04 Cardiovascular Emergencies and Resuscitation
A practical EMT-focused guide to recognizing and managing cardiovascular emergencies, cardiac arrest, shock, acute coronary syndrome, respiratory failure, stroke, and related transport decisions.
Primary assessment and priorities
Cardiovascular emergencies are managed through a consistent sequence: protect yourself and the patient, identify immediate threats, provide lifesaving treatment, reassess, and arrange transport. Scene safety and appropriate personal protective equipment come first.
Form a general impression by noting alertness, breathing effort, skin color, sweating, distress, or collapse. An unresponsive adult who is not breathing normally or is only gasping should be treated as being in cardiac arrest. A trained healthcare professional should check the carotid pulse for no more than seconds; if there is no definite pulse, begin CPR.
Assess circulation and perfusion using mental status, skin findings, pulse quality, capillary refill when appropriate, and blood pressure. Request additional resources early when the patient is unstable or may need advanced life support. Expose only what is necessary and prevent heat loss.
A useful decision priority is:
Address immediate threats to airway, breathing, and circulation.
Begin time-critical treatment without unnecessary delay.
Request ALS or other resources when indicated.
Reassess after every major intervention or change in condition.
Transport unstable patients promptly according to protocol.
The central principle is to treat the patient’s immediate physiologic problem before pursuing a detailed history or a definitive diagnosis.
Takeaway: Early recognition, rapid intervention, frequent reassessment, and appropriate transport decisions guide every cardiovascular emergency.
Cardiac arrest and
Cardiac arrest is suspected in an adult who is unresponsive, is not breathing normally or is only gasping, and has no definite pulse after a brief professional pulse check. Do not delay compressions for a blood pressure measurement, a detailed history, or unnecessary equipment preparation.
includes:
A compression rate of compressions per minute.
A compression depth of at least inches or centimeters in an average adult, while avoiding excessive depth.
Hand placement in the center of the chest over the lower half of the sternum.
Complete chest recoil after every compression.
Short, infrequent interruptions.
Ventilations sufficient to produce visible chest rise without excessive ventilation.
A compression-to-ventilation ratio of when no advanced airway is in place.
Compressor changes about every minutes, or sooner if fatigue reduces performance.
A patient with a pulse who is not breathing normally has respiratory arrest rather than cardiac arrest. Provide ventilations according to training and local protocol, and reassess the pulse frequently.
Infants and children require age- and size-appropriate equipment, techniques, and dose calculations. Patients showing signs of puberty are generally treated according to adult basic life-support guidance. Follow the applicable pediatric algorithm and medical direction.
Takeaway: Start CPR immediately when cardiac arrest is recognized, maintain compression quality, and distinguish respiratory arrest from cardiac arrest by assessing both breathing and pulse.
AED use and defibrillation
An analyzes the cardiac rhythm and advises whether a is appropriate. It can identify shockable rhythms, but it does not replace CPR.
Use the AED in this sequence:
Begin CPR while the AED is obtained.
Turn on the AED and follow its voice and visual prompts.
Expose and dry the chest.
Remove a medication patch or excessive chest hair only when necessary for pad adhesion.
Apply pads to bare skin in the positions shown on the pads or device.
Ensure that nobody touches the patient during rhythm analysis.
If a is advised, announce “Clear,” visually confirm that no one is touching the patient, and deliver the .
Immediately resume CPR after the when prompted.
Continue CPR and AED analysis cycles until signs of life appear, another trained provider takes over, the scene becomes unsafe, or you cannot continue.
Special safety points include controlling hazards such as standing water or an explosive atmosphere before using the AED, drying the chest, following local instructions for pediatric pads or an energy attenuator, and keeping pads several centimeters away from an implanted pacemaker or defibrillator when possible. If a transdermal medication patch interferes with pad placement, remove it with gloves and wipe the skin before applying the pad.
Takeaway: Keep pauses brief, maintain scene safety, clear everyone during analysis and delivery, and resume CPR without an unnecessary pulse check.
and perfusion failure
is inadequate tissue perfusion. It may be hypovolemic, cardiogenic, distributive, or obstructive, and the initial presentation can be subtle. A normal blood pressure does not exclude early .
Look for a combination of altered mental status, anxiety, restlessness, weakness, pale or cool clammy skin, a rapid or weak pulse, abnormal respirations, delayed capillary refill, nausea, thirst, dizziness, faintness, cyanosis, or mottling. Hypotension is often a late and ominous finding.
Common patterns include:
Hypovolemic : Often associated with hemorrhage, dehydration, or burns. Control bleeding, provide oxygen when indicated, prevent heat loss, and transport rapidly.
Cardiogenic : May follow myocardial infarction, severe dysrhythmia, or heart failure. Support airway and breathing, avoid unnecessary exertion, request ALS, and transport promptly.
Distributive : May occur with sepsis, anaphylaxis, or neurogenic causes. Identify and treat the cause within scope while supporting airway and breathing.
Obstructive : May involve pulmonary embolism, tension pneumothorax, or cardiac tamponade. Severe respiratory distress or sudden deterioration requires immediate ALS support and rapid transport.
General management is to correct immediate life threats, maintain the airway, support breathing, control external bleeding, keep the patient warm without overheating, and position the patient according to breathing and airway needs. An alert patient who is breathing adequately may generally remain supine if tolerated. Decreased alertness, vomiting, or airway-obstruction risk may require a recovery position when appropriate.
Do not give food or drink. Reassess frequently, document changes, and request ALS for poor perfusion, suspected internal bleeding, severe infection, cardiac pump failure, or deterioration.
Takeaway: Recognize from the overall perfusion pattern, not from blood pressure alone, and prevent deterioration while arranging definitive care.
Common cardiovascular emergencies
Several cardiovascular presentations require rapid recognition and focused treatment.
Suspect when the patient reports pressure, squeezing, fullness, or pain in the chest or discomfort in the arm, back, neck, jaw, or upper abdomen. Shortness of breath, sweating, nausea, and lightheadedness may occur with or without prominent chest pain. Symptoms can be less typical in older adults, people with diabetes, and some women.
Reduce exertion, position the patient for comfort, obtain vital signs, request ALS when indicated, and prepare for rapid transport. Aspirin and assistance with prescribed nitroglycerin are limited by scope, protocol, contraindications, and patient ability to swallow. Do not allow the patient to walk to the ambulance.
Acute heart failure and
Findings may include dyspnea, orthopnea, crackles, fatigue, anxiety, peripheral edema, jugular venous distention, and pink, frothy sputum. Keep the patient upright if tolerated, maintain airway patency, provide oxygen or positive-pressure support only as authorized and indicated, monitor closely, and request ALS.
Dysrhythmias and palpitations
A patient may describe a rapid, slow, irregular, or skipped heartbeat. The key question is whether the rhythm is causing poor perfusion. Chest pain, dyspnea, hypotension, , altered mental status, or are concerning. Assess the patient rather than treating a pulse rate in isolation.
Assess what happened immediately before the event, whether it occurred with exertion, associated chest pain or palpitations, dyspnea, headache, neurologic deficits, injury, pregnancy, bleeding, diabetes, medications, cardiac history, and the time required to return to baseline. Exertional , palpitations, cardiac history, or abnormal vital signs warrants a high index of suspicion and prompt transport.
Stroke
Use to identify sudden Balance, Eyes, Face, Arm, and Speech changes. The Time component means documenting the exact last-known-well time and activating EMS immediately. Symptoms that improve still require urgent evaluation. Check glucose when authorized and available because hypoglycemia can mimic stroke.
Takeaway: Match the intervention to the immediate threat: reduce exertion for suspected ACS, support breathing for , evaluate perfusion during palpitations or , and document last-known-well time for suspected stroke.
Decision-making and exam priorities
NREMT-style questions often include more than one plausible action. Choose the action that addresses the most immediate life threat, follows the primary assessment sequence, remains within EMT scope and local protocol, prevents deterioration, and includes reassessment and transport when the patient is unstable.
High-yield decision rules include:
An unresponsive adult with abnormal breathing and no definite pulse needs CPR and an AED, not a blood pressure measurement first.
AED analysis requires everyone to stop touching the patient.
A normal blood pressure does not rule out .
Oral medication or food is unsafe when alertness or the airway is impaired.
Correct airway, breathing, and circulation problems before focusing on a diagnosis.
Record the last-known-well time for suspected stroke, even when symptoms resolve.
Evaluate whether a pulse rate is producing poor perfusion instead of treating the number alone.
A patient with severe dyspnea and pink, frothy sputum should remain upright if tolerated while breathing support and ALS are arranged.
A concise mental checklist is:
Is the scene safe?
Is the patient responsive and breathing normally?
Is there a definite pulse when a trained professional checks?
What immediate treatment is required?
What resources and transport plan are needed?
Has the patient been reassessed after the intervention?
Final takeaway: Select the intervention that is most time-sensitive, physiologically appropriate, within scope, and connected to ongoing reassessment and definitive care.