2024CE_CARDIOLOGY.pdf

2024CE_CardiovascularSystem Right Marginal Artery CARDIOVASCULAR SYSTEM ○ Right Ventricle...

2024CE_CardiovascularSystem Right Marginal Artery CARDIOVASCULAR SYSTEM ○ Right Ventricle Jeffry T. Sangalang, RN ○ Apex Left Marginal Artery Anatomy and Physiology ○ Supplies Left Ventricle Conduction System Layers 1. Epicardium 2. Myocardium high oxygen demand 3. Endocardium Chambers 1. Atria Receiving Chamber 2. Ventricle Pumping chamber Valves 1. Atrioventricular Valve Tricuspid Valve Bicuspid / Mitral Valve Atria 2. Semilunar Valve ○ tells the heart to contract Pulmonary Valve ○ will generate the SA Aortic Valve Vasculature Electrophysiologic Properties 1. Conductivity Travel of Impulse 2. Automaticity a.k.a. “rhythm” ○ continuous or spontaneous 3. Contractility contraction 4. Excitability Initiation of a cardiac impulse 5. Refractoriness ability of cardiac cells to respond to new stimuli while still in contraction Cardiac Output **Left Anterior Descending Artery Amount of blood ejected by the left ventricle per ○ Right Ventricle minute ○ Left Ventricle Average output ○ Interventricular Septum ○ Perfect HR = 72 Left Circumflex Artery ○ Approximately 5L ○ Left Atrium and Ventricle ○ criteria for blood loss if : Right Coronary Artery 1L ○ supplies the right atrium and the right 20% ventricle Stroke Volume eia  2024CE_CardiovascularSystem ○ Amount of blood ejected by the left 8. Blood Culture ventricle per beat 9. Cardiac Biomarkers Preload Myoglobin ○ degree of stretching before contraction ○ First sign to come out during Frank Starling Law MI ○ rubber band ○ Onset : 30 - 60 minutes more you stretch, the greater ○ Range: 25 - 72 mg/mL the force Troponin ○ Most sensitive cardiac Cardiovascular Disorders biomarker ○ cardiac specific Risk Factors ○ Types: Troponin T Troponin I Modifiable [CHOSE TD CA] most ○ Cigarette Smoking sensitive ○ Hypertension Troponin C ○ Obesity ○ Onset: 4 - 7 days ○ Sedentary Lifestyle ○ Range: ○ Elevated Serum Lipids and Cholesterol ○ Standard of care: ○ Type A personality > 2 ng = MI ok-ok ○ Literature ○ DM II > 1.5 ng = MI ○ Contraception CK-MB ○ Alcohol ○ most cardiac specific Non-modifiable [GHAR] ○ Males: 50 - 325 mu/mL ○ Genetics ○ Females : 50 - 250 mu/mL ○ Hereditary ○ Onset : 3 - 6 hours ○ Age LDH ○ Race ○ Late Enzyme ○ Onset: 12 hours Laboratory and Diagnostic Findings lasts up to 14 days ○ Range: 100 - 225 mu / mL Laboratory Tests 10. Serum Electrolytes 1. CBC Hypernatremia white count Mild = ○ to check integrity of heart Moderate = 2. ESR Severe = > 170 mEq/L Males : 15 - 20 mm/hr Causes: Females : 20 - 30 mm/hr ○ Excessive sweating 3. PT ○ Diabetes Insipidus Prothrombin Time ○ Diarrhea 11 - 16 seconds S/Sx: Therapeutic Range: 1.5 - 2.0 x ○ Lethargy ○ very high chance of bleeding ○ Agitation 4. PTT Na ○ Seizure Partial Thromboplastin Time 135 - 145 ○ Coma 60 - 70 seconds mEq/L Fluid of choice : Hypotonic Therapeutic Range: 2.0 - 2.5 x ○ very high chance of bleeding Hyponatremia 5. APTT Causes: Activated PTT ○ Vomiting mas specific than PTT ○ Diarrhea 30-45 seconds ○ Blood Loss ○ (divide PTT Time by 2) ○ Altered Mental Status Therapeutic Range: 2.0 - 2.5 x forgets to drink ○ very high chance of bleeding Fluid of choice : Hypertonic ○ Not allowed: Treatment of Choice : Safety Razor ○ ADH - Conivaptan Excessive BP Taking only ADH Food high in Vit. K specific to 6. Serum Cholesterol Range hyponatremia LDL ○ Saturated Hyperkalemia HDL EKG Changes ○ Unsaturated ○ ST Elevation ○ statins = increase HDL ○ QRS Wide Preparation: ○ Tall, Tented, Peak ○ Fasting 8-10 hours T-Waves ○ NPO Midnight K ○ Small P 7. Triglyceride Normal Range 3.5 - 5.1 S/Sx: < 200 mg /dL mEq/L ○ Fatigue eia  2024CE_CardiovascularSystem ○ Irregular HR Mg Deep Tendon Reflex Medications [CHIK DDS]: Directly Proportional to Ca ○ IV Calcium ○ HCO3 Diagnostic Tests ○ Insulin +Glucose ○ Kayexalate 1. CXR ○ Diuretics 2. EKG Loop V1 : 4th ICS, Right Parasternal Line / Thiazide Border ○ Dialysis V2 : 4th ICS, Left Parasternal Line / Gold standard Border Treatment V3 : Between V3 and V4 ○ Sorbitol V4 : 5th ICS, Left Midclavicular Line causes V5 : 5th ICS, Anterior Axillary Line constipation V6 : 5th ICS, Midaxillary Line + Na Marcos is Dead, Cory is alive Polyst ○ RB yrene ○ YG = to avoid Consti pation Hypokalemia EKG Changes: ○ prominent U Wave ○ ST Depression S/Sx: ○ Irregular HR ○ decreased DTR Diet: ○ tree crops [ABCs] Apricot Banana Cantaloupe Medications: ○ Kalium Durule post meals ○ K-LOR Hypercalcemia EKG Changes: ○ QT Interval narrow S/Sx [CUMS]: ○ Constipation ○ Uhaw ○ Muscle Weakness ○ Stones Management ○ Diuretics ○ Diet Phosphorus Ca Diet 8.5 - 10.5 ○ Calcitonin mg/dL Ca enters bones Hypocalcemia EKG Changes: ○ QT Interval wide S/Sx [CTLTT]: ○ Chvostek's ○ Trousseau’s ○ Tetany Seizure ○ Laryngospasm form of tetany ○ Torsades de Pointes Management ○ Ca Supplementation ○ Non-weight bearing exercises eia  2024CE_CardiovascularSystem 5. 2D-Echo Check cardiac structure and mobility Ejection Fraction ○ percentage of blood pumped by heart ○ Normal: 50 - 70 % ○ Reduced: 15 - 20 minutes Management standard protocol for MI = Pain relief ○ therefore, Morphine Thrombolytics (TPA) ○ -kinase ○ if thrombus in nature cause of MI ○ Duration: 4-6 hours **stroke = 2-4 hours TPA won’t occur after 6 hours since job is done ○ Antidote : Aminocaproic Acid Complications MONA TASS 1. Cardiogenic Shock Morphine Pump Failure ○ decreased pain —> decreased cardiac 2. Thromboembolism demand for O2 Thrombus formation due to low quality ○ ”as prescribed” of heart pumping ○ S/E: Hx of Atrial Fibrillation bradypnea 3. Rupture of Myocardium bradycardia due to injury constipation reject muscles of pericardium ○ Antidote : Narcotic Antagonist / Narcan 4. Ventricular Aneurysm Oxygen area of ventricle weakened —>enlarged ○ other term : High-fowler’s position 5. Congestive Heart Failure ○ If no “as prescribed” on exam 6. Pericarditis (Dressler’s Syndrome = MI Specific) Nitroglycerin occurs several weeks after MI Aspirin common in trauma immune response Rhythm Feature Treatment Paroxysmal SVT Absent P-wave Vagal Nerve (140 - 250 bpm) Stimulation (Carotid Massage) Adenosine raise hand of patient Cardioversion Atrial Flutter Sawtooth Beta Blockers (250 - 350 bpm) Appearance Cardioversion Digitalis / Digoxin Atrial Fibrillation No Pattern Beta Blockers > 350 bpm Cardioversion Digitalis / Digoxin Verapamil eia  2024CE_CardiovascularSystem ”Defibriccation” Ventricular Slightly Irregular Cardioversion Tachycardia Rate medication failed ○ CC = 200 QRS Biglaan = Emergency 100 - 250 Almost Dead /Unconscious Asynchronous Torsade de VTach with Magnesium Pointes sinusoidal Heart Failure Found in oscillation of QRA Isoproterenol Hypocalcemia Supraventricular Wide QRS Right Left Tachycardia Systemic Lungs; Pulmonary AV Blocks Pacemaker = I & II (I, II, III) Ascites Anorexia III = Digitalis Digitalis if MI due to feeling of tiredness Toxicity , MI, cause = III complete block Backward Failure Breathlessness Premature Lidocaine Ventricular Cardiomegaly Cough and Crackles Contraction Distended Neck Veins Dyspnea Edema (Systemic) Edema (Pulmonary) Pacemaker Fatigue Frothy Sputum Temporary vs Permanent - due to edema ○ Permanent irreversible cardiac disorders Gallop = S3, S4 batteries are replaced Cardiomyopathy Hepatosplenomegaly Hypoxia Types of Pacemaker ○ Fixed rate Insomnia fires without regard to heart if forced to choose at exams = Left abnormal heart contractions ○ Synchronous Orthopnea starts if HR falls below the rate depends on set by the doctor Paroxysmal Nocturnal ○ Atrioventricular Dyspnea universal atrium not functioning well ventricular contraction sensed, Digitalis atrium will be paced like a normal heart Avoid: Mechanism of Action: ○ Gadgets (e.g. phones, headache) ○ (+) Inotropic ○ Microwave Strength ○ e-cig ○ (-) Chronotropic ○ Mall detectors time ○ Generator ○ (-) Dromotropic ○ MRI movement of impulse from SA ○ Lithotripsy to AV node ○ Electrocautery ○ Thus, increasing contraction through ○ decreasing HR Patient Nursing considerations: ○ has a dog tag ○ Get the apical pulse ○ encounters headache / palpitations ○ < 60 bpm = HOLD pacemaker malfunctioning ○ Tachycardia = HOLD NOTIFY MD rebound tachycardia = Side ○ gadgets must be placed on opposite effect of digitalis side Therapeutic Range ○ flying on a plane = sit down on ○ 0.6 - 1.2 (others, 1.3) Digitalis Toxicity ○ Initial Sign: Cardioversion GI ○ Late Sign: Consent Green Vision Awake CNS Atrium ○ Antidote = Digibind / DigiFab Elective Synchronous Infective Endocarditis Defibrillation eia  2024CE_CardiovascularSystem cocaine usually involved with drugs Hypertrophic thickening of muscles cellular death due to incapacity of blood vessels to catch up with strength / growth of heart Aortic Stenosis ○ cause ? seen in pregnants Hypertension Restrictive Prevents entry of the blood poor filling of blood into ventricle Rheumatic Fever / Rheumatic Heart Disease irreversible possible candidates for heart JONE’s Criteria transplant ○ cardiogenic shock ○ angina (irreversible) ○ cardiomyopathy ○ congenital heart disease ToF muscle failure of heart structure or integrity of heart is diminished Cause: ○ idiopathic Medications ○ Anticoagulants ○ Beta blockers Assessment: ○ Cardioversion ○ History of GABHS ○ Cardiac Transplant Sore throat ○ Diuretics Impetigo ○ Digitalis Valvular Heart Disease Pericarditis Stenosis Narrow ad Stiff S/Sx: ○ Pain Regurgitatio Valves become loose Exacerbated by Inspiration n Relieved by Sitting / Leaning Forward Prolapse Bulging; Does not close completely Inflammation of pericardial sac Fluid in Pericardial sac General Management ○ 15 - 20 mL ○ Anticoagulants seen in MVCs with trauma direct to chest ○ Beta blockers for good contraction Cardiac Tamponade ○ Digitalis ○ Prophylactic Antibiotic complication of pericarditis with history of RF / RHD EMERGENCY Beck’s Triad: Cardiomyopathy ○ Low BP ○ Muffled Heart Sounds ○ Jugular Vein Distention Dilated cardiomegaly Clot formations VASCULAR PATHOLOGIES eia  2024CE_CardiovascularSystem Arteries block A2 absorption by the receptors ○ Tunica Intima “-sartan” caution: ○ Tunica Media ○ DM muscle ○ Heart Failure ○ Tunica Externa ○ Renal dysfunction 3. Alpha Adrenergic Blockers Diagnostic and Laboratory Tests vasodilation decreased BP 1. Doppler UTZ decreased LDL and VLDL Venous Flow Increase HDL 2. Duplex Scan “-zosin” GOLD STANDARD e.g. imaging ○ Terazosin HCl (Hytrin) ○ can see narrowed and ○ Prazosin (Minipress) widened parts 4. Beta blockers assesses patency of blood vessel reduces CO by diminishing SNS 3. CT Scan and MRI response may have contrast “-olol” check for allergies and consent S/E: 4. Plethysmography ○ Headache Venous blood flow Contraindications: lower extremities ○ Asthma Use BP Cuff ○ Bronchoconstriction Supine position ○ COPD 5. Venography ○ DM with contrast 5. Calcium Channel Blockers ○ check for allergies and consent “-ipine” ○ except: Verapamil PERIPHERAL VASCULAR DISEASES Soptin Calan Hypertension S/E: ○ Edema Criteria: 6. Centrally Acting Sympatholytics ○ persistent increase in BP Decrease SNS Response from brainstem 2 separate readings to peripheral vessels —> Stimulate Primary management alpha-2 receptors —> increase vagal ○ Diuretic activity —> decrease serum epinephrine Methyldopa Essential a.k.a. “Primary” Clonidine unknown Adjunct with diuretics attributed highly with stress Rebound hypertension is common 7. Diuretics Secondary a.k.a. “Non-essential” Thiazide due to existing disease / ○ Diuril condition ○ Hydrodiuril causes: ○ Benzthiazide (Exna) ○ hyperthyroidism ○ Polythiazide (Renese R) ○ pheochromocytoma ○ A/E: ○ Cushing’s Hyperuricemia Hyperglycemia Malignant Targeted end-organ ○ C/I: complications Gout EMERGENCY DM Loop [BLED] Hypertensive EMERGENCY ○ Bumetanide (Bumex) Crisis ○ must be treated within 1 ○ Furosemide (Lasix) hour ○ Ethacrynic Acid (Edecrine) ○ Torsemide (Demadex) ○ A/E: Medications ototoxicity Tinnitus 1. ACE Inhibitors SIVP inhibited ACE —> Inhibited Angiotensin (1-2minutes) II (vasoconstriction) conversion —> purpura blocked release of aldosterone bleeding ”-pril” photosensitivity Side Effects: hypokalemia ○ Hyperkalemia Potassium-sparing [MAD] ○ Cough ○ Amiloride (Midamor) ○ Headache ○ Spironolactone (Aldactone) 2. ARBs ○ Triamterene (Dyrenium) eia  2024CE_CardiovascularSystem ○ At bedside: ECG Thiazide with Potassium-sparing Diuretics [AM] ○ Spironolactone + Hydrochlorothiazide (Aldactazide) ○ Amiloride + Hydrochlorothiazide (Moduretic) 8. Vasodilators 9. Antihyperlipidemics Nicotinic Acid (Niacin) Tricor (Fenofibrate) Raynaud’s Disease Lopid (Gemfibrozil) Statins ○ HMGCoA Reductase Inhibitors Middle-aged women standard protocol = 3 months Hands A/E: S/Sx: ○ Hepatotoxicity ○ hand spasms Monitor: ○ after spasm = Hyperemia SGPT, SGOT, compensation AST, ALT ○ Color pattern: ○ Rhabdomyolysis On exposure to cold: severe form of muscle White-Blue-Red wasting Management: 10. Peripheral Vasodilators ○ Avoid Cold Trental (Pentoxifylline) ○ Wear mittens ○ Quit smoking Intermittent claudication ○ Calcium-channel blocker ○ pain when walking due to deprivation of Oxygen ARTERIAL DISORDERS Buerger's Disease a.k.a. “Thromboangiitis obliterans” ○ inflammation f small arteries secondary to clot Risk Factor: ○ Nicotine ○ Men S/Sx: Aneurysm ○ 5 Ps ○ Gangrene 3As Management: ○ Outpouching ○ If smoking cause = tell to quit smoking ○ Arteriosclerosis / Atherosclerosis ○ Possible management of gangrene = ○ Hypertension amputation arterial wall damage ○ Inspect foot daily Types: ○ Foot care ○ Saccular lukewarm or tepid one site / area do not moisturize between ○ Fusiform toes entire Lanolin Lotion ○ Dissection podiatrist for callus and corns fast growing loose socks in between media and intima not barefoot Common aneurysms: cut nails straight across ○ Brain: do not shape Circle of Willis leather shoes bought at night provides an possible pooling of anastomotic blood at the feet connection between bone expands late in the anterior and the afternoon posterior circulations, comfortably loose providing collateral leather = does not flow to affected brain sweat easily regions in the event of arterial incompetency. Berry Aneurysm ○ Chest: eia  2024CE_CardiovascularSystem Thoracic Aneurysm aorta palikod pain at back ; left scapula ○ AAA: abdomen pulsatile abdominal mass two organs beat as one ”two hearts beating” ”i can feel my heartbeat in my abdomen” DO NOT PALPATE control blood pressure 4-6 cm = surgical candidate Varicose Veins Varicose related to liver failure = Hemorrhoids Characteristics: ○ Dilated, Tortuous Veins particularly, Saphenous Veins Causes: ○ prolonged sitting / standing ○ stasis ○ pregnancy ○ obesity S/sx: ○ bulging veins VENOUS DISORDERS ○ itchiness ○ sore Deep Vein Thrombosis ○ swelling ○ aching/throbbing inflammation of deep vein Management S/Sx ○ elevate above heart level ○ similar to varicose veins ○ anticoagulants ○ Homan’s Sign ○ antiembolic stockings ○ unequal calf size best answer : first thing in the ○ Virchow’s Triad: morning, before going out of Hypercoagulability of blood bed blood stasis ○ Umbrella Filter Vessel wall injury if prone to clotting Management ○ Warfarin ○ elevate above heart level ○ Heparin ○ anticoagulants LMW Heparin ○ antiembolic stockings safe for pregnancy best answer : first thing in the ○ Sclerotherapy morning, before going out of ○ Stripping / Ligation bed not as a single unit ○ Umbrella Filter end-end if prone to clotting junction-junction ○ Warfarin tell the patient ○ Heparin ○ DO NOT MASSAGE LMW Heparin dislodge clot safe for pregnancy eia  2024CE_CardiovascularSystem low pressure tria high pressure ventricle eia