The presence of chest pain and/or discomfort is a sign for further assessment and immediate intervention. Not all chest pain is related to cardiac arrest or AMI; however, timely response is imperative if it is cardiac-related.
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
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 is done in the field with the use of ECG machines. 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
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.
The ICD device is placed by a physician in the chest or abdominal area. It is used for patients with high risk type 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 cardiac electrical system, how to handle a patient with an ICD
This device is a vest worn externally under clothing. It has a defibrillator, monitor, and voice systems. The device delivers high energy shocks similar to an AED.
Terms/Concepts to Know: precautions with patient who has defibrillator vest
Patients with severe heart failure or those with need for additional support to pump blood may have this type of device. The device 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 performed by the LVFT, which impacts the ability to palpate the patient’s pulses.
Terms/Concepts to Know:difference between pulsatile and continuous LVFT
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 to the chain of survival
As a general rule, the defibrillator should be used on all non-responsive patients with no palpable pulses who exhibit signs and symptoms of cardiac emergency. 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 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
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
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
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
AED and manual defibrillators are safe to use with children. There are considerations for the type of device, pads, and pediatric attenuators for infants, those under 8 years of age, and those over 8 years of age. Seek best practice recommendations from the American Heart Association.
Terms/Concepts to Know: manual defibrillator, pediatric dose attenuator, options in absence of pediatric defibrillator
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.
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 under these conditions. This is for both the safety of patient as well as the safety of the emergency response team.
Patients may have on 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 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
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
According to the American Heart Association, “Each year, more than 350,000 emergency medical services-assessed out-of-hospital cardiac arrests occur in the United States.” Cardiac arrest is described as the cessation of the heart’s electrical 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.
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
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 AED, ROSC
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 for procedure in various scenarios is important.
Terms/Concepts to Know: handling patient with no pulse and no AED shock recommended
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
The role of the 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 AED instructions.
Terms/Concepts to Know: scope of practice between EMT and ALS team
Return of spontaneous circulation in a patient who may have not 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