Cardiology and Resuscitation Study Guide for the EMT Test

General Information

Many emergencies involve problems with the heart and its functions. You’ll need to know both the appropriate terms and actions to make the most of those few minutes you may have to save a life. This study guide outlines what you’ll need to know in this area to answer related questions correctly. Refer to your textbook for more information about all the terms listed until you are thoroughly familiar with them and their related procedures.

Cardiology

Cardiac Anatomy and Physiology

The cardiovascular system consists of arteries, veins, capillaries, and the heart. Knowledge of this system and how it works, including its potential dysfunctions and diseases, is critical to patient management in emergencies.

Heart Function

The primary function of the cardiovascular system is to ensure the flow of oxygenated blood throughout the body. Using the atrium, ventricles, and aorta, the system is precise in delivery. The veins carry blood to the heart and the arteries carry blood from the heart throughout the body. In the process of this delivery, by-products are carried to the systems that function to rid the body of waste, such as the urinary or digestive systems.

Terms/Concepts to Know: atrium, ventricles, aorta, parts of the heart, main function of upper and lower heart chambers, blood flow pathway, automaticity, autonomic, sympathetic and parasympathetic nervous system

Circulation

Circulation is the system of flow from the heart to the other tissues of the body and back again. For the system to function optimally, there must be an adequate volume of blood, patent valves, and functional vessels that dilate to allow blood flow.

Terms/Concepts to Know: myocardium, stroke volume, dilation, coronary arteries, aortic valve, cardiac output

Cardiac Pathophysiology

Diseases or dysfunction of the heart and/or the vessels are common. The Center for Disease Control and Prevention (CDC) states that one in four Americans suffer from heart disease.

Atherosclerosis

Atherosclerosis is a cardiac disease where a buildup of plaque forms inside the walls of the blood vessels. This buildup causes obstruction of blood flow and interferes with their ability to dilate or contract.

Terms/Concepts to Know: occlusion, lumen, ischemia, thromboembolism, acute myocardial infarction, cardiac arrest

Acute Coronary Syndrome

Acute coronary syndrome is a description of a conglomeration of symptoms brought on by myocardial ischemia. There are two categories in which these symptoms are labeled.

Angina Pectoris

This disease process can be painful, although not life-threatening. The pain is caused by decreased oxygen flow due to a blockage or narrowing in the blood vessels that supply the heart, or arterial spasm, and it may be present during stress or physical exertion. The pain is typically located in the mid-chest area and is described by patients as a squeezing, pressure sensation, much like reflux or GERD symptoms. There may also be jaw and/or arm pain and nausea. Angina does not cause heart cell death; however, it can cause arrhythmias and serve as a precursor or warning to initiate preventive measures.

Acute Myocardial Infarction (AMI)

The key identifiers of AMI symptoms include acute onset of nausea, sweating, chest pressure or squeezing, arm, jaw, lower back, and/or abdominal pain. Some patients experience other diverse symptoms and some patients have no symptoms prior to onset. The pain is derived from arterial blockage, which can cause irreversible cell death. Sudden death can occur as a result of an AMI.

Terms/Concepts to Know: nitroglycerin regime, syncope, signs and symptoms of ACS, difference between angina pectoris and acute myocardial infarction, symptom differential between gender and age population

Cardiogenic Shock

Low cardiac output creates decreased oxygenation to the body. This low output keeps the heart from performing at full pressure/force to send adequate amounts of oxygenated blood throughout the body, resulting in pump failure. Over time, this condition can impair organ functions.

Terms/Concepts to Know: signs and symptoms of cardiogenic shock, time frame for cardiogenic shock to occur after AMI

Congestive Heart Failure

In congestive heart failure, the heart’s pumping mechanism is weaker, resulting in slower blood flow throughout the heart and in turn the entire body. This lack of pumping action creates fluid stasis around the heart and congestion in the lungs.

Terms/Concepts to Know: function of the left ventricle and atria, pulmonary and dependent edema

Hypertensive Emergencies

Hypertension is defined as acute or chronic high blood pressure outside of the normal range. Identification of classic signs and symptoms that create hypertensive emergencies is key to accurate and timely treatment. The ideal blood pressure, according to the American Heart Association, is 120/80. High blood pressure is defined as 140/90 or higher. An EMT should be familiar with three common hypertensive emergencies: AMI, aortic aneurysm, and dissecting aortic aneurysm.

Terms/Concepts to Know: cardiac process for systolic and diastolic readings, normal blood pressure ranges for adults, possible signs and symptoms of hypertensive emergency, aortic aneurysm, differentiate symptoms of AMI and dissecting aortic aneurysm

Patient Assessment in a Cardiac Emergency

Cardiac assessment is critical no matter what the environment. In an emergency situation, accuracy, timing of treatment, and medication regimens are extremely important for the best patient outcomes.

Scene Size-Up

Gather as much information as possible, starting with information from the 911 call. Observation of the environment and information from the patient and/or witnesses regarding the incident are also helpful. Ensure the environment is stable and safe and always use universal precautions. Avoid making assumptions or letting the information you obtained pigeonhole your thinking. Use the scene size-up to gather baseline information regarding the environment, incident onset, and the pattern and duration of signs and symptoms.

Terms/Concepts to Know: key components of scene size-up

Primary Assessment

The initial patient assessment should include assessing their level of consciousness (LOC), and their airway, breathing, and circulation (ABCs). Depending on the symptoms and status, timely actions should be set in motion. Ensure there is an automated external defibrillator (AED) and oxygen in place, if needed, with Advanced Life Support (ALS) backup, if possible.

Terms/Concepts to Know: AED, CPR process

Taking History

At this point in the process, it is assumed that life-threatening factors are being monitored and controlled. During the scene size-up, some of the patient history may have been obtained. It is important to stay calm and speak to the patient and witnesses in a clear, concise, and calm tone. Clarify and fill in important medical and medication history at this juncture. Obtain and pinpoint details of associated and currently occurring signs and symptoms, as well as pertinent comorbid conditions and a history of similar events.

Terms/Concepts to Know: common symptoms of respiratory versus cardiac symptoms, key questions for the alert patient during a cardiac emergency, OPQRST mnemonic for pain assessment

Secondary Assessment

The primary assessment information is part of the foundation for the more specific, hands-on secondary assessment. Focus on the key and currently active symptoms to guide further evaluation of the respiratory, circulatory, and cardiovascular systems. Observe and assess skin condition, color, temperature, turgor, capillary refill, etc. Monitor vital signs, including blood pressure, respirations, oxygen saturation, pulse, blood sugar, and pain level. Auscultate lungs and heart, paying attention to key signs and symptoms of cardiovascular and respiratory complications.

Terms/Concepts to Know: procedure for observing and assessing the heart and lungs

Reassessment

This is the time to prepare for transportation and communication with the emergency room team. The reassessment, which is basically the same as the primary assessment, focuses on the patient’s current status, with attention to any status changes in the primary complaint/concern. Focus on improvements or lack thereof with adjustments to treatment regimes as appropriate. Ensure that documentation is complete and accurate, with interventions and times included.

Terms/Concepts to Know: determination of frequency of vital signs

Chest Pain or Discomfort

The presence of chest pain and/or discomfort is a sign for further assessment and immediate intervention. Not all chest pain is related to a cardiac event; however, timely response is imperative if it is cardiac-related.

Basic Treatment

The fundamental treatment regimens for chest pain include: positioning of the patient, basic comfort measures, removal or adjustments to clothing, and oxygen support via appropriate mechanism for condition.

Terms/Concepts to Know: oxygen titration, mechanisms for oxygen delivery, preventative ASA usage and doses

Using Nitroglycerin

Many patients who are at risk and those who have had previous cardiovascular episodes have prescriptions for nitroglycerin. The maximum dosage frequency and time frame for nitroglycerin administration for a chest pain incident is three (3) doses every 5 minutes. There are important key points in its administration: be sure to know nitroglycerin expiration, contamination, potency, prescription rights, and handling of the pills and patches.

Terms/Concepts to Know: nitroglycerin dosage, indications and contraindication, steps and precautions when administering and handling nitroglycerin

Cardiac Monitoring

Cardiac monitoring is done in the field with the use of an ECG machine. Check your jurisdiction for EMT scope of practice in placing electrodes and leads for cardiac monitoring. Prior to placing the electrodes and leads, the skin will need to be assessed and prepped for adherence patency. The placement requires accuracy to ensure an ECG strip free of extraneous interference.

Terms/Concepts to Know: artifact, position placement of electrodes and 12-lead ECG

Dealing with Heart Surgeries and Cardiac Assistive Devices

The current healthcare environment has many advanced treatments, surgeries, and technological devices that assist the patient with heart conditions. Knowledge of these devices and how they assist the patient is important for the EMT.

Implantable Cardiac Defibrillator (ICD)

The ICD device is placed by a physician in the chest or abdominal area. It is used for patients with high-risk arrhythmias that have potential for sudden cardiac arrest. It works by delivering shocks to the heart when life-threatening arrhythmias occur.

Terms/Concepts to Know: basic knowledge of the cardiac electrical system, how to treat a patient with an ICD

Defibrillator Vest

This device is a vest worn externally under clothing. It has a defibrillator, monitor, and voice system. The device delivers high energy shocks similar to an AED.

Terms/Concepts to Know: precautions with a patient who has a defibrillator vest

Left Ventricular Assist Device

Patients with severe heart failure or those with a need for additional support to pump blood may have this type of device. The left ventricular assist device (LVAD) supports the pumping function of the left ventricle. The device may be set for intermittent pumping or pulsing similar to the way the heart functions. It may also be a continuous pumping, which impacts the ability to palpate the patient’s pulses.

Terms/Concepts to Know: difference between pulsatile and continuous LVAD

Automated External Defibrillator

The AED is a computerized, interactive, semi-automated device. The invention and wide distribution and use of AEDs has supported the increased survival rate for cardiac emergencies.The device works to monitor electrical impulses from the heart through electrodes and deliver appropriate shock based on certain and often fatal arrhythmias. AEDs are designed to be easy-to-use so even non-medical personnel can use them in the event of a cardiac emergency.

Terms/Concepts to Know: five links in the chain of survival

When to Use a Defibrillator

As a general rule, the defibrillator should be used on all unresponsive patients without palpable pulses. The defibrillator will monitor and analyze if a shock is needed at any point during the time care is being provided. Always follow the defibrillator’s instructions before delivering a shock.

Terms/Concepts to Know: general function and advantages of the AED, when to avoid use of the defibrillator and rationale, bradycardia, tachycardia

Using a Defibrillator and Resuscitation

Many communities have provisions for laypersons to be trained to provide CPR. This has many benefits and often plays a large part in positive patient outcomes. The EMT may encounter patients where CPR is already in play, but should be ready to take over care when they arrive on the scene. AEDs should be used on patients for which CPR is not producing a pulse and/or the patient is unresponsive.

Terms/Concepts to Know: asystole, use of AED with active CPR

Defibrillator Maintenance

The emergency team is responsible for the proper use and maintenance of the AED on its rig. Preventive maintenance (PM) and quality checks should be a part of the emergency equipment maintenance regime and should always include the AED. Follow your jurisdiction and/or machine handbook to ensure everyone is trained on the proper use and maintenance of all relevant medical equipment.

Terms/Concepts to Know: legal risks with an AED, ways to ensure function of an AED, reporting manufacturer malfunction of an AED

Medical Supervision

There are ongoing outcome-based studies and quality improvements related to cardiac survival rates of patients where early intervention is implemented. It is important to include appropriate medical supervision in the protocols, procedures, and guidelines related to AED use. Ideally, after each time the AED is used, the emergency team should have a debriefing/review session that includes a description of the situation, what went well, and what can be improved in the future.

Terms/Concepts to Know: role of the medical director in AED use, quality improvement goals with AED

Defibrillator Use for Children

AED and manual defibrillators are safe to use with children. There are considerations for the type of device, pads, and a dose-attenuating system (energy reducer) for infants under one year of age, and for those up to eight years of age. Seek best practice recommendations from the American Heart Association.

Terms/Concepts to Know: manual defibrillator, pediatric dose attenuator, options in the absence of a pediatric defibrillator

Special Situations

There are always variables that fall outside of a “normal” defibrillation situation. Here, we will discuss three that require additional knowledge, especially with regard to safety.

Pacemakers and Implanted Defibrillators

Patients with chronic heart conditions may have implanted or internal devices. Avoid placing the AED pads directly over these devices. If a device is located where the AED pad would normally be placed, simply put the AED pad directly below the device. The anterior or posterior pad position may also be used.

Wet Patients

The scene size-up must include observation of the environment related to damp/wet areas around the patient. Water acts as a conductor of electricity, and electronics, including the AED, should not be used in water. This is for both the safety of the patient as well as the safety of the emergency response team. If the patient is lying in a large amount of water, move them out of the water and dry the skin prior to attaching the AED pads.

Transdermal Patches

Patients may wear medication patches for various reasons. Always use a gloved hand to remove any patches that may interfere with lead or AED pad placement, and wipe the area clean and dry to free it of gel or residue before application.

Terms/Concepts to Know: alternative AED pad placements

Chest Pain in a Child

Chest pain in a child is typically a benign and self-limiting condition related to an acute illness. Respiratory issues, such as choking, are typically the cause of cardiac events in children without previous cardiac history.

Terms/Concepts to Know: congenital

Cardiac Care and Age Range

Emergency care of the patient with cardiac concerns is critical. Procedures must be followed and may need to be tweaked based on the individual’s age and unique healthcare needs. For example, a pediatric patient with a history of heart disease typically has congenital defects that would require a slightly different care approach than the care given to the general pediatric population. Cardiocare for the older patient with a chronic history of cardiac and cardiovascular diseases may differ some from a patient with clear arteries.

Terms/Concepts to Know: complications common with older patients

Cardiac Arrest Care

According to the American Heart Association, “Each year, more than 350,000 cardiac arrests occur outside of the hospital in the United States.” Cardiac arrest is described as the complete cessation of the heart’s electrical and/or mechanical system to function. This is not the same as a heart attack, which is caused from a blockage that prevents blood flow to the heart.

Preparation

Safe and rapid response for a patient experiencing cardiac arrest is critical to survival. Prepare to provide care for the patient by assigning roles to team members, assessing the scene, MOI, and environment. Also, observe any additional or potential injuries and environmental factors that could impact safe care.

Terms/Concepts to Know: heart attack, cardiac arrest

Defibrillation

The defibrillation process is done in conjunction and coordination with persons performing CPR, giving rotating breaks when possible to prevent exhaustion. The AED is used on the unresponsive patient as soon as available at the scene. The AED will direct the process for delivering shocks. After each defibrillation, CPR will continue, starting with compressions.

Terms/Concepts to Know: how to coordinate CPR and defibrillation, steps for using an AED, ROSC

After Defibrillation

Post-defibrillation care includes three basic scenarios: (1) the patient has regained a pulse; (2) there is no pulse and the AED recommends shock; and (3) there is no pulse and the AED does not recommend shock. Knowing your jurisdiction policies and procedures in various scenarios is important.

Terms/Concepts to Know: treating a patient with no pulse and no AED shock recommended

Arrest During Transport

During transport, the patient should be closely monitored. If, during the course of the transport, the patient does not have a palpable pulse or a conscious patient becomes unconscious, the process for care delivery must resume according to the best practice recommendations within your jurisdiction and ALS guidelines.

Terms/Concepts to Know: resuming or starting CPR during transport

Role of ALS

The role of the Advanced Life Support (ALS) team is invaluable to the community. Ensure open, clear, concise communication with this team to support the best measures for patient care. In situations where ALS has not arrived or is not available, act in the patient’s best interests by beginning the use of the AED as soon as possible. If the patient is in ventricular fibrillation, time is of the essence, so follow the AED instructions.

Terms/Concepts to Know: scope of practice between EMT and ALS team

Spontaneous Circulation Return

Return of spontaneous circulation in a patient who may not have had palpable pulses is a positive sign. This means that the patient has regained sufficient blood flow to the body after a cardiac arrest.

Terms/Concepts to Know: how to handle ROSC