Cardiopulmonary Symptoms

TERMINAL LEARNING OBJECTIVE

Given IV administration equipment and fluids, oxygen, suction and ventilation equipment (if available), selected medications, and documentation forms. You encounter a casualty complaining of cardio-pulmonary symptoms. No other injury(ies) is/are present. NBC agents have been ruled out.

INTRODUCTION

Many signs, symptoms, and treatment for disease and/or disorders of the cardiovascular and respiratory system are similar. In this lesson, we will focus on cardiopulmonary symptoms that are non-traumatic. Unfortunately, if not recognized and treated promptly many cardiopulmonary diseases and/or disorders mentioned could result in patient death. It is essential the 91W be familiar with such diseases and/or disorders that may be encountered in a variety of situations.

Review Anatomy and Physiology

The cardiovascular system

(1) Structures

(a) Comprises the heart, arteries, capillaries, and veins

(b) Lies in center of chest, behind sternum, in front of spine, and above diaphragm

1) Endocardium - inner lining of four chambers of the heart

2) Myocardium - middle layer of the heart wall, composed of cardiac muscle

3) Epicardium - outer layer of the heart, includes visceral pericardium and connective tissue interspersed with fat

4) Surrounded by pericardium

(d) Septum divides heart cavity into right and left sides

5) Upper chambers - atria

6) Lower chambers - ventricle

(e) Four valves - thin leaf-like structures that keep blood flowing in the proper direction to prevent back flow

1) Tricuspid valve - located between right atrium and right ventricle

2) Pulmonic valve - located at the junction of the right ventricle and pulmonary artery

3) Mitral (bicuspid) valve - located between left atrium and left ventricle

4) Aortic valve - located at junction of the left ventricle and aorta

(f) Coronary arteries

1) Coronary arteries - supply blood to all parts of myocardium

2) Superior and inferior vena cava - return blood from the body to right atrium

3) Pulmonary arteries and veins

4) Aorta - main trunk of systemic arterial circulation

(2) Function

(a) Valves regulate the flow of blood through the heart chambers

1) Pulmonary artery takes blood into the lungs

2) Aorta takes blood to rest of the body

(b) Heart receives blood supply through the coronary arteries

1) Right side receives blood that has just returned from the body after delivering oxygen to body tissues

2) Left side forces blood through aorta and into smaller arteries, which distribute it to all parts of the body

(3) Electrical conduction of the heart

(a) Sinoatrial node (SA node)

1) Small bundle of nerve tissue located in the wall of right atrium

2) Heart's pacemaker which produces an electrical stimulus causing the heart to beat

(b) Both atria contract at the same time to pump blood into the ventricles

Respiratory system

(1) Structures

(a) Oropharynx

(b) Nasopharynx

(d) Lungs

(e) Bronchi

(f) Alveoli

(2) Function

(a) Brings oxygen from the outside air into the blood and eliminates carbon dioxide

(b) Air enters the body through the mouth or nose

(d) Oxygenated blood leaves lungs, it returns to the heart

(e) Cells of the body continuously need oxygen to function. As a result of using oxygen, carbon dioxide is produced

(f) Unless oxygen is continually supplied and carbon dioxide is continually eliminated from the body, death will result.

Assess Cardiac Compromise

Initial assessment

(1) Ensure open airway

(2) Assess breathing

(3) Assess circulation

(a) If pulse is present, continue assessment

(b) If no pulse, begin CPR

Focused history and physical exam (specific to cardiopulmonary symptoms)

(1) Recognize signs of cardiac compromise

(a) Squeezing, dull pressure, chest pain commonly radiating down arms or to the jaw

(b) Sudden onset of sweating

(d) Anxiety, irritability

(e) Feeling of impending doom

(f) Nausea/vomiting

(g) Unresponsive to stimuli

(2) Assess vital signs

(a) Respirations

(b) Pulse

(d) Temperature

(e) Pulse oximetry

(3) Focused history

(a) Onset of symptoms

1) Sudden

2) Gradual over time

3) Known cause or "trigger"

(b) Duration of symptoms

1) Constant

2) Recurrent

(d) Length of time

(e) Fever

(f) Smoking history

(g) Past medical history of associated diseases

(4) Assess location and level of pain

(a) Use acronym: OPQRST

1) Onset

2) Provocation

3) Quality

4) Radiation

5) Severity

6) Time

(b) Apply pain scale

1) 0 = no pain

2) 10 = worst pain

Assess specific cardiovascular disease/disorder

(1) Angina pectoris

(a) Sudden chest pain caused by lack of oxygen supply to a portion of heart muscle

(b) Reduced blood flow to heart muscle usually due to coronary artery disease

1) Physical activity

2) Stress

3) Heavy meals

4) Exposure to cold

5) Windy weather

(d) Signs and symptoms

1) Pain, pressure, tightness, or squeezing feeling in chest area lasting 3-5 minutes

2) Radiation of pain to neck, jaw, teeth, shoulder, arms, upper back, or abdomen

3) Shortness of breath

4) Weakness

5) Nausea/indigestion

6) Sweating

(2) Acute myocardial infarction (AMI)

(a) Death of a portion of the myocardium caused by inadequate blood/oxygen supply through the coronary arteries

(b) Causes include

1) Inadequate blood supply through the coronary arteries long enough in duration that myocardium is damaged from oxygen starvation

2) Damage of myocardium causes disruption of normal electrical conduction, resulting in irregular and/or ineffective heart activity

3) Blood supply may be reduced or stopped by: coronary artery spasm, embolus, arteriosclerosis, and atherosclerosis

1) Some or all signs and symptoms of angina pectoris

2) Pain may be intermittent (come and go)

3) Duration of pain may be 30 minutes to several hours

4) Pain may occur while at rest

5) Rest and/or nitroglycerin do not relieve pain

6) Signs of shock

7) Dyspnea

8) Anxiety, irritability, or denial

(3) Congestive Heart Failure (CHF)

(a) Failure of heart to pump blood adequately to maintain tissue perfusion

(b) Causes include

1) Diseased heart valves

2) Hypertension

3) Obstructive pulmonary disease

4) Ineffective pumping of left ventricle. Causes blood to back up into pulmonary circulation, resulting in congestion in the lungs. Can progress to pulmonary edema (an accumulation of fluid in lung tissues and alveoli)

5) Ineffective pumping of the right ventricle. Causes blood to back up into the systemic circulation, causing edema in hands, lower extremities, and sacral area, and distention of jugular veins.

1) Agitation

2) Tachycardia

3) Dyspnea with shallow and labored respirations

4) Orthopnea - an abnormal condition in which a person must sit or stand to breathe deeply or comfortably

5) Noisy respirations

6) Edema in extremities

7) Diaphoresis

8) Possible chest pain

9) Distended neck veins

10) Upright posture

Provide Care for Cardiac Compromise

Initial Assessmnt

(1) Assess airway - ensure open airway

(2) Assess breathing - ensure adequate ventilation

(3) Assess circulation

Manage patient with known cardiac history

(1) Place patient in position of comfort and in a quiet environment

(2) Apply oxygen, as indicated

(3) Apply cardiac monitor, if available

(4) Minimize patient exertion

(a) Use appropriate transfer procedures

(b) Do NOT allow patient to walk to stretcher or down steps

(5) Loosen restrictive clothing

(6) IV access before administering nitroglycerin

(7) Administer NTG as directed by MD/PA

(a) Reassess patient history

(b) If nitro is not prescribed to that patient, gain permission from MD/PA or follow local SOP

(d) Administration

1) Dose is one tablet or spray under tongue

2) Have patient keep mouth closed until dissolved and absorbed

3) Verify effectiveness - Patient should report burning sensation under tongue

(8) Initiate cardiac monitoring

(9) Placement of electrodes (12-lead EKG)

1) Arms - anterior forearm or biceps

2) Legs - medial aspect of lower leg

3) Chest position

a) V1 - fourth intercostal space, right sternal

b) V2 - fourth intercostal space, left sternal

c) V3 - midway between V2 and V4

d) V4 - fifth intercostal space, midclavicular line

e) V5 - same level as V4, anterior axillary line

f) V6 - same level as V4 and V5 - midaxillary line

4) Ensure patient information has been entered

5) Check leads for contact

6) Record as needed

c. Use AED, if needed

(1) Reassess patient's unresponsiveness

(2) Begin or continue CPR efforts

(3) Deliver shock

(a) Turn on power

(b) Attach device

1) One pad to right of sternum just below the clavicle

2) Other to left of precordium

(d) Deliver shock in a series of three as indicated by AED

(e) Check for pulse after three shocks

(4) Reassess vital signs

d. Perform ongoing management

(1) Monitor vitals signs every 3-5 minutes

(2) Initiate CPR as needed

(3) Run EKG as indicated by MD/PA

Assess Respiratory Symptoms

Initial assessment

(1) Assess airway - ensure open airway

(2) Assess breathing - ensure adequate ventilation

(3) Assess circulation

(a) If pulse is present, continue assessment

(b) If no pulse, begin CPR

Focused history and physical exam (specific to pulmonary symptoms)

(1) Assuming ABCs are intact, begin AMPLE history

(a) Allergies

(b) Medications

1) Asthma

2) Heart disease

3) Emphysema

5) Smoking history

(d) Last oral intake

(e) Events leading to onset, consider asking

1) Onset of symptoms

a) Sudden?

b) Gradual over time?

c) Known cause or "trigger"?

2) Duration of symptoms

a) Constant?

b) Recurrent?

3) Fever? Chills?

4) Chest pain? Shortness of breath? Difficulty breathing?

5) Have you had a cough?

a) Productive or non-productive?

b) Color of sputum?

6) Other symptoms, such as nausea and vomiting?

(2) Assess vital signs

(a) Respirations

(b) Pulse

(d) Temperature

(e) Pulse oximetry

(3) Assess patient complaints

(a) When did the medical problems start?

(b) What are the medical problems?

1) Constant

2) Recurrent

(3) Inspect chest

(a) Use of accessory muscles and sternal or muscle retraction

(b) Skin color

(d) Difficulty breathing or periods of apnea

(e) Splinting the chest

(f) Stridor

(g) Productive cough

(h) Altered mechanical effort

1) Limited rise and fall of chest

2) Gasping

3) Pursed lips

4) Chest wall paradoxical motion

(i) Medical - physiological barriers

1) Pneumonia

2) Pulmonary edema

3) Chronic Obstructive Pulmonary Disease (COPD)

(4) Palpate the chest

(a) Tenderness

(b) Pain

(d) Skin temperature

(5) Auscultate the lungs

(a) Evaluate both inspiration and expiration

(b) Wheezing

(d) Absence of breath sounds

Provide Care for Respiratory Illness

Assessment findings

(1) Signs of severe respiratory impairment

(2) Rapid, shallow and short breaths

(3) Decrease lung sounds and/or wheezing

Care for respiratory symptoms

(1) Place patient in position of comfort

(2) Apply oxygen

(3) Minimize patient exertion

(a) Use appropriate transfer procedures

(b) Do NOT allow patient to walk to stretcher or down steps

(4) Loosen restrictive clothing

(5) IV access

(6) Cardiac monitoring, if patient has shortness of breath or chest pain

Upper respiratory infection

c. (1) Common symptoms include:

(a) Inflammation of the mucous membranes

(b) Increased mucous production

(d) Coughing

(2) Provide care - supportive measures

(a) Consider pain relievers

(b) Drink plenty of fluid

Pharyngitis

(1) Most often caused by viral infections. May be caused by bacteria, such as group A streptococcus, which is commonly termed strep throat.

(2) Symptoms include

(a) Sore throat

(b) Difficulty swallowing

(d) Swollen lymph nodes

(e) Exudate on tonsils

(f) Beefy red throat

(3) Provide care

(a) For viral infections, treatment is to relieve symptoms only

1) Consider pain relievers for pain

2) Consider gargle with warm salt water

(b) Bacterial pharyngitis is treated with antibiotics

Bronchitis

(1) Acute bronchitis

(a) May be caused by any number of respiratory viruses

(b) Symptoms include

1) Cough, usually productive

2) Shortness of breath

3) Wheezing

4) Rales, rhonchi

5) Sore throat

1) Consider inhaled bronchiodilators to open constricted air passages

2) Consider antibiotics only if sputum color changes

3) Consider mucolytic agents to moisten secretions

4) Provide supportive measures

a) Rest

b) Increase humidity to soothe air passages

c) Increase fluid intake

d) Refer to MD/PA for treatment

Chronic Obstructive Pulmonary Disease (COPD)

(1) The term COPD identifies patients with emphysema and chronic bronchitis. Although emphysema and chronic bronchitis are diagnosed and treated as separate diseases, most patients with COPD have features of both conditions. Chronic bronchitis is characterized by an excess of bronchial secretions. Emphysema is characterized by a destruction of air spaces with permanent airspace enlargement

(2) Causes include

(a) Smoking- the most common

(b) Pollution

(d) Allergies

(3) Symptoms include

(a) Excessive, chronic cough

(b) Sputum production

(d) Dyspnea on exertion (DOE)

(e) In early stages of the disease, patient may be asymptomatic

(3) Provide care

(a) COPD is largely preventable. Stress smoking cessation

(b) Consider respiratory treatments to facilitate the removal of thick mucous from airways

(d) Vaccination against influenza and pneumococcal disease

(e) Refer patient to MD/PA for treatment

Pneumonia

(1) Viral

(a) Inflammation of lungs caused by a viral infection

(b) Common viral infections that cause pneumonia

1) Respiratory syncytial virus - Pediatrics

2) Influenza

1) Cough

2) Headache

3) Muscle stiffness

4) Shortness of breath

5) Fever

6) Sweating

7) Fatigue

(d) Provide care - supportive care

1) Humidified air

2) Increase fluids

3) Supplemental oxygen may be indicated

4) Antiviral medications may be considered. Consult MD/PA for treatment

(2) Bacterial

(a) Inflammation of lungs caused by bacterial infection

(b) Caused by different organisms and can range in seriousness. Two common types of organisms are

1) Pneumococcal

2) Mycoplasma

1) Rigors

2) Bloody sputum

3) Fever

4) Chest pain

(d) Provide care

1) Treat with antibiotics as directed by MD/PA

2) Provide supportive treatment

a) Supplemental oxygen

b) Respiratory treatments

h. Asthma

(1) Chronic inflammatory disorder characterized by increasing responsiveness of the airways to multiple stimuli

(a) Most acute attacks are reversible and improve spontaneously or within minutes to hours with treatment

(b) The recognition that asthma is a chronic inflammatory disorder of the airways has significant implications for diagnosis, management, and potential prevention

(c) Asthma is common in adults and more common in children. Death rates from asthma have been increasing since 1990, despite improved therapies

(2) Occur spontaneously or can be triggered by

(a) Respiratory infections

(b) Exercise

(d) Smoke and other pollutants

(e) Stress or anxiety

(f) Allergies

(3) Symptoms include:

(a) Tightness in chest

(b) Audible expiratory wheeze

(d) Course breath sounds

(e) Prolonged expiration

(f) Restlessness/anxiety

(g) Paroxysmal cough progressing from dry and hacking to productive

(h) Diaphoresis

(4) Identify key historical points

(a) Pattern of symptoms

1) Perennial

2) Seasonal

3) Onset

4) Duration

5) Frequency

(b) Aggravating factors

1) Age of onset and method of diagnosis

2) Course of disease

3) Present management and medications

4) History or oral corticosteroid use

5) Intensive care unit admissions

6) History of intubation for asthma exacerbation

7) Other medical diseases

(d) Family history

(e) Social history

1) Condition of home

2) Exposure to allergens

3) Smoking

4) Identification of participating causes

(f) Medications used

(5) Identify risk factors

(a) Past history of sudden severe exacerbations

(b) Prior intubation for asthma

(d) Two or more hospitalizations for asthma in past year

(e) Three or more emergency care visits for asthma in past year

(f) Use of more than two canisters per month

(g) Current use of systemic Corticosteroids or recent withdrawal from systemic corticosteroids

(6) Provide care

(a) Inhaled bronchodilators

(b) Inhaled corticosteroids

(d) Supportive care

1) Nebulization with inhaled sympathomimetics

2) Monitor pulse oximetry

3) Monitor BP and pulse after each nebulization

(e) Yearly influenza vaccine

(f) Pneumococcal vaccine

(g) Refer patient to MD/PA for treatment - medical emergency

(7) Status asthmaticus- Severe prolonged asthma refractory to conventional modes of therapy. Management consists of

(a) Oxygen therapy

(b) Nebulization with inhaled bronchodilators

(d) Intravenous fluids

(e) May progress to require endotracheal intubation and mechanical ventilation

Administer prescribed inhaler

(1) Reassess patient history

(2) If medication is not prescribed to that patient, gain permission from MD/PA or follow local SOP

(3) Administration

(a) Patient should first exhale deeply

(b) Have patient place lips around opening of inhaler

(d) Patient should hold their breath as long as possible to ensure medication is absorbed

(4) Verify effectiveness. Repeat second dose as needed and according to SOP or MD/PA

SUMMARY

The cardiovasular system and respiratory system undoubtedly contain many of the most important organs

in the body. If there is injury or illness to these organs, your ability to recognize the problems and treat

accordingly is your duty as a 91W, as well as essential to the life of the patient.