Comprehensive Cardiac and Stroke Emergency Medical Dispatch Notes

Blood Flow Cycle: The right side of the heart sends blood to the lungs to pick up oxygen. After oxygenation, it returns to the left side of the heart, which distributes the oxygenated blood throughout the rest of the body.
Coronary Arteries: Since the heart is a muscle, it requires its own oxygen supply. This is provided by the coronary arteries, a network of blood vessels sitting on the outside of the heart muscle.
Pathophysiology of Coronary Artery Disease (CAD): CAD occurs when the coronary arteries are "gunked up" with fats, cholesterol, or free-floating clots. Calcium and plaque then form around this material, making the vessels rigid and inelastic, a condition known as hardening of the arteries. This narrows the vessel openings and restricts the flow of oxygen-rich blood.

Definition: Angina pectoris (or angina) is a condition where the heart can meet everyday oxygen demands but fails to meet extra demands caused by stress or physical exertion.
Symptom Signaling: The body signals distress through chest pain when oxygen supply cannot meet demand.
Treatment Protocol for Stable Angina: Patients with a known history of stable angina typically do not go to the hospital for every episode. They manage it through rest and Nitroglycerin.
Nitroglycerin Forms: This medication can be administered as a tiny tablet dissolved under the tongue, a spray, or a chest patch.
Mechanism of Action: Nitroglycerin opens all blood vessels in the body. If the pain subsides within ten minutes of rest and medication, it is considered a regular stable angina episode.

Definition: Acute Myocardial Infarction is the technical term for a heart attack. "Acute" means happening now, "Myocardial" refers to the heart muscle, and "Infarction" means tissue death due to lack of oxygen.
Triggers: Pain might follow stress/exertion or wake a patient from a sound sleep (frequently noted in the "3 AM night watch" calls).
Classic Symptoms:
- Severe, crushing chest pain (often described as an elephant sitting on the chest).
- Radiating pain: Classics include pain moving to the jaw or down the arm (heavy, numbing, aching sensation).
- Weakness and shortness of breath.
- Indigestion or nausea.
- Clamminess and profuse "cold sweat."
- Impending feeling of doom: If a patient states they are going to die, the provider must believe them.
Clinical Skin Color Observations: EMS providers look for specific indicators of poor perfusion and oxygenation.
- Irrelevant Colors: Pale, pink, and red.
- Significant Colors: Ashen, blue, cyanotic, gray, purple, and mottled (an uneven, splotchy skin tone).

Mechanism of Action: While frequently called a "blood thinner," aspirin actually works by making platelets "slippery" so they do not clot.
Authorization: Aspirin must be authorized by the agency's medical director.
Eligibility Criteria:
- Patient must have chest pain and heart attack symptoms.
- Age requirement: At least 16 years old.
- Alertness: Must be at least "functionally alert" (able to chew and not choke).
- Pregnancy: Must not be pregnant (risk of birth defects).
- Stroke: No reported stroke symptoms (due to the 13% bleeding risk in strokes).
Reye’s Syndrome: This is the reason kids under 16 cannot have aspirin. It is a potentially fatal viral-linked condition identified in the 1980s. This is why "baby aspirin" is now marketed as "adult low dose."
Dosage Specifics:
- Standard Adult Dose: One tablet at $325\,mg$ .
- Adult Low Dose: Four tablets at $81\,mg$ each (totaling $324\,mg$ ).
- Method: Chewing is preferred for faster absorption. If unfeasible, it can be placed under the tongue or washed down with a mouthful of water.
Expiration: Expired aspirin is acceptable if no other option exists, as drugs typically lose potency slowly over decades rather than becoming toxic.

Priority: All chest pain is treated with equal seriousness. There is no correlation between the level of pain and the size of the heart attack.
Cardiac Age Range: Heart attacks are considered the default for men starting at age 35. Women are included as they age. However, if symptoms match, Protocol 10 is used regardless of age (e.g., a 31-year-old with classic symptoms).
Key Questions:
- Assess quality of alertness and breathing.
- "Difficulty speaking between breaths": Applies to adults; "Difficulty crying" applies to children.
- History: Even if the patient has not had a heart attack, previous bypass surgery counts as a "yes" for heart history.
Defibrillator (AED) Instruction:
- Provided if the patient is 1 year or older and coded as 10-Delta-1, 2, or 3.
- Instruction: "Send someone to get it now in case we need it later." If they have it, do not connect it yet; just have it ready.

Protocol Differentiation: Protocol 10 is for chest pain (heart attacks), while Protocol 19 is for "anything else heart-related," such as heart rate issues or device firing.
Automated Implanted Cardioverter Defibrillator (AICD):
- Purpose: To shock the heart out of rapid, dangerous heartbeats (tachyarrhythmias).
- Comparison: Pacemakers use milliamps to speed up slow hearts; AICDs use Joules (higher energy) to stop fast hearts.
- Symptom: A firing AICD may feel like a "shock" or "bam" in the chest.
Pulse Counting Procedure: This is the only protocol where dispatchers walk callers through finding a pulse.
- Location: Find the Adam's apple, slide two fingers to either side.
- Timing: Count beats out loud for 15 seconds.
- Thresholds: Less than 12 beats in 15 seconds indicates < 50\,bpm (too slow). 33 beats or more in 15 seconds indicates $130\,bpm$ or more (too fast).
Priority Symptoms for 19: Not alert, difficulty speaking, abnormal breathing, chest pain (incidental).
Cocaine (19-Charlie-5): Specifically noted because cocaine destroys heart muscle, making a young user's heart resemble that of an elderly person.

Definition: A stroke (CVA) is to the brain what a heart attack is to the heart.
Types:
- Ischemic: Blood clot (87% of cases). Theoretically benefits from aspirin.
- Hemorrhagic: Bleeding in the brain (13% of cases). Aspirin is fatal here.
Brain Connection: Symptoms are typically contralateral (a left-brain stroke affects the right side of the body).
Classic Signs:
- Sudden weakness, numbness, or paralysis on one side.
- Speech issues: Slurred speech, inability to understand, or inability to speak (Aphasia).
- Vision: Sudden painless loss of vision.
- Headache: Described as a "lightning strike" or "searing pain."
Transient Ischemic Attack (TIA): A "mini-stroke" where symptoms resolve within 24 hours. A TIA is a high-risk warning sign; it is more likely to precede a major stroke than stable angina is to precede a heart attack. EMS should still evaluate these patients even if symptoms have vanished.

Question (Audience): Regarding the age limit for aspirin, is it for a safe dosage?
Response: Correct, but specifically because of Reye's Syndrome. While pediatricians might prescribe baby aspirin, dispatchers cannot advise it for children due to the risk of fatality from Reye's.
Question (Audience): What if the patient has two delta symptoms (e.g., Delta 2 and Delta 4)?
Response: Choose the one specified by agency policy (e.g., Delta 4 for clamminess). However, ensure all relevant instructions, like the defibrillator instruction, are still given as it is the intent of the protocol.