Week 8: Cardiac Emergencies.. Part 2 Flashcards Preview

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progressive inflammatory disorder of arterial wall that is characterized by focal lipid rich deposits of atheroma that remain clinically silent until they become large enough to impair tissue perfusion

atherosclerosis

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Includes
STEMI
Non-STEMI
Unstable Angina

-Leading cause of Death in the US

 

Age:
Increased age-disease process begins early and develops gradually.
Gender:
Highest for middle-aged white caucasian
Race:
Caucasian males highest risk
Genetic:
Inherited tendencies for atherosclerosis

Coronary Artery Disease

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modifiable risk factors for CAD

  • Tobacco
  • Hypertension
  • Physical Activity
  • Obesity
  • Dyslipidemia
  • Diabetes
  • Stress
  • ETOH abuse
  • HRT

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Hypertensive crisis

higher than 180/higher than 110

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high blood pressure stage 2

160 or higher/100 or higher

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high blood pressure stage 1

140-159/90-99

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prehypertension

120-139/80-89

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Where do we want our patients with CAD for BP

less than 120/less than 180

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where do we want BMI?

19-24

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optimal total cholesterol and ldl, HDL,TC/HDL

total: less than 160

LDL: less than 100

HDL: above 45

TC/HDL: less than 3

 

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HIgh HDL promotes

promotes collateral circulation in the heart (creating new vessels around blocked vessels naturally)

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most used to treat lipid levels

Statins: effects LDL, HDL, and triglycerides

 

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what do omega fatty acids help with?

triglycerides

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How does diet affect LDL, HDL, TG

LDL: lowers it

HDL: little effect

TG: lowers it

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what does exercise really help with regards to HDL, LDL, TG?

really helps HDL and TG

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Type of angina?

Pain w/exertion-relief w/rest

stable Angina

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Type of Angina?

Pain onset w/ rest
Caused by vasospams 

Prinzmetal's

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type of angina?

Pain onset w/rest
Precursor to AMI

unstable angina

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type of angina?

Unrecognized 

Silent agina

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causative factors of Angina

  • Physical exertion
  • Temperature extremes
  • Strong emotions
  • Heavy meal
  • Tobacco use
  • Sexual activity
  • Stimulants
  • Circadian rhythm patterns

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Treatment of stable angina?

  • etiology: Myocardial ischemia
  • Symptoms: episodic, aggravated with exercise, relieved w/NTG
  • Treatment: NTG, beta blockers, ca+ channel blockers, ACE inhibitors

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Unstable angina treatment

  • etiology: ruptured or thickened plaque with platelet and fibrin thrombus
  • symptoms: increasing episodes, occurs with rest and exercise, not relieved with NTG
  • treatment: NTG, tPA, morphine (dilates vessels), ASA

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Prinzmetals angina treatment

  • etiology: Coronary vasospasams
  • symptoms: Occurs at rest, Triggered with smoking, May have ST elevation,
    AV Block or Ventricular arrhythmias
  • Treatment: Ca+ Channel Blockers

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Patho of mycocardial infarct

  • Rupture of plaque
  • Ischemia within 10 seconds
  • Hypoxia and lack of glucose
  • Anaerobic activity
  • inability to polarize: Ventricular remodeling

 

 

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Stemi vs NonStemi

  • ST elevation= stemi.  Elevation in the t "firemans cap"
  • ST depression= non-stemi.

A image thumb
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manifestations of heart attack

  • Appearance: Anxious, restless, pallor, diaphoresis
  • Blood Pressure/Pulses
  • Breathing
  • JVD (Jugular Vein Distension)
  • Auscultation/heart and lung
  • Abnormal heart sounds S3, S4
  • Shortness of Breath (SOB): Orthopnea
  • Chest Discomfort: Pleuritic-point tenderness?, Localized vs. diffuse, Palpitaion

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APQRST evaluation of chest pain

A= Associated Symptoms Dyspnea, nausea, diaphoresis, palpitations, feeling of impending doom
P= Precipitating Factors  Exertion, Cold Exposure, meals, movement
Relieved by: rest, NTG, or position?
Q= Quality Heaviness, tightness, sharp, stabbing, burning
R= Region, Radiation, Risk Factors Radiates to: arm, jaw, back, below diaphram
Region: substernal, left lateral, right chest
Risk factors: HTN, DM, Obesity, Dyslipidemia, Smoking
S= Severity Rate pain on scale 0-10
T= Timing Onset and duration of pain, nocturnal?, constant? Intermittent?

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inferior area of damage 

Right Coronary Artery
Leads II, III, AVF (see st elevation)

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anterior area of damage

Left Anterior Descending
Leads V1-V4 (st elevations)

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lateral area of damage

Circumflex
Leads I, AVL, V5, V6 (st elevations)

 

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CPK and Troponin

CPK MB: rises 4-8 hours, peaks 12-24, remains elevated for a day

Troponin: (breakdown in cardiac muscle) rises in 3 hours, peaks 12-18 hours, stays elevated for 14 days

Troponin t: 0.1 or less micrograms per liter

Troponin  I: less than 10 micrograms

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angiogram

  • View coronary arteries
  • Incr. risk if done after MI
  • Need creatinine: Dye can cause renal failure

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Echocardiogram

Safe, non-invasive, wall motion abnormalities

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C-Reactive protein

Produced by liver w/ inflammation
Rules out stable angina
Good o get pt. baseline
Reference range
Low- < 1.0 mg/dL
Average- 1.0-3.0 mg/dL
High- > 3.0 mg/dL

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normal BUN

10-20

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normal creatinine

0.5-1.1

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normal creatinine clearance

130-170 ml/min

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myoglobin

  • Peak levels occur 1-4 hours
  • Doubling in 2 hours ++ MI
  • Reference range: < 90 mcg/L

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nursing immediate action for MI

-Pt. placed in semi-fowlers position
-ECG  and Cardiac Enzyme Assessment
-IV line started (at least 18 guage)
-ASA 325 mg given: Four baby ASA, Clopidogrel (Plavix) 300 mg (becomes an issue if they need to go to surgery)
-Oxygen
-Beta Blockers
-ACE inhibitors (if CHF present): watch out for asthma patients

-NTG titrate to releive chest pain but keep SBP above 90 mm/Hg

             -start drip 5 mics per min, can titrate as high as         400
             -Works as a vasodilator
             -Decreases peripheral resistance
             -Increased coronary blood flow

 

Heparin vs Lovenox
-Neither lyse the clot only prevents new clots
-Heparin increased risk of HTP
-Lovenox longer more predictable action
-Not preferred if Surgery anticipated  

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cardiac catheterization

  • Procedure which involves placement of a catheter into RT or LT side of heart.
  • Invasive
  • Coronary angiography is often included together with cardiac catheterization
  • Diagnostic procedure and/or
  • a therapeutic procedure
  • Adults & Children

 

 

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PTCA

  • This procedures provides the doctor with a "road map" of the arteries in the heart
  • To find any areas of blockage in the arteries that supply the heart with blood.
  • May also look at the valves, chambers &  heart muscle
  • Can help in making decisions about the treatment of heart disease.

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Relative contraindications for cardiac cath

  • Peptic Ulcer
  • Anticoagulants
  • Ischemic stroke
  • Dementia
  • Recent surgery
  • Internal bleeding recent

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absolute contraindications to cardiac cath

  • Internal Bleeding
  • Cerebral Aneurysm
  • AV malformation
  • Previous Cerebral Hemorrhage
  • Pregnant
  • CVA recent
  • Uncontrolled HTN
  • Aortic Dissection
  • Traumatic CPR 

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Catheter can be  introduced through?

  • femoral, brachial or carotid artery to the knob of the aorta for coronary arteries
  • It may be advanced to the left heart to look at the LT ventricle

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Balloon Angioplasty/PTCA

  • Balloon Angioplasty is a technique used to dilate an area of arterial blockage with the help of a balloon catheter.
  • It is a way of opening a blocked blood vessel
  • Not highly effective, can rupture wall of vessel, or the plaque can just move right back

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stent placement

  • Usually  a metal stent is placed in the opened artery to make sure restenosis does not reoccur
  • Following the procedure, the balloon is deflated and additional x-rays are taken to determine how much blood flow has increased.
  • usually covered in a heparanized solution

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prevention of re-stenosis

  • Lifestyle Change
  • Healthy diet
  • adequate exercise
  • No Smoking
  • Medicine coated stents (apirin, plavix, cholesterol medicine)

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ablation

INDICATIONS

  • Atrial Fibrillation
  • Atrial Flutter
  • AV Nodal Reentrant Tachycardia
  • AV Reentrant Tachycardia
  • Atrial Tachycardia

 

Most often, cardiac ablation is used to treat rapid heartbeats that begin in the upper chambers, or atria, of the heart. As a group, these are know as supraventricular tachycardias, or SVTs. Types of SVTs are:
 

Minimally invasive treatment for arrhythmias
Live fluoroscopy and angiography techniques are used along with special electro physiologic equipment and catheters

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minimally invasive CABG

  • Minimally invasive surgery does not use CPB
  • Smaller incision
  • Emerging as a replacement for conventional CABG
  • Starting in 1990’s, MIDCAB has gained popularity
  • Usually conducted for LIMA to LDA grafts

Advantages

  • no sternotomy or CPB
  • operating time is 2-3 hours
  • recovery time 1-2 weeks
  • effectiveness 90%
  • incision only 10cm
  • reduced need for blood transfusion
  • less time on anesthesia
  • less pain
  • less expensive

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problem with MIDCAB

  • New instruments must be developed
  • Requires highly skilled surgeon and learning curve for surgeons limits number performed
  • Small incision
  • Beating heart
  • Blood in field
  • Can only be used with patients having blockages in one or two coronary arteries on the front of the heart
  • Attempts at operating on other arteries have been moderately successful, but requires even greater skill and practice

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Port access CABG

  • Uses CPB
  • Balloon catheter system for aortic occlusion and cardioplegic arrest
  • 5-8 cm left anterior thoracotomy incision
  • No sternotomy!!!
  • uses LIMA

Benefits:

  • Bloodless field
  • Heart arrested
  • allows more accurate anastomoses than MIDCAB
  • Smaller incision than CABG
  • No sternotomy

Drawbacks

  • Uses CPB
  • Technically very difficult

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Nursing management for all CABG patients

*Most important thing we look at is hemodynamics

  • Assess for signs of hemodynamic compromise
  • Hypotension
  • Decreased cardiac output
  • Shock
  • Monitor VS, ECG, MAP (70-110 mm Hg)
  • I&O – fluid and electrolyte imbalance
  • Early weaning from ventilator
  • Monitor ABGs
  • Encourage effective post-operative pulmonary toileting
  • Chest splintingPain management
  • Pharmacological management
  • Assess chest tube drainage
  • Encourage early ambulation
  • Monitor for complications of procedure
  • Advance diet as tolerated
  • Cardiac diet
  •  Emotional support of patient and family

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pulmonary toileting

  • good oral care every 2 hours
  • when extubated: incentive spirometer, turning, ambulating, sitting up, deep breathing and coughing, splinting with binder and pillow, pre-medication

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chest tubes for open heart

  • medial-stinal chest tubes placed right behind heart
  • drain excess fluid and blood that comes off
  • several hundred the first hour is normal, want to see drainage steadily decreases and goes from sanguinous to sero-sanguinous.  Also dump a lot of fluid when the sit up as well
  • If getting a lot of blood, do an H&H, if less than 6 transfuse
  • Also think about auto-transfusion.  Chest tube has an extra chamber.  Take the blood draining off and put back in.  Big problem with this is hyperkalemia (bc of K+ bath of heart with surger)

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Post operative dysrhythmias

  • Hypothermia (warming)
  • Anesthetics
  • Electrolyte imbalance 
  • Acidosis
  • MI
  • normally given lanoxin (iv version of digoxin) IV psuh

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treatment of CO/CI decreased, PCWP decreased

Inotropic support (increase contractility of the heart, dobutamine! 5mics per kg) & replacement Fluid

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treatment of SVR decreased

(means periphery is dilated) Check for Hypothermia (vasodilation related to temperatures) or volume issues

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discharge planning and teaching for CABG

  • What to expect at home
  • Pain in your chest around the incision area
  • Swelling in the leg at harvest site
  • Itchiness or tingling feeling at incision site
  • Weakness
  • Cardiac rehabilitation
  • Lifestyle & diet modification
  • Smoking cessation
  • Cardiac diet (Low salt, low cholesterol, low fat)

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