Chapter 4.docx

Chapter 4 Cardiovascular emergencies and Cardiopulmonary Resuscitation (CPR) Cardiovascular disease Cardiovascular disease is one of the leading causes of death of adults in Canada. Some of these deaths could be prevented if appropriate first aid was given. This chapter describes the first aid for c...

Chapter 4 Cardiovascular emergencies and Cardiopulmonary Resuscitation (CPR) Cardiovascular disease Cardiovascular disease is one of the leading causes of death of adults in Canada. Some of these deaths could be prevented if appropriate first aid was given. This chapter describes the first aid for cardiovascular emergencies, including First aid for angina/heart attack First aid for stroke/TIA First aid for cardiac arrest, which is CPR High blood pressure Blood pressure is the pressure of the blood against the inside walls of the blood vessels. Blood pressure goes up and down naturally. When a person is excited or emotionally stressed, blood pressure goes up, but it usually comes down once the excitement has passed. In some people, their blood pressure stays high all the time. This condition of constant high blood pressure is called hypertension. Over time, hypertension damages the tissues of the cardiovascular system. The walls of the blood vessels become thick and lose their elasticity and the heart becomes enlarged. The changes caused by high blood pressure increase the risk of stroke, heart attack, kidney, and eye problems. Unfortunately, hypertension does not always give warning signals-you may feel perfectly well but still have high blood pressure. This is why it is often called the "silent killer." If you have concerns about your blood pressure, you should speak with your primary health-care provider. Blood pressure machines located in pharmacies can help you monitor your blood pressure, but should never be used as a means of self-diagnosis. Narrowing of the arteries Arteries are the blood vessels that carry blood away from the heart. They become diseased when fatty deposits build up inside them, making the passage for blood narrower. This process of depositing fat and narrowing of the arteries is called atherosclerosis. In the coronary arteries, which carry oxygenated blood to the heart, it is called coronary artery disease. As an artery gets narrower, less and less blood can get through. When the artery gets too narrow, the tissues on the other side of the narrowing don't get enough oxygenated blood to function normally. Although the signs and symptoms of hardening of the arteries usually don't appear until middle age or later, atherosclerosis often begins in childhood. Angina Angina occurs when the blood supply feeding the heart muscle becomes limited due to narrowed, damaged, or blocked arteries. When the heart works harder and needs more blood (e.g. when you run for a bus or shovel snow), it cannot get enough blood. This causes pain or discomfort in the chest, which may spread to the neck, jaw, shoulders, and arms. Angina pain typically doesn't last long, and goes away if the person rests and takes their prescribed medication. Heart attack A heart attack happens when heart muscle tissue dies because its supply of blood has been cut off. A heart attack can feel just like angina, except the pain doesn't go away with rest and medication. If the heart attack damages the heart's electrical system, or if a lot of the heart muscle is affected, the heart may stop beating properly. This is cardiac arrest. Risk Factors A number of factors increase the risks for cardiovascular disease, heart attack, and stroke. These can be broken down into modifiable and non-modifiable risks. The modifiable risk factors can lead to dyslipidemia (increased deposits of fats), obesity, diabetes, and high blood pressure. Non-modifiable Modifiable Age Genetic History Sex Smoking Poor diet Lack of exercise Increased stress Modifiable risks can be reduced through lifestyle changes. Angina and heart attack Early recognition and denial The first step is recognizing a cardiovascular emergency. It's difficult to accept that someone is having a heart attack and could die very soon, especially if the person is a family member or a close friend. The casualty is often denying anything serious is happening as well, so it's easy to accept their reassurances. On average, casualties take several hours to get to a hospital from the time they first start feeling poorly. It is this wasted time that prevents many lives from being saved. When someone complains of chest pain, shortness of breath and looks odd you should consider it a serious problem-that's early recognition, and call for medical help. Getting the casualty to the hospital quickly gives them the best chance for survival. Chain of Survival® CPR is often what comes to mind when people think of first aid for a heart attack or cardiac arrest. But CPR is only part of the picture. There are five steps that are important when helping someone with heart problems. Immediate recognition of a cardiovascular emergency and activation of the community emergency medical services (EMS) system. This means calling for help quickly. Early CPR with an emphasis on chest compressions. Rapid defibrillation. Effective advanced life support. Integrated post-cardiac arrest care. Each of the steps is as important as the others. Time is a vital ingredient. To give a casualty in cardiac arrest a reasonable chance of survival, CPR must be started immediately followed by defibrillation as quickly as possible. For both procedures, the sooner they happen, the better. You, the first trained person on the scene, are responsible for initiating the sequence. You must recognize the cardiovascular emergency, call for medical help, start CPR if needed, and apply a defibrillator if one is available. You are the crucial first three links in the Chain of Survival®. If nothing is wrong the ambulance crew can reassure the casualty. On the other hand, if there is a serious problem, you may have saved a Iife. Signs and symptoms of angina and a heart attack: A heart attack will produce shock and may display some or all of the following: Pale, ashen skin Sweating, cold and clammy to the touch Shortness of breath Showing obvious pain or discomfort The pain or discomfort will be in the upper body, from the upper abdomen to the jaw and arms, and may feel like: Heaviness in chest Tightness or pressure in chest Squeezing or crushing chest Indigestion, nausea or vomiting Aching jaw Sore shoulder or arms Some other signs and symptoms include: Fatigue Anxiety, which produces denial Central back pain Denial is an important detail. If someone showing signs of shock, having trouble breathing and experiencing pain insists there is nothing wrong, then you should be very suspicious and take action. First aid for angina/heart attack Perform a scene survey, then do a primary survey. Ask the casualty questions : "Can you show me where it hurts?" "Have you had this pain before?" "Do you have medication for this pain?" Call for medical help and get a defibrillator. Place the casualty at rest, the semi-sitting position is usually the best option, and reassure them. Assist the conscious casualty to take their prescribed medication, usually nitroglycerin. If the casualty has no prescribed medication, or the first dose is ineffective, ask the casualty if they have any allergies to ASA, or if a doctor has ever told them not to take it. If the casualty believes they can take it, suggest they chew one regular ASA tablet (or two low-dose tablets). ASA can reduce the effects of a heart attack because of its anti-clotting properties. If the casualty loses consciousness and stops breathing, start CPR. Helping with Nitroglycerin Nitroglycerin tablets or sprays are common medications for relief of chronic angina pain. A casualty in serious distress may need your help to take their medication. Ask the casualty if they have taken any other medications today. Drugs to treat erectile dysfunction such as Viagra® or CIALIS® may cause a significant decrease in the person's blood pressure if nitroglycerin is taken as well. Have the casualty spray the medication under the tongue or place the tablets under the tongue-they aren't to be swallowed. Nitroglycerin may be repeated, if needed, every 5-10 minutes to relieve pain, or until a maximum of three doses have been taken. Remember that if you have to assist someone to take their medica- tion, you must call for medical help! Stroke and transient ischemic attack (TIA) Stroke A stroke happens when blood flow to a part of the brain is interrupted either by a blocked artery or by a ruptured blood vessel in the brain. A stroke may cause brain damage which impairs certain body functions, depending on the part of the brain affected. Transient ischemic attack (TIA) A TIA is a temporary blockage of the blood flow to part of the brain. It's typically of short duration and leaves no permanent damage but looks exactly like a stroke. Doctors now have therapies to restore blood flow to the heart muscle and brain, but they work best if used right away. This is why it's important to realize there's an emergency and call 9-1-1 to get the casualty to the hospital right away-the longer medical help is delayed, the more likely the heart or the brain will be damaged. Remember FAST as a way to check for the signs and symptoms of a stroke and to get immediate help. Facial droop. Ask them to smile. One side of the face may not move as well as the other side. Arm drift. Ask the casualty to hold both arms out with the palms up, and close their eyes. One arm may not move or drifts down compared to the other arm. Speech. Ask them to repeat a phrase you say. The casualty may slur words, use the incorrect words or is not able to speak. Time. When was the onset of symptoms? Ask the casualty, or their family, friends, or bystanders when the symptoms were first noticed. Get immediate medical help; the earlier a stroke is treated the better the outcome. Other signs and symptoms of a stroke include Blurred vision Sudden confusion Dizziness Headache Loss of balance. It is important that first aid providers do not dismiss the signs and symptoms of a stroke as intoxication. First aid for stroke/TIA Perform a scene survey, then do a primary survey; perform the FAST assessment. Call for medical help. Place the casualty at rest in the semi-sitting position. Give nothing by mouth, especially ASA. Give ongoing care. If the casualty becomes unconscious, place them in the recovery position. If there is paralysis, position the casualty with the paralyzed side up. This will reduce the chance of tissue or nerve damage to the affected side. Cardiac arrest Cardiac arrest means the heart stops beating properly. With no blood flow going to the brain the casualty becomes unresponsive and stops breathing. Cardiac arrest means the casualty is clinically dead, but if CPR is started and a defibrillator is applied quickly there is still an opportunity to restore a normal heartbeat. Common causes of cardiac arrest include: Heart attack Severe injuries Electrical shock Drug overdose Drowning Suffocation Cardiopulmonary Resuscitation (CPR) CPR is artificial respiration and artificial circulation. Artificial respiration provides oxygen to the lungs. Artificial circulation causes blood to flow through the body. The purpose of CPR is to circulate enough oxygenated blood to the brain and other organs to delay damage until either the heart starts beating again, or medical help takes over from you. CPR is most effective when interruptions to chest compressions are minimized. CPR -Adult casualty Perform a scene survey. Assess responsiveness. If there is no response, call for medical help on a mobile device, and place the phone on speaker-phone, and send someone for an AED. If no mobile phone is available, send or go for medical help and the AED, if available. Perform a primary survey: Open the airway. Check for breathing for at least 5 and no more than 10 seconds. If the casualty is not breathing, or not breathing effectively (agonal breaths) position your hands in the centre of the upper chest and your shoulders directly over your hands. Keep your elbows locked. Give 30 compressions-Push hard-Push Fast! Press the heels of the hands straight down on the breastbone. The depth of each compression should be at 5-6 cm (2-2.4 inches). Release pressure and completely remove your weight at the top of each compression to allow chest to return to the resting position. Give compressions at a rate of 100 to 120 per minute. Count compressions out loud to keep track of how many you have given, and to help keep a steady rhythm. Open the airway by tilting the head and lifting the chin. Position a barrier device and breathe into the casualty twice. For an adult casualty, each breath should take about for 1 second, with just enough air to make the chest rise. This is one cycle of 30:2 (30 compressions to 2 ventilations). Continue CPR until either an AED is applied, the casualty begins to respond, another first aider or medical help takes over or you are too exhausted to continue. The AED should be applied as soon as it arrives at the scene. Agonal breathing Agonal breathing is an abnormal pattern of breathing driven by a brain-stem reflex, characterized by irregular gasping respirations at times accompanied by strange vocalizations. They can occur with cardiac arrest and lead bystanders to believe the casualty is breathing. A casualty with agonal breathing should be treated as though they are not breathing. CPR - Child casualty Perform a scene survey. Assess responsiveness. If there is no response, send or call for medical help and an AED if available. If you are alone with no phone perform 5 cycles of CPR (two minutes) then go for medical help. Carry the child with you if possible. Perform a primary survey: Open the airway. Check for breathing for at least 5 and no more than 10 seconds. If the casualty is not breathing, or not breathing effectively (agonal breaths) position your hands in the centre of the upper chest and your shoulders directly over your hands. Keep your elbows locked. You may use one or two hands depending on the size of the child. Give 30 compressions-Push hard-Push Fast! Press the heels of the hands straight down on the breastbone. The depth of each compression should be 1/3 of the chest depth, or 5 cm (2 inches). Release pressure and completely remove your weight at the top of each compression to allow chest to return to the resting position. Give compressions at a rate of 100 to 120 per minute. Count compressions out loud to keep track of how many you have given, and to help keep a steady rhythm. Open the airway by tilting the head and lifting the chin. Position a barrier device and breathe into the casualty twice, with just enough air to make the chest rise. This is one cycle of 30:2 (30 compressions to 2 ventilations}. Continue CPR until either an AED is applied, the casualty begins to respond, another first aider or medical help takes over or you are too exhausted to continue. The AED should be applied as soon as it arrives to the scene. CPR - Infant casualty Perform a scene survey. Assess responsiveness. Gently tap the baby's feet. If there is no response, send or call for medical help and an AED if available. If you are alone with no phone perform 5 cycles of CPR (two minutes) then go for medical help. Carry the infant with you if possible. Perform a Primary Survey Open the airway. Check for breathing for at least 5 and no more 10 seconds. If the baby is not breathing, or not breathing effectively (agonal breaths) begin CPR Place two fingers on the breastbone just below the nipple line. Push down on the breastbone 1/3 the depth of the chest or about 4 cm (1 1/2 inches). Release the pressure completely but keep your fingers in light contact with the chest. Repeat the pressure and release phases rhythmically so that each phase takes the same amount of time. Give compressions at a rate of 100 to 120 per minute. Count compressions out loud to keep track of how many you have given, and to help keep a steady rhythm. Open the airway by tilting the head and lifting the chin. Position a barrier device and breathe into the casualty twice, with just enough air to make the chest rise. This is one cycle of 30:2 (30 compressions to 2 ventilations}. Continue CPR until either an AED is applied, the casualty begins to respond, another first aider or medical help takes over or you are too exhausted to continue. The AED should be applied as soon as it arrives to the scene. The back of an infant's head is quite large compared to the rest of the body. This causes the baby's head to come forward and close off their airway. Aninfant's head flexes forward when they are lying on their back. When giving CPR, it may be helpful to put a thin pad under the shoulders to help keep the airway open-but don't waste time looking for a pad. Chest compression only CPR CPR guidelines stress early recognition of the emergency and stress the importance of calling 9-1-1 or the local emergency number if you find someone collapsed and unresponsive. If you have not been trained in CPR or are hesitant to perform ventilations, for any reason-don't give up. Your actions can still save a life. Compression only CPR is CPR without mouth-to-mouth breaths. Provide high quality chest compressions by pushing hard and fast on the centre of the chest, at a rate of 100 to 120 compressions per minute. Although this does not give the casualty any oxygen, this option can be used by people not trained in conventional CPR, or those who are unsure of their ability. Dispatcher-assisted CPR In many locales, the 9-1-1 dispatcher is trained to coach you through an emergency until medical help arrives. Put your phone on speaker and place it by the casualty's head and talk to the dispatcher throughout the rescue. How to take over CPR from another rescuer Offer to help, tell the rescuer that you are trained in CPR. Ensure medical help has been called. Give 30 compressions followed by 2 breaths. Use your own barrier device if available Two-rescuer CPR If two trained rescuers are available, they can cooperate to perform CPR on a casualty. There are three advantages to two rescuers performing CPR as a team: CPR is a strenuous physical activity and as a first aider gets tired the quality of the chest compressions will deteriorate. By sharing the task of compressing the chest two rescuer CPR allows for a team to perform effective chest compressions for a longer period of time. Two-rescuer CPR minimizes the time the compressions are interrupted for ventilations to be given. Two-rescuer CPR allows the rescuers to give feedback and support each other during a stressful event. To perform two-rescuer CPR the first aider who performs the primary survey stays at the casualty's head, keeping the airway open and ventilating after 30 compressions. The second rescuer will compress the chest, but in order to maintain the most effective compressions, it is recommended that rescuers switch after every 5 cycles of compressions and ventilations (approximately 2 minutes). Automated External Defibrillation-AED Automated external defibrillation, the application of an electric shock to a heart that has stopped pumping effectively, has been proven to be one of the most important tools in saving the lives of sudden cardiac arrest casualties. It is the third link in the Chain of Survival®and is the responsibility of the first aider. An automated external defibrillator (AED) is an electronic device that is programmed to recognize and shock two types of heart rhythms, Ventricular Fibrillation (VF) and pulseless Ventricular Tachycardia (VT). If the machine recognizes either VT or VF in a casualty, it will charge and will indicate that a shock is advised. The purpose of this shock is to correct the abnormal electrical disturbance and re-establish the heart rhythm. It is important to remember that AEDs will only shock when VT or VF is present. You cannot shock a heart that is in normal rhythm, nor will the machine shock when it is not appropriate, such as when the heart is stopping (asystole) or there is pulseless electrical activity (PEA) Time is a critical factor in determining survival from cardiac arrest; the heart will only stay in fibrillation a short time before all electrical activity ceases. Defibrillation must be performed early to be most effective. CPR can keep oxygenated blood flowing to the brain, and helps extend the length of time that the heart will remain in VT or VF, the only arrhythmias that AEDs will shock. CPR then can "buy some time" for the casualty until the AED is attached and ready to deliver a shock. Using an AED (always follow the AED's voice prompts) Power on the AED. Follow the voice prompts. The audio instructions will direct you to: Bare the chest and attach electrode pads. The pads need to stick directly to the skin, so excessive sweat, water, and chest hair needs to be removed before application Stand back (or clear) Press the shock button and/or continue CPR as prompted by the machine Continue with CPR and listen for the AED to give additional instructions Defibrillation-Special Considerations and Special Circumstances Pregnant patients-AEDs can be used in all stages of pregnancy. Pacemakers or implanted defibrillators-Defibrillator pads should not be placed directly over a pacemaker site but should be approximately 2.5 cm (one inch) away. Look for scars or lumps on the chest as an indicator of implanted devices. Children under 8 years of age-Automated external defibrillators (AEDs) may be used for children and infants. Special pads or a pediatric setting on the machine are used, but if not available adult pads can be used. Some adult pads show an alternate placement for children/infants. Patch medications-some casualties wear a patch that contains medication such as nitroglycerin for angina. If the patch is in the way of the pad placement, gently remove it with gloved hands from the chest and wipe the area clean. Wet environment-AEDs can be used in wet areas. Dry the chest to ensure good pad contact. Move the casualty to a dry area if possible. If you or the casualty is submersed in water, avoid using the AED. Metal surfaces-AEDs can be used safely with the casualty on a metal surface. Jewelry and piercings-Avoid placing pads over-top of piercings, jewelry, or anything that would cause a gap. AED pads should adhere flat to the skin. Environment-Ensure the environment you are using an AED in does not contain explosive gases. Post-resuscitation care and handover to EMS If defibrillation is successful, the casualty may start breathing on their own but remain unresponsive. In this case, place the casualty into the recovery position and monitor the ABCs. Leave the AED attached. The AED will continually monitor the heart rhythm or you may need to use the device again. Certain information is important for emergency services personnel such as the time of collapse, time when CPR was started, time when first shock was delivered and number of shocks. Provide as much detail as possible and follow the directions of medical personnel once they arrive on the scene. Regulations concerning the requirement of a workplace to have an AED, and the necessary policies about AEDs, will be contained within federal, provincial, or territorial legislation. Where not specifically outlined by regulations, a workplace should have an established AED policy which outlines: Certification and recertification requirements Maintenance and inspection processes Post-use process (downloading information, resupplying pads and rescue pouch, etc.) Replacement of batteries and pads Replacement of unit at its end-of-life Troubleshooting and maintenance Sometimes the device will indicate "Check Electrodes". If this occurs, check the cable to pads connection, the cable to machine connection and the adherence of the pads to the casualty's chest. Machines will also advise if motion is detected or if the battery is low. AEDs are sold with an instruction manual that will outline troubleshooting in detail. Regular maintenance of AED units, including regular inspections, are important to ensuring the AED is available when it is needed. Most AEDs perform a daily system check and display in some manner it is ready for use. A monthly check of the unit is recommended to ensure the pads are still good (they have an expiry date), the rescue pack is present and stocked, and the status is green. Always follow manufacturer suggested guidelines and checkIists.