What to do first if patient has chest pain.
Rest!
ECG changes in an acute MI
ST elevation in 2 or more contiguous leads. Ischemia d/t full
... [Show More] thickness loss of muscle. EMERGENCY.
Inferior leads
II, III, aVF. RCA occlusion.
Septal leads
V1 & V2.
Anterior leads
V1 - V4. LAD lesion.
Lateral leads
V5, V6, I, and aVL. Circumflex lesion.
Cardiac enzymes
Troponins, CK-MB, and CK
Changes in CK
Rise: 3-6 hours
Peak: 24 hours
Normal: 3-4 days
Changes in CK-MB
Released after myocardial necrosis. Specific for myocardial damage.
Rise: 3-12 hours
Peak: 24 hours
Normal: 2-3 days
Troponin I
Protein found in cardiac muscle. High sensitivity.
Rise: 3-12 hours
Peak: 24 hours
Normal: 5-10 days
Troponin T
Protein found in cardiac muscle. High sensitivity.
Rise: 3-12 hours
Peak: 12-48 hours
Normal: 5-14 days
Common conditions that cause a murmur
Aortic dissection, aortic regurgitation (both acute & chronic), mitral valve regurgitation (both acute & chronic), mitral valve stenosis
Drugs to decrease afterload/SVR/PVR
(Arterial Dilators) Nitroprusside, nitroglycerin, amrinone, alpha (Regitine) & Ca channel blockers
Drugs to increased afterload/SVR/PVR
(Vasopressors) Epinepherine, norepinepherine, dopamine, neosynephrine
Drugs to decrease contractility/SVI
Beta blockers (atenolol, metoprolol, propranolol, labetolol, esmolol) and Ca channel blockers
Drugs to increase contractility/SVI
Positive inotropes, dobutamine, dopamine, milrinone, and digoxin
Drugs to decrease preload/CVP/PAWP
Venous Dilators - Nitroglycerin, nitroprusside, amrinone, alpha & Ca channel blockers
Diuretics - Furosemide, bumex, mannitol
Drugs to increase preload/CVP/PAWP
Volume - Colloid, crystalloids, blood, hetastarch
Dysrhythmia control - antirhythmics, pacemaker, AICD
Complications when using thrombolytics
Allergic reaction, bleeding/hemorrhage, stroke
Failure to capture
Pacer delivers a stimulus at the appropriate time but no depolarization occurs. No P or QRS wave after pacer spike.
Failure to fire/pace
No pacer spikes seen
Failure to sense
Pacemaker does not detects heart's intrinsic activity or interprets noncardiac activity as intrinsic activity. Spikes in inappropriate times.
Normal PR
0.12 - 0.20
Normal QRS
0.04-0.10
Normal QT
Less than 0.48. Varies by age, HR, and gender.
Vasopressors
Epinepherine, norepinepherine, dopamine, phenylephrine/neosynephrine, vasopressin/pitressin, milrinone/Primacor, dobutamine/Dobutrex
Indication for dopamine/Intropin
Acts on SNS to increased HR and BP. Indicated for hypotension, low CO, decreased renal blood flow. Use if patient is bradycardic.
Doses of dopamine
Low: 0.5-2 mcg/kg/min (dopaminergic)
Intermediate: 2-10 mcg/kg/min (beta receptors, increases CO)
High: over 10 mcg/kg/min (alpha receptors, vasoconstrict)
SE of dopamine
Watch volume and starting BP. Use central line. Inactivated by sodium bicarb. Can cause acidosis. SE: ectopic beats, tachycardia, tissue necrosis d/t extravasation
Treatment of dopamine extravasation
Phentaolmine 5-10 mg and possibly nitropaste to vasodilate
Indication for norepinepherine/Levophed
Indicated for diastolic hypotension (specifically decreased SVR) and septic shock. Stimulates alpha & beta receptors. Increased contractility, HR, and vasoconstriction.
Doses of norepinepherine
2-12 mcg/min. Immediate onset.
SE of norepinepherine
Replace volume first because it can cause GI and renal hypoperfusion. Have a central line. SE: dizziness, HA, hyperglycemia, myocardial/mesenteric/renal ischemia, tissue necrosis with extravasation.
Treatment of norepinepherine, epinepherinem, dobutamine, and Neosynephrine extravasation
Phentaolmine 5-10 mg.
Indications for epinepherine/Adrenalin
Simulates alpha and beta receptors. Used post cardiac surgery for "stunned" myocardium. ACLS protocol. Bronchial relaxation at low doses, increased contractility at high doses.
Dosages of epinepherine
2-20 mcg/min. Immediate onset. Irritating to heart, so only good for emergency use.
SE of epinepherine
SE: myocardial/mesenteric/renal ischemia, tachycardia, hyperglycemia, HA, tissues necrosis with extravasation
SE of phenylephrine/Neosynephrine
Pure alpha stimulator. Used during C/P bypass, anesthesia induced hypotension, vascular failure in shock. Vasoconstricts arterioles without cardiac effect.
Dosages of Neosynephrine
10-100 mcg/min. Immediate onset.
SE of Neosynepherine
Use central line. Wean this first! SE: Reflex bradycardia, myocardial/mesenteric/renal ischemia, tissue necrosis with extravasation.
Indications for vasopressin/Pitressin
Antidiuretic hormone used to vasocontric. Endogenous hormone. Vasoconstricts peripheral arterioles & vasodilates coronary, pulmonary, and CNS circulation. Effective for hypotension, shock, decreases needs of other pressors, and Cardiac surgery.
Dosages of vasopressin
1-10 units/hr. Long half-life. Not titrated.
SE of vasopressin
SE: Skin/mesenteric ischemia, bradycardia, decrease UOP & result in hyponatremia, use with caution in neurosurgery patients
Indications for dobutamine/Dobutrex
Beta I stimulator. Used to increase CO for systolic heart failure, cardiogenic shock, MV regurgitation, post MI, post cardiac surgery, C/P bypass for "stunned" myocardium.
Dosages for dobutamine
2-15 mcg/kg/min.
SE of dobutamine
Less effect on HR than dopamine. Use central line. Check compatibilities. Can be used peripherally during an emergency. SE: ectopic beats, tachycardia, arrhythmias, tissue necrosis with extravasation.
Indications for nitroprusside/Nipride
Causes peripheral vasodilation by acting on venous and arterial smooth muscle. Decreases BP, SVR, preload, and afterload therefore increasing CO. Used for HTN, CHF, and hypertensive emergency.
Dosage of nitroprusside
0.5-0.10 mcg/kg/min. Light sensitive. Start with low dose.
SE of nitroprusside
Make sure there is adequate volume and the BP is above 90. May incompatibilities (can use with nitro & heparin). Can cause thiocyanate toxicity with higher doses. Monitor for metabolic acidosis. SE: hypotension, HA, nausea, and vomiting.
Indications for milrinone/Primacor
Positive inotrope with vasoactive activity. Increases CO and decreases SVR. Used in CHF and to increase CO.
Dosage of milrinone
Bolus (50 mcg/kg over 10 minutes) and then gtt (0.375-0.75 mcg/kg/min). Precipitates with lasix. Longer half-life. Not titrated.
SE of milrinone
Renal excretion. SE: arrythmias, decreased BP, HA, hypokalemia
Indications for nitroglycerin/Nitrostat
Direct relaxation of vascular smooth muscle and vasodilation. Used for HTN, angina, CHF, and MI to decrease O2 demands.
Dosage of nitroglycerin
5-200 mcg/min. Start low. Immediate response.
SE of nitroglycerin
Use with caution for patient dependent on preload for CO (inferior wall MI or right sided MI). May see tolerance after 24 hours. SE: Hypotension, reflux tachycardia, HA, flushing, nausea.
IV antidysrhythmics
Atropine = bradycardia
Lidocaine = VT, ventricular irritability
Amiodarone = afib, VTACH, Vfib
Pronestyl = VTACH, Vfib (can cause torsades)
Verapamil = CA channel block, IV push
Diltiazem = Ca channel blocker, afib, make sure BP good
Adenosine = SLAM IT, SVT, short half-life
Indications for a pacemaker
Treat sudden cardiac death, EF < 35%, sustained VT, refractory HF despite optimal medical management
Problems with pacemakers
Failure to capture, over sensing, and under sensing
Signs and symptoms of cardiac tamponade
Rise in filling pressure with decreased CO & hypotension. CVP=PAOP=PAD. Sudden drop in bleeding. Narrowing pulse pressure. Tachycardia, dysrhythmias, decreased ECG voltage. Decreased UOP. Anxiety and restlessness. Low blood pressure and weakness. Chest pain radiating to neck, shoulders, or back. Trouble breathing or taking deep breaths. Rapid breathing. Discomfort that is relieved by sitting or leaning forward.
Postoperative care of chest tubes
Assess q15 for first few hours to monitor drainage changes. Output to average ~100 cc/hr and should gradually decrease. Average is a total of 1L output. Chest tubes are removed when total drainage is < 100 ml for 8 hours. If output > 100 ml/hr then order PT, PTT, and platelets.
Purpose of Swan (PA) catheter
Measure vascular capacity, blood volume, pump effectiveness, and tissue perfusion.
Visual of PA catheter waveforms
Normal CVP/RAP
1-8 mm Hg
Normal PAWP/LVEDP (left ventricular end diastolic pressure)
4-12 mm Hg
Normal PAP
Systolic: 15-25 mm Hg
Diastolic: 6-12 mm Hg
If PAWP is low?
Hypovolemia
If PAWP is elevated?
Hypervolemia and indicative of left ventricular failure.
Normal CO
4-8 L/min
Normal SVO2
60-80% O2 into lungs
Describe CVP waveform
Three peaks (a, c, v waves) & Two descents (x and y)
Describe "a" wave with CVP
Represents atrial contraction. Correlates to PR interval.
Describe "c" wave with CVP
Represents closure of tricuspid valve. Correlates to QRS complex. [Show Less]