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Objectives PPT-C - Cardiac

Objectives PPT-C - Cardiac. Discuss the effects and uses of medical (including pharmacological) treatments and tests as well as surgical procedures on the cardiopulmonary system, particularly on patients with cardiopulmonary impairments.

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Objectives PPT-C - Cardiac

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  1. Objectives PPT-C - Cardiac • Discuss the effects and uses of medical (including pharmacological) treatments and tests as well as surgical procedures on the cardiopulmonary system, particularly on patients with cardiopulmonary impairments. • Describe the medical and surgical management of patients/clients with cardiovascular (pulmonary) conditions commonly seen by physical therapists. • Discuss the contributions of other health care professionals in the management of patients/clients with cardiovascular (pulmonary) conditions commonly seen by physical therapists. • Explain the impact of aging, gender, and ethnicity on pathophysiology and management of cardiovascular (pulmonary) conditions commonly seen by physical therapists. • Identify the general categories, mechanisms of action, risk benefit ratio and implications on physical therapy intervention for the pharmacological agents routinely prescribed for conditions involving the cardiovascular (pulmonary) system. • Identify the need for various imaging procedures in the examination of the patient/client with cardiopulmonary conditions; and interpret the results of imaging on the practice of physical therapy with respect to the cardiopulmonary system. • Identify criteria used to determine if a diagnostic stress test is positive or negative.

  2. Saturday, January 14, 2006 Crowne Plaza Hotel, Nashua, NH Particular Impairments • Electrocardiograph Arrhythmia, Ischemia, Injury, Infarction • Chest X-Ray  Pulmonary Edema  Pump Effectiveness & Fluid Volume • Arterial Blood Gases  Respiration • Creatinine / BUN  Renal Function • Echocardiograph  Pump Effectiveness (LVEF = Systolic) (EDV = Diastolic) • BNP  Pump Effectiveness • Heart Sounds  Pump Effectiveness • CK, Troponins  Infarction • CBC  Oxygen Carrying Capacity, RBC Production • Coronary Arteries (Catherization) Myocardial Oxygen Supply (MOS) • Exercise Test  Oxygen Consumption /Energy Production Capacity • Respiratory Rate / Breathing Mechanics  Ventilation • Lung Sounds Fluid Volume • JVD / Peripheral Edema  Fluid Volume • HR x SBP = RPP Myocardial Oxygen Demand (MOD)

  3. Saturday, January 14, 2006 Crowne Plaza Hotel, Nashua, NH • For all individual sources of information you need to consider: • What impairment (s) is (are) being assessed? What physiological function is assessed? Are they in isolation or aggregated with other functions? • How does this source of information relate to other sources of information? • *Why do I need this information? • Prognosis? Intervention? • *How often can I update my understanding with this information?

  4. Saturday, January 14, 2006 Crowne Plaza Hotel, Nashua, NH Capability for Work Skeletal Muscle Oxygen Consumption Oxygen Carrying Capacity Pump Effectiveness RBC Fluid Volume Systolic Diastolic Renal Function Respiration Infarction = Ventilation MOS MOD Injury < Ischemia Arrhythmia Coronary Arteries

  5. Saturday, January 14, 2006 Crowne Plaza Hotel, Nashua, NH = MOS MOD < Closer Assessment of Particular Impairments & Interactions • Coronary Arteries (Angiogram/Catherization) Myocardial Oxygen Supply (MOS) • HR x SBP = RPP Myocardial Oxygen Demand (MOD) Contributing Factors? Ischemia? Injury? Infarct? Contributing Factors? Coronary Arteries Catherization HR x SBP = RPP Contributing Factors?

  6. Saturday, January 14, 2006 Crowne Plaza Hotel, Nashua, NH Coronary Arteries (Catherization)

  7. Saturday, January 14, 2006 Crowne Plaza Hotel, Nashua, NH Infarction = MOS MOD Injury < Ischemia Closer Assessment of Particular Impairments & Interactions • Electrocardiograph Arrhythmia, Ischemia, Injury, Infarction • CK, Troponins  Infarction Pump Effectiveness Arrhythmia • Electrocardiography • ST Changes • Blocks • Biomarkers • CK; CK-MB • Troponins • Symptoms • Chest Pain / Angina • Anginal Equivalent

  8. Saturday, January 14, 2006 Crowne Plaza Hotel, Nashua, NH Electrocardiograph Ischemia, Injury, Infarction

  9. Saturday, January 14, 2006 Crowne Plaza Hotel, Nashua, NH

  10. Saturday, January 14, 2006 Crowne Plaza Hotel, Nashua, NH Electrocardiograph Ischemia

  11. Saturday, January 14, 2006 Crowne Plaza Hotel, Nashua, NH Electrocardiograph Ischemia

  12. Saturday, January 14, 2006 Crowne Plaza Hotel, Nashua, NH Electrocardiograph Injury

  13. Electrocardiograph Injury

  14. Saturday, January 14, 2006 Crowne Plaza Hotel, Nashua, NH Electrocardiograph Infarction

  15. Saturday, January 14, 2006 Crowne Plaza Hotel, Nashua, NH Biomarkers Source: Data from Christenson RH, Azzazy HME. Biochemical markers of the acute coronary syndromes. Clinical Chemistry 1998; 44: 1855-1864; Kratz, AK, Leqand – Rowski, KB: Normal reference laboratory values. New England J of Medicine 1998; 339: 1063-1072.

  16. Saturday, January 14, 2006 Crowne Plaza Hotel, Nashua, NH Infarction Injury Ischemia Closer Assessment of Particular Impairments & Interactions Echo – Cardiac Output BNP Chest XRay Heart Sounds Blood Pressure Changes Pump Effectiveness Diastolic Systolic Echo – End Diastolic Volume Echo – Left Ventricular Ejection Fraction - LVEF • Electrocardiography • Ectopic beats – PVCs, VTach, VFib • Pulse Rate • Symptoms • Palpitations Arrhythmia

  17. Saturday, January 14, 2006 Crowne Plaza Hotel, Nashua, NH Echocardiography Report Diastolic Systolic

  18. Saturday, January 14, 2006 Crowne Plaza Hotel, Nashua, NH BNP Hobbs, 2003

  19. Saturday, January 14, 2006 Crowne Plaza Hotel, Nashua, NH Chest X Ray Classic findings of congestive heart failure - note the enlarged heart, large indistinct hila, increased prominence of the pulmonary veins draining the upper lobes ("reversal of flow"), and the bilateral alveolar pulmonary edema.

  20. Saturday, January 14, 2006 Crowne Plaza Hotel, Nashua, NH Heart Sounds http://www.wilkes.med.ucla.edu/inex.htm S3: about 140-160 msec after S2, an S3 may be heard if the volume which has been transferred is abnormally large. It can be thought of as a sound which is generated when the ventricle is forced to dilate beyond its normal range because the atrium has overloaded volume. An S3 is usually heard best with the bell of the stethoscope placed at the apex while the patient is in the left lateral decubitus position. The presence of an S3 is usually normal in children and young adults, but pathologic in those over the age of 40. S4: The late stage of diastole is marked by atrial contraction, or kick, where the final 20% of the atrial output is delivered to the ventricles. If the ventricle is stiff and non-compliant, as in ventricular hypertrophy due to long-standing hypertension, the pressure wave generated as the atria contract produces an S4. It is heard best with the bell of the stethoscope at the apex.

  21. ElectrocardiographyEctopic beats – PVCs, VTach, VFib

  22. Saturday, January 14, 2006 Crowne Plaza Hotel, Nashua, NH ElectrocardiographyEctopic beats – PVCs, VTach, VFib

  23. ElectrocardiographyEctopic beats – PVCs, VTach, VFib

  24. ElectrocardiographyEctopic beats – PVCs, VTach, VFib

  25. ElectrocardiographyEctopic beats – PVCs, VTach, VFib

  26. Saturday, January 14, 2006 Crowne Plaza Hotel, Nashua, NH ElectrocardiographyEctopic beats – PACs, AFlutter, AFib

  27. ElectrocardiographyEctopic beats – PACs, AFlutter, AFib

  28. ElectrocardiographyEctopic beats – PACs, AFlutter, AFib

  29. Capability for Work Skeletal Muscle Oxygen Consumption Pump Effectiveness Systolic Diastolic Oxygen Carrying Capacity RBC Fluid Volume Renal Function Respiration Infarction Ventilation Injury Ischemia Closer Assessment of Particular Impairments & Interactions Arrhythmia

  30. Capability for Work Skeletal Muscle Oxygen Consumption Oxygen Carrying Capacity RBC Fluid Volume Renal Function Respiration Ventilation Closer Assessment of Particular Impairments & Interactions Exercise Test CBC Chest XRay Lung Sounds Edema JVD Body Weight Creatinine BUN ABG’s RR, Breathing Mechanics

  31. Saturday, January 14, 2006 Crowne Plaza Hotel, Nashua, NH CBC / BUN / Creatinine / ABG’s • CBC – is the patient anemic? • BUN / Creatinine – are the kidneys involved? • ABG’s - is the ventilatory impairment resulting in respiratory impairment?

  32. Saturday, January 14, 2006 Crowne Plaza Hotel, Nashua, NH Exercise Test • Stress Test • Why? What? • Dobutamine Stress Test • Why? What? • Persantine Stress Test • Why? What?

  33. Medical / Surgical Interventions • Revascularization and Reperfusion of the Myocardium • Thrombolytic Therapy • Percutaneous Revascularization Procedures • Transmyocardial Revascularization • Coronary Artery Bypass Graft • Ablation Procedure • Valve Replacement • Cardiac Transplantation • Cardiac Pacemaker Implantation and Automatic Implantable Cardiac Defibrillator • Cardiac Medications

  34. Saturday, January 14, 2006 Crowne Plaza Hotel, Nashua, NH I II III IV V Programmable Antitachy Chamber Chamber Response Paced Sensed to Sensing Functions/Rate Function(s) Modulation NBG Code P: Simple programmable V: Ventricle V: Ventricle T: Triggered P: Pace M: Multi- programmable A: Atrium A: Atrium I: Inhibited S: Shock D: Dual (A+V) D: Dual (T+I) D: Dual (P+S) D: Dual (A+V) C: Communicating O: None O: None O: None O: None R: Rate modulating S: Single (A or V) S: Single (A or V) O: None

  35. Saturday, January 14, 2006 Crowne Plaza Hotel, Nashua, NH Rate Response • Rate responsive (also called rate modulated) pacemakers provide patients with the ability to vary heart rate when the sinus node cannot provide the appropriate rate • Rate responsive pacing is indicated for: • Patients who are chronotropically incompetent (heart rate cannot reach appropriate levels during exercise or to meet other metabolic demands) • Patients in chronic atrial fibrillation with slow ventricular response

  36. Saturday, January 14, 2006 Crowne Plaza Hotel, Nashua, NH Rate Responsive Pacing • SV reserves can account for increases in cardiac output of up to 50% • HR reserves can nearly triple total cardiac output in response to metabolic demands

  37. Saturday, January 14, 2006 Crowne Plaza Hotel, Nashua, NH A Variety of Rate Response Sensors Exist • Those most accepted in the market place are: • Activity sensors that detect physical movement and increase the rate according to the level of activity • Minute ventilation sensors that measure the change in respiration rate and tidal volume via transthoracic impedance readings

  38. Saturday, January 14, 2006 Crowne Plaza Hotel, Nashua, NH Medications • Beta – Blockers • Ca – Channel Blockers • ACE – I • Digoxin • Dobutamine • Diuretics

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