Acute Coronary Syndrome

 
Cardiac Compromise

            Blanket term for any heart problem.
 

Causes of Cardiac Compromise

• Coronary Artery Disease (Atherosclerosis, arteriosclerosis)
• Aneurysm
• Dysrythmia (bradycardia, tachycardia, V-Fib, V-Tach, Pulseless Electrical Activity (PEA), asystole
• Pulmonary Edema
• Congestive Heart Failure
• Cardiac Rupture
• Angina Pectoris
• Acute Myocardial Infarction

Signs and Symptoms

• Chest pain (crushing, dull, heavy or squeezing)
• Difficulty breathing
• Palpitations
• Sudden onset of sweating and nausea or vomiting
• Anxiety (feeling of impending doom, irritability)
• Abnormal pulse
• Abnormal blood pressure
• Hypotensive or hypertensive
• Loss of consciousness

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Cardiac compromise can manifest itself in many different ways, and there are numerous problems that the heart can experience.  As an EMT it is not necessarily vital that you diagnose the type of cardiac compromise that a patient may be experiencing, but rather be able to recognize that the patient is suffering from a cardiac compromise of some type.  Leave the diagnosing up to the doctors at the hospitals.  In the field it is vital to recognize the various signs and symptoms of a cardiac compromise, and how you will treat it in an out of hospital setting. 

The main symptom of a heart problem is chest pain.  It is important that you rule out chest pain due to trauma, before treating the patient for a cardiac related chest pain.  Once it is determined that the chest pain is cardiac related then you can proceed to treat for cardiac compromise.  You should have the patient describe the pain he is experiencing, this is important because some people’s perception of pain may be different than others.  They may describe it more as a discomfort, or a feeling of pressure.  Typical feelings of pain people will experience while in cardiac compromise are crushing pains, dull, heavy or squeezing.  Pain will commonly radiate along the arms, down to the upper abdomen, or up to the jaw so it is also important to ask the patient if he feels the pain anywhere else or travels anywhere else.

Other typical signs and symptoms of cardiac compromise include dyspnea.  If the patient does not mention that he is having difficulty breathing, ask if he is.  Sometimes the chest pains will focus their attention only on the chest pain and forget to mention any difficulty breathing.  Cardiac patients will often feel anxious, have feelings of impending doom or it can display itself as anxiety in the form of irritability or a short temper.  They can also experience nausea and pain or discomfort in the upper abdomen, mimicking heartburn.

An obvious symptom you will notice in a cardiac patient is a sudden onset of sweating and an abnormal pulse or blood pressure.  The patients pulse may be bradycardic or tachycardic and will frequently be irregular, and the patient may feel palpitations.  Some patients will be hypotensive, and others will be hypertensive.

Cardiac patients often times will deny that they are having heart problems, or they do not want to acknowledge that they could be having heart problems.  Also cardiac compromise can present itself in many different ways so it is imperative that you interview the patient thoroughly making sure to find any signs and symptoms they may be presenting.  Make sure that you have the patient explain their symptoms to you in their own words rather than asking leading questions like: “is your chest pain a crushing pain?”  But rather ask them open ended questions like: “describe the sensation you are having”.  If the patient is having a difficult time explaining the sensations they are having then give them examples like dull, sharp, crushing, squeezing, etc.. 

Because of the many possibilities and potentially severe complications that can arise from heart problems, it is especially important to have a high index of suspicion and treat patients that exhibit any of these signs and symptoms for cardiac compromise.  Treatments that you are able to give will not hurt them and may help them.

Treatment Guidelines

1. Place the patient in a position of comfort.
2. Apply high concentration oxygen via a nonrebreather mask.  If the patient develops an altered mental status or loses consciousness you will need to be prepared to maintain a patent airway and provide ventilations.
3. Immediately transport under these guidelines:

·         Patient has no history of cardiac problems.

·         Patient has a history of cardiac problems, but does not have nitroglycerin.

·         Systolic blood pressure is below 90-100.

1. Determine what hospital to transport the patient to, depending on hospital capabilities in your area will determine where to take the patient.
2. Depending on local protocols, give or help the patient take nitroglycerin, only if all of the following conditions are met (and local protocols or medical direction allows):

·         Patient complains of chest pain.

·         Patient has a history of cardiac problems.

·         Patient’s physician has prescribed nitroglycerin (NTG).

·         Patient has the nitroglycerin, or nitroglycerin is carried in the ambulance.

·         Patient has a pulse greater than 50 and below 100 bpm (follows local protocols).

·         Systolic blood pressure meets your protocol criteria (usually greater than 90-100 systolic).

·         Patient has not taken Viagra or a similar E.D. drug within the past 72 hours.

·         Medical direction authorizes administration of nitroglycerin.

**Make sure to document the patient’s vital signs before the first dose of nitroglycerin is administered and after each dose.  Be sure to find out how many does the patient took prior to your arrival.  Ask the patient the effects of the medication on the pain or discomfort and record the patient’s response.  This information is vital to the hospital since response or lack of response are important clues to the cause of the patient’s difficulty.**

6.      After giving one dose of nitroglycerin, give a repeat dose in 5 minutes if all of the following conditions are met (and local protocols or medical direction allows):

·         Patient experiences no relief or only partial relief.

·         Systolic blood pressure remains greater than 90-100 systolic.

·         Medical direction authorizes another dose.

1. If your EMS system and local protocols allow it, give or help the patient take aspirin if all of the following conditions are met:

·         Patient complains of chest pain.

·         Patient is not allergic to aspirin.

·         Patient has no history of asthma.

·         Patient is not already taking medications to prevent clotting.

·         Patient has no other contraindications to aspirin.

·         Patient is able to swallow without endangering the airway.

·         Medical direction authorizes administration of the medication.

        Follow your local protocols concerning dosages of nitroglycerin and aspirin.  A maximum of three doses of nitroglycerin is generally accepted, as long as the systolic blood pressure remains above 90-100, and local protocols or medical direction allows it.  Nitroglycerin is a vasodilator so after administration the patient’s blood pressure will drop which decreases the workload of the heart.  Patient may also experience a headache, and a change in pulse rate.  This is why it is imperative to know how many doses the patient took prior to your arrival, monitor the patient’s vital signs before and after administration.  Also it is vital that you ask the patient if he has taken any medications for erectile dysfunction.  E.D. drugs work like nitroglycerin, as a vasodilator, so if they have taken any E.D. medications their blood pressure will already be lowered, and any administration of nitroglycerin following any dosage of an E.D. medication will dangerously lower the blood pressure.  Be aware that female patients sometimes take E.D. medications as well, so be sure to ask all patients before administering nitroglycerin.

            Take care while transporting the patient as well.  The patient most likely will already be nervous or scared because of the stress brought on by having heart problems and being taken to the hospital in an ambulance, so a rough ride, harsh driving patterns or sirens wailing could increase the patient’s fear and apprehension, placing additional stress on the heart.  It is important that the patient reach the hospital quickly, but judicious use of sirens, and driving pattern should be balanced against the possibility of worsening the patient’s condition.

            Just keep in mind that cardiac problems can and will present in many different ways.  Recognize the signs of cardiac compromise and treat the patient for cardiac compromise according to local protocols and medical direction.  Always treat cardiac compromise with a high index of suspicion, treatments given will help, treatments not given will do the patient harm.  These patients need high concentration oxygen and prompt, safe transportation to definitive care.

Aortocaval compression syndrome

Supine Hypotensive Syndrome:

Dizziness and a drop in blood pressure caused when the mother is in a supine position and the weight of the uterus, infant, placenta, and amniotic fluids compress the inferior vena cava, reducing return of blood to the heart and cardiac output.

Signs and Symptoms

• Pallor
• Tachycardia (early sign)
• Bradycardia (very late sign)
• Sweating
• Nausea
• Hypotension
• Dizziness
• Edema of the lower extremities
• Sings of fetal hypoxia or distress (seen through CTG in hospital)
• Decreased femoral pulse

Supine hypotensive syndrome is caused when the inferior vena cava is compressed by the weight of a pregnant female’s uterus, fetus, placenta and amniotic fluids while lying in the supine position. The effects of supine hypotensive syndrome are very similar to that of shock, but they are not treated in the same fashion.

This condition can develop as early as the second trimester but is maximal during the third trimester, 36 to 38 weeks. When the pregnant female in these stages lies in the supine position, the added weight of the enlarged uterus and its contents will press down on the interior vena cava. The inferior vena cava is the route by which de-oxygenated blood from the lower half of the body returns to the heart. When the inferior vena cava is compressed it reduces the amount of blood that returns to the heart and reduces cardiac output, this can result in a loss of 30% of the effective circulating blood volume. It can take three to seven minutes for significant hypotension to become manifest.

As stated previously, supine hypotensive syndrome can mimic symptoms of shock. This is because when the blood flow from the inferior vena cava is constricted the blood pressure will drop and will contract the uterine arteries and redirect blood to the major organs. This can cause distress for the fetus, where fetal hypoxia can occur and in extreme cases, fetal demise.

The patient will experience reduced blood pressure, signs of shock such as cool, moist and clammy skin, tachycardia (early sign), bradycardia (very late sign), dizziness, syncope or near syncope, pedal edema, nausea, decreased femoral pulse, and signs of fetal distress which can only be detected by way of CTG at a hospital.

Treating supine hypotensive syndrome is rather easy. If the patient is found unconscious and supine (and supine hypotensive syndrome is suspected) the patient can be placed in the left lateral recumbent position symptoms should be immediately alleviated. If she is awake and feeling symptoms of supine hypotensive syndrome have her sit up, and lay on her side, preferably the left side. If a spine injury is suspected and the patient is secured to a backboard you can tilt the backboard by placing a folded towel or sheet under the right side of the backboard, effectively raising the patient and angling her position to the left releasing pressure from the uterus off of the inferior vena cava. This method is effective for transport of any pregnant trauma patient, as it will help to avoid supine hypotensive syndrome as well as shock. Displacing the uterus manually to the left is also a useful, if any other means of relieving the pressure are unavailable.

During labor the patient will be supine with the knees up, so supine hypotensive syndrome is possible, so it is imperative that a rolled up towel or a wedge of some sort be placed under the patients buttocks, elevating the pelvis as indicated for labor and delivery, but have the right side slightly higher than the left in order to tilt the patient to the left slightly.

For the most part, if a pregnant female is complaining of dizziness or other signs or symptoms of poor perfusion, place them in the left lateral recumbent position. This will almost immediately relieve any symptoms, and is recommended universally to place the pregnant patient in the recovery position no matter what, whenever possible. Moving the patient from the supine position to the left lateral recumbent position increases cardiac output by 20% to 100%, and 97% of reported patients in a study, being titled to the left was more satisfactory than titling to the right. As stated before, when proper procedures are performed to treat supine hypotensive syndrome symptoms will alleviate almost immediately, however, blood pressure may take a few minutes to return to its previous level. Blood pressure should be measured while the patient is in the left lateral recumbent position, or after backboard is titled for spinal precautions, as the reading will be inaccurate in the supine position.

Treatment Guidelines

• Place patient in left lateral recumbent position or elevate right hip.
• If suspected trauma or spinal injury secure to backboard, tilt backboard to left.
• High flow oxygen via non-rebreather.
• Treat for shock if other signs of shock are present.
• Keep patient warm.
• Transport with a quiet, gentle ride to the hospital.

Illustration of inferior vena cava compression by the gravid uterus.

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