Qureshi University, Advanced courses, via cutting edge technology, News, Breaking News | Latest News And Media | Current News
admin@qureshiuniversity.com

Admissions | Accreditation | A to Z Degree Fields | Booksellers | Catalog | Colleges | Contact Us | Continents/States/Districts | Contracts | Distance Education | Emergency | Emergency Medicine | Examinations | Forms | Grants | Hostels | Honorary Doctorate degree | Human Services | Internet | Investment | Instructors | Internship | Login | Lecture | Librarians | Membership | Observers | Professional Examinations | Programs | Progress Report | Recommendations | Research Grants | Researchers | Students login | School | Search | Seminar | Study Center/Centre | Sponsorship | Tutoring | Thesis | Universities | Work counseling

Physician medical emergency responder
Emergency medical responder

Emergency Medical Services Education (EMSE)
Quick assessment.

How do you diagnose and treat a reported medical emergency?
Where is the patient now?
Who has the responsibility to attend to this medical emergency?

Start with the Glasgow coma scale.
Spontaneously opening the eyes, talking, and moving limbs is a normal Glasgow scale of 15. The patient is not in a coma. If the Glasgow scale is less than 15, the patient is likely in a coma.
For example, the vital signs, level of consciousness, pulse, respiratory rate, blood pressure, temperature, pain, and input output are normal.
Survival needs at residences are available.
Safety is normal.
Any of the 155 medical emergency complaints is a medical emergency.
Any one issue among the 8 categories is a medical emergency.

5 categories of issues must be evaluated.
Glasgow coma scale
Vital signs
Survival needs
Safety
Any complaints at this point

How do you categorize the patient’s condition?
Undetermined
Good
Fair
Serious
Critical

What problems, complaints, incidents, and issues need on-the-spot diagnosis and treatment?
  1. Unconsciousness at a public location.
  2. Sudden unconsciousness at home.
  3. Trauma

  4. Burns

  5. Drowning

  6. Seizures

  7. Survival Needs

  8. Human Pregnancy Emergencies
      Maliciously impregnated (medico-legal case that needs emergency contraception).
      Spontaneous Vaginal Delivery
Glasgow Coma scale analysis.

Glasgow Coma scale analysis.
First, analyze Glasgow Coma scale, then analyze vital signs including consciousness.

When was the patient normal?
Can the patient open both eyes spontaneously?
Can the patient talk or make noise relevant to age?
Can the patient walk or move extremities relevant to age?

If yes, Glasgow Coma scale is 15.
Glasgow Coma scale of 15 means the patient is not in a coma.
The patient can have less serious medical issues.
Go ahead with vital signs, including consciousness.

When should you do on-the-spot endotracheal intubation?
If Glasgow coma scale is 9 or less with airway obstruction, even with gag reflex, you should intubate the patient. Do you know how to calculate Glasgow coma scale?
How do you intubate a patient in coma with Glasgow coma scale less than 9 with gag reflex in respiratory distress?

When should you start an on-the-spot intravenous line?
If there is blood loss with hypotension.
In case of cardiopulmonary arrest.

Cardiopulmonary resuscitation if required.

The nearest hospital with critical care is 20 minutes by vehicle.
In case of head injury with coma, prolonging diagnosis and treatment for 20 minutes may cause patient to die.

That is what happened in this case.
Patient died even though seen by a neurosurgeon and an anesthetist.

Medical emergency diagnosis and treatment of trauma with coma with respiratory distress, or imbalance in circulation, should happen within 4-6 minutes of occurrence or report of a medical emergency.

Is that clear?
Do you have any questions for me?

Ability to perform calculations: Can the patient perform simple addition, multiplication, subtraction, and division? Are the responses appropriate for the patient’s level of education?
Are there any problems in calculations?

Consciousness

Level of alertness: Is the patient conscious?
If not, can the patient be awakened?
Can the patient remain focused on your questions and conversation?
What is attention span of the patient?

In case of altered sensorium, get answers to these questions.

How would you rate Glasgow Coma Scale of this patient in the range of 3—15, with a score of 3 indicating brain death (the lowest defined level of consciousness), and 15 indicating full consciousness?

Language

How are English language understanding, reading, writing, and speaking abilities of the individual?
The individual can understand, read, write, and speak the English language.
The individual is unable to understand, read, write, and speak the English language.

Assessment by medical emergency specialist in emergency medical situation.

What should be your focus of assessment in an emergency medical situation?
Vital signs, including consciousness.
No pain, wounds, or abnormal findings that needs emergency treatment.
Glasgow coma scale.
Mobility assessment (Is individual able to walk or make limb movements relevant to age?)
Survival needs assessment.
Emotion: Anger, sadness, fear or emotions not relevant to situation need further evaluation

Criteria for discharge from medical emergency room

1. Vital signs including consciousness: Normal
2. Glasgow coma scale: 15.
3. Mobility assessment: Normal.
4. Survival needs assessment: Yes.
5. Emotions: Normal relevant to situation.
6. Psychiatric evaluation if required: Normal

Emergency diagnosis and treatment and disability assessment are two different assessments.
For example, a person can be 100% mentally fit and 95% physically fit.

This is relevant to the individual’s age.
1. Vital signs including consciousness: Normal

Are vital signs including consciousness normal?
Yes.

No pain, wounds, or abnormal findings that needs emergency treatment.

2. Glasgow coma scale: 15.

Is Glasgow coma scale 15?
Yes.

3. Mobility assessment

Is individual able to walk or make limb movements relevant to age?
Normal

4. Survival needs assessment.

Does the individual have survival needs form the state?
Yes.

Is it safe for the individual at the residence?

5. Emotions: Anger, sadness, fear, or emotions not relevant to situation needs further evaluation. Normal.

Are emotions expression normal relevant to situation?

6. Psychiatric evaluation if required.

Is this individual mentally fit relevant to age?

Advice on discharge from medical emergency room.
This depends on original complaint and diagnosis with relevant treatment.
Treatment depends on the underlying cause.

What best describes the individual’s emotions at this point?

Basic life support

What should you know about basic life support?
Basic life support is meant for an unconscious patient.
All unconscious patients need basic life support.
Not all unconscious patients need cardiopulmonary resuscitation (breathing support, chest compressions). Only unconscious patients with cardiac arrest or respiratory arrest need cardiopulmonary resuscitation including breathing support and chest compressions).

Does the unconscious patient need basic life support with CPR or without CPR?

If the unconscious patient needs basic life support with cardiopulmonary resuscitation with chest compressions here are further guidelines.
Cardiopulmonary resuscitation guidelines.

Unconscious patient.

What type of patient needs basic life support?
An unconscious patient.

Do all unconscious patients need cardiopulmonary resuscitation?
No.

How should you evaluate and treat an unconscious patient?
Assessment is very important.
Not all unconscious patients need cardiopulmonary resuscitation.
For adults, assess the victim, activate EMS and get AED, check pulse, start CPR.

When do you start cardiopulmonary resuscitation in adults?
CPR is required someone's breathing or heartbeat has stopped, as in cases of electric shock, drowning, or heart attack. CPR is a lifesaving procedure in this situation.

What is cardiopulmonary resuscitation?
Cardiopulmonary resuscitation is a combination of rescue breathing and chest compressions.
Rescue breathing provides oxygen to a person's lungs.
Chest compressions keep the person's blood circulating.
Permanent brain damage or death can occur within minutes if a person's blood flow stops. Therefore, you must continue these procedures until the person's heartbeat and breathing return, or trained medical help arrives.

In what situations is a directive like "Do not Resuscitate" justified?
Old age more than 95 years with known complications.

What is unconsciousness?
Unconsciousness means being unable to see, hear, and talk.
Often, this is called a coma or being in a comatose condition.
An unconsciousness person will be unresponsive to activity, touch, sound, or other stimulation.
He or she will not be able to communicate and won’t respond to stimulation.

Conscious means able to see, hear, and talk.
In pediatric patients younger than six months of age, the ability to make any verbal noise or cry is equivalent to talking.

A person may be unconscious for a few seconds (as is the case with fainting) or for longer periods of time.

What are the causes of unconsciousness?
Alcohol use.
Drowning.
Electric shock
Substance abuse
Severe blood loss
8 H's and 6 T's: mnemonic for mechanisms
Hypoxia
Hypovolemia
Hyperkalemia
Hypokalemia
Hypoglycemia
Hypothermia
Hyperthermia (heat stroke)
Hydrogen ions (acidosis)
Thrombosis (MI/heart attack)
Tension pneumothorax
Tamponade
Toxins/therapeutics
Thromboembolism
Trauma

What is the difference between being asleep and being unconscious?
Being asleep is not the same thing as being unconscious.
A sleeping person will respond to loud noises or gentle shaking; an unconscious person will not.

An unconscious person cannot cough or clear his or her throat. This can lead to death if the airway becomes blocked.

Is there a difference between unconsciousness and cardiopulmonary arrest?
Yes.

What is the difference between unconsciousness and cardio pulmonary arrest?
Unconsciousness is usually without cardiac arrest.
If unconsciousness is associated with cardiac arrest or respiratory arrest, cardiopulmonary resuscitation is required.

Assessment in medical emergency situation.
Patient 60-second on-the-spot diagnosis and treatment.
What questions should you ask in emergency medical history?
Where is the patient now?

-------------------------------------

What best describes this case scenario?
Unconsciousness at a public location.
Sudden unconsciousness at home.
Trauma
Survival needs issues
Seizures
Burns
Drowning
Human Pregnancy Emergencies

-------------------------------------

If yes, go ahead with on the spot diagnosis and treatment.
Do not delay in diagnosis and treatment.
Do on-the-spot diagnosis and treatment.
Do not wait for transfer of patient from the location of the medical emergency to a medical emergency room.

On-the-spot medical diagnosis and treatment.

What is on-the-spot medical diagnosis and treatment?
If a physician medical emergency responder or emergency medical responder technician is asked to attend a medical emergency on the road, in a building, in a vehicle, a drowning case in water, or any similar location, these are examples of on-the-spot medical emergency diagnosis and treatment.

What medical emergency issues need on-the-spot medical diagnosis and treatment?
Unconsciousness at a public location.
Sudden unconsciousness at home.
Trauma
Survival needs issues
Seizures
Burns
Drowning
Human pregnancy emergencies

If any of the mentioned issues, go ahead with on-the-spot diagnosis and treatment.

What is the exact location of the patient now?

-------------------------------------

Is the location reachable within 3–10 minutes by the physician who received this report?

-------------------------------------

Who is the nearest emergency medical responder a physician to attend to this medical emergency?

-------------------------------------

What should others do who are not physicians or paramedics?
Make sure airway of the patient is open and clear.

What is a patent airway?
A patent airway is one that is open and clear.

Can the patient talk?
Can the patient talk relevant to age?
If the patient can talk, alert airway is patent.

A patient who is talking and alert has a patent airway.
Take a look at emergency medical complaints.
Symptoms, signs of medical emergencies.
Emergency diagnosis and treatment.

Ideally, who should be an emergency medical responder?
Ideally, a medical doctor should be an emergency medical responder.

On February 1, 2012, in America, it was verified that an emergency medical responder has completed a course in basic life support. But if a genuine medical emergency arises that needs on-spot diagnosis and treatment, basic life support skills and knowledge are not enough.

What are the duties of emergency medical responders?
They have duties similar to an Emergency medical doctor.
Answer these questions:
Can you reach a correct diagnosis and treatment of a human being?
What is the diagnosis of this patient?
How did your reach this diagnosis?
What is the treatment for this patient?
Does the patient need to be transferred to a medical emergency room?
Assessment in medical emergency situation.
Actions/Emergency Action Planning, Including Medical Emergencies
Airway Management in Critical Illness
Cardiopulmonary Resuscitation (CPR) in Adults
Circulation and Cardiac Emergencies
Emergency Medical Services Training Programs
Duties of a medical doctor in a medical emergency room.
Duties of a nurse in a medical emergency room.
Duties of emergency medical responder.
Duties of a technician in a medical emergency room.
Glasgow Coma scale analysis.
On-the-spot emergency medical diagnosis and treatment
There are more than 7,000 human medical conditions.
Medical Emergency Procedure
Questions the state director of health needs to answer.
Symptoms, signs of medical emergencies.
Trauma / Early Management of Severe Trauma

What emergency medical complaint does the patient have?
Specific emergency medical complaint patient has to go ahead accordingly.

Has there been trauma in the past few minutes?
Has there been unconsciousness in the past few minutes?
If yes, go ahead with on the spot diagnosis and treatment.
Do not delay in diagnosis and treatment.
Do on-the-spot diagnosis and treatment.
Do not wait for transfer of patient from the location of the medical emergency to a medical emergency room.

How old is the patient?
What is the location of patient at the point of the medical emergency?
Can the patient talk relevant to age?
Can the patient walk relevant to age?
Are consciousness, pulse, blood pressure, and respiratory rate normal relevant to age?
What is the cause of the existing emergency medical scenario?

What problems, complaints, incidents, and issues need on-the-spot diagnosis and treatment?
Unconsciousness at a public location.
Sudden unconsciousness at home.
Trauma
Survival Needs
Seizures
Burns
Drowning
Human Pregnancy Emergencies

Emergency medical history

Emergency medical record
Here are further guidelines.
Medical emergencies.
Case scenario 1
Does the patient need to be transferred to a medical emergency room?
Emergency medical room

Airway Management in Critical Illness
Airway Management Equipment
Airway Management
Airway Management Equipment
Make sure airway of the patient is open and clear.

What is a patent airway?
A patent airway is one that is open and clear.

Can the patient talk?
Can the patient talk relevant to age?
If the patient can talk, alert airway is patent.

A patient who is talking and alert has a patent airway.
Take a look at emergency medical complaints.
Symptoms, signs of medical emergencies.
Emergency diagnosis and treatment.

What emergency medical complaint does the patient have?
Specific emergency medical complaint patient has to go ahead accordingly.

Oropharyngeal airway
When should I use an oral airway? A nasal airway?
Use an oral airway only for patients who have an altered level of consciousness because it tends to stimulate the gag reflex. A nasal airway, on the other hand, does not stimulate the gag reflex; you can use it for patients who are more alert but still need their airway protected. Do not use a nasal airway for any patient who has any sort of facial or head injuries.

Why is it important that the airway be of the appropriate size?
If the airway is not the correct size, it could injure the casualty's throat or even obstruct his airway. The right size keeps the casualty's tongue from falling down the back of his throat.

INSERT AN OROPHARYNGEAL AIRWAY IN AN UNCONSCIOUS CASUALTY

Remember, only use the oropharyngeal airway on an unconscious casualty, never on a conscious or semiconscious casualty.

Should you tie or tape the airway in place?
No.

What should you do if the casualty begins to regain consciousness?
Remove the airway.

Nasopharyngeal airway
Endotracheal tube
Tracheostomy tube
Airway Management
Endotracheal tube
Endotracheal tubes are used for patients undergoing a procedure that requires general anesthesia and/or mechanical ventilation. They are inserted either through the nose or the mouth past the epiglottis and vocal cords into the trachea and down to where the trachea bifurcates into the bronchi. ET tubes are not usually left in place for more than 14 days as doing so places the patient at risk for infection and airway injury. Endotracheal tubes are made of a flexible plastic material and are available in a variety of sizes. The size used depends on the age and size of the patient. For adult patients, the ET tube will usually have a cuff that is inflated with air after insertion to prevent air from leaking around the tube and to prevent oral and gastric secretions from being aspirated.

Airway management is the number one priority in basic and advanced life support.
* Medical Doctor/EMT-First Responder

o Immbolization
o Monitoring
o Ambulance

* Medical Doctor/EMT-Basic*

o Airway
o Monitoring
o IV and IO initiation
o IV and IO maintenance
o Endotracheal intubation
o Medication

* Medical Doctor/EMT-Intermediate

o Needle decompression/surgical airway
o Immunizations
o Drips and pumps
o 12 lead transmit

* Medical Doctor/EMT-Paramedic*

o 12 lead interpretation
o Medications
o Fibrinolytic with 12 lead interpretation
o Critical Care Transport

Emergency medical responder

Questions the state director of health needs to answer.
Questions you need to answer.
Are emergency medical responders medical doctors?
Are medical doctors educated with the proper curriculum?
Are emergency medical services instructors experienced medical doctors?
What will happen if emergency medical responders are not competent medical doctors?
On-the-spot diagnosis and treatment of medical emergency was required by a medical doctor. Findings verified that patients died due to delayed diagnosis, wrong diagnosis, and improper treatment in a medical emergency.
Has every preventable death been researched and investigated by different sources?
Are communications like e-mail, fax, telephone, postal mail, and Internet secure and uninterrupted? Do they present their continuing research?
Is the response to emergencies rapid, competent, and effective?

Medical Emergency Procedure
Emergency medical responder
Procedures by certification level
Treatment issue Emergency Medical Responder
Airway & Breathing Bag Valve Mask
Head-tilt chin lift
Jaw Thrust
Modified Chin Lift
Manual Obstruction Removal
Oxygen Therapy via Non-rebreather mask or Nasal cannula
Upper airway suctioning
Positive Pressure Ventilation via Bag Valve Mask
Oropharyngeal Airway
Nasopharyngeal airway
Cricoid pressure
Assessment Here are further guidelines.
Manual blood pressure
Pharmacological Interventions Route of Administration
Unit dose auto-injectors for self or peer care (MARK I)
Oral Glucose (Under medical control)
Epinephrine Auto-Injector (Varies by jurisdiction)
Emergency Trauma Care Manual cervical stabilization
Manual extremity stabilization
Splinting
Eye irrigation
Long spine board
Cervical Collar
Direct pressure
Hemorrhage control
Emergency moves for endangered patients
Medical/Cardiac Care CPR
Automated external defibrillator (AED)
Human Pregnancy Emergencies
    Maliciously impregnated (medico-legal case that needs emergency contraception).
    Spontaneous Vaginal Delivery
    Assisted normal delivery (Emergency Childbirth)
    Here are further facts.

Emergency Medicine Procedures
Emergency Room Physician
Section 1. Introductory Chapters
Section 2. Respiratory Procedures
Section 3. Cardiothoracic Procedures
Section 4. Vascular Procedures
Section 5. Gastrointestinal Procedures
Section 6. Orthopedic and Musculoskeletal Procedures
Section 7. Skin and Soft Tissue Procedures
Section 8. Neurologic and Neurosurgical Procedures
Section 9. Anesthesia and Analgesia
Section 10. Obstetrical and Gynecologic Procedures
Section 11. Genitourinary Procedures
Section 12. Ophthalmologic Procedures
Section 13. Otolaryngologic Procedures
Section 14. Dental Procedures
Section 15. Podiatric Procedures
Section 16. Miscellaneous Procedures

Actions
Emergency Action Planning, Including Medical Emergencies
ER
Review the patient's history, including past medical history.
Perform a physical exam.
Establish last known well if not already done.
Support the ABC's (airway, breathing, and circulation).
Give oxygen as needed.
Transport the patient quickly.
Bring a family member or witness to confirm last known well
Alert the receiving hospital.
Check glucose levels.
Assess circulation, airway, breathing and evaluate vital signs.
Give oxygen if patient is hypoxemic (less than 94% saturation). Consider oxygen is patient is not hypoxemic.
Make sure that an IV has been established.
Take blood samples for blood count, coagulation studies, and blood glucose. Check the patient's blood glucose and treat if indicated. Give dextrose if the patient is hypoglycemic. Give insulin if the patient's serum glucose is more than 300. Give thiamine if the patient is an alcoholic or malnourished.
Obtain a 12-lead ECG and assess for arrhythmias.
Order a CT brain scan without contrast and have it read quickly by a qualified specialist.
The CT scan should be completed within 25 minutes from the patient's arrival in the ED and should be read within 45 minutes.
Transfer patient to intensive care if indicated.
Critical Care
Here are further guidelines.


Symptoms, signs of medical emergencies.
What should you be able to elaborate on a symptom or sign?

What is it?
What are the consequences of this symptom or sign?
What are the salient features of this symptom or sign?
    When did the problem start?
    Where did the problem start?
    How did the problem start?
    What relieves or aggravates the problem?
    How long does this problem last?
    Does this problem occur in any specific situation?
    What are the further details of the situation?
    Is there any other problem associated with this problem?
    What are the further details of the associated problem?
    What medication have you taken for this problem?
    Have you seen any medical doctor for this problem?
    How many medical doctors have you seen for this problem?
    What did the medical doctor diagnose and recommend for this problem?

    What is the diagnosis?
    Is it a medical emergency or non-emergency?
    Is it a medical emergency or medicolegal emergency?
    Is it a medical disability?
    Is it a medical condition without a medical emergency or disability?
    Is there a difference between a medical emergency and disability?
    Yes.

    What is the difference between a medical emergency and disability?
    http://www.qureshiuniversity.com/healthcareworld.html

    What should a doctor write or announce in his or her documentation of the patient?

    If there is an emergency diagnosis, what is the emergency diagnosis?

    In what setting does this patient need treatment?
    This patient needs on the spot treatment.
    This patient needs treatment in the emergency room.
    This patient needs treatment in a hospital ward.
    This patient needs treatment in the intensive care unit.
    This patient needs treatment in the operation theater.

    If it is not a medical emergency, here are the guidelines.

    It is not a medical emergency.
    It is not a medical emergency because all functions and vitals are normal.
    This patient needs home health care.
    Is it an administrative emergency?
What other terms are related to this symptom or sign?
What causes it?
Human symptoms and signs

How many human symptoms and signs are there?
1305

What are various examples?

Here are further guidelines.

Cardiopulmonary Resuscitation (CPR) in Adults
CPR is an organized, sequential response to cardiac arrest, including
Recognition of absent breathing and circulation
Basic life support with chest compressions and rescue breathing
Advanced cardiac life support (ACLS) with definitive airway and rhythm control Postresuscitative care

Prompt initiation of uninterrupted chest compression and early defibrillation (when indicated) are the keys to success. Speed, efficiency, and proper application of CPR determine successful outcome; the rare exception is profound hypothermia caused by cold water immersion, when successful resuscitation may be accomplished even after prolonged arrest (up to 60 min).

Circulation and Cardiac Emergencies
Acute Coronary Syndrome (ACS) Term that describes a range of clinical conditions, including unstable angina, that are due to insufficient blood supply to the heart muscle resulting from coronary heart disease (CHD)
Acute Myocardial Ischemia An episode of chest pain due to reduced blood flow to the heart muscle
Angina Pectoris Pain in the chest that comes and goes at different times; caused by a lack of oxygen reaching the heart; can be stable (occurring under exertion or stress) or unstable (occurring at rest, without reason)
Arrhythmia Disturbance in the regular rhythmic beating of the heart
Asystole A condition where the heart has stopped generating electrical activity
Atherosclerosis A condition in which deposits of plaque, including cholesterol (a fatty substance made by the liver and found in foods containing animal or animal products) build up on the inner walls of the arteries, causing them to harden and narrow, reducing the amount of blood that can flow through; develops gradually and can go undetected for many years
Atrial Fibrillation Irregular and fast electrical discharges of the heart that lead to an irregular heartbeat; the most common type of abnormal cardiac rhythm
Atrioventricular (AV) Node A cluster of cells in the center of the heart, between the atria and the ventricles; serves as a relay to slow down the signal received from the sinoatrial (SA) node before it passes through to the ventricles
Automated External Defibrillator (AED) A portable electronic device that analyzes the heart's electrical rhythm and, if necessary, can deliver an electrical shock to a person in cardiac arrest
Cardiac Arrest A condition in which the heart has stopped or beats too irregularly or weakly to pump blood effectively
Cardiac Chain of Survivial A set of four critical steps in responding to a cardiac emergency: early recognition and access to the EMS system, early cardiopulmonary resuscitation (CPR), early defibrillation, and early advanced medical care
Cardiopulmonary Resuscitation (CPR) A technique that combines chest compressions and ventilations to circulate blood containing oxygen to the brain and other vital organs for a person whose heart and breathing have stopped
Cardiovascular Disease A disease affecting the heart and blood vessels
Chest Compressions A technique used in CPR, in which external pressure is placed on the chest to increase the level of pressure in the chest cavity and cause the blood to circulate through the arteries
Cholesterol A fatty substance made by the liver and found in foods containing animal or animal products; diets high in cholesterol contribute to the risk of heart disease
Commotio Cordis Sudden cardiac arrest from a blunt, non-penetrating blow to the chest, of which the basis is ventricular fibrillation (V-fib) triggered by chest wall impact immediately over the heart
Congestive Heart Failure A chronic condition in which the heart no longer pumps blood effectively throughout the body
Coronary Heart Disease (CHD) A disease in which cholesterol and plaque build up on the inner walls of the arteries that supply blood to the heart; also called coronary artery disease (CAD)
Defibrillation An electrical shock that disrupts the electrical activity of the heart long enough to allow the heart to spontaneously develop an effective rhythm on its own
Electrocardiogram (ECG or EKG) A test that measures and records the electrical activity of the heart
Heart A fist-sized muscular organ that pumps blood throughout the bod
Hypertension Another term for high blood pressure
Implantable Cardioverter-Defibrillator (ICD) A miniature version of an AED, implanted under the skin that acts to automatically recognize and help correct abnormal heart rhythms
Myocardial Infarction (MI) The death of cardiac muscle due to a sudden deprivation of circulating blood; also called a heart attack
Normal Sinus Rhythm (NSR) The normal, regular rhythm of the heart, set by the sinoatrial node in the right atrium of the heart
Pacemaker A device implanted under the skin, sometimes below the right collarbone, to help regulate heartbeat in someone with a weak heart, a heart that skips beats, or one that beats too fast or too slow
Risk Factors Conditions or behaviors that increase the chance that a person will develop a disease
Silent Heart Attack A heart attack during which the patient has either no symptoms or very mild symptoms that the person does not associate with heart attacks; mild symptoms include indigestion or sweating
Sinoatrial (SA) Node A cluster of cells in the right atrium that generates the electrical impulses that set the pace of the heart's natural rhythm
Sudden Cardiac Arrest A condition where the heart's pumping action stops abruptly, usually due to abnormal heart rhythms called arrhythmias, most commonly V-fib; unless an effective heart rhythm is restored, death follows within a matter of minutes
Transdermal Medication Patch A patch on the skin that delivers medication; commonly contains nitroglycerin, nicotine, or other medications; should be removed prior to defibrillation
Ventricular Fibrillation (V-fib) A life-threatening heart rhythm in which the heart is in a state of totally disorganized electrical activity
Ventricular Tachycardia (V-tach) A life-threatening heart rhythm in which there is very rapid contraction of the ventricles

Cardiovascular Emergencies
Scene Size-up
Scene Safety Ensure scene safety and safe access to the patient. Standard precautions should include a minimum of gloves. Determine the number of patients. ALS should be requested. Assess the need for additional resources.
Mechanism of Injury (MOI)/ Nature of Illness (NOI) Determine the MOI/NOI. Ensure that the cardiac emergency is not the result of a traumatic event. Dispatch information, observations at the scene, and comments from family or bystand- ers will help you develop an idea of the NOI. Usually the NOI can be determined by the patient’s chief complaint. Chest pain, dif?culty breathing, and syncope are some indicators that the NOI may be a cardiac emergency.

Primary Assessment
Form a General Impression Observe overall appearance of the patient, age, body position, and responsiveness. Observe work of breathing and circulation. Pale skin and cyanosis are indicators of poor perfusion. Determine the level of consciousness using the AVPU scale. Is the patient calm or anxious? Is the patient able to speak in full sentences? Identify immediate threats to life. Determine priority of care based on the MOI/NOI. If the patient is unconscious, determine whether CPR is needed. If the patient has a poor general impression, call for ALS assistance. A rapid visual examination will help you identify and manage life threats.
Airway and Breathing Ensure the airway is open, clear, and self-maintained. If needed, open and maintain the air- way using a modi?ed jaw-thrust if a cervical-spine injury is suspected or a head-tilt—chin-lift in nontrauma patients. A patient with an altered level of consciousness may need emergency airway management; consider inserting a properly sized oropharyngeal airway in an unconscious patient or use a nasopharyngeal airway if the patient has an intact gag re?ex. Assess for gur- gling and stridor. Suction as needed. Evaluate the patient’s ventilatory status for rate and depth of breathing, respiratory effort, and tidal volume. Quickly assess the chest for DCAP-BTLS, accessory muscle use, and intercostal and abdominal muscle use, and treat any threats to life.

Assess lung sounds and determine whether they are normal, decreased, abnormal, or absent. Patients with cardiac problems may present with crackles or rales, indicating ?uid (edema) in the lungs. Administer high-?ow oxygen at 15 L/min, providing ventilatory support as needed.
Circulation Evaluate distal pulse rate, quality (strength), and rhythm. Tachycardia may be an indicator of shock or a myocardial infarction. Bradycardia might be due to cardiogenic shock as the heart attempts to reduce oxygen demand. Observe skin color, temperature, and condition and capillary re?ll time. Look for and treat any external bleeding. The transport of blood and oxygen may be reduced if cardiac output is low. If distal pulses are not palpable, assess for a central pulse.
Transport Decision If the patient has an airway or a breathing problem, severe chest discomfort, signs and symptoms of internal bleeding, or other life threats, manage the problems immediately, and con- sider rapid transport, performing the secondary assessment en route to the hospital. Delayed transport in a cardiac emergency will cause more cardiac muscle damage. For patients without life threats and in stable condition, perform a thorough assessment and history on scene. Do not allow the patient to exert himself or herself by walking to the ambulance; a carrying device should be used. Transportation should be to a cardiac care facility if one is close, otherwise take the patient to the nearest hospital for evaluation and stabilization. Do not delay transport to manage non—life-threatening conditions, instead treat en route to the hospital. Lights and sirens might cause anxiety and stress to a patient with a cardiac problem; patient condition and dis- tance from the hospital are factors you can use to evaluate the need to use lights and siren.

History Taking
Investigate Chief Complaint Investigate the chief complaint. Conscious patients can supply you with a brief history, ask OPQRST and SAMPLE questions. Find out when the problem started; if anything makes it feel better or worse; and if the patient has pain, what type of pain it is, and if it radiates. Ask the patient to rate the pain on a scale of 0 to 10, with 10 being the worst pain ever experienced, and how long the pain lasts. Ask the patient about previous heart attacks, heart problems, high blood pressure, aneurysms, lung disorders, diabetes, and kidney disease. Ascertain whether there are any risk factors for coronary disease, and obtain a family history. SAMPLE can also be obtained from family members and medical alert tags. The patient may have more than one complaint, such as chest pain and dif?culty breathing; try to determine which presented ?rst. Patients having a cardiac emergency may also complain of dizziness, appear anxious, or have a sense of impending doom. Some patients may deny that the symptoms are cardiac-related, and others may appear frightened. Nausea, vomiting, fatigue, headache, arm pain, jaw pain, and palpitations are other complaints the patient may have. Identify pertinent negatives. Determine if there was any trauma and if the pain increases on inhalation (pleuritic) or movement. Maintain a calm, pro- fessional attitude; be honest; and provide reassurance. Place the patient in a position of comfort.

Secondary Assessment
Physical Examinations Focus primarily on the cardiovascular system. Assess central and peripheral pulse quality. Exam- ine the skin color; pallor and cyanosis are indicators of hypoxia (low oxygen level). Also assess skin temperature and condition. Look for edema in the extremities, which may be an indicator of cardiovascular failure. Inspect, palpate, and auscultate the chest, focusing on the respiratory effort and adequacy of ventilation. Crackles (rales) heard on auscultation of lung sounds and jugular vein distention are indicators of possible heart failure.
Vital Signs Obtain baseline vital signs, and repeat depending on patient impression, monitoring trends. Vital signs should include blood pressure by auscultation, pulse rate and quality, respiratory rate and quality, and skin assessment for perfusion. Use pulse oximetry, if available, to assess the patient’s perfusion status, keeping in mind that readings for patients with poor circulation may not be accurate.

Reassessment
Interventions Patients who are unresponsive, without breathing or a pulse, need CPR. An automated exter- nal de?brillator (AED) should be applied as soon as it becomes available. Airway control using adjuncts may be necessary. Patients who are conscious should be placed in a position of com- fort, usually sitting up. Loosen any tight clothing. Reassess the primary assessment ?ndings, vital signs, and chief complaint. Assist breathing as required, administering high-?ow oxygen. CPAP might be indicated for patients with congestive heart failure (CHF). If permitted, adminis- ter 162 to 324 mg of chewable low-dose aspirin, and if the blood pressure is adequate, assist the patient in taking his or her prescribed nitroglycerin. Do not delay transport.
Communications and Documentation Contact medical control and/or the receiving hospital with a radio report. Include a thorough description of the MOI/NOI, the position in which the patient was found, and vital signs. Include treatments performed and patient response. Document interventions performed and any changes in patient status and the time the interventions and changes occurred. Follow local protocols. Document the reasoning for your treatment and the patient’s response. Obtain a signature from the hospital physician or nurse on patient transfer.
Cardiovascular Emergencies
General Management of Cardiovascular Emergencies

Managing life threats to the patients ABCs and ensuring the delivery of high-flow oxygen are primary concerns with any cardiovascular emergency. If the patient is unconscious, determine whether CPR is needed. In conscious patients, obtain a thorough history. “Time is muscle,” so rapid transport will be needed to a cardiac care facility for patients presenting with signs and symptoms of a myocardial infarction. If local protocols allow, administer aspirin and assist the patient in taking his or her prescribed nitroglycerin. Be prepared to de?brillate if the patient becomes pulseless.

Cardiogenic Shock

Shock is a state of hypoperfusion. The hypoperfusion from cardiogenic shock is due to failure of the pump (heart). The container (blood vessels) is intact, and the ?uid (blood) is still present within the container. EMTs need to be able to recognize cardiogenic shock over other types of shock because the management is different. The ?rst clue is that there is no mechanism of injury. Chest pain is usually the chief complaint. The pulse may be irregular. The patient may have respiratory distress due to ?uid buildup in the lungs (pulmonary edema) due to poor cardiac output. As with other shocks, the blood pressure is low. Do not place this patient in the shock or Trendelenburg’s position because it will increase the workload of the heart and cause increased ?uid collection

in the lungs. Place the patient in a position of comfort. Administer high-concentration oxygen. Request ALS support if transport is delayed. Do not give nitroglycerin; the blood pressure is already low. If a specialty center is close by, transport there; if not, transport to the nearest hospital.

Congestive Heart Failure

Fluid in the lungs is called pulmonary edema. Pulmonary edema can be caused by cardiac failure after an AMI (CHF) or a noncardiogenic cause such as a toxic inhalation. In either case, the outcome is the same, ?uid in the lungs prevents the ef?cient exchange of oxygen and carbon dioxide. The patient will present with respiratory distress, usually severe, and appear very anxious. The skin will be cool, pale, and moist. The patient’s blood pressure is often high unless the AMI is so severe as to cause cardiogenic shock. Patients with a history of CHF will often sleep with mul- tiple pillows or upright in a recliner. Jugular vein distention is common. The patient needs high- ?ow oxygen. Assisted ventilation or CPAP is often helpful. Assist the patient in taking his or her prescribed nitroglycerin if medical control or protocol allows, ensuring the systolic blood pressure is more than 100 mm Hg before giving the nitroglycerin. Patients experiencing pulmonary edema may require positive-pressure ventilation with a bag-mask device or CPAP. CPAP is the most effective way to assist a person with CHF to breathe effectively and prevent an invasive airway management technique. Transport promptly to the closest emergency department.
Last Updated: May 14, 2018