ever felt. 2 • Ask the patient about the time frame, did the pain develop suddenly or gradually, ask about what they were doing when it started. How long has the pain lasted? Possible Meds that may indicate Cardiac Hx. • Antiarrhythmics ( Propranolol, Verapamil, Amiodarone) • Anticoagulants (Warfarin, Heparin) • Beta-blockers (Metoprolol, Atenolol, Bisoprolol) **** “lol” drugs • Calcium channel blockers (Amlodipine, Nifedipine, Diltiazem) • Digitalis (Lanoxin) • Diuretics (Hydrochlorothiazide, Furosemide, spironolactone) • Nitrates (Nitroglycerin spray, tablets, Isosorbide) • Platelet aggregate inhibitors (Plavix, Aggrenox, ASA) • Its also helpful to be aware of what medications look like, in case patients are unable to provide the bottles Tx. Of Angina. • Place patient at rest to minimize physical exertion ( Do Not walk Patient) • Administer O2 as per BLS Standards • Obtain vitals and ECG • Manage as Cardiac Ischemia and treat delivering ASA and Nitroglycerin if no contraindications are found. As Per ALS PCS. • Monitor the patient for deterioration and discontinue treatment if the patients vitals fall outside of protocol at any time • Rapid Transport • If Patient is refusing transport due to resolved chest pain strongly encourage they be assessed in hospital M.I Review. • A portion of the myocardium has sustained a prolonged period of oxygen deprivation this causes necrosis and death of the cells • Most often associated with Atherosclerotic heart disease, in where the diseased artery develops a thrombus • Arrhythmias are the most common complication • Congestive heart failure can be seen as well due to the decreased ability of the heart to pump effectively Assessment of M.I. • Assessment and treatment of a Myocardial Infarction is the same as the assessment and treatment of Angina since we are unable to determine exactly what is happening, these are both treated as Ischemic Chest Pain • Unlike Angina, someone experiencing and MI will have symptoms that last longer then Angina, and have very little relief with rest or nitro administration • Pain usually develops acutely and is commonly described as 10/10, constant and crushing • Often C/O sudden nausea and vomiting • Pale, Cool, Diaphoretic skin 3 • Possible “Feeling of impending Doom” Other possible S/S’s • Syncope • Weakness/ fatigue • Restlessness or anxiety • Palpitations • Lethargy • Behaviour changes • Epigastric pain ( common in women) • Nausea • Elderly patients, women, or diabetic patients may present with atypical signs and symptoms. Possibly experiencing a MI with the absence of chest pain. (Silent MI) Tx. Of M.I. Minimize all physical and emotional exertion Apply O2 as per BLS Standards Obtain vitals, ECG and 12 Lead Administer ASA and Nitroglycerin if no contraindications are found as Per ALS PCS Monitor the Patient for deterioration ( Life Threatening arrhythmias) Rapid Transport – Bypass if criteria met Avoid all refusals if at all possible. Review of CHF. • Damage to the heart has compromised its ability to provide adequate output for the bodies needs • Causes a fluid overload into the body • Can develop acutely CHF Assessment: • C/O dyspnea – possibly coughing up large amounts of pink-tingled sputum -Cyanosis • Crackles or “Wet sound” on auscultation or can be audible -Unable to speak in full sentences – typically 2-3 words dyspnea • Pale, Cool, diaphoretic skin possibly mottling • ++ Edema to extremities • JVD • Ascites Treatment of CHF: • Do not make the patient exert themselves in anyway • Provide O2 as per BLS Standards • Treat Patient under the Acute Cardiogenic Pulmonary Edema Protocol if appropriate (Providing Nitroglycerin) as PER ALS PCS • Provide CPAP if appropriate as Per the ALS PCS provided there are no contraindications. • Monitor patient continuously for deterioration 4 • Rapid Transport Cardiogenic Shock • Occurs when the ventricular function is severely compromised and the heart can no longer adequate pump to meet the body's needs • Often seen after an MI • The body tries to compensate, but is unable to maintain the demands and begins to fail. Assessment of Cardiogenic Shock: • Chief complaint could be anything from chest pain to unconsciousness • An MI often precedes cardiogenic shock so therefore the symptoms may initially be the same • After the patient begins to decompensate, they will become hypotensive, and arrhythmias are likely. • Skin is pale, cool and diaphoretic • Patient is tachypneic Tx. Of Cardiogenic Shock: • Treat the underlying causes ie MI or CHF • Provide O2 as per BLS PCS • Rapid Transport Cardiac Arrest. • Absence of ventricular contraction • Causes an immediate failure of the circulatory system • Typically caused by an arrhythmia Assessment of Cardiac Arrest: • Patient is unresponsive • Apneic • Pulseless • Obtain HX including is the arrest witnessed, if not how long since the patient was last seen, was CPR initiated ( obtaining an approximate total downtime) • Obtain SAMPLE Hx if possible Tx. Of C.A: • Confirm the patient is VSA and begin CPR as per current standards. ( if not obviously dead or have valid DNR) • Ensure patent airway using authorized airways initially. Then after ( King LT, LMA, etc) if there is a need for ventilatory • assistance and other management is ineffective. Be ready to suction if emesis is present • Attach the Defibrillator • Run protocol for Medical Cardiac arrest as per ALS PCS 5 • Patch to BHP for Medical Termination of Resuscitation after the 3rd analysis. (Follow deceased patient standard if TOR implemented) • If the patch fails, or TOR doesn’t apply transport to the closest facility following ROSC or 4th analysis CONSIDER RAPID TRANSPORT AFTER 1ST ANALYSIS FOR PT.’S THAT ARE… • > 20 weeks pregnant • Hypothermic • Airway obstruction • Suspected pulmonary embolism • Overdose • Or other reversible causes • Pediatric ROSC • Continue ventilation if the patient continues to be apneic or respirations are inadequate (Optimize ventilation and oxygenation) • Monitor patient for re-arrest • Obtain vitals every 15min for the first hour and then every 30 min thereafter as per BLS PCS • If patient re-arrests, preform one analysis and then resume transport • Titrate oxygen administration to 94-98% • Avoid hyperventilation keeping ETCO2 to 30-40mmhg with good wave form ( if available) • Consider obtaining a 12 lead and interpretation Deceased Patient Standard (Any Death) • Confirm that the Patient is dead and treat with respect and dignity • Tend to the needs of the family members, compassionately inform the family that the patient is dead • Follow all directions given by the coroner • If the death/TOR happens in the ambulance on route, advise CACC to contact the coroner and continue to destination unless other wise directed. • If a TOR is implemented while in the ambulance, but before leaving the scene, you will remain on scene until the coroner arrives and gives further instruction. • If the patient is obviously dead, inform CACC and document the time which the dead was confirmed. Deceased Patient Standard (Unexpected Death) • If a TOR has been granted, CACC will be notified and they will notify the Police to attend the scene. The police will then contact the coroner. • If the coroner will be attending the scene, you will stay on scene until they arrive, if they will not be attending you will remain on scene until the appointed persons arrive. • If police are on scene, you may depart as soon as required documentation is completed • You must follow all directions given to you by the coroner. 6 Deceased Patient Standard (Expected Death) • Advised CACC of the Patients death • Request that someone on scene contact the primary care giver or member of the Palliative Care Team to attend • the scene • If they are unable to contact the primary care giver or member of the palliative care team, CACC will be advised and they will attempt to contact • If the care giver or Palliative care team member will be attending, you will remain on scene until they arrive. • *If there is a responsible person/persons on scene that will take over care of the body temporarily, you may leave as soon as documentation is completed • If no one will assume responsibility of the body, you will advise CACC and they will notify the police and or coroner to attend the scene. You will follow all instruction provided by the coroner. • DNR (BLS Standards) • In a situation where a paramedic obtains a Valid MOHLTC DNR Confirmation Form, The Paramedic will not initiate any of the interventions listed in the definition of CPR • Chest compression Defibrillation • Artificial ventilation • Insertion of an oropharyngeal, nasopharyngeal or supraglottic airway • Endotracheal intubation. Transcutaneous pacing • Advanced resuscitation drugs such as, but not limited to, vasopressors, antiarrhythmic agents and opioid antagonists • A Valid DNR must be presented to the paramedics to be considered. Is can be the original or photocopy of the original. This must include • A serial number • Patients given and surname • One of the check boxes marked, that identifies one of the criteria has been met. • Box checked off by a Medical Doctor (M.D.), Registered Practical Nurse (R.P.N.), Registered Nurse (R.N.), or Registered Nurse in the Extended Class (R.N. [EC]) who is signing the form. The name must also be clearly printed on the DNR, and signed. • The form must be dated before or on the date that the form is presented • *If any items are not completed the DNR is considered invalid. • A paramedic, upon obtaining a Valid MOHLTC DNR Confirmation Form SHALL NOT initiate CPR on the patient in the event that the patient experiences respiratory or cardiorespiratory arrest (i.e. respirations and pulse are absent for at least three minutes from the time that respiratory or cardiac arrest was noted by the paramedic). • A paramedic shall initiate CPR on a patient who has experienced respiratory or cardiorespiratory arrest when • the patient with a Valid MOHLTC DNR Confirmation Form appears to the paramedic to be capable and expresses clearly a wish to be resuscitated in the event that he/she experiences a respiratory or cardiac arrest • the patient with a Valid MOHLTC DNR Confirmation Form appears to the paramedic to be capable and expresses a wish to be resuscitated in the event that he/she 7 experiences respiratory or cardiorespiratory arrest, but the request is vague, incomplete or ambiguous such that it is no longer clear what the wishes of the patient are. • The paramedic shall provide patient management necessary to provide comfort or alleviate pain, as required by the patient’s clinical condition • Once it has been determined that death has occurred, the paramedic shall advise the CACC/ACS and follow the Deceased Patient Standard • In conjunction with the Documentation of Patient Care Standard, the paramedic shall note and document the time at which the paramedic confirms the patient was deceased