6.3 Cardiovascular Red Flags and Escalation

Symptoms Outrank the Tracing

The governing rule of this section: treat the patient, not the monitor. If urgent symptoms appear during or after an EKG, routine workflow stops and escalation begins. A clean tracing on a deteriorating patient is worthless.

Red-Flag Symptoms Requiring Prompt Escalation

Classic acute-coronary presentation pairs chest pressure with diaphoresis, nausea, and arm/jaw radiation. Note that women, older adults, and people with diabetes may present atypically (fatigue, indigestion-like discomfort, isolated dyspnea) - take these seriously.

Lethal Rhythms: Recognize, Do Not Diagnose

The CCMA may recognize that a pattern is concerning and escalate immediately, but documents observations, not a diagnosis.

Before calling a flat line asystole, rule out a disconnected lead - check the electrode and patient first.

The Escalation Sequence and BLS

When a red flag appears, follow a Stay - Stop - Notify - Act - Document sequence:

1. Stay with the patient if it is unsafe to leave them; call out for help.
2. Stop nonurgent setup - abandon perfecting electrode placement.
3. Notify the provider immediately, or activate the office emergency response / call EMS (911) for a possibly unstable patient.
4. Act within your training and policy: keep the patient safe (lower to floor if syncopal), retrieve emergency supplies/AED, and begin Basic Life Support (BLS) if the patient is pulseless and not breathing - CCMAs are commonly BLS-certified.
5. Document after care: symptoms, exact times, any vitals obtained, who was notified and when, and actions taken.

BLS / AED Essentials

• Check responsiveness and breathing; if absent, start chest compressions at 100-120/min, about 2 inches deep on an adult, allowing full recoil.
• Apply the Automated External Defibrillator (AED) as soon as available, follow its voice prompts, and ensure no one is touching the patient during analysis or shock.
• Continue CPR until the AED advises, the patient revives, or EMS/advanced help takes over.

Common Traps Tested

• Continuing to adjust electrodes while a patient reports new chest pain or shortness of breath.
• "Finishing the task" before notifying the provider when red flags are present.
• Telling the patient they are "having a heart attack" - that is a provider diagnosis.
• Leaving a syncopal patient unattended to go find supplies.
• Documenting first and helping second.

Worked example: Mid-EKG, a patient develops crushing chest pressure radiating to the left arm, with diaphoresis. The correct first action is to stop the setup, stay with the patient, and notify the provider / activate emergency protocol immediately - not to complete the tracing, and not to tell the patient it is a heart attack.

Recognizing Without Diagnosing: Drawing the Line

The exam repeatedly tests the seam between recognition (allowed) and diagnosis (not allowed). A CCMA may say to a colleague or provider, "The patient is reporting chest pressure and the strip looks chaotic" and act on it by escalating. A CCMA may not tell the patient "You're having a heart attack" or chart "acute MI." The safe verbal pattern with the patient is reassurance plus action: "I'm going to get the provider right away," never an interpretation. This boundary protects both the patient (who needs the right clinician deciding) and the CCMA (who is acting within license).

Vital Signs and Positioning Support

While awaiting the provider or EMS, a CCMA can perform supportive measures within training and order/policy:

• Obtain vital signs (pulse, blood pressure, respirations, oxygen saturation) if it does not delay calling for help.
• Position the patient appropriately: lower a fainting patient to prevent a fall; allow a dyspneic patient to sit upright; lay a pulseless patient flat for CPR.
• Loosen tight clothing and keep the patient calm and still.
• Do not give medications (such as aspirin or nitroglycerin) unless specifically ordered and within scope - administering or advising medication independently is out of bounds.

Common Office Cardiac Emergencies

The unifying theme: when in doubt, escalate. It is never wrong for a CCMA to call the provider for a patient who looks unwell - delaying that call to finish a task is the error the exam punishes.