Module II: Cardiovascular

NREMT PRACTICE ANALYSIS TASK ITEMS
•	Provide care to a patient experiencing cardiovascular compromise. 
•	Attempt to resuscitate a patient in cardiac arrest. 
•	Provide post-resuscitation care to a cardiac arrest patient. 
COGNITIVE OBJECTIVES
At the completion of this unit, the paramedic will be able to:
2.1	Identify the major therapeutic objectives in the treatment of patients with any arrhythmia. (C-1) / 5-2.51	
2.2	Identify the major mechanical, pharmacological and electrical therapeutic interventions. (C-3) / 5-2.52	
2.3	Based on field impressions, identify the need for rapid intervention for the patient in cardiovascular compromise. (C-3) / 5-2.53	
2.4	Identify the clinical indications for transcutaneous and permanent artificial cardiac pacing. (C-1) / 5-2.55	
2.5	Describe the components and the functions of a transcutaneous pacing system. (C-1) / 5-2.56	
2.6	Explain what each setting and indicator on a transcutaneous pacing system represents and how the settings may be adjusted. (C-2) / 5-2.57	
2.7	Describe the techniques of applying a transcutaneous pacing system. (C-1) / 5-2.58	
2.8	Specify the measures that may be taken to prevent or minimize complications in the patient suspected of myocardial infarction. (C-3) / 5-2.83	
2.9	Describe the most commonly used cardiac drugs in terms of therapeutic effect and dosages, routes of administration, side effects and toxic effects. (C-3) / 5.2.84	
2.10	List the interventions prescribed for the patient in acute congestive heart failure. (C-2) / 5-2.94	
2.11	Describe the most commonly used pharmacological agents in the management of congestive heart failure in terms of therapeutic effect, dosages, routes of administration, side effects and toxic effects. (C-1) / 5-2.95	
2.12	Identify the paramedic responsibilities associated with management of a patient with cardiac tamponade. (C-2) / 5-2.101	
2.13	From the priority of clinical problems identified, state the management responsibilities for the patient with a hypertensive emergency. (C-2) / 5-2.109	
2.14	Identify the drugs of choice for hypertensive emergencies, rationale for use, clinical precautions and disadvantages of selected antihypertensive agents. (C-3) / 5-2.110	
2.15	Describe the most commonly used pharmacological agents in the management of cardiogenic shock in terms of therapeutic effects, dosages, routes of administration, side effects and toxic effects. (C-2) / 5-2.118	
2.16	Identify the paramedic responsibilities associated with management of a patient in cardiogenic shock. (C-2) / 5-2.120	
2.17	Identify the critical actions necessary in caring for the patient with cardiac arrest. (C-3) / 5-2.125	
2.18	Describe the most commonly used pharmacological agents in the management of cardiac arrest in terms of therapeutic effects. (C-3) / 5-2.129	
2.19	Develop, execute, and evaluate a treatment plan based on field impression for the patient in need of a pacemaker. (C-3) / 5-2.158	
2.20	Develop, execute, and evaluate a treatment plan based on the field impression for the heart failure patient. (C-3) / 5-2.168	
2.21	Develop, execute and evaluate a treatment plan based on the field impression for the patient with cardiac tamponade. (C-3) / 5-2.171	
2.22	Develop, execute and evaluate a treatment plan based on the field impression for the patient with a hypertensive emergency. (C-3) / 5-2.171	
2.23	Develop, execute, and evaluate a treatment plan based on the field impression for the patient with cardiogenic shock. (C-3) / 5-2.177	
2.24	Integrate pathophysiological principles to the assessment and field management of a patient with chest pain. (C-3) / 5-2.183	

PSYCHOMOTOR OBJECTIVES
At the completion of this unit, the paramedic will be able to:
2.25	Set up and apply a transcutaneous pacing system. (P-3) / 5-2.202	
2.26	Given the model of a patient with signs and symptoms of heart failure, position the patient to afford comfort and relief. (P-2 ) / 5-2.203	
2.7	Demonstrate satisfactory performance of psychomotor skills of basic and advanced life support techniques according to the current American Heart Association Standards and Guidelines, including: (P-3) / 5-2.205 
•	Cardiopulmonary resuscitation 
•	Defibrillation 
•	Synchronized cardioversion 
•	Transcutaneous pacing 

DECLARATIVE
I.	Management of the patient with arrhythmias 
A.	Assessment 
B.	Pharmacological 
1.	Gases (such as oxygen) 
2.	Sympathetic (such as epinephrine) 
3.	Anticholinergic (such as atropine) 
4.	Antiarrhythmic (such as lidocaine) 
5.	Beta blocker 
a.	Selective (such as metoprolol) 
b.	Non-selective (such as propranolol) 
6.	Vasopressor (such as dopamine) 
7.	Calcium channel blocker (such as verapamil) 
8.	Purine nucleoside (such as adenosine) 
9.	Platelet aggregate inhibitor (such as aspirin) 
10.	Alkalinizing agents (such as sodium bicarbonate) 
11.	Cardiac glycoside (such as digitalis) 
12.	Narcotic/ analgesic (such as morphine) 
13.	Diuretic (such as furosemide) 
14.	Nitrate (such as nitroglycerin) 
15.	Antihypertensive (such as sodium nitroprusside) 
C.	Electrical 
1.	Purpose 
2.	Methods 
a.	Synchronized cardioversion 
b.	Defibrillation 
3.	Cardiac pacing 
a.	Implanted pacemaker functions 
i.	Characteristics 
ii.	Pacemaker artifact 
iii.	ECG tracing of capture 
iv.	Failure to sense 
a.	ECG findings 
b.	Clinical significance 
v.	Failure to capture 
a.	ECG findings 
b.	Clinical significance 
vi.	Failure to pace 
a.	ECG findings 
b.	Clinical significance 
vii.	Pacer-induced tachycardia 
a.	ECG findings 
b.	Clinical significance 
c.	Treatment 
b.	Transcutaneous pacing 
i.	Criteria for use 
ii.	Bradycardia 
a.	Patient is hypotensive/ hypoperfusing 
b.	No change with pharmacologic intervention 
iii.	Second degree AV block 
a.	Patient is hypotensive/ hypoperfusing 
b.	No change with pharmacologic intervention 
iv.	Complete AV block 
a.	Patient is hypotensive/ hypoperfusing 
b.	No change with pharmacologic intervention 
i.	Asystole 
ii.	Overdrive 
a.	Deter occurrence of recurrent tachycardia 
1.	Set-up 
a.	Placement of electrodes 
b.	Rate and milliampere (mA) settings 
c.	Pacer artifact 
d.	Capture 
e.	Failure to sense 
i.	Causes 
ii.	Implications 
iii.	Interventions 
f.	Failure to capture 
i.	Causes 
ii.	Implications 
iii.	Interventions 
g.	Failure to pace 
i.	Causes 
ii.	Implications 
iii.	Interventions 
h.	Hazards 
i.	Complications 
i.	Interventions 
A.	Transport 
1.	Indications for rapid transport 
2.	Indications for no transport required 
3.	Indications for referral 
B.	Support and communications strategies 
1.	Explanation for patient, family, significant others 
2.	Communications and transfer of data to the physician 
II.	Myocardial infarction 
A.	Epidemiology 
B.	Morbidity / Mortality 
C.	Initial Assessment Findings 
D.	Focused History 
E.	Detailed Physical Exam 
F.	Management 
1.	Position of comfort 
2.	Pharmacological 
a.	Gases 
b.	Nitrates 
c.	Platelet aggregate inhibitor 
d.	Analgesia 
e.	Increase or decrease heart rate 
f.	Possible antiarrhythmic 
g.	Possible antihypertensives 
3.	Electrical 
a.	Constant ECG monitoring 
b.	Defibrillation/ synchronized cardioversion 
c.	Transcutaneous pacing 
4.	Transport 
a.	Criteria for rapid transport 
i.	No relief with medications 
a.	Hypotension/ hypoperfusion 
b.	Significant changes in ECG 
b.	ECG criteria for rapid transport and reperfusion 
i.	Time of onset of pain 
ii.	ECG rhythm abnormalities 
c.	Indications for "no transport" 
i.	Refusal 
ii.	No other indications for no-transport 
d.	Support and communications strategies 
i.	Explanation for patient, family, significant others 
ii.	Communications and transfer of data to the physician 
III.	Heart failure 
A.	Epidemiology 
B.	Morbidity / Mortality 
C.	Initial Assessment 
D.	Focused History 
E.	Detailed Physical Exam 
F.	Complications 
G.	Management 
1.	Position of comfort 
2.	Pharmacological 
a.	Gases 
b.	Afterload reduction 
c.	Analgesia 
d.	Diuresis 
e.	Other 
3.	Transport 
a.	Refusal 
b.	No other indications for no-transport 
H.	Support and communications strategies 
1.	Explanation for patient, family, significant others 
2.	Communications and transfer of data to the physician 
IV.	Cardiac tamponade 
A.	Pathophysiology 
B.	Morbidity / Mortality 
C.	Initial Assessment 
D.	Focused History 
E.	Detailed Physical Examination 
F.	Management 
1.	Airway management and ventilation 
2.	Circulation 
3.	Pharmacological 
4.	Non-pharmacological 
5.	Rapid transport for pericardiocentesis 
G.	Support and communications strategies 
1.	Explanation for patient, family, significant others 
2.	Communications and transfer of data to the physician 
V.	Hypertensive Emergencies 
A.	Epidemiology and precipitating causes 
B.	Mortality / Morbidity 
1.	Hypertensive encephalopathy 
2.	Stroke 
C.	Initial Assessment 
1.	Airway/breathing 
2.	Circulation 
D.	Focused History 
1.	Chief complaint 
2.	Medication history 
3.	Home oxygen use 
E.	Detailed Physical Examination 
1.	Airway 
2.	Breathing 
3.	Circulation 
4.	Diagnostic signs/symptoms 
F.	Management 
1.	Non-pharmacologic 
a.	Position of comfort 
b.	Airway and ventilation 
2.	Pharmacological 
a.	Gases 
b.	Other 
3.	Rapid transport 
a.	Refusal 
b.	No other indications for no transport 
G.	Support and communications strategies 
1.	Explanation for patient, family, significant others 
2.	Communications and transfer of data to the physician 
VI.	Cardiogenic Shock 
A.	Pathophysiology 
B.	Initial Assessment 
C.	Focused History 
D.	Detailed Physical Examination 
E.	Management 
1.	Position of comfort 
a.	May prefer sitting upright with legs in dependent position 
2.	Pharmacological 
a.	Gases 
b.	Vasopressor 
c.	Analgesia 
d.	Diuretics 
e.	Glycoside 
f.	Sympathetic agonist 
g.	Alkalinizing agent 
h.	Other 
F.	Transport 
1.	Refusal 
2.	No other indications for no transport 
G.	Support and communications strategies 
1.	Explanation for patient, family, significant others 
2.	Communications and transfer of data to the physician 
VII.	Cardiac arrest 
A.	Pathophysiology 
B.	Initial assessment 
C.	Focused history 
D.	Management 
1.	Related terminology 
a.	Resuscitation - to provide efforts to return spontaneous pulse and breathing to the patient in full cardiac arrest 
b.	Survival - patient is resuscitated and survives to hospital discharge 
c.	Return of spontaneous circulation (ROSC) - patient is resuscitated to the point of having pulse without CPR; may or may not have return of spontaneous respirations; patient may or may not go on to survive 
2.	Indications for NOT initiating resuscitative techniques 
a.	Signs of obvious death 
i.	For example - rigor; fixed lividity; decapitation 
b.	Local protocol 
i.	For example - out-of-hospital advance directives 
3.	Advanced airway management and ventilation 
4.	Circulation 
a.	CPR in conjunction with defibrillation 
b.	IV therapy 
c.	Defibrillation 
d.	Pharmacological 
i.	Gases (oxygen) 
ii.	Sympathetic 
iii.	Anticholinergic 
iv.	Antiarrhythmic 
v.	Vasopressor 
vi.	Alkalinizing agents 
vii.	Parasympatholytic 
5.	Rapid transport 
6.	Support and communications strategies 
a.	Explanation for patient, family, significant others 
b.	Communications and transfer of data to the physician