CEN Cardiovascular Emergencies

  1. Acute Coronary Syndrome?
    acute myocardial ischemia caused by atherosclerotic plaque rupture and thrombus formation
  2. Non-ST elevation CAD?
    prolonged resting chest pain >20min

    unstable angina:  may have ST segment depression

    Non-STEMI:  positive CK, CK-MB, troponin or both
  3. Pathophysiology of Non-ST elevation CAD?
    partial occlusion of coronary artery
  4. Managment of Non-STEMI MI?
    • 1. close monitoring for progression
    • 2. platelet aggregation inhibitors and anticoagulants:  ASA, heparin, lovenox
    • 3. Beta blockers\
    • 4. nitrates
    • 5. PCI
  5. ST elevation MI S/S?
    • 1. prolonged resting CP >20 min
    • 2. ST elevation
    • 3. Q waves eventually develop in some
  6. Pathophysiology of STEMI?
    complete occlusion of a coronary artery
  7. Management of STEMI?
    • 1. ASA and beta blockers
    • 2. reperfusion therapy:  PCI, fibrinolytics followed by ASA, heparin, lovenox
    • 3. nitrates\
    • 4. ACE inhibitors
  8. Hyperhomocysteinemia?
    homocysteine level of >14
  9. Homocysteine?
    essential sulfur-containing amino acid that is formed during the processing of dietary protein:  elevted levels are toxic to the vascular endothelium and increase coagulabilty
  10. What deficiencies may cause elevated levels of homocysteine?
    folate, vitamin B12 and B6
  11. Arteriorsclerosis?
    thickening and loss of elasticity of the arterial walls
  12. What consequences can occur as a result of atherosclerosis?
    angina, MI, HF, dysrhythmias caused by ischemia, sudden death
  13. Angina pectoris?
    transient chest pain associated with myocardial ischemia
  14. Predisposing factors for angina pectoris?
    Factors that decrease supply:  arteriosclerosis, coronary artery spasm, aortitis, dysrhythmia, anemia, shock

    Factors that increase demand:  HTN, aortic valve disease, tachydysrhythmias, HF, hyperthyroidism,
  15. What causes ischemia that results in angina pectoris?
    temporary imbalance b/t myocardial oxygen supply and myocardial oxygen demand that causes ischemia
  16. Common precipitating factors for angina pectoris:
    • the 5 E's plus smoking:
    • Exercise:  running
    • Exertion:  lifting, valsalva
    • Emotion:  catacholamine release
    • Eating:  shunting of blood to gut
    • Smoking:  nicotine increase HR and BP
  17. Pathophysiology of chest pain in angina pectoris?
    ischemia leads to anaerobic metabolism and accumulation of lactic acid which causes chest pain
  18. What relieves angina pectoris?
    rest and nitro
  19. What happens to cardiac markers in angina pectoris?
    CK-MB and troponin are negative
  20. What ECG change may occur with unstable angina?
    ST segment depression
  21. What medications are used to Tx variant angina?
    Ca Channel blockers and nitro
  22. Consideration when giving nitro to male patients?
    do not give NTG if ED medication has been taken w/in 36 hours :  can cause severe hypotension and a decreased LOC
  23. Activity for chest pain pt?
    bed rest during pain = decreased O2 demand
  24. Use of beta blockers for angina patients?
    decrease myocardial workload and myocardial O2 demand by decreasing HR and contractility
  25. When are beta blockers contraindicated for chest pain patients?
    variant angina and in pt with ischmia/infarction r/t cocaine use

    blocking beta receptor leaves alpha receptors unopposed and perpetuates vascular spasm
  26. CRP?
    byproduct that rises rapidly after an inflammatory response - stimulates release and expression of inflammatory mediators
  27. How long does it take heart to heal after ischemic damage?
    2to 3 months - scar does not contract or conduct electrical impulses
  28. Q wave?
    indicates mass loss of myocardium
  29. Block of L main coronary artery with cause what kind of MI?   ECG changes?
    extensive anterior MI

    V1-V6
  30. L circumflex artery blockage causes what type of MI?

    ECG changes?
    Lateral HIGH:  I and aVL

    Lateral LOW:  V5 and V6
  31. L anterior descending artery blockage cuases what kind of MI?
    \
    ECG changes?
    septal:  V1 and V2

    Anterior:  V3 and V4
  32. R coronary artery occlusion causes what type of MI?

    ECG changes?
    inferior:  II, III, aVF

    Posterior:  reciprocal changes in V & V2 indicative of changes in V7-V9 especially V8 & V9

    R ventricle:  V4R-V6R especially V4R
  33. What population of ppl die twice as much with MI's?
    women twice the mortality of men when they have MI
  34. What patients are less likely to have pain with MI?
    • older adults
    • diabetics
    • heart transplant patients (denervated)
  35. Clues that suggest silent MI?abed
    • new onset HF
    • acute change in mental status
    • abd pain
    • dypsnea
    • fatigue
  36. Tachycardia is seen most oftern with ___ MI and bradycardia is seen most often with ___ MI.
    anterior

    inferior
  37. When may elevated temp occur with MI?
    48-72 hours after MI
  38. CK normal values?
    Time to rise?
    Peak time?
    Return to normal?
    30-170 (men low 30 higher, women high 30 lower)

    • time to rise after injury 4-6 hrs
    • peak 24 hours
    • return to normal 3-4 days
  39. CK-MB normal?
    Time to rise?
    Peak?
    Return to normal?
    • 0% of total CK
    • 6-10 hrs
    • 12-24 hours
    • 2-3 days
  40. Myoglobin normal?
    Time to rise?
    Peak?\
    Return to normal?
    • <85
    • 1-4 hours
    • 6-12 hours
    • 1-2 days
  41. Cardiac Troponin I normal?
    Time to rise?
    Peak?
    Return to normal?
    • <1.5 ng/ml
    • 3-6 hours
    • 24 hours
    • 5-12 days
  42. How often should ECG of chest pain pt be repeated?
    every 30 minutes until pain ceases or until ECG is clearly diagnostic
  43. Criteria for prompt reperfusion therapies?
    ST segment elevation of <1mm in at least 2 contiguous leads

    new L BBB
  44. Morphine admin for MI/chest pain?

    Actions of morphine for MI pt?
    2to 4mg every 5 minutes until pain is relieved

    decreases preload and catecholemine release via pain relief
  45. What complication may occur r/t NTG admin?
    reflex tachycardia
  46. What Tx may be used for reflex tachycardia after admin of NTG?
    beta blockers
  47. What may be used for intractable chest pain?
    intra-aortic balloon pump - increases coronary artery perfusion pressure
  48. Absolute contraindications for fibrinolytic therapy?
    • intracranial or intraspinal surgery or trauma within 2 months
    • systolic BP >200, diastolic BP > 120 or both
    • prolonged or traumatic cardiopulmonary resusitation
    • pregnancy
    • Hx of hemorrhagic stroke, intracranial neoplasm, AV malformation, or aneurysm
  49. Heparin goal PTT after MI?
    45-60 seconds
  50. Heparin dose for MI patients?
    • bolus 60units/kg
    • drip 12units/kg/hour
  51. Why are beta blockers given with MI?
    • block effects of catecholemines:  decreased
    • HR, contractility, and O2 consumption
  52. Contraindications for beta blockers?
    • HR <50, SBP <100
    • 2nd or 3rd degree heart block
    • HF
    • bronchospasm
  53. What beta blockers are cardioselective and may
    be given to pt with Hx of bronchospastic lung disease?
    metoprolol, esmolol
  54. When may ACE inhibitors be given with MI?
    with anterior or large inferior MI or with evidence of HF

    *decrease water and sodium retention
  55. Teaching for pt to prevent valsalva maneuver?
    exhale when turning in bed
  56. When should RV MI be suspected?
    with acute inferior MI
  57. Indications of RV MI?
    • ECG changes in leads:  V4R, V5R, and V6R
    • R sided S4
  58. Tx specific to R sided MI?
    • 1. admin volume:  colloids
    • 2. avoid use of diuretics and venous dilators
    • 3. maintain contractility:  inotropes:  dobutamine
  59. Tx specific to cocaine induced MI?
    • 1. Beta blockers are contraindicated
    • 2. dilatizem to reduce coronary artery spasm
    • 3. diazepam to reduce risk of seizures
  60. Typical first s/s of HF?
    cough, exertional dyspnea, fatigue, edema
  61. What electrolyte imbalances typically occur with HF?
    hypokalemia, hypocalcemia, and hyponatremia
  62. LR is contraindicated in patients with ___ disease.
    liver
  63. Replacement of ___, ____ ___, and ____ should be considered with multiple blood transfusions.
    platelets, clotting factors, and calcium
  64. Acute sodium and fluid restrictions for HF patients?
    • fluid:  <2000mL/24hours
    • sodium:  <2 to 3 g/24hours
  65. Nesiritide/Natrecor?
    form of BNP:  brain-type natriuretic peptide:  hormone released by heart in response to stretching of vessels r/t increased blood volume

    reduces preload and afterload
  66. Atrial dysrhythmias and HF?
    increased volume stretches atria and causes atrial irritability and atrial dysrhythmias

    Tx of HF can resolve atrial dysrhythmias
  67. Complications of HF?
    dysrhythmias:  common cause of sudden death

    • DVT or PE
    • cardiogenic shock
  68. Complications of therapy for HF?
    fluid and electrolyte imbalance:  hypokalemia, hypocalcemia, and hypomagnesemia r/t diuretics

    digiatalis toxicity
  69. 3 types of cardiomyopathy?
    • dilated
    • hypertrophic
    • restrictive
  70. Predisposing factors for cardiomyopathy?
    anything that can damage heart:  infection/viral, toxins, electrolyte/vitamin deficiency, pregnancy, neuromuscular disorderes, connective tissue disorders, hyperthyroidism
  71. S/S of cardiomyopathy?
    • syncope, weakness, fatigue, ortho hypotension
    • cp and palpitations
    • s/s of HF:  dyspnea, edema
    • murmurs, valve regurg
    • s/s of LVF and RVF:  S3, crackles, JVD, peripheral edema, hepatomegally
  72. CXR with cardiomyopathy?
    • cardiomegaly\pulmonary congestion
    • pleural effusion
  73. Tx of cardiomyopathy?
    • mitral valve replacement or cardiac transplantation
    • hypertrophic:  prevent obstruction of LV outflow with beta blockers or Ca channel blockers and avoid inotropic agents (increase outflow obstruction)
    • Restrictive:  Tx cause, may use steroids
  74. Major complication of pericarditis?
    cardiac tamponade
  75. How much fluid can cause cardiac tamponade?
    50-100mL if fluid accumulation is acute and rapid
  76. Patho of constrictive percarditis and cardiac tamponade?
    decreases diastolic filling:  systemic or pulmonary congestion, decreased CO

    may lead to shock
  77. S/S of pericarditis?
    • CP
    • hoarseness, dysphagia, dyspnea
    • cough, hemoptysis
    • tachypnea, tachycardia
    • fever, malaise
    • heart sound changes:  *friction rub, muffled heart sounds
  78. What is CP like with pericarditis?
    What makes it better/worse?
    • precordial or L pleuritic CP that radiates to L shoulder, neck, arms, or abd
    • aggravated by inspiration, cough, and supine position
    • alleviated by sitting up or leaning forward
  79. What is the hallmark sign of percarditis?
    friction rub
  80. ECG of pericarditis?
    diffuse concave ST elevation in all leads except aVL aVR V1, upright T waves flattened, no Q waves
  81. What should pulse ox goal be for pt with COPD?
    O2 admin to get SpO2 to 90%
  82. Complications of pericarditis?
    • dysrhythmias
    • constrictive pericarditis, cardiac tamponade
    • HF
  83. Patho of myocarditis?
    viral infections causes immune response that becomes autoimmune process that leads to inflammation of myocardium
  84. What occurs in diffuse and focal damage to myocardium?
    diffuse injury may cause HF

    focal injury may damage conduction system and cause conduction blocks
  85. S/S of myocarditis?
    • CP:  soreness, burning, pressure
    • easily fatigued, syncope
    • URI or GI viral infection
    • sudden unexplained dyspnea, orthopnea or PND
    • fever
    • crackles
    • heart sound changes:  S3, S4, distant heart sounds, murmur of mitral regurg, pericardial friction rub
  86. What dysrhythmias and blocks may occur with myocarditis?
    SVT, ventricular dysrythmias, AV or bundle branch blocks
  87. Medication for fungal infections with myocarditis?
    amphotericin B/Abelcet
  88. When may steriods be used for myocarditis?

    When are they contraindicated?
    for connective tissue diseases

    contraindicated in early infectious viral myocarditis
  89. Complications of myocarditis?
    • dilated cardiomyopathy
    • dysrhythmias
    • blocks
    • pericarditis: monitor for cardiac tamponade
    • systemic emboli:  may receive anticoagulants
  90. What may be required with myocarditis r/t complication of blocks?
    temporary or permanent pacemaker
  91. Infective endocarditis?
    usually occurs in heart valves and my involve prostheses
  92. Predisposing factors for endocarditis?
    • valvular heart disease:  septal defects, rheumatic heart disease, Hx of endocarditis
    • cardiac Sx:  esp valve repair or replacement
    • invasive tests/monitoring
    • skin, bone, or pulmonary infections
    • poor oral hygiene and dental procedures
    • long-term venous access devices
    • body piercing
    • immunosuppressed state
  93. What valves of heart are most often affected with endocarditis in IV drug users?
    R sided heart valves

    L side usually affected with other types of endocarditis
  94. What happens to valve affected by endocarditis?
    becomes incompetent and may later scar to become stenotic
  95. S/S of endocarditis?
    • infectious s/s:  fever, malaise, body aches, etc
    • pleuritic cp, abd pain, back pain
    • s/s of HF:  dyspnea, orthopnea, PND
    • cough, hemoptysis
    • new or changed murmur
    • confusion/delerium
    • s/s of embolic or allergic vasculitis
    • may have s/s of HF
    • Image Upload 1
  96. S/S of embolic or allergic vasculitis that may occur with endocarditis?
    • splinter hemorrhages of nail beds
    • petechiae
    • roth spots:  round white lesions on the retina
    • janeway lesions:  flat, painless eerythematous lesions on the palms, soles of feet, and extremities
    • osler nodes:  painful nodules on fingers and toes
  97. roth spots
    round white lesions on retina
  98. Janeway lesions?
    flat, painless erythematous leasions on the palms, the soles of feet and extremities
  99. Osler nodes?
    painful nodules on fingers and toes
  100. How long is ABX therapy usually for endocarditis?
    4 to 8 weeks
  101. Complications of endocarditis?
    • HF, cardiogenic shock, and pulmonary edema
    • extension of infection: abscess, fistula
    • systemic emboli and stroke
    • neurologic complications:  stroke-like s/s
    • bacterial or myocotic aneurysm:  localized abnormal expansion of a vesseel as a result of destruction of part of all ov the vessel wall from growth of bacteria or fungi
    • dysrhythmias or blocks
    • septic shock
  102. Consideration for ppl with valvular heart disease having a procedure?
    should receive prophylactic ABX before intrusive procedures:  dental procedures, cardiac cath
  103. Hypertensive crisis?
    • rapid rise in BP and is severe enough to cause threat of vascular necrosis and end-organ damage
    • BP usually >240/140
    • associated with organ damage to kidneys, brain, heart, eyes, or vascular system
  104. HTN?
    BP above 140/90
  105. Predisposing factors for HTN crisis?
    • untreated essential HTN:  noncompliance is frequently cause
    • renal disease
    • eclampsis/preeclampsia
    • CNS injuries
    • burns
    • drug side effects:  oral contraceptives, steroids, cocaine, amphetamines, meth, and decongestions
  106. Organs most likely to be damaged by HTN?
    heart, brain, kidneys, retina
  107. S/S of hypertensive crisis?
    • Hx HTN
    • significant elevated BP above normal
    • epistaxis may occur
    • cardiovascular:  cp, s/s of LV hypertrophy, s/s LVF, carotid/abd bruits
    • renal involvement:  nocturia, pressure-related diuresis, hematuria, elvated bun/creatinine
    • retinal involvement:  visual disturbances, funduscopic changes
    • neurologic involvement:  occipital or anterior HA esp in am, NV, seizures, focal neurologic s/s
  108. What is widening of the mediastinum on CXR indicative of?
    dissecting thoracic aortic aneurysm
  109. BP checks with hypertensive crisis?
    every 5 minutes until stable
  110. Sodium restriction for HTN crisis?
    2g/24hours
  111. Reduction of MAP in hypertensive crisis by no more than __ to ___ % during first 2 hours.

    Why?
    20-25%

    may cause neurologic damge by significantly decreasing cerebral perfusion pressure if decreased too quickly
  112. What drug is usually the first-line agent for HTN crisis?

    Why?
    nitroprusside/nipride

    rapid onset and short duration of effect
  113. What is the medication of choice for hypertensive crisis r/t eclampsia?
    hydralazine
  114. What drug use for HTN crisis is contraindicated in HF patients?
    nicardipine/cardene
  115. What type of drug is phentolamine/regitine?
    alpha blocker
  116. What type of hypertensive crisis contraindicates beta blockers?

    What may be used instead?
    autonomic dysreflexia because of bradycardia that occurs

    alpha blockers used instead:  phentolamine
  117. Why may beta blockers be used in HTN crisis?
    block the reflex tachycardia associated with vasodilators
  118. Alpha and beta blockers selective and nonselective?
    Image Upload 2
  119. What type of drug is phentolamine?

    What it may used for?
    alpha blocker

    HTN crisis r/t autonomic dysreflexia because of bradycardia - cannot use beta blocker
  120. In what type of HTN crisis is  a beta blocker contraindicated?
    autonomic dysreflexia r/t bradycardia
  121. Why may a beta blocker be used for htn crisis?
    blocks reflex tachycardia caused by vasodilators
  122. What type of beta blocker is esmolol?

    When is it contraindicated?
    cardioselective beta blocker:  does not effect airway

    HF, heart block, and htn caused by stimulants
  123. Which beta blocker is preferred for htn in patients with aortic dissection:  propranolol or esmolol?
    propranolol
  124. What type of drug is labetalol?

    When is it contraindicated?
    alpha and noncardioselective beta blocker

    contraindicated with HF, asthma, and heart block
  125. When are ACE inhibitors particularly helpful in HTN crisis?
    with HF
  126. Only IV ACE inhibitor?
    enalapril/vasotec
  127. Complications of htn crisis?
    • cerebral infarction
    • MI
    • HF or pulmonary edema
    • dissection of aorta
    • renal failure
  128. Predisposing factors for arterial occlusion?
    arterial embolization:  Afib, valvular heart disease, HF, ventricular aneurysm, bacterial endocarditis

    • injury to arterial wall:  vascular trauma, arterial pnuctures, postcardiac catheterization, PCI, and vascular surgery
    • compression of artery with swelling:  fracture, circumferential burn
  129. Ankle-brachial index?
    • comparison of ankle and brachial systolic BP
    • obtained with a doppler stethoscope0
  130. What ankle-brachial index is not compatible with limb viability?
    <0.30
  131. Diagnostic study for arterial occlusion?
    antiography indicates arterial occlusion
  132. Procedures to reestablish the patency of an artery?
    • intra-arterial fibrinolytics/tpa
    • percutaneous endovascular
    • Sx
  133. Predisposing factors for acute aortic aneurysm?
    • HTN
    • degenerative changes of aging
    • congenital weakness of aorta
    • pregnancy esp in 3rd trimester
    • coarctation of aorta
    • syphilis
    • severe systemic infection
    • marfan syndrome
    • trauma esp accel/decel injury
  134. What s/s occurs as an aortic aneurysm as dissection extends?
    pain moves from site of origin to other sites
  135. S/S of acute aortic aneurysm?
    usually asymptomatic until dissection or rupture

    • sharp, knife-like, tearing/ripping pain
    • normal to high BP - hypotension suggests cardiac tamponade or aortic rupture
    • pulsatile mass
    • increased aortic ciameter on palpation
    • bruit over the aorta
  136. CXR with aortic aneurysm?
    • mediastinal widening
    • widening of aortic silhouette
    • aortic calcification
    • L pleural effusion
  137. What test will show presence, size, shape, and location of aortic aneurysm?
    ultrasound
  138. BP management of aortic aneurysm if dissection occurs or if patient is hypertensive?
    maintain MAP at approx 70mmHG

    • nitroprusside with propranolol
    • labetalol
  139. Blunt cardiac injury/myocardial contusion?
    transient or permanent myocardial dysfunction caused by blunt trauma to the heart - may include myocardial necrosis without CAD
  140. What is the most common cause of blunt cardiac trauma/myocardial contusion?
    ace/decel injury in MVA
  141. What type of blunt cardiac injury can cause sudden cardiac death?
    blunt, nonpenetrating blow to the precordium
  142. S/S of blunt cardiac trauma/myocardial contusion?
    • precordial cp:  usually increased with inspiration, cough, and mvmt - unresponsive to nitro - decreased with O2, antiinflammatories, and narcotics
    • dyspnea\palpitations
    • tachycardia, tachypnea
    • hypotension
    • ecchymosis
    • chest wall tenderness with palpation
    • cardiac arrest r/t vent arrhythmias
  143. What part of the heart is usually affected by blunt cardiac trauma/cardiac contusion?
    atria and R ventricle r/t anterior positioning
  144. Why are inotropes used with cardiac contusion and blunt cardiac trauma?
    improve RV contractility
  145. What type of drug is dobutamine?
    inotrope
  146. Treatment of atrial arrhythmia r/t cardiac blunt trauma?
    digitalis, cardioversion
  147. Tx of ventricular arrhythmias r/t cardiac blunt trauma?
    usually amiodarone
  148. Tx of blocks r/t blunt cardiac trauma?
    temporary or permenant pacemaker
  149. Complications of penetrating cardiac trauma?
    • hemorrhagic shock
    • cardiac tamponade
    • hemothorax
    • pneumothorax
  150. S/S of great vessel injury?
    • Hx of events/MOI
    • pain that radiates to back
    • dyspnea
    • dysphagia/hoarseness
    • sensory or motor changes in the lower ext
    • tachycardia
    • htn, hypotension
    • difference b/t L and R arms or upper and lower ext
    • tracheal shift
  151. BP control for great vessel injury?
    antihypertenisives to keep MAP below 90
  152. Complications of great vessel injury
    • hemorrhagic shock
    • cardiac tamponade
    • hemothorax
    • false aneurysm
  153. Predisposing factors for cardiac tamponade?
    • heart injury
    • post MI
    • pericarditis esp in anticoagulated pt
    • iatrogenic:  pacemaker wire injury, invasive catheters, intracardiac injection, cardiac needle biopsy
    • transmyocardial revascularization
    • after cpr or cardioversion
    • fibrinolytic or anticoagulant therapy
    • connective tissue disease:  rheumatoid arthritis, SLE, scleroderma
    • metabolic disease:  renal failure, hepatic, failure, or myxedema
    • inflammation:  pericarditis
    • infection
  154. How much fluid is usually contained in the percardial space?
    <50 ml
  155. S/S of cardiac tamponade?
    • precordial fullness/pain
    • dyspnea - improved with sitting up
    • anxiety, impending doom
    • tachycardia - early sign
    • hypotension and narrowed pulse pressure
    • JVD
    • absent PMI
    • dullness to percussion below L scapula
    • pulsus paradoxus: SBP decrease of <10 with inspiration
    • Beck triad:  hypotension, distended neck veins, and muffled heart sounds
  156. Beck triad?
    • hypotension, distended neck veins, and muffled heart sounds
    • s/s of cardiac tamponade
  157. CXR with cardiac tamponade?
    widened mediastinum, enlarged heart

    |"water bottle silhouette"
  158. ECG with cardiac tamponade?
    decrease amplitude of ZRS or electrical alternans (alternating tall/small QRS)

    bradycardia (may indicate impending PEA)
  159. What is usually an early sign of cardiac tamponade?
    tachycardia
  160. What may bradycardia indicate with cardiac tamponade?
    impending PEA
  161. Tx of bradycardia in cardiac tamponade?
    atropine or trascutaneous pacing
  162. Tx of emergency cardiac tamponade?
    percardiocentesis
  163. Pt position during pericardiocentesis?
    semi-Fowler position
  164. Complications of cardiac tamponade?
    • laceration of coronary artery or conduction system
    • myocardial perforation
    • pneumothorax
    • dysrhythmias
    • hypotension
Author
mbeklj
ID
342737
Card Set
CEN Cardiovascular Emergencies
Description
CEN, Cardiac Emergencies
Updated