Cardiac Conditions: A Paramedic’s Guide

Posted on Oct 21, 2024 in Medicine & Health

Module 1: Cardiac Basics

Cardiovascular Disease (CVD)

CVD is an umbrella term encompassing coronary artery disease, heart failure, stroke, peripheral artery disease, and others.

History Taking (CVD)

  1. Current event history (e.g., hypertension, hypercholesterolemia, or diabetes)
  2. Past medical history
  3. Family and social history (smoking)
  4. Surgical and medication history

Common Cardiac Complaints

  1. Chest pain
  2. Dyspnea (SOB)
  3. Dizziness/syncope/fatigue
  4. Unexplained nausea with or without vomiting
  5. Swollen ankles, abdominal bloating, or increased JVP
  6. Palpitations or tachycardia

Identifying Risk Factors (Cardiac History)

  • Previous cardiovascular history
  • Family history
  • Smoking
  • Hypertension
  • Diabetes

Non-Modifiable Risk Factors

  • Age
  • Gender
  • Genetic factors
  • Race and ethnicity

Modifiable Risk Factors

  • Smoking and excessive alcohol consumption
  • Obesity
  • High blood pressure
  • Sedentary lifestyle
  • Poor diet
  • Diabetes

Cardiovascular Examination

  1. Gain consent and explain the procedure.
  2. Position patient semi-recumbent.
  3. Inspect hands, face (jaundice, anemia), neck (JVP), chest, back, and peripheries.
  4. Obtain vital signs (BP, RR, SpO2).
  5. Auscultate all four heart valves and lungs.
  6. Assess central perfusion.
  7. Obtain a 12-lead ECG.
  8. Gather medical, current/past/social history.

Heart Sounds

Listen for murmurs, gallops (S3 and S4), clicks, muffled heart sounds, and friction rubs.

Module 2: Bradycardia & SVT

Bradycardia

Pathophysiology

Impaired conduction impulse results in a slow heart rate.

Clinical Manifestations of Deterioration

  • Chest pain
  • SOB
  • Dizziness or light-headedness/syncope
  • Fatigue
  • Change in level of consciousness

Management (Asymptomatic Bradycardia)

  • Masterly inactivity (monitor but do nothing more)
  • Transport, observe, and repeat ECGs

Management (Symptomatic Bradycardia)

Intervention is necessary only if clinically significant symptoms are present (e.g., hypotension, SOB, syncope/dizziness).

  • Reassurance
  • Call for backup
  • Monitor, ECG, and observe
  • Consider nervous system and drug effects:
  • Atropine (to block excess parasympathetic nervous system activity)
  • Adrenaline (to increase heart rate)
Escape Rhythms (Electrical Blocks)
  • Establish IV access
  • Administer oxygen if SpO2 is <94%
  • Trial atropine
  • External cardiac pacing if unresponsive to atropine
  • Observe, reassure, and transport

Supraventricular Tachycardia (SVT)

Pathophysiology

Caused by re-entry circuits or abnormal spontaneous electrical impulses generated at or above the AV node, causing the heart to beat faster than normal.

SVT Inclusion Criteria

  • Regular narrow complex tachycardia
  • Rate > 120 bpm
  • QRS duration <120ms in all 12 leads
  • No P waves seen (embedded in QRS complex)

Signs and Symptoms

  • May be asymptomatic
  • Heart palpitations
  • Chest pain
  • Fatigue and light-headedness
  • Sweating
  • Increased HR and SOB

Management

  1. Treat the person, not the ECG (primary or secondary tachycardia)

Causes of Tachycardia (Physiological and Pathological)

  • Pain, anxiety, exercise, hypoglycemia, hypoxia, sepsis, and toxicity

Modified Valsalva Maneuver

  1. Explain the procedure and obtain consent.
  2. Place the patient in a semi-recumbent position.
  3. Prepare a 10 ml syringe with a loosened plunger.
  4. Encourage the patient to blow into the syringe for 15 seconds with enough pressure to move the plunger (forced expiration/strain).
  5. Immediately after the 15-second strain, lie the patient flat and raise their legs to 45 degrees for 15 seconds.
  6. Return the patient to a semi-recumbent position for 30 seconds.
  7. After 45 seconds, reassess the rhythm with a 12-lead ECG.
  8. Repeat as necessary (maximum three times).
  9. Transport to the ED.

Management of SVT

Hemodynamically Stable
  • Modified Valsalva maneuver (up to three times)
  • Adenosine if Valsalva is ineffective
Unstable (With Pulse)
  • DC synchronized cardioversion

Module 3: Acute Coronary Syndrome (ACS) & Other Conditions

ACS Types

  • Unstable angina (minimal occlusion)
  • NSTEMI (severe occlusion)
  • STEMI (complete occlusion)

STEMI vs. NSTEMI

  • STEMI: ST-segment elevation (requires immediate PCI or fibrinolysis)
  • NSTEMI: ST-segment depression or T-wave inversion (no ST elevation)

Medications to Reverse Clotting

  • Antiplatelets
  • Anticoagulants
  • Thrombolytics

Points of Delay

  • Patient delay
  • Paramedic delay
  • Hospital delay

STEMI

Pathophysiology

Complete artery blockage/occlusion causing myocardial ischemia and necrosis.

Signs and Symptoms

  • Sudden, severe chest pain radiating to the left arm or jaw
  • Diaphoresis (sweating)
  • SOB
  • Nausea and vomiting
  • Sense of impending doom

Management

  • Reassure, call for backup, monitor, and obtain a 12-lead ECG.
  • Transmit ECG to the hospital; check the affected region of the heart.
  • Administer aspirin 150-300 mg (all patients with suspected ACS).
  • Obtain vital signs and establish two IV lines.
  • Administer nitrates (GTN) to reduce pain and increase coronary blood flow (vasodilator).
  • Administer analgesia (morphine/fentanyl) to reduce cardiac oxygen demand.
  • Administer oxygen only if SOB and SpO2 <90%; use fluids cautiously.
  • Transport to a hospital with a catheterization lab for PPCI or fibrinolysis (only if PPCI is not feasible).

Contraindications to GTN

  • Erectile dysfunction drugs used in the last 24-36 hours
  • BP <90 mmHg

NSTEMI

Signs and Symptoms

  • Milder or intermittent chest pain
  • SOB
  • Fatigue
  • May occur at rest or with minimal exertion

Management

  • Reassure, call for backup, monitor, obtain ECG, and observe.
  • Administer aspirin.
  • Administer nitroglycerin if needed.
  • Administer oxygen if SpO2 <94%.
  • Transport to the hospital for further evaluation.

Heart Failure

Heart failure is a broad term indicating the heart’s inability to meet the body’s needs for blood and oxygen. It’s caused by a structural or functional issue that decreases the heart’s preload or afterload.

  • Structural: Heart damage (e.g., ischemia)
  • Functional: Dysrhythmia (very fast or slow heart rhythm)

Life-Threatening Complications

  • Fluid overload (e.g., pulmonary edema)
  • Ventricular ejection failure (e.g., cardiogenic shock)

Types of Heart Failure

  • Right-sided, left-sided, both, or ejection fraction (EF)

Management

  • Treat underlying causes.
  • Manage symptoms.
  • Improve perfusion (oxygen, positioning, diuretics if needed, nitrates if appropriate).

Complications

  • Stroke
  • Arrhythmia
  • Mental health issues
  • Hepatic dysfunction

Cardiogenic Shock

Cardiogenic shock involves inadequate blood flow to organs due to a dysfunctional heart. It is a medical emergency.

Other Cardiac Conditions (Non-ACS)

  • Pulmonary embolism (PE)
  • Myocarditis
  • Pericarditis
  • Cardiac tamponade
  • Aortic aneurysm

Pericarditis

(Acute or chronic—lasting over three months)

Symptoms

  • Sharp, stabbing pain worsened by deep breathing
  • Pain relieved when sitting up
  • Palpitations
  • SOB, especially when lying down
  • History of infection (viral—influenza, COVID-19, or recent cold)
  • Fever (may be present)
  • Fatigue or general malaise

Diagnosis

  1. ECG (global ST elevation often with associated PR segment depression)
  2. Chest pain
  3. Pericardial friction rub (auscultation)
  4. Pericardial effusion (increased blood results and inflammation on CXR or echocardiogram)

Note: Pericarditis is not easily identified on a 12-lead ECG (sinus tachycardia, T-wave inversion). Blood tests, viral PCR testing, MRI, and biopsy may be necessary.

Myocarditis

(Acute or chronic)

Causes

  • Viral or bacterial (most common)
  • Medications
  • Toxins
  • Reactions

Symptoms

  • SOB
  • Chest pain
  • Palpitations

Diagnosis

  • 12-lead ECG (non-specific findings)
  • Blood tests
  • Biopsy
  • Viral PCR testing
  • Cardiac MRI

Aortic Aneurysm

Pathophysiology

  • Can occur anywhere in the body
  • Majority occur in the aorta due to constant high pressure
  • Outpouching or bulging of the aortic wall

Causes

  • Atherosclerosis (plaque formation leading to erosion of the internal aortic wall)
  • Chronic hypertension (increased stress on the aortic wall)

Symptoms

  • Pain
  • SOB
  • Altered consciousness
  • Hypotension
  • Decreased perfusion
  • Increased HR

Progression

Abdominal aortic aneurysm > Large abdominal aneurysm > Ruptured AAA

Management

Free Rupture or Contained Leak
  • Resuscitation and surgery
Non-Surgical Care
  • Palliative care and analgesia

Ruptured Abdominal Aortic Aneurysm (RAAA)

Symptoms

  • Hypotension
  • Pain
  • Sweating

Complications

  • Death
  • Ischemia
  • Decreased blood flow to the intestines

Management

Same as Aortic Aneurysm

Acute Pulmonary Edema (APO)

Signs and Symptoms

  • SOB, cyanosis, and increased RR
  • Crackles (auscultation)
  • Frothy (pink) sputum
  • JVD and peripheral edema

Management

  • Call for backup, monitor, and obtain ECG.
  • Sit the patient up to decrease pulmonary congestion.
  • Establish IV access and administer oxygen (maintain SpO2 >92%).
  • Administer diuretics (furosemide) to decrease fluid overload.
  • Administer glyceryl trinitrate (GTN) if blood pressure allows, to relieve pulmonary congestion.
  • Administer CPAP for respiratory distress.
  • Treat the underlying cause (hypertension, MI, or arrhythmias).
  • Transport and reassure.

Contraindications to CPAP

  • Pneumothorax
  • Hemodynamic instability
  • Severe facial trauma
  • Unconsciousness

Pulmonary Embolism (PE)

Definition

A blood clot or other material blocks a blood vessel in the lungs, causing hypoxia and hypotension.

Types

  • Massive PE (life-threatening, can cause cardiac arrest)
  • Sub-massive PE (can affect the left or right side of the heart, occluding arteries)

Main Symptoms

  • Hypotension (decreased cardiac output)
  • Hypoxia (decreased oxygen levels in the blood)

Embolism

Definition

A blood clot or foreign material dislodges and travels through the bloodstream, causing a blockage in a blood vessel.

Causes (Deep Vein Thrombosis [DVT])

  • Inactivity (bedridden or prolonged periods of inactivity)
  • Predisposing factors (clotting disorder or medications)

Symptoms (DVT)

  • Unilateral swelling and pain (lower legs)
  • Redness in the affected calf
  • Pain worsened by palpation and standing

If the clot dislodges, it can cause:

  • Wheezing
  • SOB
  • Coughing up blood
  • Chest pain
  • Syncope

Complications (DVT)

The clot can break off and travel to the right side of the heart and pulmonary arteries, leading to a pulmonary embolism.

Module 4: Pediatric Cardiology

Pediatric vs. Adult Cardiology

The most common pediatric cardiac condition is congenital heart disease.

Cardiac Anatomy (Adult vs. Pediatric)

  • Pediatric hearts are proportionately larger than their body size.
  • Pediatric hearts are spherical (adult hearts are elongated).
  • Pediatric patients have a higher heart rate (faster rate, smaller stroke volume).
  • Children’s ventricular walls are thinner than adults’.
  • Pediatric hearts contain more water.

Fetal Cardiology

Key Structures

  • Shunt
  • Placenta
  • Umbilical vessels

Embryology (Cardiac)

The study of the development of the cardiovascular system in the womb.

Fetal Circulation

Exchange of oxygen, waste, and nutrients.

Cyanotic vs. Acyanotic Pediatric Patients

Cyanotic Pediatric Patients

Signs and Symptoms
  • Blue or gray skin
  • Lethargy
  • Increased respiratory rate
  • Poor feeding
Management
  • Calm the child to decrease heart rate and oxygen consumption.
  • Knee-to-chest position to increase left ventricular pressure and right outflow.
  • Supplemental oxygen (aim for SpO2 85%, start low flow).
  • Careful monitoring

Acyanotic Pediatric Patients

Signs and Symptoms
  • Normal skin color (pink)
  • May be in heart failure (increased JVP and pulmonary congestion)
  • Mild fatigue and difficulty feeding
Management
  • Trial oxygen, but be aware it may worsen hypoxia (pulmonary vasodilator)

ECG Placement (Pediatric)

Same as adults, but in children younger than five years old, V4 is moved to V4R.

Common Pediatric Arrhythmias

  • SVT (vagal maneuvers or apply ice to trigger the diving reflex and decrease heart rate)
  • WPW (short PR interval and notched R upstroke)

Pacing and Pacemakers

Standard management for patients with complete AV block. Refer to bradyarrhythmia, tachyarrhythmia, or cardiac arrest guidelines.