Angina Pectoris

 Epidemiology & Pathophysiology

Pathophysiology
 Angina occurs when the heart’s demand for oxygen
exceeds the blood’s oxygen supply.
 Commonly caused by artherosclerosis.
 May also result from spasm of the coronary arteries
(Prinzmetal’s angina).
Stable vs. Unstable Angina
Disease Progression
Spectrum of coronary artery disease best
referred to as acute coronary syndrome
 Angina Pectoris
 Causes of Chest Pain
 Cardiovascular, including acute coronary syndrome,
pericarditis, or thoracic dissection of the aorta
 Respiratory, including pulmonary embolism,
pneumothorax, pneumonia, and pleural irritation
 Gastrointestinal, including cholecystitis, pancreatitis,
hiatal hernia, esophageal disease, gastroesophageal
reflux, peptic ulcer disease, and dyspepsia
 Musculoskeletal, including chest wall syndrome,
costochondritis, acromioclavicular disease, herpes
zoster, chest wall trauma, and chest wall tumors
 Angina Pectoris
 Field Assessment
Signs of Shock
Chest Discomfort
 Typically sudden onset, which may radiate or be
localized to the chest.
 Patient often denies chest pain.
Duration
 Episodes last 3–5 minutes.
 Pain relieved with rest and/or nitroglycerin.
 Angina Pectoris
Breathing
History
 Past episodes of angina:
• Episodes of angina that are increasing in frequency,
duration, or severity are significant.
ECG
 Do not delay scene time.
 12-Lead ECG preferred:
• Angina typically causes nonspecific ST changes.
 Angina Pectoris
 Management
 Relieve anxiety:
 Place the patient in a position of physical and emotional
comfort.
 Administer oxygen.
 Establish IV access.
 Monitor ECG.
 Consider medication administration:
 Nitroglycerin tablets or spray
 Nifedipine or other calcium channel blockers
 Morphine sulfate
 Angina Pectoris
Special Considerations
 Patients with new-onset or crescendo angina often
require hospitalization.
 Symptoms not relieved by rest, nitroglycerin, and
oxygen may indicate an overall worsening of the
disease or the early stages of a myocardial
infarction.
 Patients may refuse transport after pain is relieved,
even though the underlying problem is not
addressed.
 Myocardial Infarction
 Pathophysiology
 Death and necrosis of
heart muscle due to
inadequate oxygen
supply.
 Causes may include
occlusion, spasm,
microemboli, acute
volume overload,
hypotension, acute
respiratory failure,
and trauma.
 Location and size
dependent on the
vessel involved.
Myocardial Infarction
Transmural vs. Subendocardial MIs.
Effects of a Myocardial Infarction
 Dysrhythmias
 Heart Failure
 Ventricular Aneurysm
Goals of Treatment
 Pain Relief
 Reperfusion
 Myocardial Infarction
 Field Assessment
 Breathing
 Signs of Shock
 Chief Complaint
 Typically related to chest pain.
 Evaluate using OPQRST:
• Discomfort > 30 minutes.
• Radiation to arms, neck, back, or epigastric region.
 Patients may minimize symptoms.
 Feelings of “impending doom.”
Myocardial Infarction
 Other Symptoms
 Nausea and vomiting
 Diaphoresis
 Myocardial Infarctions & the ECG
 Diagnostic ECGs:
• 12-lead ECGs
• S-T segment
• Pathological Q waves
 Dysrhythmias:
• Asystole, PEA, VF, VT.
• Dysrhythmias are the leading cause of death in MI.
Myocardial Infarction
Reperfusion Screening
 Reperfusion of ischemic/injured tissue.
 Time from onset to treatment < 12 hours.
 Absence of history that would exclude
thrombolytics.
Transport
 Rapid transport indicated when acute MI suspected
 Myocardial Infarction
 Management
 Prehospital
 Administer oxygen.
 Establish IV access.
 Consider medication administration:
• Aspirin
• Morphine sulfate
• Nitroglycerin
• Antiarrhythmia medication as indicated
Myocardial Infarction
 Monitor ECG.
 Rapid transport as indicated.
 Avoid patient refusals if possible.
 Identify candidates for thrombolytic therapy.
In-Hospital:
 Diagnostic ECGs.
 Enzyme levels.
 Risk assessment.
 Treatment:
 thrombolytic therapy. If not candidate do
• Cardiac catheterization, PTCA, and CABG.
 Heart Failure
 Left
Ventricular
Failure
Pathophysiology
 Results in
increased back
pressure into
the pulmonary
circulation.
Heart failure with reduced ejection fraction (systolic heart failure )
Heart failure with preserved ejection fraction (diastolic heart failure )
 Heart Failure
 Right
Ventricular
Failure
Pathophysiology
 Results in
increased back
pressure into the
systemic venous
circulation.
Pulmonary
Embolism
 Heart Failure
 Congestive Heart Failure
Pathophysiology
 Reduction in the heart’s stroke volume causes fluid
overload throughout the body’s other tissues.
Manifestation
 Heart Failure
 Field Assessment
 Pulmonary Edema:
 Cough with copious amounts of clear or pink-tinged
sputum.
 Labored breathing, especially with exertion.
 Abnormal breath sounds, including rales, rhonchi, and
wheezes.
 Paroxysmal Nocturnal Dyspnea (PND)
 Medications:
 Diuretics.
 Digoxin to increase cardiac contractile force.
 Home oxygen. In PE place the patient in a sitting position with legs dependent
Emergency Management in PE : This position :
reducing the venous return to the heart 1- increase lung volume and vital capacity
Improving mycardial contractility
Decreasing myocardial oxygen demand 2- diminshes work of respiration
Improving ventilation and oxygenation 3- reduces the venous return to the heart
PE in setting of severe HTN should
prompt the paramedic to consider rapid
afterload reduction with high dose nitro
 Heart Failure
 Mental Status
 Mental status changes indicate low C.O.P.
 Breathing
 Signs of labored (difficult) breathing.
 Tripod positioning.
 “Number of pillows.”
 Skin
 Color changes. (pallor from low COP)
 Peripheral and/or sacral edema.
 Heart Failure
 Management
General management:
 Avoid supine positioning.
 Avoid exertion such as standing or walking.
Maintain the airway.
Administer oxygen.
Establish IV access.
 Limit fluid administration.
 Heart Failure
Monitor ECG.
Consider medication administration:
 MONA if the cause is ACS
 Lasix, digoxin
 Dopamine/ dobutamine (in cardiogenic shock)
Avoid patient refusals if at all possible.
 Cardiac Tamponade
 fluid accumulation between visceral and parietal pericardium,
impairing diastolic filling.
 trauma or MI are the common acute causes.
 may be caused by cancer, pericarditis, renal disease, and
hypothyroidism (benign presentations).
 Cardiac Tamponade
 Field Assessment
 Patient History
 Determine precipitating causes.
 history of dyspnea and orthopnea.
 Exam
 Rapid, weak pulse
 Faint, muffled heart sounds
 Decreasing systolic pressure
 Narrowing pulse pressure.
Most important reliable signs of cardiac tamponade are :
- JVD
- hypotension
- distant heart sounds (beck triad )
 Cardiac Tamponade
 general & definitive management
Maintain airway, give O2, IV line, rapid
transport & drugs to treat the cause or
complications.
 Cardiac Tamponade

Pericardiocentisis
 Pericardiocentisis is the definitive treatment.
 Insertion of a cardiac needle and aspiration of fluid
from the pericardium.
 Procedure should be performed only if allowed by
local protocol.
 Procedure should be performed only by personnel
adequately trained in the procedure.
 Hypertensive
Emergencies
 Hypertensive Emergency
 Causes
 Typically occurs only in patients with a history of HTN.
 1- noncompliance with prescribed antihypertensive
medications.(= not taking the drugs regularly)
 2- toxemia of pregnancy.(EPH/C)
 Hypertensive
Emergencies
 Field Assessment
 Initial Assessment (ABC)
 Alterations L.O.C (CVA), cardiogenic shock.
 Signs & Symptoms
 Headache accompanied by nausea and/or vomiting,
 Blurred vision, Shortness of breath, Epistaxis, Vertigo,
Tinnitus.
 Hypertensive
Emergencies
History
 Known history of hypertension
 Compliance with medications
 toxemia of pregnancy
Exam
 BP > 160/90, Strong, bounding pulse
 Signs of left ventricular failure (e.g. edema),
cardiogenic shock & CVA
 Hypertensive
Emergencies
 Management
 Maintain airway.
 Administer oxygen.
 Establish IV access.
 Consider medication administration:
 Furosemide (Lasix)
 Nitroglycerin
 Sodium nitroprusside
 Labetalol
 Cardiogenic Shock
 - Severe form of pump failure.
 - High mortality rate.
 Causes
 Tension pneumothorax and cardiac tamponed.
 Impaired ventricular emptying. ( HTN, valve stenosis).
 Impaired myocardial contractility (ACS).
 (can occurs inTrauma, medical cases)
Usually is caused by extensive MI or by diffuse ischemia
Cardiogenic shock is present when shock persists after correction of existing dysrhtymias,volume defict
decreased vascular tone.
Cardiogenic Shock
History:-
 chest pain (in ACS), shortness of breath,
unconsciousness, or altered mental state.
 Onset may be acute or progressive, History of
recent MI (in ACS).

 EX.
 --altered LOC, SOB, low BP, pale cool clammy skin
 , weak rapid pulse & bilateral basal cripitations.
 Cardiogenic Shock
 Management
Maintain airway.
Administer oxygen
Identify and treat underlying problem.
Establish IV access.
Consider medication administration:
 Vasopressors (dopamine, dobutamine)
 Other meds
Cardiogenic Shock
 Cardiac Arrest
 Sudden Death
 the most common cause is A.C.S.
 Cardiac Arrest
 Field Assessment
Initial Assessment
 Unresponsive, apneic, pulseless patient
ECG
 Dysrhythmias
History
 Prearrest events
 Bystander CPR
 “Down time”
 Cardiac Arrest
 Management
 Resuscitation
 Return of Spontaneous Circulation
 Survival
 Role of Basic Life Support, ACLS
 Cardiac Arrest
Withholding Resuscitation
 Rigor mortis
 Dependent hypostasis.
 Decapitation, decomposition, incineration
 Valid DNR
 Cardiac Arrest
Terminating Resuscitation
 Indications for termination of resuscitation
• Old aged patient.
• Cardiac cause.
• .ACLS standards applied throughout the arrest, with
successful ETT intubation.
• On-scene effort > 25 minutes, or four rounds of drug
therapy.
• ECG remains asystolic.
 Cardiac Arrest
 Contraindications to termination of resuscitation:
• Patient under 18 years old.
• Arrest is of a treatable cause.
• Present or recurring VF/VT.
• Transient return of a pulse.
• Signs of neurological viability.
• Witnessed arrest.
• Family or others opposed to termination of resuscitation.
 Always follow local protocols related to termination of
resuscitation.
 Support the family or others after termination of
resuscitation.
 Coordinate with law enforcement as required.
Peripheral Vascular and Other
Cardiovascular Emergencies
 Atherosclerosis The reason is accumlation of fat
When calcium ‫ ﯾﺘﺮﺳﺐ‬: arteriosclcerosis
 Pathophysiology
 Progressive degenerative disease of the medium-sized
and large arteries.
 Results from the buildup of fats on the interior of the
artery.
 Fatty buildup results in plaques and eventual stenosis of
the artery.
 Arteriosclerosis Calph muscle

 Claudication Severe pain in claud muscle due to inadequate blood supply

It typically occur with exertion and subside with rest
Peripheral Vascular and Other
Cardiovascular Emergencies
 Aneurysm
 Pathophysiology
 Ballooning of an arterial wall, usually the aorta, that
results from a weakness or defect in the wall
 Types
 Atherosclerotic
 Dissecting
 Infectious
 Congenital
 Traumatic
 Peripheral Vascular and Other
Cardiovascular Emergencies
The most common site dor an AAA is below the renal arteries and above the branching of the common iliac arteries
AAAs are 10 times more common in men

Clots may form in the enlarged aorta

Abdominal Aortic
Aneurysm
and cause obstructed blood vessel in the legs

 Often the result of

atherosclerosis
 Signs and
symptoms
• Abdominal pain
• Back/flank pain
• Hypotension
• Urge to defecate
Peripheral Vascular and Other
Cardiovascular Emergencies
Dissecting Aortic Aneurysm
 Caused by degenerative changes in the smooth
muscle and elastic tissue.
 Blood gets between and separates the wall of the
aorta.
 Can extend throughout the aorta and into
associated vessels.
Peripheral Vascular and Other
Cardiovascular Emergencies
 Acute Pulmonary Embolism
Pathophysiology
 Blockage of a pulmonary artery by a blood clot or
other particle.
 The area served by the pulmonary artery fails.
Signs and Symptoms
 Dependent upon size and location of the blockage.
 Onset of severe, unexplained dyspnea.
 History of recent lengthy immobilization.
Peripheral Vascular and Other
Cardiovascular Emergencies
 Acute Arterial Occlusion
 Pathophysiology
 Sudden occlusion of arterial blood flow due to trauma,
thrombosis, tumor, embolus, or idiopathic means.
 Frequently involves the abdomen or extremities.

 Vasculitis
 Pathophysiology
 Inflammation of the blood vessels.
 Commonly stems from rheumatic diseases and
syndromes.
Peripheral Vascular and Other
Cardiovascular Emergencies
 Noncritical Peripheral Vascular
Conditions
 Peripheral Arterial Atherosclerotic Disease
 Can be acute or chronic.
 Often associated with diabetes.
 Extremities exhibit pain, coldness, numbness, and pallor.
 Deep Venous Thrombosis
 Blood clot in a vein.
 Typically occurs in the larger veins of the thigh and calf.
 Swelling, pain, and tenderness, with warm, red skin.
 Varicose Veins
 Dilated superficial veins, common with pregnancy and
obesity.
Peripheral Vascular and Other
Cardiovascular Emergencies
 General Assessment and
Management of Vascular
Disorders
Assessment
 Initial Assessment
 Circulatory Assessment
• Pallor
• Pain
• Pulselessness
• Paralysis
• Paresthesia
Peripheral Vascular and Other
Cardiovascular Emergencies
 Chief Complaint
• OPQRST
 Physical Exam
• Prior history of vascular problems
• Differences in pulses or blood pressures
 Management
 Maintain the airway.
 Administer oxygen if respiratory distress or signs of
hypoperfusion present.
 Consider administration of analgesics.
 Transport rapidly if signs of hypoperfusion present.
 Prehospital ECG
Monitoring
 Prehospital
12-Lead
ECG
Monitoring
Prehospital ECG Monitoring
Prehospital ECG Monitoring
Prehospital ECG Monitoring
Prehospital ECG Monitoring
Prehospital ECG Monitoring
Prehospital ECG Monitoring
Prehospital ECG Monitoring
Prehospital ECG Monitoring
Prehospital ECG Monitoring
Prehospital ECG Monitoring
Prehospital ECG Monitoring
Prehospital ECG Monitoring
Prehospital ECG Monitoring
Prehospital ECG Monitoring
Prehospital ECG Monitoring
 Summary
 Assessment of the Cardiovascular
Patient
 Management of Cardiovascular
Emergencies
 Management of Specific
Cardiovascular Emergencies
 Prehospital Monitoring