CCRN Prep 2019 Cardiovascular
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This document discusses cardiovascular topics including acute coronary syndromes, myocardial infarction, hypertensive crisis, heart failure, dysrhythmias, valvular heart disease, cardiac tamponade, aortic aneurysms, cardiomyopathy, vascular disease, and cardiac medications. It provides objectives, definitions, signs and symptoms, treatments, and other details regarding these conditions.
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CCRN Prep 2019 Cardiovascular
- 1. CARDIOVASCULAR 2019 Sherry Knowles, RN, CCRN, CMC
- 3. 1. Differentiate between different types of acute coronary syndromes and their treatments. 2. Identify basic coronary circulation and how it relates to different types of myocardial infarctions. 3. Anticipate potential complications associated with an acute myocardial infarction and the various treatments. 4. Recognize the signs and symptoms of severe valvular stenosis and regurgitation. 5. Discuss the common etiologies of valvular stenosis and regurgitation. 6. Distinguish between the different types of AV blocks. 2 CARDIOVASCULAR OBJECTIVES
- 4. 7. Recognize the signs & symptoms of heart failure and the treatment. 8. Define aortic aneurysms and list the most common classifications of aortic aneurysms. 9. Understand the different types of aortic dissections. 10. Differentiate between the different types of cardiomyopathy and their treatment. 11. List the basic effects of vasoactive medications. 12. Differentiate between commonly used cardiovascular medications. 3 CARDIOVASCULAR OBJECTIVES Cont.
- 5. Acute Coronary Syndrome DEFINITIONS • Term used to cover a group of conditions associated with acute myocardial ischemia • Acute myocardial ischemia results from insufficient blood supply to the heart muscle usually resulting from coronary artery disease 4
- 6. Acute Myocardial Infarction CAUSE • Infarction occurs due to mechanical obstruction of a coronary artery (or branch) caused by a thrombus, plaque rupture, coronary spasm and/or dissection. • STEMI vs. NSTEMI (non-STEMI) 5
- 7. Acute Myocardial Infarction SIGNS & SYMPTOMS • Complains Vary • May include crushing chest pain (which may or may not radiate), back, neck, jaw, teeth and/or epigastric pain, SOB, nausea/vomiting and dizziness • ST elevations on ECG • Elevated cardiac enzymes 6
- 8. CARDIAC ENZYMES • Troponin • Normal Troponin = or < 0.1 • Rises within 4-6 hours, peaks in 24 hours and returns to baseline within 7-10 days • CKMB • Normally less than 5% of CK • Rises within 4-8 hours, peaks in 8-58 hours (average 24 hours) and returns to baseline within 3-4 days 7 Acute Myocardial Infarction
- 9. CARDIAC ENZYMES • LDH1 • Cardiac specific isoenzyme • When LGH1 > LDH2, an AMI is probably occurring • The LDH rises in 24-48 hours, peaks in 3-6 days and returns to baseline within 8-14 days 8 Acute Myocardial Infarction
- 11. 12 LEAD ECG 10 I _________ aVR _________ V1 _________ V4 _________ II _________ aVL _________ V2 _________ V5 _________ III _________ aVF _________ V3 _________ V6 _________ II ______________________________________________ V ______________________________________________
- 12. How to Read a 12 Lead ECG 11 1) Analyze the Rhythm 2) Look for ST Elevations 3) Look for ST Depressions 4) Look for Patterns (in Groups) 5) Look for Pathological Q Waves
- 13. The Pathological Q Wave 12
- 14. Acute Myocardial Infarction 13 ST ELEVATIONS Anterior-Septal Wall MI Leads V1-V4 Reciprocal changes in leads III and aVF Supplied by the LAD Inferior Wall MI Leads II, III and aVF Reciprocal changes in leads I, and aVL Usually supplied by the RCA
- 15. Acute Myocardial Infarction 14 ST ELEVATIONS Lateral Wall MI I, aVL, V5 and V6 Area supplied by the Circumflex artery Reciprocal changes in leads II, III and aVF Posterior Wall MI Reflected on the opposite walls Opposite deflections Reciprocal changes in leads V1-V3 V2
- 16. Complications of an AMI 15 Dysrhythmias Heart Failure Cardiogenic Shock Pericarditis Pericardial Effusions Ventricular Thrombus Ventricular Aneurysms Mitral Regurgitation Papillary Muscle Rupture VSD Infarct Extension Death
- 17. Nursing Interventions in AMI 16 • O2 • Bedrest • Serial ECG’s • Serial cardiac enzymes • Keep pain free (NTG. MSO4) • MONA (Morphine, O2, Nitroglycerin, Aspirin), Heparin, Beta Blockers, and Ace Inhibitors. May also include thrombolytics, fibrinolytics or Gp2b3a Inhibitors • PCI, PTCA, IABP, CABG • Education
- 18. AMI Core Measures 17 • Aspirin at Arrival • Aspirin Prescribed at Discharge • ACEI or ARB for LVSD • Adult Smoking Cessation • Beta-Blocker Prescribed at Discharge • Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival • Primary PCI Received Within 90 Minutes of Hospital Arrival • Statin Prescribed at @ Discharge
- 19. Acute Myocardial Infarction 18 TREATMENT • Time is Heart Muscle • Prompt ECG, Start Treatments GOALS • Relieve pain • Limit the size of the infarction • Prevent complications • Primarily lethal dysrhythmias
- 20. Acute Myocardial Infarction 19 TREATMENT • MONA (Morphine, O2, Nitroglycerin, Aspirin), Heparin, Beta Blockers, and Ace Inhibitors. May also include thrombolytics, fibrinolytics or Gp2b3a Inhibitors • Cardiac Catheterization (with angioplasty, atherectomy and/or stent) • IABP, CABG, Education • Meet all AMI Core (Quality) Measures
- 23. Atherectomy 22
- 24. Acute Myocardial Infarction 23 SPECIFIC TREATMENTS Inferior Wall (IWMI) • Fluids (with RV infarct) • Inotropes • Afterload reducing medications Anterior Wall (AWMI) • Diuretics • Inotropes • Afterload reducing medications
- 25. Valvular Heart Disease 24 CAUSES • Rheumatic Heart Disease • Congenital Anomalies • Chronic Heart Failure • Infection (Endocarditis) • Age (Degenerative, Calcification) • Autoimmune Diseases • Myocardial Infarction • Trauma
- 27. Valvular Heart Disease 26 SIGNS & SYMPTOMS • Chest Pain or Palpitations • SOB OR DOE • Syncope or Lightheadedness
- 28. Valvular Heart Disease 27 OTHER SIGNS & SYMPTOMS • Infection (Endocarditis) • Heart Failure • RHF (Swollen Ankles) • LHF (Pulmonary Edema) • Afib • Cardiomegally • Murmurs • Angina • Pulmonary Hypertension
- 29. Valvular Heart Disease 28 TREATMENTS • Medications • Valvuloplasty • Valve Replacement or Repair • Mechanical Versus Tissue Valve • Mitral Clip • TAVR/TAVI
- 31. Endocarditis 30
- 32. Endocarditis 31
- 35. Septal Defects
- 36. Cardiac Surgeries 35 TYPES • Open Heart Surgery • Off Pump Surgery • Minimally Invasive Surgery • PCI (Percutaneous Coronary Intervention) • Transcatheter Repairs
- 37. Cardiac Surgeries 36 MANY SURGERIES • CABG • Valve Replacement or Repair • Aneurysm Repair • Myectomy or Myotomy • TMR (Transmyocardial Revascularization) • Left Ventricular Remodeling Surgery • MAZE • LVAD/RVAD Insertion • Heart Transplant
- 38. Cardiac Surgeries 37 OTHER PROCEDURES • Valvuloplasty • TAVR/TAVI • Mitral Clip • Pacemaker Insertion • Ablations
- 39. Transcatheter Valve Repair 38 TAVR MitraClip
- 40. Cardiac Surgeries 39 COMPLICATIONS • Heart Failure • Bleeding • Tamponade • Dysrhythmias • CVA • Pain • Renal Failure • Vascular Issues • CHF • Valvular Insufficiency • Pulmonary Edema • Fluid Balance Issues • Pulmonary Issues • Infection • Confusion • Death
- 41. Cardiac Surgeries 40 WHAT TO MONITOR • Continuous ECG monitoring • Frequent Vital Signs • Be Alert for Tamponade • Monitor Heart & Lung Sounds • Monitor Neurological Status • Monitor Renal Function • Monitor Access Sites • Assess Peripheral Pulses • Treat Pain
- 42. Cardiac Tamponade 41 DEFINITIONSDEFINITIONS • Compression of the heart by an accumulation of fluid in the pericardial sac
- 43. Cardiac Tamponade SIGNS & SYMPTOMS • SOB or DOE • Chest Pain • Dry Cough • Fatigue • Hypotension • Tachypnea 42 • Pulsus Paradoxsus • Narrowing Pulse Pressure • Enlarged Cardiac Silhouette • Becks Triad
- 45. Cardiac Tamponade 44 TREATMENT • O2 • Get ECHO • Pericardiocentesis • Pericardial Window
- 46. Aortic Aneurysms DEFINITIONS • A bulge or ballooning of the aorta • When the walls of the aneurysm include all three layers of the artery, they are called true aneurysms • When the wall of the aneurysm include only the outer layer, it is called a pseudo-aneurysm • May be thoracic or abdominal 45
- 47. Aortic Aneurysms CAUSES • Atherosclerosis • Marfan Syndrome • Hypertension • Crack Cocaine • Smoking • Trauma 46
- 48. Aortic Aneurysm Rupture • An aortic aneurysm, depending on its size, may rupture, causing life-threatening internal bleeding • The risk of an aneurysm rupturing increases as the aneurysm gets larger • The risk of rupture also depends on the location of the aneurysm • Each year, approximately 15,000 Americans die of a ruptured aortic aneurysm. 47
- 49. Aortic Aneurysms CLASSIFICATIONS • Classified by shape, location along the aorta, and how they are formed • May be symmetrical in shape (fusiform) or a localized weakness of the arterial wall (saccular) 48
- 51. Aortic Aneurysms SIGNS & SYMPTOMS • Often produces no symptoms • If an aortic aneurysm suddenly ruptures it presents with extreme abdominal or back pain, a pulsating mass in the abdomen, and a drastic drop in blood pressure • An increase in the size of an aneurysm means an increased in the risk of rupture 50
- 52. Aortic Aneurysms THORACIC SIGNS & SYMPTOMS • Back, shoulder or neck pain • Cough, due to pressure placed on the trachea • Hoarseness • Strider, dyspnea • Difficulty swallowing • Swelling in the neck or arms 51
- 53. Aortic Aneurysms AAA SIGNS & SYMPTOMS • Often produces no symptoms • A pulsating feeling near the navel • Deep, constant pain in the abdomen or on the side of the abdomen • Back pain • “Cold foot” 52
- 54. Aortic Aneurysms 53 TREATMENT • Medical Management • Control BP • Quit Smoking • PCI or Surgical Repair • Endovascular Graft • Abdominal Surgery: Synthetic Tube (graft) • Coiling
- 55. Aortic Dissections DEFINITIONS • Tearing of the inner layer of the aortic wall, which allows blood to leak into the wall itself and causes the separation of the inner and outer layers • Usually associated with severe chest pain radiating to the back 54
- 56. Aortic Dissections 55 Type A Dissection beginning in the ascending aorta Type B Whenever the ascending aorta is not involved
- 57. Aortic Dissections 56 Type A Dissection beginning in the ascending aorta Type B Whenever the ascending aorta is not involved
- 60. Aortic Dissections SIGNS & SYMPTOMS • Severe chest, abdominal or back pain • Sharp, ripping of tearing sensation • SOB • Weak pulse in one arm compared to the other • Stroke like symptoms 59
- 62. Aortic Dissections COMPLICATIONS • Rupture • Peripheral embolization • Infection • Spontaneous occlusion of aorta 61
- 63. Aortic Dissections TREATMENT • Medical Management • Control BP (within specific range) • Surgical Repair • > 4.5 cm in Marfan patients or > 5 cm in non- Marfan patients will require surgical correction or endovascular stent placement 62
- 64. Hypertensive Crisis DEFINITION • An acute life-threatening rise in blood pressure that will lead to end organ damage or death if left untreated. 63
- 65. Hypertension TYPES • Essential/Primary Hypertension DBP > 90 • Secondary Hypertension DBP > 90 • Accelerated Hypertension DBP > 120 • Malignant Hypertension DBP > 140 • Hypertensive Encephalopathy BP > 250/150
- 66. Hypertension CLASSIFICATION Stage 1 SBP 140-159 or DBP 90-99 Stage 2 SBP 160-179 or DBP 100-109 Stage 3 SBP 180 + or DBP 110 +
- 67. Hypertension Primary Hypertension • Family history of high blood pressure • Obesity (body mass index of 30 or greater) • Lack of regular exercise • Smoking • Kidney or endocrine disease • Insulin resistance • Advanced age
- 68. Hypertension Secondary Hypertension • Sleep apnea • Kidney or endocrine disease • Cirrhosis of the liver • Cushing Disease • Pheochromocytoma • Coarctation of the aorta • Pregnancy • Medications
- 69. Hypertension Accelerated Hypertension • DBP > 120 • Retinopathy with exudates • Retinal hemorrhages • Headache • Restlessness • Epitaxis • Rales • S3, S4
- 70. Hypertension Malignant Hypertension • DBP > 140 • Papilledema • Retinopathy • Headache • Blurred Vision • Dyspnea • Chest pain • Symptoms seen in accelerated hypertension
- 71. Hypertension Hypertensive Encephalopathy • BP > 250/150 • Retinopathy • Papilledema • Severe headache • Vomiting • Mental status changes • Transitory neurologic signs (nystagmus) • Localized weakness • Seizures • Diuresis • Coma
- 72. Hypertension Treatment • Find Cause • CBC, CMP, UA, • Renal Ultrasound or Angiogram • EKG • CXR • CT scan
- 73. Hypertension Interventions • Antihypertensive medications • Diuretics • Monitor response to medications • Titrate medications to desired BP levels • Monitor ECG for dysrhythmias • Monitor electrolytes • Monitor for c/o sudden chest pain (dissecting aortic) • Monitor for changes in LOC, nausea, vomiting, headache, visual changes
- 74. Vascular Disease 73 Aorto/Iliac Disease: Pre & Post PTA/Stent
- 75. Peripheral Vascular Disease TREATMENTS • Medical • ASA, Coumadin, Ticlid, Plavix • D/C Oral Contraceptives, Hormones • Invasive • PTA, Atherectomy, Stents • Surgical • Grafts 74
- 76. Peripheral Vascular Disease 75 Bypass Grafts
- 79. Deep Vein Thrombosis (DVT) 78
- 80. Deep Vein Thrombosis (DVT) 79 Signs & Symptoms • Swelling of the leg or along a vein • Pain or tenderness in the leg • Increased warmth & redness in the area • Positive Homan’s Sign
- 81. Deep Vein Thrombosis (DVT) 80 Positive Homan’s Sign
- 82. Cardiomyopathy DEFINITION • Diseases of the heart muscle that cause deterioration of the function of the myocardium 81
- 83. CLASSIFICATION • Primary / Idiopathic (intrinsic) • Heart disease of unknown cause, although viral infection and autoimmunity are suspected causes • Secondary (extrinsic) • Heart disease as a result of other systemic diseases, such as autoimmune diseases, CAD, valvular disease, severe hypertension, or alcohol abuse 82 Cardiomyopathy
- 84. Cardiomyopathy TYPES • Dilated Cardiomyopathy • Restrictive Cardiomyopathy • Hypertropic Cardiomyopathy 83
- 85. Hypertropic Cardiomyopathy Bizarre Hypertrophy of the septum • Previously called IHSS • Idiopathic Hypertropic Subaortic Stenosis • Known as HOCM • Hypertropic Obstructive Cardiomyopathy Positive Inotropic Drugs Should Not Be Used • Contractility will outflow tract obstruction Nitroglycerin Should Not Be Used • Dilation will Make the Problem Worse 84
- 86. Harley 85
- 87. Hypertropic Cardiomyopathy TREATMENT • Relax the Ventricles • Beta Blockers • Calcium Channel Blockers • Slow the Heart Rate • Increase filling time • Use Negative Inotropes • Optimize diastolic filling • Do Not use NTG • Dilation will worsen the problem 86
- 88. Restrictive Cardiomyopathy Rigid Ventricular Wall • Due to endomyocardial fibrosis • Obstructs ventricular filling Least Common Form • Rare 87
- 89. Restrictive Cardiomyopathy TREATMENT • Positive Inotropes • Diuretics • Low Sodium Diet 88
- 90. Dilated Cardiomyopathy Grossly dilated ventricles without hypertrophy • Global left ventricular dysfunction • Leads to pooling of blood and embolic episodes • Leads to refractory heart failure • Leads to papillary muscle dysfunction secondary to LV dilation 89
- 91. Dilated Cardiomyopathy TREATMENT • Positive Inotropes • Afterload Reducers • Anticoagulants with AFib 90
- 93. Cardiomyopathy GENERALIZED TREATMENT • Positive Inotropes • Except with Hypertropic Cardiomyopathy • Vasodilators • Except with Hypertropic Cardiomyopathy • Reduce Preload & Afterload • Diuretics • Beta Blockers • Calcium Channel Blockers • IABP • Vasodilators (as indicated) • Fluid Restriction • Daily weights, prn O2, planned activities, education, and emotional support • Consider Heart Transplant 92
- 94. BREAK
- 95. Conduction Defects STABLE vs UNSTABLE • Stable • Start with medication • Unstable • Shock (cardioversion or defibrillation) 94
- 96. Heart Rate 60 - 100 bpm Rhythm Regular P Wave Before each QRS & identical PR Interval (in secs) 0.12 to 0.20 QRS (in seconds) < 0.12 Normal Sinus Rhythm (NSR)
- 97. Heart Rate Irregular conduction to ventricles Rhythm Irregular Fibrillatory Waves Multifocal atrial impulses Rate 300-600/min QRS (in seconds) < 0.12 (usually) Atrial Fibrillation (AFib)
- 98. Heart Rate Variable conduction to ventricles Regularly blocked impulses at AV node Rhythm Irregular (usually) Flutter Waves Atrial impulses at rate of 250-350/min Atrial impulses at rate of 250-350/min Saw tooth flutter waves QRS (in seconds) < 0.12 (usually) Atrial Flutter (AFL)
- 99. Heart Rate < 100 Rhythm Irregular (usually) P Waves Three or more p wave morphologies Multifocal ectopic foci in atria Variable PR interval QRS (in seconds) < 0.12 (usually) Wandering Atrial Pacemaker (WAP)
- 100. Heart Rate > 100 Rhythm Irregular (usually) P Waves Three or more p wave morphologies Multifocal ectopic foci in atria Variable PR interval QRS (in seconds) < 0.12 (usually) Multifocal Atrial Tachycardia (MAT)
- 101. Heart Rate Supraventricular rate 150-250 Rhythm Regular P Waves P waves that cannot be positively identified QRS (in seconds) < 0.12 Supraventricular Tachycardia (SVT) Atrial Tach = supraventricular rhythm with a p wave morphology that is noticeably different from the sinus p wave
- 102. Heart Rate Ventricular rate 100-250 Rhythm Regular (usually) P Waves None QRS (in seconds) > 0.12 Pulse May or may not be present Ventricular Tachycardia (VT)
- 103. Rate 150 -250 Polymorphic VT VT with alternating ventricular focus Rhythm Irregular (usually) P Waves None QRS (in seconds) < 0.12 Torsades de Pointes
- 104. Heart Blocks (AV Blocks) Sinus Rhythm with First Degree AV Block Sinus Rhythm with Second Degree AV Block, Type 2 Sinus Rhythm with Second Degree AV Block, Type 1 Third Degree AV Block
- 105. Wolff Parkinson White (WPW)
- 106. • Genetic Disorder associated with abnormal sodium channels • High risk of Sudden Death (due to VT) • ST segment elevation in V1 - V3 • Family History of Sudden Death • May need ICD Brugada Syndrome
- 107. Brugada Syndrome
- 108. • Intrinsic or Induced • High Risk of VT • May have increased QTc interval in response to standing Long QT Syndrome
- 109. Pacemaker Undersensing Atrial Undersensing Ventricular Undersensing
- 111. Pacemaker Malfunction Failure to Capture Failure to Pace
- 113. Heart Failure DEFINITIONS • A condition in which the heart cannot pump sufficient blood to meet the metabolic needs of the body • Pulmonary (LVF) and/or Systemic (RVF) congestion is present 112
- 114. Cardiac Output Cardiac Output (CO) = SV X HR • Stroke Volume (SV) • Preload • the volume of blood in the ventricles at end diastole • Afterload • the resistance the ventricles must overcome to eject it’s volume of blood • Contractility • the force with which the heart muscle contracts 113
- 115. Congestive Heart Failure Pulmonary Edema • Fluid in the alveolus that impairs gas exchange by altering the diffusion between alveolus and capillary • Acute left ventricular failure causes cardiogenic pulmonary edema • Non-cardiogenic pulmonary edema is a synonym for Adult Respiratory Distress Syndrome (ARDS) 114
- 116. Heart Failure COMPENSATORY MECHANISMS • Sympathetic nervous system stimulation • Tachycardia • Vasoconstriction and increased SVR • Renin-Angiotension-Aldosterone System • RASS • Hypoperfusion to the kidneys (Renin) • Vasoconstriction (Angiotension II) • Sodium and water retention (Aldosterone) • Ventricular dilation 115
- 117. Heart Failure FUNCTIONAL CLASSIFICATIONS • Class I Without noticeable limitations • Class II Symptoms upon activity • Class III Severe symptoms upon activity • Class IV Symptoms at rest 116
- 118. Heart Failure COMPLICATIONS • Hypotension • Dysrhythmias • Respiratory Failure • Progressive Deterioration • Acute Renal Failure • Fluid & Electrolyte Imbalances 117
- 119. Heart Failure TREATMENT • Improve Oxygenation • Decrease Myocardial Oxygen Demand • Decrease Preload • Decrease Afterload • Increase Contractility • Manage Dysrhythmias • Educate! 118
- 120. Heart Failure Core Measures 119 • Evaluation of LV Function • ACEI or ARB for EF < 40% • Adult Smoking Cessation Counseling • Discharge Instructions • Activity Level • Diet • Medications • Follow Up Appointments • Weight Monitoring • What to Do If Symptoms Worsen
- 121. Intra Aortic Balloon Pump (IABP)
- 122. • Decreases Afterload • Decreases Work of Heart • Increased Cardiac Output • Improves Coronary Perfusion Intra Aortic Balloon Pump (IABP)
- 123. • Cardiogenic shock • Left ventricular failure • Acute MR and VSD • Acute myocardial infarction • Support during PCI • During cardiac surgery • Weaning from cardiopulmonary bypass IABP Indications
- 124. • Unstable angina • Refractory ventricular arrhythmias • Unstable cardiomyopathies • Severe sepsis • Bridge to transplant • Infants & children with cardiac anomalies IABP Indications
- 125. ABSOLUTE CONTRAINDICATIONS • Aortic Regurgitation • Aortic Dissection • Aortic Stents • End-stage heart failure with no anticipation of recovery IABP Contraindications
- 126. RELATIVE CONTRAINDICATIONS • Abdominal aortic aneurysm • Severe peripheral vascular disease • Tachyarrhythmias • Uncontrolled sepsis • Major arterial reconstruction surgeries IABP Contraindications
- 127. • Aortic dissection • Hematoma and/or bleeding at insertion site • Limb ischemia and/or absent pulses • Compartment syndrome • Thrombocytopenia • Coagulation disturbances • Displacement of the balloon catheter obstructing left subclavian artery or renal artery perfusion • Vascular injury • Balloon leak, rupture, gas loss from the balloon • Infection at site of insertion • Timing issues IABP Complications
- 128. Intra Aortic Balloon Pump
- 129. • Increased Afterload • Increased myocardial oxygen demand • Potential aortic regurgitation Intra Aortic Balloon Pump
- 130. • Decreased coronary profusion Intra Aortic Balloon Pump
- 131. • Decreased coronary profusion • Decreased afterload reduction • Increased myocardial workload Intra Aortic Balloon Pump
- 132. • Reduced afterload reduction • Increased myocardial oxygen demand • Potential increase in afterload Intra Aortic Balloon Pump
- 134. Impella
- 135. • Unloads Left Ventricle • Increases Mean Arterial Pressure • Increased Cardiac Output • Improves Coronary Perfusion • Works Independently of Cardiac Rhythm Impella
- 136. Impella versus IABP
- 137. Hemodynamics
- 138. Cardiac Output Cardiac Output (CO) = HR X SV Stroke Volume (SV): • Preload • Volume of blood in the ventricles at end diastole • Afterload • Resistance the ventricles must overcome to eject it’s volume of blood • Contractility • Force with which the heart muscle contracts
- 139. Cardiac Output Cardiac Output (CO) = HR X SV Stroke Volume (SV): • Preload • Volume of blood in the ventricles at end diastole • Afterload • Resistance the ventricles must overcome to eject it’s volume of blood • Contractility • Force with which the heart muscle contracts
- 140. CONTRAINDICATIONS • Mechanical Tricuspid or Pulmonary Valve • Right Heart Mass (thrombus and/or tumor) • Tricuspid or Pulmonary Valve Endocarditis Invasive PA Catheter
- 142. 4th ICS Mid-Axillary. HOB elevated 0-30 Degrees Phlebostatic Axis
- 143. • RAP (CVP) • RVP • PAP • PAWP • SVR 0-8 mmHg 15-30/0-8 mmHg 15-30/6-12 mmHg 8 - 12 mmHg 700-1500 dynes/sec/cm2 Normal Hemodynamic Values
- 144. • CI 2.5 – 4.5 L/min/m2 • SVRI 1970 – 2390 dynes/sec/cm-5/m2 • SVI 35 – 60 mL/beat/m2 • EDVI 60 – 100 mL/m2 Normal Hemodynamic Values
- 145. • Measured in the pulmonary artery • End result of O2 delivery and consumption • Measures O2 consumption • An average estimate of venous saturation for the whole body • Does not reflect separate tissue perfusion or oxygenation Mixed Venous O2 Saturation (SvO2)
- 146. • Measure All Hemodynamic Values at End-Expiration • “Patient Peak” • “Vent Valley” Measuring PA Pressures
- 148. Cardiac Output Cardiac Output (CO) = HR X SV Stroke Volume (SV): • Preload • Volume of blood in the ventricles at end diastole • Afterload • Resistance the ventricles must overcome to eject it’s volume of blood • Contractility • Force with which the heart muscle contracts
- 149. CONTRAINDICATIONS • Mechanical Tricuspid or Pulmonary Valve • Right Heart Mass (thrombus and/or tumor) • Tricuspid or Pulmonary Valve Endocarditis Invasive PA Catheter
- 151. 4th ICS Mid-Axillary. HOB elevated 0-30 Degrees Phlebostatic Axis
- 152. • RAP (CVP) • RVP • PAP • PAWP • SVR 0-8 mmHg 15-30/0-8 mmHg 15-30/6-12 mmHg 8 - 12 mmHg 700-1500 dynes/sec/cm2 Normal Hemodynamic Values
- 153. • CI 2.5 – 4.5 L/min/m2 • SVRI 1970 – 2390 dynes/sec/cm-5/m2 • SVI 35 – 60 mL/beat/m2 • EDVI 60 – 100 mL/m2 Normal Hemodynamic Values
- 154. • Measured in the pulmonary artery • End result of O2 delivery and consumption • Measures O2 consumption • An average estimate of venous saturation for the whole body • Does not reflect separate tissue perfusion or oxygenation Mixed Venous O2 Saturation (SvO2)
- 155. • Measure All Hemodynamic Values at End-Expiration • “Patient Peak” • “Vent Valley” Measuring PA Pressures
- 157. • Measure all pressures at END-EXPIRATION • End expiration measured just before inspiration • Top curve with Spontaneous Respiration • “Patient-Peak” • Bottom curve with Mechanical Inspiration • Vent Valley Measuring PA Pressures
- 160. PAWP Waveform
- 161. • Cardiogenic Shock is the only shock with PAWP • Early (Hyperdynamic) Shock is the only shock with CO and SVR • Neurogenic Shock is the only shock with Bradycardia • Anaphylactic Shock has the definitive characteristic of wheezing due to bronchospasm Parameter Hypovolemic Cardiogenic Neurogenic Anaphylactic Early Septic Late Septic CVP/RAP PAWP or Norm CO BP SVR HR Normal Shock Profiles
- 162. • Minimally Invasive Flo Trac • Measured through Arterial Line • Capitalizes on Pulsus Paradoxus • Measures preload responsiveness • SVV > 10-15 % = preload responsive (responsive to fluids) • SVV < 10–15% = not preload responsive Stroke Volume Variation (SVV)
- 163. Cardiac Drugs 162 ACE Inhibitors Beta Blockers Anti-Arrhythmics Inotropes Thrombolytics Calcium Channel Blockers Anti-Thrombin Meds Anti-Platelet Meds Anti-Coagulants Diuretics GPIIbIIIa Inhibitors Anti-Lipidemics Nitrates Vasopressors Angiotensin II Antagonists
- 164. Cardiac Drugs Alpha receptors Dopa receptors Beta receptors
- 165. Cardiac Drugs Alpha Receptors • On Blood Vessels • Stimulation causes vasoconstriction • Blocking cause vasodilation
- 166. Cardiac Drugs Beta Receptors • On Heart and Lungs • Beta1 and Beta2 • Cardioselective vs Non-Selective
- 167. Cardiac Drugs Beta Receptors • Beta1 • Stimulation causes positive inotropic effects • Blocking causes negative inotropic effect
- 168. Cardiac Drugs Beta Receptors • Beta2 • Stimulation causes bronchodilation • Blocking causes bronchoconstriction
- 169. Cardiac Drugs Dopa Receptors •On Renal (Mesenteric) Vessels (and Brain) • Stimulation causes vasodilatation • Blocking causes vasoconstriction
- 170. ACE Inhibitors • Causes Vasodilation • Reduces Afterload • Reduces work of heart • Remodeling Effects Cardiac Drugs
- 171. Cardiac Drugs ACE Inhibitors • Causes Vasodilation • Reduces Afterload • Reduces work of heart • Remodeling Effects
- 172. Angiotensin II Antagonists • ARB • Vasodilator • Afterload Reducer • May be used in place of ace inhibitors Cardiac Drugs
- 173. Beta Blockers • Slow Heart Rate • Lower BP • Slow Conduction • Promote Electrical Stability Cardiac Drugs
- 174. Calcium Channel Blockers • Slow Heart Rate • Vasodilates • Prevents Arterial Vasospasms Cardiac Drugs
- 175. Antiarrhythmics • Slow Conduction • Slow Heart Rate • Includes • Beta Blockers • Calcium Channel Blockers • More Cardiac Drugs
- 176. Cardiac Drugs GPIIbIIIa Inhibitors • Inhibit Platelet Activation • ReoPro, Integrilin, Aggrastat • Must monitor Platelet Levels • Check within 4-6 hours after initiation • Monitor daily and prn any bleeding
- 177. Vasopressors • Vasoconstrictors • Increases Blood Pressure • Increases Heart Rate • Increases Myocardial Demand Cardiac Drugs
- 178. Nitrates • Arterial & Venous Vasodilator • Reduces Preload & Afterload • Reduces Work of the Heart • Improves Cardiac Output Cardiac Drugs
- 179. Anticoagulants • Heparins • Vitamin K antagonists • Thrombin Inhibitors • Platelet Inhibitors • Factor Xa Inhibitors • Thrombolytics/Fibrinolytics Cardiac Drugs
- 180. Heparin • Heparin (Unfractionated) • Low Molecular Heparin (LMWH) • Lovenox (Enoxaparin) • Fragmen (Dalteparin) • Arixtra (Fondaparinux) Cardiac Drugs
- 181. Vitamin K Antagonist • Coumadin (Warfarin) • Must monitor PT/INR • Vitamin K to reverse Cardiac Drugs
- 182. Thrombin Inhibitors • Heparin • Argatroban • Angiomax (Bivalirudin) • Pradaxa (Dabigatran) • Refludan (Lepirudin) Cardiac Drugs
- 183. Platelet Inhibitors • Aspirin (Acetylsalicylic Acid) • Plavix (Clopidogrel) • Effient (Prasugrel) • Brilinta (Ticlopodine) • Ticlid (Ticlopidine) • Persantine (Dipyridamole) • Aggrastat (Tirofiban) Cardiac Drugs
- 184. Factor Xa Inhibitors • Heparin (Unfractionated) • Arixtra (Fondaparinux) • Xarelto (Rivaroxaban) • Eliquis (Apixaban) Cardiac Drugs
- 185. Thrombolytics/Fibrinolytics • Streptase (Streptokinase) • tPa (Tissue Plasminogen Activator, Alteplase, Activase, Cathflo) • Retavase (Reteplase) • TNKase (Tenecteplase) • Urokinase (Abbokinase) Cardiac Drugs
- 186. Anti-Lipidemics • HDL • High Density Lipoprotein • Associated with risk • LDL • Low Density Lipoprotein • Associated with risk • Ratios Matter • TC/HDL Cardiac Drugs
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