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Cardiovascular Emergencies Part 1

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  1. Cardiovascular Emergencies Part 1

  2. Assessment • Primary survey/ • resuscitation • Secondary survey

  3. Unmodifiable Age Sex Heredity Race Modifiable B/P Obesity Dyslipidemia Smoking Sedentary life style Stress Diabetes Factors For Consideration

  4. Focused Survey Subjective data • Chief complaint • History of present illness • Pain: PQRST • Provocation • Quality • Region/radiation • Severity • Time • Duration • Development over time • Periodicity (? Comes/goes)

  5. Dyspnea SOB Dyspnea on exertion Positional dyspnea Paroxysmal nocturnal dyspnea Orthopnea Cough Dry, “cardiac” cough Hemoptysis Syncope Palpitations Fatigue Nausea and Vomiting Headache Behavioral change Activity limitations Injury: mechanism and time Focused Survey (Continued)

  6. Medical History • Coronary Heart Disease • Angina • Previous MI • Hypertension • CHF • Pulmonary Disease • Diabetes • Renal Disease • Previous Cardiac Surgery • Congenital Anomalies • Allergies

  7. Current/Past Medication Use • Nitrates • Beta Blockers • Calcium Channel Blockers • Anti- hypertensives • Digitalis • Diuretics • Antidysrhythmics • Anticoagulants • Steroids • Specific Pulmonary Drugs • Illicit Drugs • OVC Medications

  8. Physical Exam • General Survey • LOC • Respiratory status • Rate, regularity, effort, breath sounds • Integumentary • Color, temperature, moisture, capillary refill • Edema • Dependent, extremities, sacrum, pleural effusion, ascitis, cardiac (pitting)

  9. Physical Exam 0 = absent 1 = thready 2 = normal 3 = bounding • Cyanosis • Central • Peripheral • Clubbing • B/P Measurement • Both arms • Orthostatic (supine, sitting, standing)

  10. Physical Exam • Apical heart rate • Regular, irregular, regularly irregular, irregular irregular • Peripheral pulses • Pupils • Size, equality, reactive

  11. Inspection • Tracheal position • Neck veins • Can guesstimate CVP • Thorax • Configuration • Deformities, anterior, posterior, A-P diameter, symmetrical movement • Injuries, penetrating, blunt (ecchymosis, contusions) evidence of scars, surgery • Abnormal chest movement, asymmetrical, paradoxical

  12. Physical Exam (Inspection) • Precordium • Apical pulse • Abnormal precordial movements, heaves, lifts, pulsations, retractions • Epigastrium, pulsations

  13. Physical Exam: Palpation • Areas tender, or crepitus • Epigastrium

  14. Auscultatorysites Murmurs: systolic/diastolic Variations in rhythm Extra sounds Pericardial friction rub Venous hum Arterial bruits Clicks Physical Exam: Auscultation

  15. Physical Exam: Diagnostic Procedures • ECG, 12 lead • Rate, rhythm • Presence of cardiac dysrhythmias • Evidence of myocardial ischemia, injury • Presence of intraventricular conduction defect • Evidence of previous MI

  16. Physical Exam:Diagnostic Procedures • CBC • Serum electrolytes • Cardiac serum markers • Troponin • Myoglobin • Basic metabolic profile • Coagulation studies • Digoxin level • Serum creatinine, BUN • T& C • ABGs • Routine urinalysis

  17. Comparison of Diagnostic Markers

  18. Pulse oximetry Radiography Chest x-ray Heart size and location Presence of edema Pulmonary infiltrates Pleural effusions Air and fluid levels in trauma patients Mediastinal width Bony structure integrity Cardiac catheterization Echocardiogram Diagnostic Procedures

  19. Interventions • Determine priorities • Airway, vital signs, cardiac rhythm, ABGs, Pulse oximetry, • Control pain • Relieve anxiety • Education patient/other • Prevent complications • Establish care plan • Emergency equipment • Initiate appropriate interventions • Document data • Monitor responses and adjust

  20. Pediatrics • Growth & Development • R/T congenital heart disease (heart defects) • Acquired heart disease (rheumatic fever) • Endocrine (diabetes) • Other • Drug ingestions, ex: tricyclics, digoxin • Trauma (falls, MVCs) • Suffocation (plastic bags, drowning, accidental hanging)

  21. Pediatric • Pearls: • Cardiac arrest usually d/t progressive deterioration in respiratory and heart function • CHF, cardiogenic shock, dysrhythmias are unusual. If occur congenital. • Immature conduction system and autonomic innervation may contribute to dysrhythmias

  22. Presence of chronic diseases Altered drug metabolism Multiple physiological differences and changes in lab values must be considered when assessing the older patient Psychological and social changes: patient may have different goals for their treatment, discuss with patient Geriatric patients can adapt to disease so well that symptoms are not obvious Arteriosclerotic changes in aorta and peripheral pulses may pose a difficulty in palpating Rhythm abnormalities are so common that they may be “normal” Geriatric

  23. Pearls • “Go slow, stay low” with medications • Concurrent use of other medications cause problems, • Easy to use meds are helpful (transdermals) • One time or two time doses daily • Evaluate medications on a frequent basis

  24. Angina • Stable • Symptom of ischemia • “pain or discomfort” • Poorly localized • Flow/Demand imbalance • May be chronic, acute, or unstable

  25. Angina (continued) • Unstable angina • New symptoms of angina • Increasing symptoms that occur at rest or with on exertion • Usually due to platelet aggregation • Leads to atypical chest pain

  26. Angina (Continued) • Unstable angina diagnosis • Angina is at rest, as well as minimal exertion (usually 20 minutes or longer) • Angina of new onset (several weeks), starting with physical exertion, and markedly limits activity • Previously diagnosed stable angina

  27. Normal ECG

  28. Abnormal ECG Same Patient, Inverted T Waves

  29. Angina cont’d • Variant Angina • May or may not be due to atherotic changes • Thought to be due to coronary spasm • Prinzmetal’sangina • May occur at the same time, daily • Usually not associated with exertion or stress • Occurs at younger ages • ST elevation seen during pain, then disappears

  30. Angina: Curveballs • GERDs • Biliary Colic • Chest Wall Pain • Pericarditis • PE • Aortic Dissection • Dysrhythmias

  31. Angina: Data • Physical exam: • Elevated B/P • Increased Heart Rate • Rapid, shallow respirations • Diaphoresis • Transient pulmonary rales (with pain)

  32. Diagnostic Procedures: ECG • ST depression may accompany pain with stable angina • Transient ST-segment deviations (depression or elevation), and T wave inversion occur commonly with unstable angina • Variant angina: ST elevation occurs with pain, subsides when pain does • May see LV hypertrophy, old MI, nonspecific ST and T-wave abnormalities and AV defects

  33. Diagnostic Procedures (Continued) • CBC • Cardiac serum markers…no elevation should occur unless cell damage • Chest X-ray ( CHF, cardiomegaly)

  34. Interventions • Continuous monitoring • O2 • IV, Draw labs • 12 Lead ECG • Rest • Decrease anxiety • SL NTG, B/P 100 mm HG followed by a drip • Assess for H/A • Reflex tachycardia • Cautious with elderly

  35. Interventions (continued) • Beta blockers • If clinical situation deteriorates after B Blocker, consider coronary artery spasm • Assess for signs of heart failure • Adverse effects of blockers are considered more common and severe in geriatric

  36. Interventions (continued) • Administer antiplatelet agents • ASA (4-5 baby aspirin) • Administer ASAP • Decreases platelet activation and thrombus formation • TEACH/EDUCATION

  37. Acute Myocardial Infarction

  38. Myocardial Infarction (MI)-Coronary OcclusionHeart Attack

  39. MI: Data • Physical exam • General appearance: Anxious, restless, clenched fist against chest (Levine sign) Look of doom • Heart rate: may be ok, tachycardia (most common), bradycardia (inferior and RV), Regular or irregular PVCs common

  40. Data (continued) • Arterial BP • Majority of patients with uncomplicated MI are normotensive • May be elevated due to SNS stimulation • Pain and anxiety • Decreased as a result of impaired cardiac function or due to drug administration (nitrates, M.S.)

  41. Data (continued) • Respiratory rate: Initially elevated. Should return to normal after pain relief • Patients with CHF, respiratory rate correlates with severity of condition

  42. Data (continued) • Peripheral: How bad is the patient’s condition? • Pallor, cyanosis, diaphoreses, mottled, cool, peripheral pulses variable • Temperature: Often increases 4-8 hours post MI • Heart Sounds: muffled. murmurs may be transient or permanent

  43. Diagnosis • Continuous cardiac monitoring • 12 lead ECG • Determine Location of infarct (next slide)

  44. Myocardial Infarction Zones