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Cardiac emergencies 2

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Cardiac emergencies 2

  1. 1. 1 CARDIAC EMERGENCIES
  2. 2. The Heart Superior Vena Cava Right Atrium Aorta Left Atrium Left Ventricle Right Ventricle Tricuspid Bicuspid Aortic valve Pulmonary valve
  3. 3. Electrolyte effect:- Sodium:Sodium: action potentialaction potential Calcium:Calcium: vascular tone, myocardial contractility andvascular tone, myocardial contractility and cardiac excitabilitycardiac excitability Potassium:Potassium: ventricular depolarization and repolarization.ventricular depolarization and repolarization. Magnesium:Magnesium: essential for enzyme, protein, lipid andessential for enzyme, protein, lipid and carbohydrate functions..carbohydrate functions..
  4. 4. Conduction System SA Node AV Node Left Bundle Branch Right Bundle Branch Purkinje Fibers
  5. 5. Preload And Afterload Preload:Preload: degree of stretch of the cardiac muscles justdegree 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 ejectthe pressure the heart must overcome to eject blood from the ventriclesblood from the ventricles
  6. 6. Investigation:-
  7. 7. Blood TestsBlood Tests CT ScansCT Scans EchocardiographyEchocardiography Electrocardiograms (EKG)Electrocardiograms (EKG) Holter and Event (Loop) MonitoringHolter and Event (Loop) Monitoring Exercise Stress TestsExercise Stress Tests MRIsMRIs
  8. 8. BLOOD TESTS Antistreptolysin-O test – protein produced byAntistreptolysin-O test – protein produced by streptococcal bacteriastreptococcal bacteria Arterial blood gasesArterial blood gases Blood fat profileBlood fat profile Blood calcium testBlood calcium test Complete blood countComplete blood count ElectrolyteElectrolyte Erythrocyte sedimentation rate (ESR)Erythrocyte sedimentation rate (ESR) Cardiac enzyme testsCardiac enzyme tests Glucose test.Glucose test. Prothrombin time tests .Prothrombin time tests . Total serum proteinTotal serum protein
  9. 9. BLOOD FAT PROFILEBLOOD FAT PROFILE  Cholesterol  HDL (good cholesterol)  LDL (bad cholesterol)  Triglycerides
  10. 10. Cholesterol Level:- Desirable Mg/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
  11. 11. CARDIAC ENZYME TESTS:-CARDIAC ENZYME TESTS:- Creatine kinase-MBCreatine kinase-MB An elevation occurs within 4 toAn elevation occurs within 4 to 6 hours and peaks 18 to 24 hours following an acute6 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. Normallyfollowing 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. MyoglobinMyoglobin rises within 1hour after cell death, peaksrises within 1hour after cell death, peaks in 4 to 6 hours.in 4 to 6 hours.
  12. 12. 12 Cardiac Disease -HTN-HTN -CAD-CAD - MIMI -CHF-CHF - Valvular diseases- Valvular diseases
  13. 13. 13 Cardiac Disease Risk Factors Non Modifiable /UncontrollableNon Modifiable /Uncontrollable AgeAge SexSex RaceRace HeredityHeredity
  14. 14. 14 Modifiable/ControllableModifiable/Controllable SmokingSmoking High BPHigh BP High blood cholesterolHigh blood cholesterol DiabetesDiabetes
  15. 15. 15 Risk Factors:- ObesityObesity Lack of exerciseLack of exercise StressStress PersonalityPersonality
  16. 16. Hypertension
  17. 17. 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 medicationPoor 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
  18. 18. Clinical manifestation:- Headache: especially in theHeadache: especially in the morningmorning EpistaxisEpistaxis Visual disturbanceVisual disturbance VertigoVertigo Chest painChest pain Shortness of breathShortness of breath WeaknessWeakness NauseaNausea
  19. 19. Diagnostic Testing for HTN CBCCBC Kidney functionsKidney functions Elevated BUN/CreatinineElevated BUN/Creatinine ProteinuriaProteinuria CXRCXR 12 Lead EKG12 Lead EKG
  20. 20. 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
  21. 21. 21 Coronary Artery Disease
  22. 22. 22 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)
  23. 23. 23 Atherosclerotic Plaque Formation
  24. 24. 24 Angina Pectoris “A choking in the chest” Myocardial oxygenMyocardial oxygen demand exceedsdemand exceeds supply during periodssupply during periods of increasedof increased activity, exercise,activity, exercise, or stressful eventor stressful event
  25. 25. 25 Types of Angina Pectoris Stable AnginaStable Angina Occurs with exerciseOccurs with exercise PredictablePredictable Relieved by rest or NitroglycerinRelieved by rest or Nitroglycerin
  26. 26. 26 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 andRequires immediate treatment and transport to appropriate facilitytransport to appropriate facility
  27. 27. 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
  28. 28. ASSESSMENT OF PAINASSESSMENT OF PAIN OO nsetnset PP rovocationrovocation QQ ualityuality RR adiationadiation SS everityeverity TT imeime ??
  29. 29. 29 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 ofMay be associated with shortness of breath, nausea, sweatingbreath, nausea, sweating
  30. 30. 30 Pain usually associated with 3E’sPain usually associated with 3E’s ExerciseExercise EatingEating EmotionEmotion Pain seldom lasts > 30 minutesPain seldom lasts > 30 minutes Pain relieved byPain relieved by RestRest NitroglycerinNitroglycerin
  31. 31. 31 Acute Myocardial Infarction “Heart Attack” Inadequate perfusionInadequate perfusion of myocardiumof myocardium Death of myocardiumDeath of myocardium InfarctInfarct Damage to myocardiumDamage to myocardium IschemiaIschemia
  32. 32. 32 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”
  33. 33. Temple College EMS Program 33 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
  34. 34. Temple College EMS Program 34 Chest PainChest Pain Unrelieved by rest/nitroglycerinUnrelieved by rest/nitroglycerin Pain lasts longer than angina pain (upPain lasts longer than angina pain (up to 12 hours)to 12 hours) ““Silent’ MISilent’ MI 15% of patients with MI,15% of patients with MI, particularly common in elderly andparticularly common in elderly and diabeticsdiabetics
  35. 35. 35 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 DenialDenial 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
  36. 36. 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 enzymesCardiac enzymes
  37. 37. 37 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
  38. 38. 38 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 10Has 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 threeq 5 minutes until pain relieved or three tablets administeredtablets administered
  39. 39. Medical Treatment Morphine sulfate – 2-4 mg titrated for painMorphine 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 therapyThrombolytic therapy –– HeparinHeparin Aspirin 325mg p.o.Aspirin 325mg p.o. StreptokinaseStreptokinase Beta blockersBeta blockers Calcium channel blockersCalcium channel blockers
  40. 40. Temple College EMS Program 40
  41. 41. 41 Congestive Heart Failure CHF :- Inability of the heart toCHF :- Inability of the heart to pump sufficient blood to meet thepump 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 peripheralheart failure and presents with peripheral venous congestionvenous congestion BiventricularBiventricular
  42. 42. 42 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
  43. 43. 43 Congestive Heart Failure Right-sided failure most commonlyRight-sided failure most commonly caused by Left-sided failure. Bloodcaused 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
  44. 44. 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 ofSpontaneous of unknown etiologyunknown etiology
  45. 45. 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
  46. 46. 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-GanzPA Catheter Swan-Ganz
  47. 47. EMERGENCY MEDICALEMERGENCY MEDICAL CARECARE ResponsiveResponsive Perform initial assessmentPerform initial assessment Focused HX and PEFocused HX and PE Place patient in position of comfortPlace patient in position of comfort Cardiac - c/o pain or discomfortCardiac - c/o pain or discomfort 100% oxygen100% oxygen Assess vitalsAssess vitals
  48. 48. (ASSESSMENT OF(ASSESSMENT OF PAIN) QUESTIONPAIN) QUESTION OO nsetnset PP rovocationrovocation QQ ualityuality RR adiationadiation SS everityeverity TT imeime ??
  49. 49. 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
  50. 50. 50 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
  51. 51. EMERGENCY MEDICALEMERGENCY 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
  52. 52. 52 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 aboutDO NOT worry about damage to pacemaker)damage to pacemaker)
  53. 53. Pericarditis inflammation of the pericardium and the frequent production ofinflammation of the pericardium and the frequent production of exudate.exudate. SymptomsSymptoms 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
  54. 54. Endocarditis Infection of the endothelial surface of the heart most oftenInfection 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
  55. 55. Nursing Considerations for Pericarditis Position of comfortPosition of comfort OxygenationOxygenation Cardiac and hemodynamic monitoringCardiac and hemodynamic monitoring Pain control: NSAIDS, Steroids, antibiotics(inPain control: NSAIDS, Steroids, antibiotics(in pericarditis)pericarditis) No anticoagulantsNo anticoagulants Pericardiocentesis if necessaryPericardiocentesis if necessary Antipyretics in endocarditisAntipyretics in endocarditis
  56. 56. Valvular Heart Disease
  57. 57. 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 atriumbuckle back into the atrium
  58. 58. Mitral Stenosis Mitral valve becomesMitral valve becomes narrownarrow andand constrictedconstricted CausesCauses ↑ 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 5thth ICSICS Extended dyspnea and fatigueExtended dyspnea and fatigue
  59. 59. 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 tissueCan 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
  60. 60. Mitral Regurgitation Retrograde blood flow from L. VentricleRetrograde 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 murmurSymptoms R/T acute or chronic murmur Heard best at 5Heard best at 5thth ICSICS May feel a thrillMay feel a thrill More common in women than menMore common in women than men
  61. 61. Valvular Regurg - picture
  62. 62. Aortic Stenosis Blood flow restricted from L. Ventricle toBlood 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
  63. 63. Aortic Regurgitation Retrograde blood flow from theRetrograde blood flow from the Ascending Aorta into L. VentricleAscending Aorta into L. Ventricle Results in:Results in: L. VentricleL. Ventricle dilation & LVHdilation & LVH,, leading toleading to ↓contractility of the heart↓contractility of the heart murmurmurmur Soft S1, S3 or S4Soft S1, S3 or S4 Causes: Congenital, Rheumatic HeartCauses: Congenital, Rheumatic Heart DiseaseDisease May have Orthopnea, Exertional dyspnea,May have Orthopnea, Exertional dyspnea, paroxysmal nocturnal dyspneaparoxysmal nocturnal dyspnea
  64. 64. Tricuspid Valve Disease Stenosis & RegurgitationStenosis & Regurgitation Tricuspid StenosisTricuspid Stenosis is uncommonis uncommon R. Atrium enlargement &R. Atrium enlargement & ↑systemic↑systemic venous pressurevenous pressure Tricuspid RegurgitationTricuspid Regurgitation Volume overload in R. Atrium andVolume overload in R. Atrium and Ventricle occursVentricle occurs Causes: R. Ventricular dysfunction, orCauses: R. Ventricular dysfunction, or pulmonary HTNpulmonary HTN
  65. 65. Diagnosing Valve Disease History and Physical ExamHistory and Physical Exam EchocardiographyEchocardiography Cardiac CatheterizationCardiac Catheterization ECGECG
  66. 66. 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
  67. 67. Nursing Management/Goals Maintaining normal cardiac functionMaintaining normal cardiac function Monitoring Cardiac output, fluid volumeMonitoring Cardiac output, fluid volume excessexcess Improving activity toleranceImproving activity tolerance Educating patients on the disease processEducating patients on the disease process and preventative measuresand preventative measures
  68. 68. Mitral Valve repair
  69. 69. Valve Replacement Mechanical/BiologicMechanical/Biologic AntibioticsAntibiotics Lifelong anticoagulation therapyLifelong anticoagulation therapy mechanicalmechanical Good oral hygieneGood oral hygiene Prevent infectionsPrevent infections
  70. 70. V-O-M-I-T VV= Vital Signs= Vital Signs OO = Oxygen= Oxygen MM = Monitor= Monitor II = IV Access= IV Access TT = Treatment= Treatment
  71. 71. 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 Henleact on the Loop of Henle • Lasix, BumexLasix, Bumex • Monitor: BP, Lytes, BS, Uric Acid, Renal FunctionMonitor: BP, Lytes, BS, Uric Acid, Renal Function
  72. 72. Beta Blockers Action: prevents catecholamines from binding with beta cells andAction: 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, decreaseDesired 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
  73. 73. Calcium Channel Blockers Action: inhibits calcium ion influx which inhibitsAction: 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)
  74. 74. Cardiac Glycoside Action: increases contractility which improves CO andAction: 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
  75. 75. Angiotensin Converting Enzyme Inhibitors (Ace Inhibitors) Inhibits conversion of Angiotensin I to Angiotensin II whichInhibits 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 metalicSide effect: cough from bradykinin breakdown and bitter metalic tastetaste Monitor: BP, electrolyes, signs of CHF, renal function andMonitor: 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
  76. 76. Angiotensin II Blocker Blocks action of Angiotensin II A potentBlocks 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
  77. 77. 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
  78. 78. Peripheral Vasodilators Action: inhibit release of NorephinephrineAction: inhibit release of Norephinephrine Indication: HTNIndication: HTN Monitor: BP, syncope, palpitationsMonitor: BP, syncope, palpitations Drugs:Drugs: HydralazineHydralazine
  79. 79. Centrally Acting Agents Inhibits sympathetic vasomotor center inInhibits 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)
  80. 80. 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
  81. 81. Vasopressin Action: potent vasoconstrictionAction: potent vasoconstriction Indications: V-Fib, hemodynamic shock support inIndications: V-Fib, hemodynamic shock support in sepsissepsis Not for patients with CADNot for patients with CAD ExpensiveExpensive
  82. 82. 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 5-10Loading: 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
  83. 83. Amiodarone (Cordarone) Action: suppression of atrial/ventricularAction: 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 andVFIB/VTACH no pulse: 300mg IVP and may repeat 150mg Q 3-5 min not to exceedmay 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
  84. 84. Procainamide Action: decreases ventricular ectopy, decreased activityAction: decreases ventricular ectopy, decreased activity of all pacemakers, slows intraventricular conductionof all pacemakers, slows intraventricular conduction Dose: 20-30 mg/min until suppression of arrhythmiaDose: 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
  85. 85. Adenosine Action: interupts re-entry pathways through the AVAction: 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 developCaution: periods of asystole, asthmatics can develop bronchconstriction, blurred vision, facial flushingbronchconstriction, blurred vision, facial flushing
  86. 86. Atropine Action: initiates electrical activity , restores normalAction: initiates electrical activity , restores normal AV node conduction , increases SA node activityAV node conduction , increases SA node activity Indications: asystole, PEA, SymptomaticIndications: asystole, PEA, Symptomatic Bradycardia, Last Resort in 2Bradycardia, Last Resort in 2ndnd and 3and 3rdrd Heart BlocksHeart 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 minBradycardia: 0.5-1mg IVP Q 3-5 min Maximum dose 0.3-0.4mg/kgMaximum dose 0.3-0.4mg/kg
  87. 87. 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 andCaution: may cause tachyarrhythmias and tissue necrosis for infiltrationtissue necrosis for infiltration
  88. 88. 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 withincreases risk of arrhythmias, tissue necrosis with infiltrationinfiltration
  89. 89. Calcium Chloride Action: increases calcium levels which improvesAction: increases calcium levels which improves contractility. Decreases potassium and magnesiumcontractility. 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 in8-16 mg/kg of 10% solution for severe elevation in potassium and calcium channel blocker ODpotassium and calcium channel blocker OD
  90. 90. 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

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