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Bunch of Heart Stuff

Bunch of Heart Stuff. Chemeketa Community College EMT-Paramedic Program. Objectives. Left Ventricular Failure Right Ventricular Failure Pulmonary Edema Cor Pulmonale Acute Pulmonary Embolism EKG’s. Left Ventricular Failure. Affects over 2% of US pop. Disproportionate # of EMS calls

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Bunch of Heart Stuff

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  1. Bunch of Heart Stuff Chemeketa Community College EMT-Paramedic Program

  2. Objectives • Left Ventricular Failure • Right Ventricular Failure • Pulmonary Edema • Cor Pulmonale • Acute Pulmonary Embolism • EKG’s

  3. Left Ventricular Failure • Affects over 2% of US pop. • Disproportionate # of EMS calls • #1 Dx of inpatients >65 • Incidence of CHF doubles per decade of life • Mortality Rate with CHF • 8 times for men • 5 times for women

  4. Left Ventricular Failure • The failure of the LV to effectively pump forward • Synonymous with CHF • Acute CHF • Rapid • Chronic CHF • Slow • Midnight Shoppers

  5. LVF • Common Causes • Systemic HTN • Afterload • Coronary Artery Disease • Arteriosclerosis/Atherosclerosis • Ischemia • Local/temporary occlusion

  6. LVF • Common Causes • Infarction • Permanent, necrosis • Cardiomyopathy • Diseased heart muscle tissue • ETOH • Enlargement

  7. LVF • Causes • Volume overload • Bag of Potato Chips • Severe anemia • Hypoxemia

  8. LVF • Fluid will collect in LA • Small & Relatively incapable • Pulmonary Vasculature Fills • Pulmonary Congestion Occurs • Pulmonary Edema 2nd to LVF

  9. LVF S/S • Generalized Weakness • Fatigue • Chest Pain • May be masked by respiratory complaint • Anxiety • Dyspnea

  10. LVF S/S • Tachypnea • Orthopnea • Paroxysmal Nocturnal Dyspnea • Elevation of pulmonary venous & cap pressures • Wakening from sleep • Decrease in exercise tolerance

  11. LVF S/S • Rales • Wheezes • Reflex Airway Spasm • Cardiac Asthma • Rhonchi (Larger airway) • Dull percussion at lung bases

  12. Edema in Lungs

  13. LVF S/S • Productive Cough • Foamy-Blood-tinged sputum • Cyanosis • B/P • Initial HTN

  14. LVF S/S • Pulse • Rapid • Possible Dysrhythmia • Location of infarct • Diaphoresis

  15. Right Ventricular Failure • Causes • #1 Cause of RVF is LVF • Stenosis: • Pulmonary valve • Mitral Valve • Pulmonary Vascular HTN • RV AMI

  16. RVF – Who Cares • Inability of RV to pump forward • Overwhelmed by venous return • Backflow in systemic circulation

  17. RVF – S/S • Tachycardia • Venous Congestion • Engorged Liver, spleen • JVD • Peripheral Edema • Dependent Edema • Pitting Edema • Sacral (Bedridden)

  18. RVF-S/S • Ascites • Accumulation of serous fluid in peritoneal cavity – Taber’s 19th • Pleural Effusion • Peripheral Cyanosis • Tachy if isolated RVF • Right sided hypertrophy • X-ray

  19. RVF – S/S • Clubbing of fingers • Dx: Chronic Hypoxia with RHF • Most of the other LVF S/S also • CP • SOB • Tachypnea • Anxiety • Etc…

  20. Cor Pulmonale • Cause of RVF • Pulmonary Parenchymal or vascular disease • CP is a disease process • Case Scenario Explanation

  21. Cor Pulmonale – Case • 58 yo male • Hx of Chronic bronchitis or emphysema • Typical S/S of bronchitis • Progression • Deterioration of Pulmonary capillaries • Alveolar Fibrosis • Chronic Hypoxemia

  22. Cor Pulmonale – Case • Progression caused: • Increase in pulmonary artery pressures • Result RV afterload increase • RV ill equipped • RV Enlarges (Hypertrophy) • Chronic RH HTN leads to RVF

  23. Cor Pulmonale – Case • Patient displays all signs of: • RVF • Initial causative pulmonary condition • Voila’

  24. Treatment of RVF & LVF • CHF a circumstance not a Dx • Treatment objectives • Decrease myocardial: • Workload • Oxygen demand • Increase force & efficiency of contraction • Reduce fluid retention

  25. Tx • Decrease Workload • No Physical activity • Sitting upright • Oxygen • Pt may tolerate BVM • Morphine 

  26. Tx • Vasodilatory Therapy (Nitrates) • AMI reperfusion • Container expansion reduces preload • Increase Contractility • Shock algorithm directs • Dopamine • Dobutamine • Norepinephrine

  27. Tx • Reduce Fluid Retention • Diuretics • Lasix • Bumex

  28. Acute Pulmonary Embolism Chemeketa Community College Paramedic Program

  29. Acute Pulmonary Embolism

  30. Acute Pulmonary Embolism

  31. Defined • Blood clot lodged in pulmonary artery • Blocks pulmonary artery flow • Supplied area ceases to function • Decreased gas exchange • V/Q mismatch

  32. Defined • Typically forms in deep veins of thighs • Can also be fat or air

  33. History • Anticoagulation therapy • Heparin – 1930s • Streptokinase – 1930 • Urokinase – 1951 • 1960s – Large study of clot resolution • Recently TPA

  34. Incidence • Unknown, range from 50,000-100,000/yr • Higher than diagnosed, most diagnosed postmortem • 8% death rate with heparin tx • 1/3 will die within 1 hour

  35. Risk Factors • Deep vein thrombosis • Prolonged immobilization • Surgery • Trauma • Pelvic or femur fractures • Late pregnancy

  36. Risk Factors • Thrombophlebitis • Certain meds • Oral contraceptives • Atrial fibrillation • Smoking • Unknown

  37. Increasing Frequency • Older population • Malignancies • More sedentary • Heart failure • COPD • Surgical procedures

  38. Presentation • Variable and Non-specific • Dyspnea • Pleuritic chest pain • Syncope • Hemoptysis • RHF • Tachycardia

  39. Presentation • No physical findings significantly accurate • Deep venous thrombosis in proximal lower ext. helpful for Dx • Only about ½ source known

  40. Why doesn’t lung tissue die from emboli like heart muscle? • Lung has two blood supplies • Pulmonary and Bronchial • Share capillary beds

  41. Pre-hospital Treatment • Good Physical Exam and History • Index of suspicion • Airway • High flow O2 • IV • Rapid Transport

  42. Treatment ??? • Heparin • Thrombolytic agents • Streptokinase • TPA • Catheter fragmentation • Catheter embolectomy • Open-chest embolectomy

  43. Definitive Diagnosis • ???? • Angiographic • V/Q scan (venous/perfusion mismatch) • Operative • Multiple sources of evidence

  44. Pneumonia Herpes Zoster Pleurisy COPD Rib fracture Asthma Angina MI Pneumothorax Pancreatitis Hepatitis Salicylate OD Bronchitis Hyperventilation Lung carcinoma Sepsis TB Muscle pain Costochondritis CA Pericarditis CHF Percardial tamponade Differential Diagnosis

  45. Watch Out • Extraordinarily difficult to diagnose • Watch out for hyperventilation • Young women

  46. Group Projects! Work in Pairs and find the answers

  47. List As Many Drugs As You Can That Will Dilate Blood Vessels. • Name the source • Describe why they work

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