Cardiology and Resuscitation Essentials
Looking at the basic structure and functions of the cardiovascular system
Assessing cardiovascular findings and identifying acute coronary syndrome
Taking care of potential cardiovascular problems
More Americans experience cardiovascular-related medical conditions and emergencies than any
other disease. That’s the reason why the national EMT examination makes this condition a section unto itself.
It has become clear that emergency medical services (EMS) can make a big difference in the big daddy of cardiovascular disease, the acute myocardial infarction (AMI). Early detection of an AMI, along with safe, rapid transport to a receiving facility of heart attack victims quickly reduces the likelihood of death and promotes a better life long after the event is over.
If AMI is the big daddy, then cardiac arrest is the big momma. Sudden cardiac arrest used to be almost always fatal. However, with early, high-quality CPR and rapid use of automated external
defibrillators, EMTs are part of the chain of survival that can reduce the patient’s chance of dying.
There are many other causes of chest pain that this chapter explores. Many have signs and symptoms of an AMI. It’s not absolutely critical that you can tell the difference all the time; what matters most is making sure that you give each patient the benefit of the doubt as you perform your assessment.
In this chapter, you get the basics on the cardiovascular system, discover normal and irregular cardiovascular findings, and figure out how to handle a number of cardiovascular problems.
Checking Out the Cardiovascular System
The cardiovascular system is broken down into three broad areas: the heart, the vasculature, and the
blood. They interact closely to be able to create enough pressure in the system to produce perfusion
(more commonly known as circulation).
Surveying major structures
The heart is the sophisticated pump that powers the cardiovascular system (see Figure 10-1). Its four
chambers can be divided in two ways:
Top and bottom, or the atria and ventricles, respectively
Right and left, or pulmonary and peripheral circulation, respectively
Illustration by Kathryn Born, MA
Figure 10-1: The heart’s chambers.
One-way valves separate the atria from the ventricles, and pulmonary circulation from peripheral
circulation. This structure has the effect of forcing blood to move in one direction only, starting with
blood entering the heart from the right atrium and exiting to the body through the left ventricle.
Blood is fluid that’s comprised primarily of plasma, which contains mostly water along with various
salts, minerals, and proteins. Red blood cells (erythrocytes) carry most of the oxygen you need to live.
White blood cells (leukocytes) fight off infection and are part of your immune system (which I
describe in Chapter 11). Platelets begin the coagulation, or clotting, process when a tear in the
vasculature is detected. Carbon dioxide, nutrients such as glucose, and waste such as urea are carried
in the plasma.
You’ve probably heard the phrase, “Blood is thicker than water.” Well, besides having to do
with the relatives you’re born with, it is indeed true that blood has a consistency, or viscosity,
that’s slightly heavier than water. The cardiovascular system relies on this viscosity to help create
pressure within the vasculature.
The vasculature is the combination of pipes that the heart pumps blood into, creating pressure. The
arterial side of the vasculature carries blood away from the heart, either to the lungs via the
pulmonary artery to pick up oxygen or to the rest of the body via the aorta to deliver oxygen to the body
in the peripheral circulation.
Arteries are made of smooth muscle and have the ability to stretch and snap back to their original
shape, which helps tremendously with the flow of blood. They can also constrict and dilate, depending
on the demands of the tissue for oxygen and nutrients.
Arteries divide into smaller vessels called arterioles, which divide again numerous times and finally
terminate in capillary beds within the tissues. Gas exchange occurs at the capillary beds. In Chapter 9,
you find out how that happens in the lungs; the process is the same everywhere else. Diffusion of CO2
and oxygen occurs based on the concentration of each gas between the capillary and the tissue cells.
The heart itself has its own vasculature. Coronary arteries branch off right where the aorta exits the left
ventricle, and they supply the heart tissue, or myocardium.
Helping to return blood back to the heart is the venous system. Blood leaves the venous side of the
capillary beds, collecting in venules. They, in turn, collect into veins. The veins are much more rigid
than the arteries, which helps to maintain blood pressure as blood returns to the heart. Inside the veins
are one-way valves that again force blood to travel in one direction.
All together, these vessels create a closed system of pipes that, with the heart acting as a pump, creates
a pressure within itself (see Figure 10-2). You measure that pressure with a blood pressure cuff. By
measuring the patient’s blood pressure early in your assessment, you can get a sense of how well the
system is working.
Illustration by Kathryn Born, MA
Figure 10-2: The perfusion triangle.
The heart, blood and vasculature make up a perfusion triangle, where all three parts interact with
each other to create circulation. In reality, you measure perfusion by assessing the patient’s blood
pressure.
Understanding blood pressure
One way of talking about blood pressure is with this formula:
Blood pressure (BP) = Cardiac output (CO) × systemic vascular resistance (SVR) (the size of the
vasculature)
Before you panic, rest assured — you won’t be calculating BP this way! However, the formula quickly
illustrates what really counts in maintaining blood pressure.
Cardiac output is the amount of blood that is sent out of the left ventricle in 1 minute. It, too, has a
formula:
Cardiac output (CO) = Heart rate (HR) × stroke volume (SV) (the amount of blood squeezed out
per contraction)
Again, don’t panic — no math is needed here either. But put both formulas together and this is what
you get:
BP = (HR × SV) × SVR
What does all this mean? The human body controls its blood pressure through essentially one of three
ways: by adjusting heart rate, stroke volume, or systemic vascular resistance. In fact, blood pressure is
usually controlled via a combination of the three. Here’s an example: A patient is having an AMI that’s
targeting the heart’s electrical system (see the later section “Distinguishing acute coronary syndrome
from everything else” for details). The result is that the heart rate slows down. If everything were to
stay the same, blood pressure would drop. But it doesn’t: The body constricts its arterial beds in the
skin and other parts of the body so that SVR increases. The result is that the patient turns pale, the skin
cools, and blood pressure remains near normal.
So, if the primary function of the cardiovascular system is to maintain perfusion throughout the body, it
makes sense that keeping a handle on moment-to-moment changes in blood pressure controls the
system. Baroreceptors in the carotid arteries do exactly that. As the receptors sense a drop in BP, they
send signals to the brain that, in turn, sends signals to the body to do such things as increase heart rate,
increase the strength of ventricular contractions, constrict appropriate arteries, and even decrease the
amount of water being filtered by the kidneys so that more fluid stays within the bloodstream. The
process is really more complicated, but in a nutshell, that’s how the body keeps its perfusion within a
very narrow band of pressure.
Knowing the Cardiovascular Issues to Look for
When You Assess Patients
So what are the cardiovascular system findings you should look for when assessing the patient? The
following sections start with the normal findings, move to irregular findings, and wrap up with acute
coronary syndrome.
Recognizing normal cardiovascular findings
You can use yourself as a “normal” picture when it comes to cardiovascular findings. Your normal
resting pulse should be strong, regular, and pumping at about 60–100 beats per minute while at rest.
You should be able to easily find this pulse by checking your radial artery on the thumb side of your
wrist.
While you’re feeling the pulse, get a sense of how the skin looks and feels. Unless something is
happening to you that I can’t see right now, I’d guess that your skin has a normal color; has a normal,
warm temperature; and is dry. That’s because your skin, an organ of the body, is being adequately
perfused. Now, skin can be cooler to the touch when it’s cool outside or a little sweaty when you’ve
just finished a workout (or you’re panicking about your national exam), but it should return to its
normal look and feel within a matter of minutes.
Your blood pressure should be roughly around 120 mm Hg or less systolic and about 80 mm Hg or less
diastolic when measured at the distal bicep region of the arm. Many people have blood pressures that
are higher than normal (hypertension) but live with that pressure. On the other hand, athletes and other
fit folks often live with much lower BP. In general, having a lower-than-normal BP is much better than
having high BP.
Tightly connected to the cardiovascular system is the respiratory system; what happens in one
is often reflected in the other. Under normal conditions, the patient’s respiratory rate should be
about 12 to 20 breaths per minute without any major effort. When things start to go wrong with the
cardiac system, the respiratory system tries to compensate for the issue. Flip to Chapter 9 for
more information about the respiratory system.
A 73-year-old female complains of chest tightness and difficulty catching her breath. Her
blood pressure is 140/90 mm Hg, her pulse rate is 90, and her respiratory rate is 18 breaths per
minute. Her skin is pale, warm, and dry; and her oxygen saturation level is 95 percent. Which of
the following actions is appropriate?
(A) Lay her supine with her legs slightly elevated.
(B) Place her in a position of comfort.
(C) Administer high-flow oxygen with a nonrebreather mask.
(D) Ventilate her with a bag-valve mask.
The correct answer is Choice (B). While she may be experiencing a medical condition, her vital signs
appear to be within normal limits. Keeping her comfortable will help reduce her anxiety and lower
body stress. The modified Trendelenberg position, represented by Choice (A), isn’t necessary, as her
blood pressure isn’t low. Her oxygen saturation level is normal, and she appears to be breathing
normally; oxygen administration, Choice (C), is not indicated. She is breathing well on her own, so
manual ventilations, Choice (D), aren’t necessary.
Noting when cardiovascular findings aren’t normal
Problems can arise within the cardiovascular system itself, and problems found elsewhere in the body
can cause the cardiovascular system to compensate for the issue, sometimes responding so severely
that it injures itself. (You find a list of common issues later in this chapter.)
When the body senses that perfusion is or may be compromised, several things happen. Heart rate
increases, and the skin turns cool, pale, and clammy. Breathing speeds up too, trying to add more
oxygen to the bloodstream and take out excess carbon dioxide. Combine all of these changes and the
blood pressure remains as close to normal as possible, even higher than normal sometimes.
If the problem isn’t repaired, at some point the cardiovascular system can no longer compensate and
begins to fail. Blood pressure falls. The heart slows. The brain, suffering from worsening hypoxia,
loses its ability to maintain an alert state; the patient moves from being anxious to being confused and
finds it harder to stay awake. As the condition worsens further, the patient becomes unconscious and
unresponsive to a painful stimulus.
A 73-year-old female complains of chest tightness and difficulty catching her breath. Her
blood pressure is 82/60 mm Hg, her pulse rate is 50, and her respiratory rate is 24 breaths per
minute. Her skin is pale, cool, and dry, and her oxygen saturation level is 90 percent. Which of
the following actions is appropriate?
(A) Have her sit in a chair.
(B) Administer the patient’s prescribed nitroglycerin, if available.
(C) Administer high-flow oxygen with a nonrebreather mask.
(D) Ventilate her with a bag-valve mask.
The correct answer is Choice (C). This patient’s vital signs are well outside the ordinary range. She is
having difficulty breathing, and her oxygen saturation level is low, making Choice (C) necessary. Her
blood pressure isn’t high enough to support sitting in a chair, Choice (A), or the administration of
nitroglycerin, Choice (B). She is still breathing adequately, so manual ventilation, Choice (D), isn’t
indicated.
Distinguishing acute coronary syndrome from everything else
The heart is especially sensitive to changes in perfusion. Because of its importance, the heart has a
well-developed system of coronary arteries that feed the myocardial muscle. These arteries are fairly
small and become easily blocked with a rupture of plaque (a layer of fat and minerals that embeds
within the inner layers of an artery) or emboli (small particles of plaque) that float in from other parts
of the body and lodge within the coronary artery itself. If either of these happens, the patient may
experience a partial or complete loss of blood flow distal to the blockage. This occurrence marks the
beginning of an acute myocardial infarction (AMI), or death of cardiac tissue.
As the cardiac tissue becomes ischemic (starved of oxygen and becoming more acidic), it sends
signals back to the brain. In turn, the brain interprets these signals as the sensation of pressure, burning,
tightness, sharpness, or aching. The patient may also feel nauseous, faint, lightheaded, or dizzy.
Additionally, because of the close relationship of the lungs and heart, the patient can experience
shortness of breath. Because of the way the nerves make their way through the body, the brain may
sense related or radiating pain or discomfort to the arms, jaw, or other places in the body.
Sometimes coronary blood flow isn’t blocked by plaque or emboli. The patient may have
atherosclerosis, or narrowing of the arteries that decreases blood flow to the myocardial tissue.
Sometimes the arteries themselves can experience a spasm. In these situations the condition known as
angina may occur. These patients have a lot of the same signs and symptoms as those with myocardial
infarction. Usually someone with angina can relieve the symptoms by resting or self-administering
nitroglycerin, which dilates the arteries and increases blood flow.
Angina and AMI are part of a spectrum of conditions known as acute coronary syndrome, or
ACS. Recognizing these signs as early as possible is critical. Because determining the difference
between angina and AMI often isn’t possible, your safest bet is to assume the worst and treat the
patient quickly. Part of that treatment is to transport as quickly and safely as possible to the
nearest hospital that’s capable of rapidly restoring coronary blood flow, either through
angioplasty or fibrinolytic therapy.
A 50-year-old male has a sudden onset of epigastric pressure that comes on without warning.
He also has pain in his jaw and feels nauseous. He has a history of ulcers and takes medication
for them. He refuses your care, as he believes the discomfort is related to his ulcer history. Which
of the following actions is most appropriate?
(A) Assist the patient in taking his ulcer medication.
(B) Advise the patient that he may be having a heart attack.
(C) Stay with the patient until the discomfort resolves.
(D) Begin moving the patient to your ambulance, as time is of the essence.
The answer you’re looking for is Choice (B). Although this episode may in fact be a gastrointestinal
event, the symptoms also point to possible acute coronary syndrome. As an EMT, you’re not
authorized to help someone with his ulcer medications, Choice (A). Staying with the patient, Choice
(C), isn’t feasible, and you can’t extricate the patient, Choice (D), without his consent.
Acting on Potential Cardiovascular Problems
Like the respiratory system (covered in Chapter 9), the cardiovascular system can be affected both
directly and by conditions outside of it. In the following sections, you discover problems with the
heart, vasculature, and blood, and you find out how to handle a cardiac arrest.
Pump problems
In order to work effectively, the heart has to have good blood flow to its muscle via its coronary
arteries and an intact electrical system that controls the rate, strength, and timing of the contractions
between the atria and ventricles. Table 10-1 outlines the most common heart conditions.
Table 10-1 Conditions Affecting the Heart
Problem Signs and Symptoms Action Steps
Acute
coronary
syndrome
Described earlier in this chapter; beware of women,
diabetics, and older patients having unusual signs such
as shortness of breath, sudden weakness, or syncope,
or no signs at all other than unexplained diaphoresis.
Find position of comfort; evaluate need for oxygen and administer
supplemental O2 as needed to maintain saturation. If patient has
prescribed nitroglycerin and blood pressure is above 100 mm Hg
systolic, assist with medication. If authorized, administer aspirin.
Rhythm
disturbances:
Too fast, too
Rates that are too fast or too slow can cause blood
pressure to decrease. Radial pulses become difficult to
find. Patient may experience chest pain, shortness of
breath, or nausea. You may find a pacemaker or an
implanted defibrillator under the skin, either in the chest
Find position of comfort. Provide oxygen as needed to maintain
adequate saturation. Keep an automated external defibrillator
(AED) nearby and ready for use if patient loses consciousness and
slow, or too
irregular
or abdominal area.
Irregular heartbeat may also cause blood pressure
issues or a lethal rhythm disturbance.
pulse. Note any signs of a pacemaker or implanted defibrillator. If
patient becomes pulseless, place AED pads at least 1 inch away
from pacemaker or implanted defibrillator.
Lethal
rhythm
disturbances
Ventricular fibrillation or ventricular tachycardia that
doesn’t generate a pulse. Patient is unconscious,
apneic, or has gasping respirations; skin is cyanotic,
cool, or diaphoretic.
High-quality CPR with at least a 2-inch compression depth and a
rate of at least 100 beats per minute. If witnessed, apply AED and
follow prompts. Ventilate at a ratio of 2 breaths per 30
compressions.
Cardiogenic
shock
Poor cardiac output due to AMI or other condition.
Hypotension; cool, pale, and diaphoretic skin; may have
chest pain associated with poor perfusion.
Lay patient supine if possible; treat for shock by maintaining body
temperature and oxygen saturation.
Congestive
heart failure
(CHF)
Fluid from capillary beds leaking into the alveoli in the
lungs due to too-high or too-low pressure. May
auscultate crackles or wheezes in lung fields. May have
pedal edema from long-term CHF. If pressure is too
high, may have jugular venous distension (JVD). May
complain of chest pain or shortness of breath.
If blood pressure is high, place patient in full sitting position with
feet dangling if possible. Apply oxygen to maintain adequate
saturation levels. Ventilate if patient is breathing inadequately. If
patient is in severe respiratory distress and conscious, apply
continuous positive airway pressure (CPAP).
It is a warm, humid morning. A 78-year-old woman is attending services at her church when
she faints. Church members help her to the floor. She is awake and confused as to the day and
time. Her skin is cool, pale, and diaphoretic. She has a blood pressure of 82/50 mm Hg, a heart
rate of 100, and a respiratory rate of 20 breaths per minute. She doesn’t have any complaints of
pain or discomfort and wants to sit up. Which of the following actions is most appropriate?
(A) Assist her to a chair and perform a secondary assessment.
(B) Provide cool compresses to reduce her body temperature.
(C) Provide spinal precautions and transport to an emergency department.
(D) Place her supine on the gurney and transport to an emergency department.
The correct answer is Choice (D). Syncope, or fainting, may be caused by a variety of medical
conditions. However, in this case the most serious possibility is an acute myocardial infarction,
making Choice (D) the best option. The information doesn’t suggest that she is experiencing heat
stroke, as Choice (B) implies, nor is there any indication that she may have injured her spine to
warrant Choice (C). With her blood pressure low, sitting, Choice (A), may cause her to faint again.
Pipe problems
The body’s vasculature can develop leaks that cause fluid to leave the system quickly. On occasion,
part of the vasculature can weaken, potentially causing massive failure. Table 10-2 notes common
vasculature conditions.
Table 10-2 Conditions Affecting the Vasculature
Problem Signs and Symptoms Action Steps
Aortic
aneurysm/dissection
A weakening in the aorta’s wall causing it to bulge out (aneurysm) or tear
(dissection) resulting in loss of pressure and bleeding. Patient may
complain of sudden tearing or knifelike pain in chest or centered between
shoulder blades; may have unequal pulses in arms or legs; may experience
a rapid drop in blood pressure, tachycardia, or tachypnea. In rare cases,
may have a palpable abdominal mass.
Move patient quickly but carefully; lay
supine if possible. Administer oxygen to
maintain saturation. Maintain body
temperature.
Place patient in position of comfort; try
Hypertensive
emergency
Sudden rise in blood pressure over minutes to a few hours. Patient may
have a rapid onset of headache; a spontaneous nosebleed; sudden ringing
in the ears (tinnitus); a strong, bounding pulse; or very high blood pressure.
to keep head elevated. Maintain oxygen
saturation levels with supplemental
oxygen. Attempt to control any
nosebleed by pinching near base of
nose and having patient lean forward.
Severe infection
(sepsis)
Toxins from bacteria cause vasculature to leak fluids to surrounding tissue
(third spacing). Patient may have signs of infection (fever, nausea, vomiting,
diarrhea); decreasing oral fluid intake; hypotension, tachycardia, or
tachypnea. Skin may be hot, dry, and pale with dark purple-colored areas
where microbleeding is occurring (purpura), especially in dependent body
areas of the back, buttocks, and legs.
Place patient in supine position and
monitor closely for signs of difficulty
breathing. If patient is in shock,
administer supplemental oxygen to
maintain saturation and prevent body
temperature loss.
Anaphylaxis
Massive immune response causes vasculature to dilate and leak fluid.
Patient may identify source of allergen (a bee sting or peanuts, for
example); may aucultate stridor or wheezing; may have hives or swelling of
upper airway, hypotension, tachycardia, or tachypnea.
Remove allergen if possible; assist
patient with prescribed epinephrine
autoinjector; if patient is in shock,
administer supplemental oxygen to
maintain saturation and prevent body
temperature loss.
A 53-year-old male is lifting several boxes at work when he feels sudden, knife-like pain in
the middle of his back. He is awake and anxious, with cool, pale, and diaphoretic skin. He has a
history of back surgery and hypertension. His radial pulse is weak, fast, and thready; you cannot
detect pedal pulses. Of the following suspected conditions, which is most likely?
(A) Aortic abdominal aneurysm
(B) Ruptured vertebral disk
(C) Unsuspected angina
(D) Diaphragmatic hernia
The correct answer is Choice (A). The faint, fast, radial pulse and loss of pedal pulses point to a loss
of blood pressure, which isn’t likely to result from a vertebral disk rupture, angina, or a diaphragmatic
hernia, Choices (B), (C), and (D), respectively.
Fluid problems
If there isn’t enough blood inside the vasculature for the heart to pump, perfusion is affected. Table 10-
3 notes common conditions related to blood volume.
Table 10-3 Conditions Related to Blood Volume
Problem Signs and Symptoms Action Steps
Dehydration
Loss of water from the blood; causes include excessive physical activity, decrease in
oral intake, diarrhea, vomiting, long periods of fever (sweating), and hot environmental
temperatures. Patient may complain of weakness or dizziness that may lead to a
syncopal episode; cool, pale skin may be dry or wet; tachycardia or tachypnea may be
present; may be hypotensive in later stages.
If patient is in shock, administer
supplemental oxygen to maintain
saturation and prevent body
temperature loss. Cool patient if
experiencing heat stroke by removing
extra clothes and fanning. In most
situations, restrict oral intake.
Bleeding
Bleeding in lower GI tract may produce dark, tarry stools (melena). Patients with upper
GI bleeding may have bright red or dark, coffee-ground emesis (hematemesis). If
significant, patients may appear in shock with cool and clammy skin, tachycardia,
tachypnea, or hypotension.
If patient is in shock, administer
supplemental oxygen to maintain
saturation and prevent body
temperature loss. Suction and
maintain airway if patient is vomiting.
Fluids leak into the interstitial tissue surrounding the capillaries, as in sepsis or
anaphylaxis. Patient may have signs of infection (fever, nausea, vomiting, diarrhea);
Place patient in supine position and
monitor closely for signs of difficulty
Third
spacing
volume loss
decreasing oral fluid intake; hypotension, tachycardia, and tachypnea. Skin may be
hot, dry, and pale with dark purple-colored areas where microbleeding is occurring
(purpura), especially in dependent body areas of the back, buttocks, and legs. Massive
immune response causes vasculature to dilate and leak fluid. Patient may identify
source of allergen (a bee sting or peanuts, for example); may have hives, swelling of
upper airway, hypotension, tachycardia, or tachypnea.
breathing. If patient is in shock,
administer supplemental oxygen to
maintain saturation and prevent body
temperature loss. Remove allergen if
possible; assist patient with
prescribed epinephrine autoinjector.
A 40-year-old female is feeling faint and has difficulty breathing. You auscultate wheezing in
both lung fields. Her blood pressure is 85/70 mm Hg, she has a heart rate of 110, and she is
breathing 24 times per minute. Her oxygen saturation level is 85 percent. She has a prescribed
inhaler for asthma and an epinephrine autoinjector for anaphylaxis. What should you do next?
(A) Assist the patient with her inhaler.
(B) Assist the patient with her epinephrine autoinjector.
(C) Complete a physical examination.
(D) Administer oxygen at 2 LPM with a nasal cannula.
The correct answer is Choice (B). Your findings are consistent with anaphylaxis, and epinephrine is
the appropriate intervention for this case. Asthma, which Choice (A) points to, is unlikely to cause low
blood pressure. Her oxygen level is very low, so high-flow oxygen would be a better answer than
Choice (D). Although you may be able to conduct a full physical examination, Choice (C), that would
come after the administration of epinephrine.
Managing a cardiac arrest
A heart that beats so weakly that it doesn’t create a pulse or doesn't contract at all causes the
condition known as cardiac arrest. Because there is no blood flow, skin becomes cold and
cyanotic (blue), and the patient becomes unresponsive to all stimuli. If cardiac arrest continues
for more than a few minutes, enough brain cells die to cause permanent death.
Research in the past decade has shown that effective chest compressions are the foundation of
successful resuscitation. In other words, during a “working code” everything that is done revolves
around the nonstop, high-quality chest compressions. Keep these points in mind:
After checking to see whether the patient is unconscious, spend no more than 10 seconds to confirm
there is no carotid pulse and breathing is absent or inadequate (gasping).
Begin CPR with compressions, not ventilations. Immediately begin pushing on the chest, while
others are assembling other equipment and preparing to ventilate.
For adults, administer compressions at a rate of at least 100 per minute, with at least 2 inches of
depth, and a full recoil of the chest during release. For pediatric patients, compress the chest at
least one-third to one-half the depth of the chest.
For adults, space ventilations so two breaths are provided after every 30 compressions. Deliver
just enough to make the chest visibly rise. For two-person CPR on a pediatric patient, space
ventilations so two breaths are provided after every 15 compressions.
Rescuers should switch roles every 2 minutes or 5 cycles of compressions and ventilations, to
keep compressions accurate and effective.
Apply AED pads as soon as possible.
As soon as the pads are applied, everyone stops and the AED is activated. Follow the prompts and
make sure everyone stands clear of the patient. After the AED has analyzed, continue compressions
while the AED is charging for defibrillation. When the AED is charged, stop compressions, clear
the patient, and deliver the shock. Immediately afterward (or if the AED tells you that no shock is
indicated), immediately begin CPR again. Do not pause to check for a pulse.
At the end of the next 2-minute interval, look for signs of effective breathing and check for a pulse.
If they are absent, immediately resume CPR. If the AED indicates a shock is needed, continue
compressions while the AED charges and then clear the patient and deliver the shock.
During two-person CPR on a child or infant, the ratio of compressions to ventilations is 15:2. This
ratio allows more ventilations to be delivered to the patient.
You and three other trained crew members arrive at a park, where you see a jogger lying on
the sidewalk. Two bystanders are performing CPR, with one administering chest compressions
while the other is providing mouth-to-mouth ventilations. What should you do next?
(A) Stop compressions and check for a radial pulse.
(B) Stop compressions and apply the AED pads to the patient’s chest.
(C) Have other trained crew members take over compressions and ventilations at the end of a cycle.
(D) Apply AED pads during compressions and push the button to analyze when another 5 cycles of
compression and ventilations are complete.
The correct choice is (C). You want to minimize interruptions to compressions, and Choice (C)
accomplishes this better than Choices (A) and (B). You want to analyze the rhythm as soon as you are
able, rather than waiting for 5 cycles of compressions and ventilations to be completed, as Choice (D)
indicates.
Looking at the basic structure and functions of the cardiovascular system
Assessing cardiovascular findings and identifying acute coronary syndrome
Taking care of potential cardiovascular problems
More Americans experience cardiovascular-related medical conditions and emergencies than any
other disease. That’s the reason why the national EMT examination makes this condition a section unto itself.
It has become clear that emergency medical services (EMS) can make a big difference in the big daddy of cardiovascular disease, the acute myocardial infarction (AMI). Early detection of an AMI, along with safe, rapid transport to a receiving facility of heart attack victims quickly reduces the likelihood of death and promotes a better life long after the event is over.
If AMI is the big daddy, then cardiac arrest is the big momma. Sudden cardiac arrest used to be almost always fatal. However, with early, high-quality CPR and rapid use of automated external
defibrillators, EMTs are part of the chain of survival that can reduce the patient’s chance of dying.
There are many other causes of chest pain that this chapter explores. Many have signs and symptoms of an AMI. It’s not absolutely critical that you can tell the difference all the time; what matters most is making sure that you give each patient the benefit of the doubt as you perform your assessment.
In this chapter, you get the basics on the cardiovascular system, discover normal and irregular cardiovascular findings, and figure out how to handle a number of cardiovascular problems.
Checking Out the Cardiovascular System
The cardiovascular system is broken down into three broad areas: the heart, the vasculature, and the
blood. They interact closely to be able to create enough pressure in the system to produce perfusion
(more commonly known as circulation).
Surveying major structures
The heart is the sophisticated pump that powers the cardiovascular system (see Figure 10-1). Its four
chambers can be divided in two ways:
Top and bottom, or the atria and ventricles, respectively
Right and left, or pulmonary and peripheral circulation, respectively
Illustration by Kathryn Born, MA
Figure 10-1: The heart’s chambers.
One-way valves separate the atria from the ventricles, and pulmonary circulation from peripheral
circulation. This structure has the effect of forcing blood to move in one direction only, starting with
blood entering the heart from the right atrium and exiting to the body through the left ventricle.
Blood is fluid that’s comprised primarily of plasma, which contains mostly water along with various
salts, minerals, and proteins. Red blood cells (erythrocytes) carry most of the oxygen you need to live.
White blood cells (leukocytes) fight off infection and are part of your immune system (which I
describe in Chapter 11). Platelets begin the coagulation, or clotting, process when a tear in the
vasculature is detected. Carbon dioxide, nutrients such as glucose, and waste such as urea are carried
in the plasma.
You’ve probably heard the phrase, “Blood is thicker than water.” Well, besides having to do
with the relatives you’re born with, it is indeed true that blood has a consistency, or viscosity,
that’s slightly heavier than water. The cardiovascular system relies on this viscosity to help create
pressure within the vasculature.
The vasculature is the combination of pipes that the heart pumps blood into, creating pressure. The
arterial side of the vasculature carries blood away from the heart, either to the lungs via the
pulmonary artery to pick up oxygen or to the rest of the body via the aorta to deliver oxygen to the body
in the peripheral circulation.
Arteries are made of smooth muscle and have the ability to stretch and snap back to their original
shape, which helps tremendously with the flow of blood. They can also constrict and dilate, depending
on the demands of the tissue for oxygen and nutrients.
Arteries divide into smaller vessels called arterioles, which divide again numerous times and finally
terminate in capillary beds within the tissues. Gas exchange occurs at the capillary beds. In Chapter 9,
you find out how that happens in the lungs; the process is the same everywhere else. Diffusion of CO2
and oxygen occurs based on the concentration of each gas between the capillary and the tissue cells.
The heart itself has its own vasculature. Coronary arteries branch off right where the aorta exits the left
ventricle, and they supply the heart tissue, or myocardium.
Helping to return blood back to the heart is the venous system. Blood leaves the venous side of the
capillary beds, collecting in venules. They, in turn, collect into veins. The veins are much more rigid
than the arteries, which helps to maintain blood pressure as blood returns to the heart. Inside the veins
are one-way valves that again force blood to travel in one direction.
All together, these vessels create a closed system of pipes that, with the heart acting as a pump, creates
a pressure within itself (see Figure 10-2). You measure that pressure with a blood pressure cuff. By
measuring the patient’s blood pressure early in your assessment, you can get a sense of how well the
system is working.
Illustration by Kathryn Born, MA
Figure 10-2: The perfusion triangle.
The heart, blood and vasculature make up a perfusion triangle, where all three parts interact with
each other to create circulation. In reality, you measure perfusion by assessing the patient’s blood
pressure.
Understanding blood pressure
One way of talking about blood pressure is with this formula:
Blood pressure (BP) = Cardiac output (CO) × systemic vascular resistance (SVR) (the size of the
vasculature)
Before you panic, rest assured — you won’t be calculating BP this way! However, the formula quickly
illustrates what really counts in maintaining blood pressure.
Cardiac output is the amount of blood that is sent out of the left ventricle in 1 minute. It, too, has a
formula:
Cardiac output (CO) = Heart rate (HR) × stroke volume (SV) (the amount of blood squeezed out
per contraction)
Again, don’t panic — no math is needed here either. But put both formulas together and this is what
you get:
BP = (HR × SV) × SVR
What does all this mean? The human body controls its blood pressure through essentially one of three
ways: by adjusting heart rate, stroke volume, or systemic vascular resistance. In fact, blood pressure is
usually controlled via a combination of the three. Here’s an example: A patient is having an AMI that’s
targeting the heart’s electrical system (see the later section “Distinguishing acute coronary syndrome
from everything else” for details). The result is that the heart rate slows down. If everything were to
stay the same, blood pressure would drop. But it doesn’t: The body constricts its arterial beds in the
skin and other parts of the body so that SVR increases. The result is that the patient turns pale, the skin
cools, and blood pressure remains near normal.
So, if the primary function of the cardiovascular system is to maintain perfusion throughout the body, it
makes sense that keeping a handle on moment-to-moment changes in blood pressure controls the
system. Baroreceptors in the carotid arteries do exactly that. As the receptors sense a drop in BP, they
send signals to the brain that, in turn, sends signals to the body to do such things as increase heart rate,
increase the strength of ventricular contractions, constrict appropriate arteries, and even decrease the
amount of water being filtered by the kidneys so that more fluid stays within the bloodstream. The
process is really more complicated, but in a nutshell, that’s how the body keeps its perfusion within a
very narrow band of pressure.
Knowing the Cardiovascular Issues to Look for
When You Assess Patients
So what are the cardiovascular system findings you should look for when assessing the patient? The
following sections start with the normal findings, move to irregular findings, and wrap up with acute
coronary syndrome.
Recognizing normal cardiovascular findings
You can use yourself as a “normal” picture when it comes to cardiovascular findings. Your normal
resting pulse should be strong, regular, and pumping at about 60–100 beats per minute while at rest.
You should be able to easily find this pulse by checking your radial artery on the thumb side of your
wrist.
While you’re feeling the pulse, get a sense of how the skin looks and feels. Unless something is
happening to you that I can’t see right now, I’d guess that your skin has a normal color; has a normal,
warm temperature; and is dry. That’s because your skin, an organ of the body, is being adequately
perfused. Now, skin can be cooler to the touch when it’s cool outside or a little sweaty when you’ve
just finished a workout (or you’re panicking about your national exam), but it should return to its
normal look and feel within a matter of minutes.
Your blood pressure should be roughly around 120 mm Hg or less systolic and about 80 mm Hg or less
diastolic when measured at the distal bicep region of the arm. Many people have blood pressures that
are higher than normal (hypertension) but live with that pressure. On the other hand, athletes and other
fit folks often live with much lower BP. In general, having a lower-than-normal BP is much better than
having high BP.
Tightly connected to the cardiovascular system is the respiratory system; what happens in one
is often reflected in the other. Under normal conditions, the patient’s respiratory rate should be
about 12 to 20 breaths per minute without any major effort. When things start to go wrong with the
cardiac system, the respiratory system tries to compensate for the issue. Flip to Chapter 9 for
more information about the respiratory system.
A 73-year-old female complains of chest tightness and difficulty catching her breath. Her
blood pressure is 140/90 mm Hg, her pulse rate is 90, and her respiratory rate is 18 breaths per
minute. Her skin is pale, warm, and dry; and her oxygen saturation level is 95 percent. Which of
the following actions is appropriate?
(A) Lay her supine with her legs slightly elevated.
(B) Place her in a position of comfort.
(C) Administer high-flow oxygen with a nonrebreather mask.
(D) Ventilate her with a bag-valve mask.
The correct answer is Choice (B). While she may be experiencing a medical condition, her vital signs
appear to be within normal limits. Keeping her comfortable will help reduce her anxiety and lower
body stress. The modified Trendelenberg position, represented by Choice (A), isn’t necessary, as her
blood pressure isn’t low. Her oxygen saturation level is normal, and she appears to be breathing
normally; oxygen administration, Choice (C), is not indicated. She is breathing well on her own, so
manual ventilations, Choice (D), aren’t necessary.
Noting when cardiovascular findings aren’t normal
Problems can arise within the cardiovascular system itself, and problems found elsewhere in the body
can cause the cardiovascular system to compensate for the issue, sometimes responding so severely
that it injures itself. (You find a list of common issues later in this chapter.)
When the body senses that perfusion is or may be compromised, several things happen. Heart rate
increases, and the skin turns cool, pale, and clammy. Breathing speeds up too, trying to add more
oxygen to the bloodstream and take out excess carbon dioxide. Combine all of these changes and the
blood pressure remains as close to normal as possible, even higher than normal sometimes.
If the problem isn’t repaired, at some point the cardiovascular system can no longer compensate and
begins to fail. Blood pressure falls. The heart slows. The brain, suffering from worsening hypoxia,
loses its ability to maintain an alert state; the patient moves from being anxious to being confused and
finds it harder to stay awake. As the condition worsens further, the patient becomes unconscious and
unresponsive to a painful stimulus.
A 73-year-old female complains of chest tightness and difficulty catching her breath. Her
blood pressure is 82/60 mm Hg, her pulse rate is 50, and her respiratory rate is 24 breaths per
minute. Her skin is pale, cool, and dry, and her oxygen saturation level is 90 percent. Which of
the following actions is appropriate?
(A) Have her sit in a chair.
(B) Administer the patient’s prescribed nitroglycerin, if available.
(C) Administer high-flow oxygen with a nonrebreather mask.
(D) Ventilate her with a bag-valve mask.
The correct answer is Choice (C). This patient’s vital signs are well outside the ordinary range. She is
having difficulty breathing, and her oxygen saturation level is low, making Choice (C) necessary. Her
blood pressure isn’t high enough to support sitting in a chair, Choice (A), or the administration of
nitroglycerin, Choice (B). She is still breathing adequately, so manual ventilation, Choice (D), isn’t
indicated.
Distinguishing acute coronary syndrome from everything else
The heart is especially sensitive to changes in perfusion. Because of its importance, the heart has a
well-developed system of coronary arteries that feed the myocardial muscle. These arteries are fairly
small and become easily blocked with a rupture of plaque (a layer of fat and minerals that embeds
within the inner layers of an artery) or emboli (small particles of plaque) that float in from other parts
of the body and lodge within the coronary artery itself. If either of these happens, the patient may
experience a partial or complete loss of blood flow distal to the blockage. This occurrence marks the
beginning of an acute myocardial infarction (AMI), or death of cardiac tissue.
As the cardiac tissue becomes ischemic (starved of oxygen and becoming more acidic), it sends
signals back to the brain. In turn, the brain interprets these signals as the sensation of pressure, burning,
tightness, sharpness, or aching. The patient may also feel nauseous, faint, lightheaded, or dizzy.
Additionally, because of the close relationship of the lungs and heart, the patient can experience
shortness of breath. Because of the way the nerves make their way through the body, the brain may
sense related or radiating pain or discomfort to the arms, jaw, or other places in the body.
Sometimes coronary blood flow isn’t blocked by plaque or emboli. The patient may have
atherosclerosis, or narrowing of the arteries that decreases blood flow to the myocardial tissue.
Sometimes the arteries themselves can experience a spasm. In these situations the condition known as
angina may occur. These patients have a lot of the same signs and symptoms as those with myocardial
infarction. Usually someone with angina can relieve the symptoms by resting or self-administering
nitroglycerin, which dilates the arteries and increases blood flow.
Angina and AMI are part of a spectrum of conditions known as acute coronary syndrome, or
ACS. Recognizing these signs as early as possible is critical. Because determining the difference
between angina and AMI often isn’t possible, your safest bet is to assume the worst and treat the
patient quickly. Part of that treatment is to transport as quickly and safely as possible to the
nearest hospital that’s capable of rapidly restoring coronary blood flow, either through
angioplasty or fibrinolytic therapy.
A 50-year-old male has a sudden onset of epigastric pressure that comes on without warning.
He also has pain in his jaw and feels nauseous. He has a history of ulcers and takes medication
for them. He refuses your care, as he believes the discomfort is related to his ulcer history. Which
of the following actions is most appropriate?
(A) Assist the patient in taking his ulcer medication.
(B) Advise the patient that he may be having a heart attack.
(C) Stay with the patient until the discomfort resolves.
(D) Begin moving the patient to your ambulance, as time is of the essence.
The answer you’re looking for is Choice (B). Although this episode may in fact be a gastrointestinal
event, the symptoms also point to possible acute coronary syndrome. As an EMT, you’re not
authorized to help someone with his ulcer medications, Choice (A). Staying with the patient, Choice
(C), isn’t feasible, and you can’t extricate the patient, Choice (D), without his consent.
Acting on Potential Cardiovascular Problems
Like the respiratory system (covered in Chapter 9), the cardiovascular system can be affected both
directly and by conditions outside of it. In the following sections, you discover problems with the
heart, vasculature, and blood, and you find out how to handle a cardiac arrest.
Pump problems
In order to work effectively, the heart has to have good blood flow to its muscle via its coronary
arteries and an intact electrical system that controls the rate, strength, and timing of the contractions
between the atria and ventricles. Table 10-1 outlines the most common heart conditions.
Table 10-1 Conditions Affecting the Heart
Problem Signs and Symptoms Action Steps
Acute
coronary
syndrome
Described earlier in this chapter; beware of women,
diabetics, and older patients having unusual signs such
as shortness of breath, sudden weakness, or syncope,
or no signs at all other than unexplained diaphoresis.
Find position of comfort; evaluate need for oxygen and administer
supplemental O2 as needed to maintain saturation. If patient has
prescribed nitroglycerin and blood pressure is above 100 mm Hg
systolic, assist with medication. If authorized, administer aspirin.
Rhythm
disturbances:
Too fast, too
Rates that are too fast or too slow can cause blood
pressure to decrease. Radial pulses become difficult to
find. Patient may experience chest pain, shortness of
breath, or nausea. You may find a pacemaker or an
implanted defibrillator under the skin, either in the chest
Find position of comfort. Provide oxygen as needed to maintain
adequate saturation. Keep an automated external defibrillator
(AED) nearby and ready for use if patient loses consciousness and
slow, or too
irregular
or abdominal area.
Irregular heartbeat may also cause blood pressure
issues or a lethal rhythm disturbance.
pulse. Note any signs of a pacemaker or implanted defibrillator. If
patient becomes pulseless, place AED pads at least 1 inch away
from pacemaker or implanted defibrillator.
Lethal
rhythm
disturbances
Ventricular fibrillation or ventricular tachycardia that
doesn’t generate a pulse. Patient is unconscious,
apneic, or has gasping respirations; skin is cyanotic,
cool, or diaphoretic.
High-quality CPR with at least a 2-inch compression depth and a
rate of at least 100 beats per minute. If witnessed, apply AED and
follow prompts. Ventilate at a ratio of 2 breaths per 30
compressions.
Cardiogenic
shock
Poor cardiac output due to AMI or other condition.
Hypotension; cool, pale, and diaphoretic skin; may have
chest pain associated with poor perfusion.
Lay patient supine if possible; treat for shock by maintaining body
temperature and oxygen saturation.
Congestive
heart failure
(CHF)
Fluid from capillary beds leaking into the alveoli in the
lungs due to too-high or too-low pressure. May
auscultate crackles or wheezes in lung fields. May have
pedal edema from long-term CHF. If pressure is too
high, may have jugular venous distension (JVD). May
complain of chest pain or shortness of breath.
If blood pressure is high, place patient in full sitting position with
feet dangling if possible. Apply oxygen to maintain adequate
saturation levels. Ventilate if patient is breathing inadequately. If
patient is in severe respiratory distress and conscious, apply
continuous positive airway pressure (CPAP).
It is a warm, humid morning. A 78-year-old woman is attending services at her church when
she faints. Church members help her to the floor. She is awake and confused as to the day and
time. Her skin is cool, pale, and diaphoretic. She has a blood pressure of 82/50 mm Hg, a heart
rate of 100, and a respiratory rate of 20 breaths per minute. She doesn’t have any complaints of
pain or discomfort and wants to sit up. Which of the following actions is most appropriate?
(A) Assist her to a chair and perform a secondary assessment.
(B) Provide cool compresses to reduce her body temperature.
(C) Provide spinal precautions and transport to an emergency department.
(D) Place her supine on the gurney and transport to an emergency department.
The correct answer is Choice (D). Syncope, or fainting, may be caused by a variety of medical
conditions. However, in this case the most serious possibility is an acute myocardial infarction,
making Choice (D) the best option. The information doesn’t suggest that she is experiencing heat
stroke, as Choice (B) implies, nor is there any indication that she may have injured her spine to
warrant Choice (C). With her blood pressure low, sitting, Choice (A), may cause her to faint again.
Pipe problems
The body’s vasculature can develop leaks that cause fluid to leave the system quickly. On occasion,
part of the vasculature can weaken, potentially causing massive failure. Table 10-2 notes common
vasculature conditions.
Table 10-2 Conditions Affecting the Vasculature
Problem Signs and Symptoms Action Steps
Aortic
aneurysm/dissection
A weakening in the aorta’s wall causing it to bulge out (aneurysm) or tear
(dissection) resulting in loss of pressure and bleeding. Patient may
complain of sudden tearing or knifelike pain in chest or centered between
shoulder blades; may have unequal pulses in arms or legs; may experience
a rapid drop in blood pressure, tachycardia, or tachypnea. In rare cases,
may have a palpable abdominal mass.
Move patient quickly but carefully; lay
supine if possible. Administer oxygen to
maintain saturation. Maintain body
temperature.
Place patient in position of comfort; try
Hypertensive
emergency
Sudden rise in blood pressure over minutes to a few hours. Patient may
have a rapid onset of headache; a spontaneous nosebleed; sudden ringing
in the ears (tinnitus); a strong, bounding pulse; or very high blood pressure.
to keep head elevated. Maintain oxygen
saturation levels with supplemental
oxygen. Attempt to control any
nosebleed by pinching near base of
nose and having patient lean forward.
Severe infection
(sepsis)
Toxins from bacteria cause vasculature to leak fluids to surrounding tissue
(third spacing). Patient may have signs of infection (fever, nausea, vomiting,
diarrhea); decreasing oral fluid intake; hypotension, tachycardia, or
tachypnea. Skin may be hot, dry, and pale with dark purple-colored areas
where microbleeding is occurring (purpura), especially in dependent body
areas of the back, buttocks, and legs.
Place patient in supine position and
monitor closely for signs of difficulty
breathing. If patient is in shock,
administer supplemental oxygen to
maintain saturation and prevent body
temperature loss.
Anaphylaxis
Massive immune response causes vasculature to dilate and leak fluid.
Patient may identify source of allergen (a bee sting or peanuts, for
example); may aucultate stridor or wheezing; may have hives or swelling of
upper airway, hypotension, tachycardia, or tachypnea.
Remove allergen if possible; assist
patient with prescribed epinephrine
autoinjector; if patient is in shock,
administer supplemental oxygen to
maintain saturation and prevent body
temperature loss.
A 53-year-old male is lifting several boxes at work when he feels sudden, knife-like pain in
the middle of his back. He is awake and anxious, with cool, pale, and diaphoretic skin. He has a
history of back surgery and hypertension. His radial pulse is weak, fast, and thready; you cannot
detect pedal pulses. Of the following suspected conditions, which is most likely?
(A) Aortic abdominal aneurysm
(B) Ruptured vertebral disk
(C) Unsuspected angina
(D) Diaphragmatic hernia
The correct answer is Choice (A). The faint, fast, radial pulse and loss of pedal pulses point to a loss
of blood pressure, which isn’t likely to result from a vertebral disk rupture, angina, or a diaphragmatic
hernia, Choices (B), (C), and (D), respectively.
Fluid problems
If there isn’t enough blood inside the vasculature for the heart to pump, perfusion is affected. Table 10-
3 notes common conditions related to blood volume.
Table 10-3 Conditions Related to Blood Volume
Problem Signs and Symptoms Action Steps
Dehydration
Loss of water from the blood; causes include excessive physical activity, decrease in
oral intake, diarrhea, vomiting, long periods of fever (sweating), and hot environmental
temperatures. Patient may complain of weakness or dizziness that may lead to a
syncopal episode; cool, pale skin may be dry or wet; tachycardia or tachypnea may be
present; may be hypotensive in later stages.
If patient is in shock, administer
supplemental oxygen to maintain
saturation and prevent body
temperature loss. Cool patient if
experiencing heat stroke by removing
extra clothes and fanning. In most
situations, restrict oral intake.
Bleeding
Bleeding in lower GI tract may produce dark, tarry stools (melena). Patients with upper
GI bleeding may have bright red or dark, coffee-ground emesis (hematemesis). If
significant, patients may appear in shock with cool and clammy skin, tachycardia,
tachypnea, or hypotension.
If patient is in shock, administer
supplemental oxygen to maintain
saturation and prevent body
temperature loss. Suction and
maintain airway if patient is vomiting.
Fluids leak into the interstitial tissue surrounding the capillaries, as in sepsis or
anaphylaxis. Patient may have signs of infection (fever, nausea, vomiting, diarrhea);
Place patient in supine position and
monitor closely for signs of difficulty
Third
spacing
volume loss
decreasing oral fluid intake; hypotension, tachycardia, and tachypnea. Skin may be
hot, dry, and pale with dark purple-colored areas where microbleeding is occurring
(purpura), especially in dependent body areas of the back, buttocks, and legs. Massive
immune response causes vasculature to dilate and leak fluid. Patient may identify
source of allergen (a bee sting or peanuts, for example); may have hives, swelling of
upper airway, hypotension, tachycardia, or tachypnea.
breathing. If patient is in shock,
administer supplemental oxygen to
maintain saturation and prevent body
temperature loss. Remove allergen if
possible; assist patient with
prescribed epinephrine autoinjector.
A 40-year-old female is feeling faint and has difficulty breathing. You auscultate wheezing in
both lung fields. Her blood pressure is 85/70 mm Hg, she has a heart rate of 110, and she is
breathing 24 times per minute. Her oxygen saturation level is 85 percent. She has a prescribed
inhaler for asthma and an epinephrine autoinjector for anaphylaxis. What should you do next?
(A) Assist the patient with her inhaler.
(B) Assist the patient with her epinephrine autoinjector.
(C) Complete a physical examination.
(D) Administer oxygen at 2 LPM with a nasal cannula.
The correct answer is Choice (B). Your findings are consistent with anaphylaxis, and epinephrine is
the appropriate intervention for this case. Asthma, which Choice (A) points to, is unlikely to cause low
blood pressure. Her oxygen level is very low, so high-flow oxygen would be a better answer than
Choice (D). Although you may be able to conduct a full physical examination, Choice (C), that would
come after the administration of epinephrine.
Managing a cardiac arrest
A heart that beats so weakly that it doesn’t create a pulse or doesn't contract at all causes the
condition known as cardiac arrest. Because there is no blood flow, skin becomes cold and
cyanotic (blue), and the patient becomes unresponsive to all stimuli. If cardiac arrest continues
for more than a few minutes, enough brain cells die to cause permanent death.
Research in the past decade has shown that effective chest compressions are the foundation of
successful resuscitation. In other words, during a “working code” everything that is done revolves
around the nonstop, high-quality chest compressions. Keep these points in mind:
After checking to see whether the patient is unconscious, spend no more than 10 seconds to confirm
there is no carotid pulse and breathing is absent or inadequate (gasping).
Begin CPR with compressions, not ventilations. Immediately begin pushing on the chest, while
others are assembling other equipment and preparing to ventilate.
For adults, administer compressions at a rate of at least 100 per minute, with at least 2 inches of
depth, and a full recoil of the chest during release. For pediatric patients, compress the chest at
least one-third to one-half the depth of the chest.
For adults, space ventilations so two breaths are provided after every 30 compressions. Deliver
just enough to make the chest visibly rise. For two-person CPR on a pediatric patient, space
ventilations so two breaths are provided after every 15 compressions.
Rescuers should switch roles every 2 minutes or 5 cycles of compressions and ventilations, to
keep compressions accurate and effective.
Apply AED pads as soon as possible.
As soon as the pads are applied, everyone stops and the AED is activated. Follow the prompts and
make sure everyone stands clear of the patient. After the AED has analyzed, continue compressions
while the AED is charging for defibrillation. When the AED is charged, stop compressions, clear
the patient, and deliver the shock. Immediately afterward (or if the AED tells you that no shock is
indicated), immediately begin CPR again. Do not pause to check for a pulse.
At the end of the next 2-minute interval, look for signs of effective breathing and check for a pulse.
If they are absent, immediately resume CPR. If the AED indicates a shock is needed, continue
compressions while the AED charges and then clear the patient and deliver the shock.
During two-person CPR on a child or infant, the ratio of compressions to ventilations is 15:2. This
ratio allows more ventilations to be delivered to the patient.
You and three other trained crew members arrive at a park, where you see a jogger lying on
the sidewalk. Two bystanders are performing CPR, with one administering chest compressions
while the other is providing mouth-to-mouth ventilations. What should you do next?
(A) Stop compressions and check for a radial pulse.
(B) Stop compressions and apply the AED pads to the patient’s chest.
(C) Have other trained crew members take over compressions and ventilations at the end of a cycle.
(D) Apply AED pads during compressions and push the button to analyze when another 5 cycles of
compression and ventilations are complete.
The correct choice is (C). You want to minimize interruptions to compressions, and Choice (C)
accomplishes this better than Choices (A) and (B). You want to analyze the rhythm as soon as you are
able, rather than waiting for 5 cycles of compressions and ventilations to be completed, as Choice (D)
indicates.
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