Cardio 2012

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Cardiovascular

System 2011Sonny M. Moreno, RN, USRN, MAN

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Anatomy and Physiology

How many layers?

What is the outer membrane?

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Valve between RA and RV?

Valve between LA and LV?

Valve between RA and PA?

Valve between LV and Aorta?

Most important valve?

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Location of valves?

ECG electrodes (6)?

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sound created after closure of AV valves?

sound created after closure of SL valves?

Indication of gallop? Indication of murmur?

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Heart sound is best heard in?

Apex and base of the heart?

Location of the heart?

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Great blood vessels?

1st branch of Aorta?

Blood supplyof myocardium?

BC

A

CC

A LS

A

Stroke volumeCardiac output

Ejection fraction

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Trace the pulmonary

circuit?

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Conduction system?

Main generator?

Reserve generator?ANS

SA-bachmanns bundle and

internodal tract (anterior,middle, posterior)

AV-bundle of his R & Lbundle purkinje fiber

purkinje network

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Layers

Chambers

Valves PMI

Pulmonary Circuit

Conduction System

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Cardiovascular Disorders

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Hyperlipidemia

Primary: Genetic Secondary: DM, Hypothyroidism, Nephrotic Syndrome, Liver

Disease, Obesity, diet, use of Beta Blockers and Diuretics

Dx: >200 mg/dl, >LDL,

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Atheroma

EFFECTS?

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Coronary Artery Disease CAD

MCC: Atherosclerosis

Risk Factors: MRF and NMDRF

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Difference b/n Angina and MI

Angina

1. Incomplete block

2. Less 15 minutes (pain)

3. Relieved by NTG4. ST and T wave changes

5. Attack is precipitatedby activity

6. Not life threatening

MI

1. Complete block

2. Over 15 minutes (pain)

3. Not relieved by NTG4. ST segment depression

and T wave inversion

5. Attack is not

precipitated by activity6. Life threatening*

Impending doom,

levines sign

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Angina and MI

Dx:1. Pain and NTG test

2. Coronary angiography

3. MUGA: MULTI GATED ACQUISITION SCAN(Nuclear Medicine)

Thallium 201 Imaging (normal)

Technetium-99 Imaging (necrotic)

4. Cardiac enzymes: increased Troponin-T or I

CK MB

LDH1 higher than LDH2(flipped LDH)

AST

5. ECG

6. WBC, ESR and Myoglobin*

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Possible ECGresults:

Elevation of STsegment = MI

Peaked orinverted T wave

= MI Pathological Q

wave = MI

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MI management: ER!!!

1. CBR without BP & supine position

2. Oxygen therapy

3. IV access line

4. Pain control,Morphine or Meperidine, IV bolus

5. Vasodilator (NTG), IV drip or patch

6. Anxiolytic (Benzodiazepine)

7. Cardiac monitor

8. Central venous access line

9. Cardiac enzymes evaluation

10. ACLS*

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Other drugs for MI:

Pharmacologic Therapy1. Thrombolytic Agents

1. TPA tissue plasminogen activator2. Streptokinase (streptase)3. Urokinase

2. Anticoagulant

1. Heparin2. Warfarin3. ASA (antiplatelets)4. Plavix

3. Beta adrenergic blocking agents1. Propranolol

4. Antidysrhythmic1. Lidocaine (Xylocaine)5. Calcium Channel Blockers

1. Diltiazem*

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MI surgical interventions:

PTCA PercutaneousTransluminal CoronaryAngioplasty

IABP Intraaortic BalloonPump

CABG coronary arterybypass graft

Triple

Saphenous Vein, LIMA and

RITA*

PTCA

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PTCA

Percutaneous Transluminal Coronary

Angioplasty

IABP

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IABP

Intra aortic Balloon Pump

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CABG

Coronary Artery Bypass Graft

Postop: Cardiac rehab

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Conduction of Heart

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ECG Tracings and Interpretations

1. Observe P wave

2. Evaluate Atrial rhythm

3. Determine Atrial rate (6-10 per strip/6sec)

4. Calculate PR interval (0.12-0.20 sec or 3-5

ss)5. Evaluate Ventricular rhythm (QRS)

6. Determine Ventricular rate (6-10 perstrip/6 sec)

7. Calculate the duration of QRS (0.06-0.08

sec or 1.5-2 ss)8. Calculate QT interval (0.36-0.44 sec or 9-

11 ss)

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Cardiac Dysrhythmias

Atrial Arrhythmias:

1. Premature Atrial Contraction (PAC) No mx unless symptomatic

2. Atrial Flutter Antiarrhythmic (Amiodarone and Flecainide) Digitalis

Betablockers

Antiplatelet and anticoagulant

3. Atrial Fibrillation Digitalis

Defibrillation

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Cardiac Dysrhythmias

Ventricular Arrhythmias:1. Premature Ventricular Contraction (PVCs)

Xylocaine

2. Ventricular Tachycardia (vtach)

Defibrillation (unsynchronized)

3. Ventricular Fibrillation (vfib)

Defibrillation (unsynchronized)

CPR

Epi 1mg (1st 2 min) Repeat Defib-CPR Amiodarone 300 mg (2nd 2 min) 2nd dose 150 mg

Repeat Defib-CPR Vasopressor (Dopa) 2-10mcg/kg/min (3rd 2 min)

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A and V Arrhythmias

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Asystole

CPR

Epi 1mg (x Atropine Sulfate)

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Heart Block

1st Degree

2nd Degree

Type I (Mobitz)

Type II (Mobitz)

3rd Degree

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Heart Block

1st Degree

> 0.20 sec PR interval

Prolonging PR interval

Cause: BB and CCB

Mx: none not unless symptomatic

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Heart Block

2nd Degree

Type I (Mobitz)

60-100 beats/min

More P wavesthan QRS

Prolonging

PR interval

Cause: BB and CCB

Mx:

Pacemaker (TCP to Permanent)

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Heart Block

2nd Degree

Type II (Mobitz)

60-100 beats/min

More P wavesthan QRS

Missing QRS

ProlongingPR interval

Cause: BB and CCB

Mx:


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Heart Block

3rd Degree Divorced P and QRS

Less QRS (40-50 beats/min)

Cause: BB and CCB Mx: ER!!!


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Heart Block

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Elevation of ST segment = MI

STEMI-fatalNSTEMI

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Peaked or inverted T wave = MI

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Pathological Q wave = MI

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Flattening of T wave = Hypokalemia

U wave = Hypokalemia

Depression of ST segment = Hypokalemia

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Elevated T wave = Hyperkalemia

L QT i l H l i

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Long QT interval = Hypocalcemia

(Torsades de Pointes)

Administer Mg Sulfate

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P i di i

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Pericarditis

Post MI complication

(Dresslers Syndrome)

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CHF

Cause: FVE, heart problems Dx:

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Its all about the LEFT ventricle PRELOAD is the initial stretching of the heart prior to

contraction

AFTERLOAD "load" that the heart must eject blood against

EJECTION FRACTION

EDV = 120 ml (amt of blood in the LV before contraction) SV = 70 ml (amt of blood ejected in the LV per contraction)

ESV = 50 ml (amt of blood in the LV after contraction)

Ef = 58%

Formula:

=SV/EDV

=70/120

=58%

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Cardiac Arrest Treatment:1. Increase CO2. Cardiovascular drugs and mechanical equipment

utilization3. Cardiovascular Drugs:

IV Dopamine (vasopressor)IV Dobutamine (diuretic effects)IV Epinephrine (vasoconstrictor)IV Nitroprusside (vasodilator)

4.Mechanical:IABP intra aortic balloon pump (improve coronary

perfusion)Defibrilator (arrhythmias can be stopped)Cardiac monitor (to detect arrhythmias)*

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Cardiogenic Shock!

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Dont be too late!

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Dont be too late!

ORGANS EARLY S/SX

Reversible

LATE S/SX

IrreversibleBRAIN LOC (disorientation) Coma

HEART tachy Brady

KIDNEYS Oliguria (>30mL/H) Anuria (>10mL/H)

LUNGS tachy Brady

SKIN Pallor Cyanosis

GIT Ulceration Ulceration-bleeding

LIVER detoxification Sepsis

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Outpouching of arterial wall bruit Abdominal Aortic Aneurysm

Aneurysm: BV dilates, arterial wall

Cause: AVM (arteriovenous

Malformation), diseases Dx: MRI

S/sx: as/sx, depending on thearea involved

Mx: Drugs? Anti-HPN drugs (ABCD) BB, anticoagulant Avoid valsalva maneuver Surgical clipping Endovascular coiling (coils initiate a clotting

or thrombotic reaction within the aneurysm)

Stent

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Peripheral Vascular Disorders

Artery TAO

Vein

DVT Thrombophlebitis

CVI

Varicosities

Artery and Vein

RP

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Buerger-Allen exercises - A series of exercises

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Buerger Allen exercises A series of exercisesadministered to patients with peripheral vasculardisease. These exercises are repeated 6-7 times

at each sitting and done several times a day.1. Support legs in an elevated position at 60-90degrees for 30-180 seconds, or until youproduce blanching of the extremity. The patient

is instructed to actively dorsiflex and plantarflexthe ankle throughout the procedure.

2. Allow feet to dangle over the edge of the bed for2-5 minutes or as long as it takes to producehyperemia, then add one minute. The total timeshould not exceed 5 minutes.

3. Place legs in a horizontal position for 3-5minutes.

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Disorders

DVT pulmo embolism

Thrombophlebitis

CVI chronic venous insufficiency

Varicosities

DVT1. Pratts sign (squeezing of

the calf)2. Virchows triad

Decreased blood flow

Increased coagulation

Damaged wall

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Disorders

DVT

Thrombophlebitis

CVI

Varicosities

Irritated lining

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Disorders

DVT

Thrombophlebitis

CVI

Varicosities

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Disorders

DVT

Thrombophlebitis

CVI

Varicosities

Stasis of blood (prof, saleslady,

Preggy, obese, post op patient,

coma) = quadriceps teaching

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Tandaan!!!

DVT Venous stasis

Vein

S/sx:Homans sign

POOLING

Duplex UTZ test (sounds to image) Venogram

Thrombectomy

Embolism

Fibrinolytics and anticoagulant

Dipyridamole (Persantin)ANTIPLATELET: to prevent occlusion

Clot formation no massage maydislodge

Antiembollic stockings, bago tumayo

TAO Smoking

Artery

S/sx:Intermittent claudication

LOSS OF SENSATION

Doppler UTZ test (speed) Arteriogram

Endarterectomy

Gangrene (clostridium perfringens)

Fibrinolytics and anticoagulant

Dipyridamole (Persantin)ANTIPLATELET: to prevent occlusion *

No raising, level of heart = noperfusion

RP R d Ph

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RPRaynauds Phenomenon orVasospastic Disorder

Cause: X, AutoImmune,cold stress

Dx: Cold StimulationTest and Nail fold

Capillaroscopy S/sx: White (spasm)-

Blue (dilate) -Red(constriction)

Cx: gangrene Mx: x smoking, avoid

trigger, 1. CCBA, BB,sympathectomy Raynauds Disease: bilateral involvement
http://en.wikipedia.org/wiki/File:Raynaud's_Syndrome.jpg

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Thank you

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Cardio 2012