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What is coronary artery disease?
Atherosclerosis of the coronary Arteries
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What is atherosclerosis?
- the accumulation of lipids and fibrous tissue causing progressive narrowing of the lumen (stenosis), increasing resistance to blood flow, decreasing the ability to adapt to myocardial oxygen demand.
- --also causes stiffening of the coronary artery walls causing loss of dilatory response which decreases ability to adapt to myocardial oxygen demand.
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What three conditions make up Acute Coronary Syndrome?
STEMI, Unstable Angina, NSTEMI
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What is unstable angina?
- ischemia of the heart without cardiac damage. Characterized by chest pain.
- S/S of ischemia are present at rest and can occur with or w/o ST depression. Pain is NOT relieved by SL NTG.
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What is an NSTEMI?
Non-ST segment elevation MI. Heart damage is present. Presents like unstable angina however cardiac enzymes are released to indicate damage to the myocardial tissue. CK, CK-mb, Triponin 1
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What is a STEMI?
ST segment elevation MI. ST Segment is elevated >1 mm and chemical markers are released. Characterized by severe chest discomfort with pain and heaviness that is unrelieved by SL NTG . Pt has a sense of impending doom, diaphoretic, N&V. CAN BE ASYMPTOMATIC.
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Pt reports to ER with chest pain and nausea. What are you going to do in the first 10 minutes?
Vitals with O2 sat, 12 lead EKG, Targeted H&P, labs (CK, troponin, CBC, electrolytes, coags, Portable Chest Xray, O2 @ 4L, Aspirin 160-325, Nitro SL x 3 q 5 min--hold if SBP is <100, morphine 2-4 mg IV q 5 min, IV access, continuous EKG.
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Left Anterior Descending Infarction
Septal--V1-V2 conduction problems, Septal defects
Anterior wall--V3-V4 Tachy, heart failure, aneurysms
Lateral wall--V5-V6, I, aVL
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Left circumflex artery infarctino
Lateral wall I, aVL, V5-V6
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Right Coronary Artery infarction
- inferior wall
- II, III, aVF
- Bradycardia, 1st and 2nd degree type 1 HB, GI symptoms
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What does a targeted H&P include?
- 1. Time of sx onset
- 2. History of CAD, MI, CABG, Cath, PCI, HTN, DM
- 3. Eligibility for thrombolytics
- 4. Heart lungs, pulses
- 5. Skin--color, temp, diaphoretic?
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What will the results of the EKG show?
- --ST elevation or new BBB
- --ST depression or T wave inversion
- --Non-diagnostic
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What does it mean if they have an ST elevation or a new BBB?
- REquires IMMEDIATE treatment:
- Heparin IV, NTG IV, Morphine, Beta Blockers (decr the risk of sudden cardiac death, decr O2 demand and HR)
- Choose reperfusion strategy (percutaneous coronary intervention, thrombolytics)
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Thrombolytics--What do they do and interventions
- Clot fibrinolysis--Door to injections <30 minutes.
- Drugs: Alteplase (TPA), Retaplase (RPA), Tenecteplase (TNK)
Interventions: Separate IV site, don't infuse other meds in this site until TPA admin, cont. EKG, monitor PTT and overt S/S of bleeding, avoid injections and blood draws, no auto BP cuff.
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Contraindications for Thrombolytics
- Absolute CI:
- Prior intracranial hemorrhage, CVA, Aortic dissection, active bleeding, head/facial trauma
- Relative CI:
- recent surgery, uncontrolled HTN, pregnancy, current coumadin with INR >1.7, peptic ulcer
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Nursing Care for STEMI
- Admit to ICU w/continuous EKG looking for ectopy, reperfusion, vtach, st segment changes.
- Pain mgmt--Nitro IV 10-200 mcg/min, morphine 2-4 mg IVP PRN
- Frequent BP's, consider Art line,
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Cardiac Cath post procedure care
q15 min assess insertion site, bleeding, hematoma, bruising, distal pulses, color, temp. VS q15 for 1 hour, q 30 min for 2 hours, then q1h for 2 hour. Bedrest. Don't bend leg for 6-12 hours post removal of sheath. HOB <30 degrees, log roll. Monitor for S?S of decr CO, heart sounds, lung sounds, perfusion, pulses, urine output, cognition.
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Medications
- Heparin--IV infusion to maintain PTT @50-70
- Aspirin 160 mg qday
- Calcium channel blockers--Verapamil, Diltiazem
- Ace Inhibitors--Enalapril, Lisinopril
- Specific to PCI & Stents:
- Plavix 300 mg PO before PCI or on admit to CCU then 75 mg qd
- GPIIb/IIIa receptor inhibitors--Peopro, aggrastat, integrillin
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Low Cardiac Output Syndrome
- Etiology: Abnormal heart rate, bradycardia, tachy, hypovolemia, Poor LV function.
- Clinical Manifestations: Hypotension, oliguria, cool extremities
- What monitor will show: Hypovolemia--low CVP, PAP, PCWP
- Poor LV function--high CVP, PAP, PAWP
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Treatments for Low Cardiac Output Syndrome
- Bradycardia--Epicardial pacing
- Tachy--Esmolol (500 mcg/kg/min X 1 min loading and 50-200 mcg/kg/min maintenance), Diltiazem 5-15 mg/hr
- A fib--diltiazem, cardioversion
- Hypovolemia--volume replacement
- crystalloid solutions (LR, NaCl)
- Colloid solutions (Normosol, Plasmanate, Hetastarch)
- Packed RBC's
- Poor LV function--Positive inotropic (ctx) agents: Dobutamine, milrinone
- Diuretics--Furosemide
- Vasopressors--Dopamine
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Cardiac Tamponade
S/S Decr chest tube output, muffled heart sounds, decreased EKG amplitude, Incr CVP, PAP, PCWP, Pulsus paradoxus (10 mm/gh fall in SBP w inspiration)
Treatment: Remove Chest tube obstruction, pericardiocentesis, REturn to surgery.
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Hypertensive Crisis "Emergency"
- Sudden severe elevation of BP >180 systolic and/or 120 diastolic. increased risk for end organ damage
- Caused by Acute renal failure, neurovascular, illicit drugs, elcampsia, pheochromocytoma
- CM: Depends on end organ affected:
- CNS--headache seizure, LOC
- Renal--Acute intrinsic Renal failure
- CVS--chest pain, MI, Heart failure, Abdominal pain=aortic dissection
- Treatment: 1 or more of the following
- Sodium nitroprusside, NTG, Hydralazine (eclampsia), Short acting Beta Blockers (aortic dissection), Enalapril (heart failure) consider lasix.
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