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CARDIAC EMERGENCIES

The Heart

Superior Vena Cava

Right Atrium

Aorta

Left Atrium

Left Ventricle

Right Ventricle

Tricuspid Bicuspid

Aortic valve

Pulmonary valve

Electrolyte effect:-

� Sodium: Sodium: action potentialaction potential

� Calcium: Calcium: vascular tone, myocardial contractility and vascular tone, myocardial contractility and cardiac excitabilitycardiac excitability

� Potassium: Potassium: ventricular depolarization and repolarization.ventricular depolarization and repolarization.

� Magnesium: Magnesium: essential for enzyme, protein, lipid and essential for enzyme, protein, lipid and carbohydrate functions..carbohydrate functions..

Conduction System

SA Node

AV Node

Left Bundle Branch

Right Bundle Branch

Purkinje Fibers

Preload And Afterload

� Preload: Preload: degree of stretch of the cardiac muscles just degree of stretch of the cardiac muscles just before the contractionbefore the contraction

� ContractilityContractility: The ability of mucscle tissue to contract.: The ability of mucscle tissue to contract.

� Afterload: Afterload: the pressure the heart must overcome to eject the pressure the heart must overcome to eject blood from the ventriclesblood from the ventricles

Investigation:-

� Blood TestsBlood Tests� CT ScansCT Scans� EchocardiographyEchocardiography� Electrocardiograms (EKG)Electrocardiograms (EKG)� Holter and Event (Loop) Monitoring Holter and Event (Loop) Monitoring � Exercise Stress TestsExercise Stress Tests� MRIsMRIs

BLOOD TESTS� Antistreptolysin-O test – protein produced by Antistreptolysin-O test – protein produced by

streptococcal bacteriastreptococcal bacteria� Arterial blood gases Arterial blood gases � Blood fat profile Blood fat profile � Blood calcium testBlood calcium test� Complete blood count Complete blood count � ElectrolyteElectrolyte� Erythrocyte sedimentation rate (ESR)Erythrocyte sedimentation rate (ESR)� Cardiac enzyme tests Cardiac enzyme tests � Glucose test.Glucose test.� Prothrombin time tests . Prothrombin time tests . � Total serum protein Total serum protein

BLOOD FAT PROFILEBLOOD FAT PROFILE

Cholesterol

HDL (good cholesterol)

LDL (bad cholesterol)

Triglycerides

Cholesterol Level:-

DesirableMg/dl

Border line Mg/dl

High Risk Mg/dl

Total Cholesterol < 200 200 – 240 > 240

LDL Cholesterol 100 100 – 150 > 150

HDL Cholesterol > 40 30 - 40 < 30

Triglyceride 150 150 - 200 > 200

CARDIAC ENZYME TESTS:-CARDIAC ENZYME TESTS:-� Creatine kinase-MB Creatine kinase-MB An elevation occurs within 4 to An elevation occurs within 4 to

6 hours and peaks 18 to 24 hours following an acute 6 hours and peaks 18 to 24 hours following an acute ischemic attack.ischemic attack.

� Lactate dehydrogenaseLactate dehydrogenase: Elevations :-24hours : Elevations :-24hours following MI and peak in 48 to 72hours. Normally following MI and peak in 48 to 72hours. Normally LDH 1 is more then LDH 2.LDH 1 is more then LDH 2.

� Normal value :140 to 280 international units/L.Normal value :140 to 280 international units/L.� Myoglobin Myoglobin rises within 1hour after cell death, peaks rises within 1hour after cell death, peaks

in 4 to 6 hours.in 4 to 6 hours.

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Cardiac Disease

-HTN-HTN

-CAD-CAD- MIMI

-CHF-CHF

- Valvular diseases- Valvular diseases

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Cardiac Disease Risk Factors

� Non Modifiable /UncontrollableNon Modifiable /Uncontrollable� AgeAge� SexSex� RaceRace� HeredityHeredity

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� Modifiable/Controllable Modifiable/Controllable � SmokingSmoking� High BPHigh BP� High blood cholesterolHigh blood cholesterol� DiabetesDiabetes

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Risk Factors:-

� ObesityObesity� Lack of exerciseLack of exercise� StressStress� PersonalityPersonality

Hypertension

Etiology:-

� PrimaryPrimary� Family historyFamily history� StressStress� High fat dietHigh fat diet� High sodium dietHigh sodium diet� Sedentary lifestyleSedentary lifestyle� AgingAging� Tobacco useTobacco use� Oral contraceptivesOral contraceptives� Poor medication Poor medication

compliancecompliance

� SecondarySecondary� Renal diseaseRenal disease� Adrenal disorderAdrenal disorder� CV DisorderCV Disorder� CNS Disorders/injuriesCNS Disorders/injuries� Medication side effectsMedication side effects� Volume overloadVolume overload

Clinical manifestation:-

� Headache: especially in the Headache: especially in the morningmorning

� EpistaxisEpistaxis� Visual disturbanceVisual disturbance� VertigoVertigo� Chest painChest pain� Shortness of breathShortness of breath� WeaknessWeakness� NauseaNausea

Diagnostic Testing for HTN

� CBCCBC� Kidney functionsKidney functions

� Elevated BUN/CreatinineElevated BUN/Creatinine� ProteinuriaProteinuria

� CXRCXR

� 12 Lead EKG12 Lead EKG

Treatment of HTN

� Elevate HEAD END OF BEDElevate HEAD END OF BED� Cardiac monitoringCardiac monitoring� Strict I&O’SStrict I&O’S� Frequent neuro assessmentsFrequent neuro assessments� PharmacologyPharmacology

� VasodilatorsVasodilators� NitroprussideNitroprusside� Hydralazine: drug of choice for pregnancyHydralazine: drug of choice for pregnancy� NitroglycerinNitroglycerin

� SympatholyticsSympatholytics� LabetololLabetolol� Nifedipine or procardiaNifedipine or procardia

� DiureticsDiuretics

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Coronary Artery Disease

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Coronary Artery Disease

� AtherosclerosisAtherosclerosis� Narrowing of lumenNarrowing of lumen

� plaque formation - related to Risk Factorsplaque formation - related to Risk Factors� results in decreased myocardial perfusionresults in decreased myocardial perfusion

� Poor tissue perfusion causes:Poor tissue perfusion causes:� tissue damage (ischemia)tissue damage (ischemia)� tissue death (infarction)tissue death (infarction)

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Atherosclerotic Plaque Formation

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Angina Pectoris “A choking in the chest”

� Myocardial oxygen Myocardial oxygen demand exceeds demand exceeds

supply during periods supply during periods of increased of increased activity, exercise, activity, exercise, or stressful eventor stressful event

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Types of Angina Pectoris

� Stable AnginaStable Angina� Occurs with exerciseOccurs with exercise� PredictablePredictable� Relieved by rest or NitroglycerinRelieved by rest or Nitroglycerin

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� Unstable AnginaUnstable Angina� More frequent/severeMore frequent/severe� Can occur during restCan occur during rest� May indicate impending MIMay indicate impending MI� Requires immediate treatment and Requires immediate treatment and

transport to appropriate facilitytransport to appropriate facility

� Variable or Prinzmetal’s angina: Variable or Prinzmetal’s angina:

-Caused by coronary artery spasm, -Caused by coronary artery spasm,

-Can occur at rest and can be cyclic-Can occur at rest and can be cyclic

ASSESSMENT OF PAINASSESSMENT OF PAIN

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Symptoms -Angina Pectoris

� PainPain� SubsternalSubsternal� Squeezing/Crushing/HeavinessSqueezing/Crushing/Heaviness� May radiate to arms, shoulders, jaw, May radiate to arms, shoulders, jaw,

upper back, upper abdomen backupper back, upper abdomen back� May be associated with shortness of May be associated with shortness of

breath, nausea, sweatingbreath, nausea, sweating

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� Pain usually associated with 3E’sPain usually associated with 3E’s� ExerciseExercise� EatingEating� EmotionEmotion

� Pain seldom lasts > 30 minutes Pain seldom lasts > 30 minutes � Pain relieved byPain relieved by

� RestRest� NitroglycerinNitroglycerin

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Acute Myocardial Infarction “Heart Attack”

� Inadequate perfusion Inadequate perfusion of myocardiumof myocardium� Death of myocardiumDeath of myocardium

� InfarctInfarct� Damage to myocardiumDamage to myocardium

� Ischemia Ischemia

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Symptoms - AMI

� Chest PainChest Pain - cardinal sign of - cardinal sign of myocardial infarctionmyocardial infarction� Occurs in 85% of MI’sOccurs in 85% of MI’s� SubsternalSubsternal� ““Crushing,” “squeezing,” “tight,” Crushing,” “squeezing,” “tight,”

“heavy”“heavy”

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� Chest PainChest Pain� May radiate to arms, shoulders, jaw, May radiate to arms, shoulders, jaw,

upper back, upper abdomen backupper back, upper abdomen back� May vary in intensityMay vary in intensity� Unaffected by:Unaffected by:

� swallowingswallowing� coughingcoughing� deep breathingdeep breathing� movementmovement

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� Chest PainChest Pain� Unrelieved by rest/nitroglycerinUnrelieved by rest/nitroglycerin� Pain lasts longer than angina pain (up Pain lasts longer than angina pain (up

to 12 hours)to 12 hours)� ““Silent’ MI Silent’ MI

� 15% of patients with MI, 15% of patients with MI, � particularly common in elderly and particularly common in elderly and

diabeticsdiabetics

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Symptoms - AMI� Shortness of breathShortness of breath� Weakness, dizziness, faintingWeakness, dizziness, fainting� Nausea, vomitingNausea, vomiting� Pallor and diaphoresis (heavy sweating)Pallor and diaphoresis (heavy sweating)� Sense of impending doomSense of impending doom� Denial Denial

� 50% of deaths occur in first two hours50% of deaths occur in first two hours� Average patient waits 3 hours before seeking helpAverage patient waits 3 hours before seeking help

AREA OF INFARCTION IN ECG?

� Anterior: V1-V4 (LAD)Anterior: V1-V4 (LAD)� Septal: V1-V2 (LAD)Septal: V1-V2 (LAD)� Lateral: I, AVL, V5-V6 (Circumflex)Lateral: I, AVL, V5-V6 (Circumflex)� Inferior: II, III, AVF (RCA)Inferior: II, III, AVF (RCA)� Right Ventricular: Right V4-V6 (RCA) Right Ventricular: Right V4-V6 (RCA)

� Cardiac enzymes Cardiac enzymes

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Management� Early treatment is importantEarly treatment is important� Goal is to preserve myocardial tissueGoal is to preserve myocardial tissue� Position of ComfortPosition of Comfort� Patent AirwayPatent Airway� High concentration OHigh concentration O22

� Reassure the patientReassure the patient� Obtain a brief history and physical examObtain a brief history and physical exam� Cardiac monitoring with 15 minutesCardiac monitoring with 15 minutes� BP in both armsBP in both arms� 3 IV’S: at least 1 in the left arm3 IV’S: at least 1 in the left arm

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� Nitroglycerin- Nitroglycerin- Dilates coronary arteriesDilates coronary arteries

� 0.4mg tablet sublingual0.4mg tablet sublingual� Patient should be sitting or lying downPatient should be sitting or lying down� Has Pt. Taken nitroglycerin in last 10 Has Pt. Taken nitroglycerin in last 10

minutes? Is pain relieved? Headache?minutes? Is pain relieved? Headache?� Is BP > 90 systolic?Is BP > 90 systolic?� q 5 minutes until pain relieved or three q 5 minutes until pain relieved or three

tablets administeredtablets administered

Medical Treatment� Morphine sulfate – 2-4 mg titrated for pain Morphine sulfate – 2-4 mg titrated for pain

reliefrelief� decreases blood return to the heartdecreases blood return to the heart� decreases anxietydecreases anxiety� relaxes smooth muscle in the lungsrelaxes smooth muscle in the lungs� has analgesic effecthas analgesic effect

� Thrombolytic therapy Thrombolytic therapy ––� HeparinHeparin� Aspirin 325mg p.o.Aspirin 325mg p.o.� StreptokinaseStreptokinase

� Beta blockersBeta blockers� Calcium channel blockersCalcium channel blockers

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Congestive Heart Failure� CHF :- Inability of the heart to CHF :- Inability of the heart to

pump sufficient blood to meet the pump sufficient blood to meet the demands of the bodydemands of the body

� ClassificationsClassifications� Left heart failureLeft heart failure: most common, results in : most common, results in

pulmonary congestionpulmonary congestion� Right heart failureRight heart failure: can result from left : can result from left

heart failure and presents with peripheral heart failure and presents with peripheral venous congestionvenous congestion

� BiventricularBiventricular

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Congestive Heart Failure

� Usually begins with left-sided failure.Usually begins with left-sided failure.� Left ventricle failsLeft ventricle fails� Blood “stacks up” in lungsBlood “stacks up” in lungs� High pressure in capillary bedsHigh pressure in capillary beds� Fluid forced out of capillaries into alveoliFluid forced out of capillaries into alveoli

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Congestive Heart Failure

� Right-sided failure most commonly Right-sided failure most commonly caused by Left-sided failure. Blood caused by Left-sided failure. Blood “backs up” into systemic circulation“backs up” into systemic circulation� Distended neck veinsDistended neck veins� Fluid in abdominal cavityFluid in abdominal cavity� Pedal edemaPedal edema

Etiology of Heart Failure

Left HeartLeft Heart� CADCAD� MIMI� HTNHTN� Rheumatic HT DZRheumatic HT DZ� Valvular dysfunctionValvular dysfunction� Aortic stenosisAortic stenosis� Ventricular aneurysmVentricular aneurysm� Pulmonary HTNPulmonary HTN� Endocardial fibrosisEndocardial fibrosis� Myocardial fibrosisMyocardial fibrosis

Right HeartRight Heart� Left heart failureLeft heart failure� MIMI� Pulmonary HTNPulmonary HTN� DrugsDrugs� Valvular dysfunctionValvular dysfunction� Spontaneous of Spontaneous of

unknown etiologyunknown etiology

SYMPTOMS of CHF

Left HeartLeft Heart� DyspneaDyspnea� Cough w/frothy sputumCough w/frothy sputum� Rales/rhonchiRales/rhonchi� HypoxiaHypoxia� Weak/fatigueWeak/fatigue� TachycardiaTachycardia� S3S3� CyanosisCyanosis� Resp AlkalosisResp Alkalosis

Right HeartRight Heart� JVDJVD� Bounding pulsesBounding pulses� OliguriaOliguria� N/V, AnorexiaN/V, Anorexia� Weight gainWeight gain� MurmurMurmur� Peripheral edemaPeripheral edema� OrganomegalyOrganomegaly

Diagnostic Findings� History and physicalHistory and physical� CXRCXR� Hemodynamic and cardiac monitoringHemodynamic and cardiac monitoring� LabsLabs

� ABG: Respiratory alkalosisABG: Respiratory alkalosis� BNPBNP� ElectrolytesElectrolytes� Cardiac EnzymesCardiac Enzymes� CBCCBC� LFT’SLFT’S

� 12 lead EKG, 12 lead EKG, ECHOECHO� MUGA ScanMUGA Scan� Pressure monitoring cathetersPressure monitoring catheters

� PA Catheter Swan-Ganz PA Catheter Swan-Ganz � Arterial line; SBP, DBP, MAPArterial line; SBP, DBP, MAP

EMERGENCY MEDICAL EMERGENCY MEDICAL CARECAREResponsiveResponsive� Perform initial assessmentPerform initial assessment� Focused HX and PEFocused HX and PE� Place patient in position of comfort Place patient in position of comfort � Cardiac - c/o pain or discomfortCardiac - c/o pain or discomfort

� 100% oxygen100% oxygen� Assess vitalsAssess vitals

(ASSESSMENT OF (ASSESSMENT OF PAIN) QUESTIONPAIN) QUESTION

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Nursing Intervention For CHF

� Elevate HEAD END OF BEDElevate HEAD END OF BED� Oxygen therapyOxygen therapy� Cardiac and hemodynamic monitoringCardiac and hemodynamic monitoring� Strict I&O’SStrict I&O’S� Pharmacologic:Pharmacologic:

� Diuretics: lasix, natrecorDiuretics: lasix, natrecor� Positive inotropics: dopamine, dobutamine, digoxinPositive inotropics: dopamine, dobutamine, digoxin� Pain/anxiety: morphinePain/anxiety: morphine� Vasodilators: NTG, Hydralazine, niprideVasodilators: NTG, Hydralazine, nipride

� Potential advanced airways: BIPAP, intubationPotential advanced airways: BIPAP, intubation

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Management of CHF� Sit patient up, let feet dangleSit patient up, let feet dangle

� Administer high concentration OAdminister high concentration O22

� Assist ventilation as neededAssist ventilation as needed� Monitor vital signs q 5-10 minutesMonitor vital signs q 5-10 minutes� Request early ALS back-upRequest early ALS back-up

EMERGENCY MEDICAL EMERGENCY MEDICAL CARE PulselessCARE Pulseless

� Patient > 12 yrs old - CPR with AEDPatient > 12 yrs old - CPR with AED

� Patient < 12 yrs old or < 90 lbs - CPRPatient < 12 yrs old or < 90 lbs - CPR

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Pacemaker Failure/Coronary Artery Bypass

� Position of comfortPosition of comfort� Patent airwayPatent airway

� High Concentration OHigh Concentration O22

� Assist ventilations as neededAssist ventilations as needed� ALS InterceptALS Intercept� CPR as needed (CPR as needed (DO NOT worry about DO NOT worry about

damage to pacemaker)damage to pacemaker)

Pericarditis� inflammation of the pericardium and the frequent production of inflammation of the pericardium and the frequent production of

exudate.exudate.

� Symptoms Symptoms

� Chest painChest pain� More pain laying backMore pain laying back� Pain with deep inspirationPain with deep inspiration� FeverFever� MalaiseMalaise� WeaknessWeakness� TachycardiaTachycardia� Pericardial friction rub in 30% of casesPericardial friction rub in 30% of cases� DiaphoresisDiaphoresis� DyspneaDyspnea� HypotensionHypotension

Endocarditis

Infection of the endothelial surface of the heart most often Infection of the endothelial surface of the heart most often of the valvesof the valves

SymptomsSymptoms� Fever or chillsFever or chills� MurmurMurmur� Janeway lesions: red macules on hands/feetJaneway lesions: red macules on hands/feet� Roth spots: retinal hemorrhagesRoth spots: retinal hemorrhages� Anorexia, malaise, PetechiaeAnorexia, malaise, Petechiae� Splenomegaly or splenic infarctSplenomegaly or splenic infarct� CHF,Glomerulonephritis or infarctCHF,Glomerulonephritis or infarct� Cerebrovascular disease, or vertigoCerebrovascular disease, or vertigo

Nursing Considerations for Pericarditis

� Position of comfortPosition of comfort� OxygenationOxygenation� Cardiac and hemodynamic monitoringCardiac and hemodynamic monitoring� Pain control: NSAIDS, Steroids, antibiotics(in Pain control: NSAIDS, Steroids, antibiotics(in

pericarditis)pericarditis)� No anticoagulants No anticoagulants � Pericardiocentesis if necessaryPericardiocentesis if necessary� Antipyretics in endocarditisAntipyretics in endocarditis

Valvular Heart Disease

Understanding Terms

� StenosiStenosiss = Constriction or narrowing of = Constriction or narrowing of orificeorifice

� RegurgitationRegurgitation = Retrograde of the flow of = Retrograde of the flow of blood from one chamber back into anotherblood from one chamber back into another

� ProlapseProlapse = valve leaflets billow back or = valve leaflets billow back or buckle back into the atrium buckle back into the atrium

Mitral Stenosis

� Mitral valve becomes Mitral valve becomes narrownarrow and and constrictedconstricted

� Causes Causes ↑ L. Atrial pressure and volume↑ L. Atrial pressure and volume� Most are due to Rheumatic Heart diseaseMost are due to Rheumatic Heart disease� Symptoms: murmur at 5Symptoms: murmur at 5 thth ICS ICS� Extended dyspnea and fatigueExtended dyspnea and fatigue

Mitral Valve Prolapse

� Valve billows back into L. AtriumValve billows back into L. Atrium� Cause is unknownCause is unknown� Heard as a murmurHeard as a murmur� Can be familial due to connective tissue Can be familial due to connective tissue

disorderdisorder� Most people asymptomatic, benignMost people asymptomatic, benign� Most common valve disorderMost common valve disorder� May lead to Mitral Valve RegurgitationMay lead to Mitral Valve Regurgitation� Diagnosed by ECHODiagnosed by ECHO

Mitral Regurgitation

� Retrograde blood flow from L. Ventricle Retrograde blood flow from L. Ventricle to L. Atriumto L. Atrium

� Etiology R/T: MI, Rheumatic heart disease, Etiology R/T: MI, Rheumatic heart disease, MVPMVP

� Symptoms R/T acute or chronic murmur Symptoms R/T acute or chronic murmur � Heard best at 5Heard best at 5 thth ICS ICS� May feel a thrillMay feel a thrill

� More common in women than menMore common in women than men

Valvular Regurg - picture

Aortic Stenosis

� Blood flow restricted from L. Ventricle to Blood flow restricted from L. Ventricle to AortaAorta

� Results inResults in LVHLVH, & , & ↑myocardial oxygen ↑myocardial oxygen consumptionconsumption

� Causes: congenital, Rheumatic Fever, Causes: congenital, Rheumatic Fever, atherosclerosisatherosclerosis

� Symptoms - Symptoms - ↓ S1 or S2 sound↓ S1 or S2 sound– MurmurMurmur– S4S4

Aortic Regurgitation

� Retrograde blood flow from the Retrograde blood flow from the Ascending Aorta into L. VentricleAscending Aorta into L. Ventricle

� Results in: Results in: L. VentricleL. Ventricle dilation & LVHdilation & LVH, , leading to leading to ↓contractility of the heart↓contractility of the heart

� murmurmurmur� Soft S1, S3 or S4Soft S1, S3 or S4� Causes: Congenital, Rheumatic Heart Causes: Congenital, Rheumatic Heart

DiseaseDisease� May have Orthopnea, Exertional dyspnea, May have Orthopnea, Exertional dyspnea,

paroxysmal nocturnal dyspneaparoxysmal nocturnal dyspnea

Tricuspid Valve Disease

� Stenosis & RegurgitationStenosis & Regurgitation� Tricuspid StenosisTricuspid Stenosis is uncommon is uncommon

� R. Atrium enlargement & R. Atrium enlargement & ↑systemic ↑systemic venous pressurevenous pressure

� Tricuspid RegurgitationTricuspid Regurgitation� Volume overload in R. Atrium and Volume overload in R. Atrium and

Ventricle occursVentricle occurs� Causes: R. Ventricular dysfunction, or Causes: R. Ventricular dysfunction, or

pulmonary HTNpulmonary HTN

Diagnosing Valve Disease

� History and Physical ExamHistory and Physical Exam� EchocardiographyEchocardiography� Cardiac CatheterizationCardiac Catheterization� ECGECG

Collaborative Care for Valvular

Disease� Ask about history of Rheumatic Heart DiseaseAsk about history of Rheumatic Heart Disease� Use of antibiotic prophylaxisUse of antibiotic prophylaxis� DigitalisDigitalis� DiureticsDiuretics� Anticoagulation (ASA, Coumadin)Anticoagulation (ASA, Coumadin)� Surgical repair or replacementSurgical repair or replacement

Nursing Management/Goals

� Maintaining normal cardiac functionMaintaining normal cardiac function� Monitoring Cardiac output, fluid volume Monitoring Cardiac output, fluid volume

excessexcess� Improving activity toleranceImproving activity tolerance� Educating patients on the disease process Educating patients on the disease process

and preventative measuresand preventative measures

Mitral Valve repair

Valve Replacement

� Mechanical/BiologicMechanical/Biologic� AntibioticsAntibiotics� Lifelong anticoagulation therapyLifelong anticoagulation therapy

� mechanicalmechanical� Good oral hygieneGood oral hygiene

� Prevent infectionsPrevent infections

V-O-M-I-T� VV= Vital Signs= Vital Signs� OO = Oxygen = Oxygen� MM = Monitor = Monitor� I I = IV Access= IV Access� T T = Treatment= Treatment

Cardiac Drugs� Diuretics: decrease volume loadDiuretics: decrease volume load

� Indications: CHF, HTN, edema, diuresisIndications: CHF, HTN, edema, diuresis� Classifications:Classifications:

� ThiazideThiazide: acts on distal tubules: acts on distal tubules

• HCTZ, ZaroxolynHCTZ, Zaroxolyn

• Monitor: BP, Uric Acid, BS, Cholesterol, CNSMonitor: BP, Uric Acid, BS, Cholesterol, CNS� Potassium sparingPotassium sparing: acts on the distal loop: acts on the distal loop

• Spironolactone or AldactoneSpironolactone or Aldactone

• Monitor BP and PotassiumMonitor BP and Potassium� Loop:Loop: act on the Loop of Henle act on the Loop of Henle

• Lasix, BumexLasix, Bumex

• Monitor: BP, Lytes, BS, Uric Acid, Renal FunctionMonitor: BP, Lytes, BS, Uric Acid, Renal Function

Beta Blockers� Action: prevents catecholamines from binding with beta cells and Action: prevents catecholamines from binding with beta cells and

forming norephinephrine a potent vasoconstrictor. forming norephinephrine a potent vasoconstrictor.

� Desired outcome: lower pulse, decrease CO, lower BP, decrease Desired outcome: lower pulse, decrease CO, lower BP, decrease myocardial O2 consumption, decrease contractilitymyocardial O2 consumption, decrease contractility

� Monitor: BP, pulse, signs of CHF, CNS, EKG changesMonitor: BP, pulse, signs of CHF, CNS, EKG changes

� Beta 1: acts on the heartBeta 1: acts on the heart� Indicated for HTN, MI, angina and CHFIndicated for HTN, MI, angina and CHF� Metoprolol or Lopressor, AtenololMetoprolol or Lopressor, Atenolol

� Beta 2: acts on the lungs: Beta 2: acts on the lungs: � Indicated for HTN, angina and arrhythmiasIndicated for HTN, angina and arrhythmias� Propranolol (Inderal), LabetololPropranolol (Inderal), Labetolol

Calcium Channel Blockers

� Action: inhibits calcium ion influx which inhibits Action: inhibits calcium ion influx which inhibits muscle contractionmuscle contraction

� Indications: HTN, SVT, angina, MIIndications: HTN, SVT, angina, MI

� Monitor: BP, signs of CHF, CNS, EKG, bowel habitsMonitor: BP, signs of CHF, CNS, EKG, bowel habits

� Drugs:Drugs:� Nifedipine (Procardia)Nifedipine (Procardia)� Verapamil (Calan)Verapamil (Calan)� Diltiazem (Cardizem)Diltiazem (Cardizem)� Nicardipine (Cardene)Nicardipine (Cardene)

Cardiac Glycoside

� Action: increases contractility which improves CO and Action: increases contractility which improves CO and blood flow to the peripheryblood flow to the periphery

� Indications: CHF, cardiac arrhythmiasIndications: CHF, cardiac arrhythmias

� DrugsDrugs� Digoxin (Lanoxin)Digoxin (Lanoxin)� Amrinone (Inocor)Amrinone (Inocor)

� Antidote for Digoxin is DigibindAntidote for Digoxin is Digibind

Angiotensin Converting Enzyme Inhibitors (Ace Inhibitors)

� Inhibits conversion of Angiotensin I to Angiotensin II which Inhibits conversion of Angiotensin I to Angiotensin II which lowers BP and dilates the arteries.lowers BP and dilates the arteries.

� Indications: CHF, HTN, MIIndications: CHF, HTN, MI

� Side effect: cough from bradykinin breakdown and bitter metalic Side effect: cough from bradykinin breakdown and bitter metalic tastetaste

� Monitor: BP, electrolyes, signs of CHF, renal function and Monitor: BP, electrolyes, signs of CHF, renal function and hematologic functionhematologic function

� DrugsDrugs� Captopril (Capoten)Captopril (Capoten)� Enalapril (Vasotec)Enalapril (Vasotec)� AltaceAltace� Lisinopril (Zestril)Lisinopril (Zestril)� AccuprilAccupril� LotensinLotensin

Angiotensin II Blocker

� Blocks action of Angiotensin II A potent Blocks action of Angiotensin II A potent vasoconstrictorvasoconstrictor

� Indications: HTNIndications: HTN

� Monitor: BP, lytes, signs of CHFMonitor: BP, lytes, signs of CHF

� Drugs:Drugs:� CozaarCozaar� DiovanDiovan� AtacandAtacand

Alpha 1 Blocker

� Action: dilates peripheral blood vesselsAction: dilates peripheral blood vessels

� Indications: HTN, CHFIndications: HTN, CHF

� Monitor: BP and CNSMonitor: BP and CNS

� Drugs:Drugs:� MinipressMinipress� TerazosinTerazosin� CarduraCardura

Peripheral Vasodilators

� Action: inhibit release of NorephinephrineAction: inhibit release of Norephinephrine

� Indication: HTNIndication: HTN

� Monitor: BP, syncope, palpitationsMonitor: BP, syncope, palpitations

� Drugs:Drugs:� HydralazineHydralazine

Centrally Acting Agents

� Inhibits sympathetic vasomotor center in Inhibits sympathetic vasomotor center in CNSCNS

� Indicated for HTN, drug withdrawlsIndicated for HTN, drug withdrawls

� Monitor: BP, HR, signs of CHFMonitor: BP, HR, signs of CHF

� DrugDrug� Catapres (Clonidine) Catapres (Clonidine)

Code Medications� Epinephrine: 1mg IVP Q3-5min, 2-2.5 x IV dose for ETTEpinephrine: 1mg IVP Q3-5min, 2-2.5 x IV dose for ETT

� Medication of choice for all pulseless patientsMedication of choice for all pulseless patients� ActionAction

� Makes VF more susceptible to current counter shockMakes VF more susceptible to current counter shock� Increases SVRIncreases SVR� Increases HRIncreases HR� Increases arterial BPIncreases arterial BP� Increases automaticityIncreases automaticity� Increases coronary/cerebral blood flowIncreases coronary/cerebral blood flow� Increases strength of myocardial contractionIncreases strength of myocardial contraction� Increases myocardial O2 consumptionIncreases myocardial O2 consumption

Vasopressin

� Action: potent vasoconstrictionAction: potent vasoconstriction

� Indications: V-Fib, hemodynamic shock support in Indications: V-Fib, hemodynamic shock support in sepsissepsis

� Not for patients with CADNot for patients with CAD

� ExpensiveExpensive

LIDOCAINE� Action: Action:

� Suppression of ventricular arrhythmiasSuppression of ventricular arrhythmias� Decreases automaticityDecreases automaticity� Decreases irritability of ischemic myocardiumDecreases irritability of ischemic myocardium

� Indications: ventricular dysrhythmia’sIndications: ventricular dysrhythmia’s

� DoseDose� Loading: 1-1.5mg/kg IV Q 5min, then 0.5-0.75mg/kg Q 5-10 Loading: 1-1.5mg/kg IV Q 5min, then 0.5-0.75mg/kg Q 5-10

min, total 3 mg/kgmin, total 3 mg/kg� IV drip 1-4 mg/minIV drip 1-4 mg/min� ETT: 2-2.5 X IV doseETT: 2-2.5 X IV dose

Amiodarone (Cordarone)

� Action: suppression of atrial/ventricular Action: suppression of atrial/ventricular arrythmias, useful with LVF w/EF <40%, CHFarrythmias, useful with LVF w/EF <40%, CHF

� Dose: V-Tach with pulse 150mg/10minDose: V-Tach with pulse 150mg/10min� VFIB/VTACH no pulse: 300mg IVP and VFIB/VTACH no pulse: 300mg IVP and

may repeat 150mg Q 3-5 min not to exceed may repeat 150mg Q 3-5 min not to exceed 2.2mg/kg in 24 hrs2.2mg/kg in 24 hrs

� IV drip: 1mg/min and titrate to ordersIV drip: 1mg/min and titrate to orders

� Caution: renal failure, half-life 40 daysCaution: renal failure, half-life 40 days

Procainamide� Action: decreases ventricular ectopy, decreased activity Action: decreases ventricular ectopy, decreased activity

of all pacemakers, slows intraventricular conductionof all pacemakers, slows intraventricular conduction

� Dose: 20-30 mg/min until suppression of arrhythmia Dose: 20-30 mg/min until suppression of arrhythmia and then start dripand then start drip� Maximum dose 17mg/kgMaximum dose 17mg/kg

� Monitor: BP, heart blocks, lytes, arrhythmiasMonitor: BP, heart blocks, lytes, arrhythmias

Adenosine� Action: interupts re-entry pathways through the AV Action: interupts re-entry pathways through the AV

node to restore a sinus rhythmnode to restore a sinus rhythm

� Indications: SVT, junctional arrhythmias, WPWIndications: SVT, junctional arrhythmias, WPW

� Dose: 6mg rapid IVP, if no conversion in 1-2 minutesDose: 6mg rapid IVP, if no conversion in 1-2 minutes� 12 mg rapid IVP, if no conversion in 1-2 minutes12 mg rapid IVP, if no conversion in 1-2 minutes� 12 mg rapid IVP12 mg rapid IVP

� Caution: periods of asystole, asthmatics can develop Caution: periods of asystole, asthmatics can develop bronchconstriction, blurred vision, facial flushingbronchconstriction, blurred vision, facial flushing

Atropine� Action: initiates electrical activity , restores normal Action: initiates electrical activity , restores normal

AV node conduction , increases SA node activity AV node conduction , increases SA node activity

� Indications: asystole, PEA, Symptomatic Indications: asystole, PEA, Symptomatic Bradycardia, Last Resort in 2Bradycardia, Last Resort in 2ndnd and 3 and 3rdrd Heart Blocks Heart Blocks

� Dose: 1mg IVP Q3-5 minDose: 1mg IVP Q3-5 min� ETT: 2-2.5 X IV doseETT: 2-2.5 X IV dose� Bradycardia: 0.5-1mg IVP Q 3-5 min Bradycardia: 0.5-1mg IVP Q 3-5 min � Maximum dose 0.3-0.4mg/kgMaximum dose 0.3-0.4mg/kg

Dopamine

� Action: precursor of norephinephrine, Action: precursor of norephinephrine, vasoconstrictor, inotropic supportvasoconstrictor, inotropic support

� Dose: 5-20 mcg/kg/min and titrate to BPDose: 5-20 mcg/kg/min and titrate to BP

� Caution: may cause tachyarrhythmias and Caution: may cause tachyarrhythmias and tissue necrosis for infiltration tissue necrosis for infiltration

Norepinephrine/levophed

� Action: vasoconstriction, increases contractionAction: vasoconstriction, increases contraction

� Indications: shock statesIndications: shock states

� Dose: 0.5-1 mcg/min IV drip and titrate to BPDose: 0.5-1 mcg/min IV drip and titrate to BP

� Caution: increases myocardial O2 consumption, Caution: increases myocardial O2 consumption, increases risk of arrhythmias, tissue necrosis with increases risk of arrhythmias, tissue necrosis with infiltrationinfiltration

Calcium Chloride

� Action: increases calcium levels which improves Action: increases calcium levels which improves contractility. Decreases potassium and magnesium contractility. Decreases potassium and magnesium levels.levels.

� Indications: calcium channel blocker toxicityIndications: calcium channel blocker toxicity

� Dose: 2-4mg/kg of 10% solution for arrestsDose: 2-4mg/kg of 10% solution for arrests� 8-16 mg/kg of 10% solution for severe elevation in 8-16 mg/kg of 10% solution for severe elevation in

potassium and calcium channel blocker ODpotassium and calcium channel blocker OD

Sodium Bicarbonate

� Action: buffers acidosisAction: buffers acidosis

� Indications: counters increased potassium, Indications: counters increased potassium, counters tricyclic and phenobarbital overdosescounters tricyclic and phenobarbital overdoses

� Dose: 1meq/kg IVP according to ABGDose: 1meq/kg IVP according to ABG� Half the dose if ABG is not availableHalf the dose if ABG is not available