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Cardiac Assessment 1

Cardiac Assessment 1. Alison Ketchell HECS 2063. Brief anatomy & physiology revision Cardiac diseases Assessment in practice 1 ~ ‘The patient with chest pain’. The cardiovascular system. Pulmonary arteries Pulmonary veins Left atrium Mitral (bicuspid) valve

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Cardiac Assessment 1

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  1. Cardiac Assessment 1 Alison Ketchell HECS 2063 • Brief anatomy & physiology revision • Cardiac diseases • Assessment in practice 1 ~ ‘The patient with chest pain’ ACK - 2007

  2. The cardiovascular system ACK - 2007

  3. Pulmonary arteries Pulmonary veins Left atrium Mitral (bicuspid) valve Aortic valve Left ventricle Septum Endocardium Myocardium Pericardium Cardiac anatomy Aorta SVC Right atrium IVC Tricuspid valve Pulmonary valve Right ventricle ACK - 2007

  4. The coronary circulation RCA - Rightcoronaryartery RV - Right ventricular M - Marginal PD - Posterior descending LCA - Leftcoronaryartery LMS - Left Main Stem LAD - Left anterior descending D - Diagonal S - Septal Cx - Circumflex OM - Obtuse marginal O ACK - 2007

  5. Cardiac electrophysiology The sinus (SA) node The atrio-ventricular (AV) node The Common Bundle Left Of His Bundle Branch Right Bundle Branch (RBB) (LBB) Purkinje fibres ACK - 2007

  6. Cardiac disorders • Acute coronary syndrome (ACS) - (Stable angina) - Unstable angina - Myocardial infarction (MI) • Valve disease • Electrical disorders • Cardiomyopathy • Infection • Heart failure - Left ventricular failure (LVF) - Congestive cardiac failure (CCF) ACK - 2007

  7. Coronary Artery Disease • Ischaemia (Angina) Atherosclerotic narrowing Plaque rupture Platelet aggregation = ‘white clot’ Partial occlusion Severely restricts blood / O2 flow Ischaemic myocardium Pain @ exertion rest • Myocardial infarction (MI) Atherosclerotic narrowing Plaque rupture Platelet aggregation Thrombus formation = ‘red clot’ Total occlusion Ischaemic myocardium Injured myocardium Infarcted myocardium ACK - 2007

  8. Acute coronary syndrome (ACS) All conditions caused by sudden impairment of blood flow in a coronary artery that leads to ischaemia / infarction of the myocardium (Crawford & DiMarco, 2001) Unstable angina Pain @ rest ?? ECG changes -ve Troponin Non ST elevation MI (NSTEMI) ?? Pain ?? ECG changes +ve Troponin Stable angina Pain on exertion ?? ECG changes on ETT -ve Troponin ST elevation MI (STEMI) ?? Pain ECG changes +ve Troponin ACK - 2007

  9. Mr X arrives in A & Ewith chest pain • Emergency / acute phase ~ 1st hour • ABC assessment priority …. then glean more detail • Establish presentingcomplaint ~signs / symptoms • Relief of symptoms • Haemodynamic status • Differential diagnosis • Initiate prompt treatment • BLS / ALS available ACK - 2007

  10. A - Airway • Look, listen, feel ~ clear? unobstructed? guedal airway? B - Breathing • Skin colour – cyanosis? central? peripheral? • Respiration - rate, depth, noise, character • O2 saturations - > 95%? • ABG’s?? C - Circulation • Pulse - rate, regularity, rhythm • Cardiac monitor • BP ACK - 2007

  11. Establish presenting complaint ~ signs & symptoms Patient history ~ chest pain - Site - Character - Speed of onset / cessation - Radiation - Precipitating / aggravating / relieving factors - Duration - Associated symptoms - Pain scale • Locality & characteristics may reveal differential diagnosis ACK - 2007

  12. Associated signs & symptoms - Breathless ~ rest : exertion - Nausea / vomiting - Sweating, pale, cold, clammy - Restless - Palpitations - Syncope - Oedema - Cyanosis ACK - 2007

  13. Relief of symptoms • Pain ~ - Rest - Suscard buccal 2 - 5mg or sublingual GTN spray ii - IV Diamorphine 2.5 – 10mg • Nausea / vomiting ~ - IV Metoclopramide (maxalon) 10mg - IV Cyclizine 50mg • Breathlessness ~ - High flow O2 therapy 10 – 15L/min • Anxiety ACK - 2007

  14. Haemodynamic status • General – skin colour, warmth, ? distressed, temperature • Continuous observation - Pulse - Cardiac rhythm ~ 3 lead ECG monitor - BP - Respirations - O2 sats • 12 lead ECG ACK - 2007

  15. The ECG Electrode ~ sensor detects electrical activity Lead ~ transmits information Monitor ~ receives signal ~ interprets and transduces ~ amplifies ~ displays signal as waveform ~ records on screen or paper ACK - 2007

  16. The PQRST complex ACK - 2007

  17. Venous Blood Sampling • Capillary blood sample - BM Stix ?? • Venous blood sampling - Troponin T < 0.1 ……. > 1.5 - Full Blood Count (FBC) - Urea & Electrolytes (U&E’s) - Thyroid Function Tests (TFT’s) - Liver Function tests (LFT’s) - Cholesterol - ?? Clotting - ?? CK / CKMB ACK - 2007

  18. Differential diagnosis • Stable angina – await Troponin T if < 0.1 = discharge or ETT • Unstable angina/ NSTEMI – admit CCU for treatment – - Bed rest & continuous monitor, 12 lead ECG with pain - Oral aspirin (75 – 150mg daily) & Clopidogrel (10mg OD) - S/C LMW heparin - If in pain IV GTN ~ BP every 30 mins - ?? IV GPIIb / IIIa - Full medical history, biographical data, nursing assessment - CK / CKMB - Further investigations – ETT, Angiography, PTCA & stent - Oral beta blockers, nitrates, Ca2+ blockers, ACEI, statin • ST elevation MI (STEMI) ACK - 2007

  19. Initiate prompt treatment for STEMI - Anti platelet ~ Oral aspirin 300mg - Contraindications to treatment 1) IV Thrombolysis ~ Streptokinase or TPA or TNK within 30 mins of hospital arrival …. ‘ door to needle time’ - Monitor HR, rhythm, BP, O2 saturations continuously during therapy - Brief biography – next of kin !! - Admit to CCU for observation ACK - 2007

  20. Primary Percutaneous Coronary Intervention (PPCI) for STEMI - National pilot project ….. Leeds ….. Mid Yorks from march - Immediate angioplasty & stent (NOT thrombolysis) - Improved mortality & morbidity IF facility & expertise on site - Time dependent outcomes - ??? Viability / efficacy of transfer to regional centres instead of locally administered TNK - Anti platelet ~ Oral aspirin 300mg & Clopidogrel - Post PCI care ….. ?? IABP - Thrombolysis remains mainstay MI treatment at present ACK - 2007

  21. The next 12 hours • Bed rest & continuous monitor, 12 lead ECG with pain • Full biographical & nursing assessment – ADL’s • Further history - Past medical history (PMH) • - Social history (SH) & family history (FH) • - Risk factors (RF’s) • - Drug history (prescribed & social) • Observe - 4 hourly Temp, P, BP, R, O2 sats - Fluid balance chart, urinalysis, ?? BM stix • Post PCI care …. ?? IABP …. Arterial sheath removal ACK - 2007

  22. Further medical examination - JVP, precordial palpation, auscultation - CXR, ?? ABG’s, Echo - Systemic enquiry • Further treatment • - S/C LMW heparin for 48hrs post TNK • - Oral aspirin (75 – 150mg daily) & Clopidogrel (10mg OD) • - Oral beta blockers eg atenolol 25 – 100mg OD • - Oral ACEI eg Ramipril 1.25 – 5mg OD • - Oral statin 20 – 40mg OD ACK - 2007

  23. Pre ….. Post discharge • Other specific investigations & intervention • - Modified ETT, Dobutamine stress test, CT scan, MRI • - Angiography …… PTCA ….. Stent…..CABG • Cardiac rehabilitation - Return to ‘normal’ healthy lifestyle - Information, advise, counselling - Smoking cessation - Diet - Exercise - Anxiety ACK - 2007

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