cardiac1.txt

• P-Pneumonia, P.E., pericardial tampanade
• A-AMI, Angina
• I-Ingestion
• N-Pneumothorax/pneumonia
• E-Esophageal rupture/issues

• M-Morphine
• O-O2
• N-Nitro
• A-Aspirin

It is a pneumonic for the possible causes for chest pain

It is a pneumonic used for the treatment of cardiac chest pain

PEA is any organized pulses organized rhythm (besides VT)

• Age
• Family History
• Diabetes
• Hypertension
• Hyperlipidemia
• High Cholesterol
• Cigarette smoking
• Preexisting Cardiac Disease
• Cocaine use
• Carbohydrate Intolerance

Parietal means most superficial, toward the outside

Visceral means deep, more interior.

The Endocardium is the layer of tissue in the heart that actually touches the heart

The Myocardium is the muscle of the heart

The Epicardium is the serous membrane that covers the heart

The Parietal pericardium is the serous membrane lines the fibrous pericardium of the heart

The Fibrous pericardium is the Fibrous outer layer of the heart

• Fibrous pericardium
• Parietal layer of serous pericardium
• Pericardial Cavity (Where the Serous fluid is held)
• Visceral layer of serous pericardium (Epicardium)
• Myocardium (Cardiac muscles)
• Endocardium

Reduces Friction

• 4 Pulmonary veins
• 2 Superior and inferior vena cavae
• 1 Coronary Sinus

The Coronary sinus is a collection of veins joined together to form a large vessel that collects blood from the myocardium of the heart. It delivers deoxygenated blood to the Right atrium in conjunction with the superior and inferior vena cave.

• Right and Left atrium
• Right and Left ventricular

The septum of the heart is separated into 2 sections, the Interatrial septum and the Interventricular septum

The Interatrial septum is the wall of tissue that separated the right and left atrium of the heart.

The Introventricular septum is the stout wall separating the left and right Ventricles of the heart

The septum of the heart is an electrically inert area, its a tendon like substance

• Tricuspid
• Pulmonary
• Mitral (Bicuspid)
• Aortic

There are 3 tricuspid valves in the heart. The Tricuspid, the Pulmonary and the Aortic valves are all tricuspid in structure

The Coronary arteries fill during diastole of the contraction.

The Semilunar Valves are the Aortic and the Pulmonary Valve

The Semilunar Valves permit blood to be forced into the arteries, but prevent back-flow of blood from the arteries into the ventricles.

• Aorta
• Arteries
• Arterioles
• Capillaries
• Veinules
• Veins
• Inferior/superior vena cava

• Tunica Adventitia
• Tunica Media
• Tunica Intima

The Tunica Intima is the most inner Smooth, slick tissue in the arteries and veins

The Tunica Media is the muscular tissue of the arteries and the veins

The Tunica Adventitia is the Outermost layer of the Arteries and the veins (loose connective tissue)

After load is the amount of pressure is the heart pushes against

Pre-load is the amount of pressure on the ventricles of the heart and determines the amount of stretch

The Tunica Interna is made up of Epithelial cells

The Tunica Media is regulated by Sympathetic vasomotor nerve fibers

The Tunica externa is made up of Connective tissue which is used as reinforcement

• Conducting (Large)
• Distributing (Small to Medium)
• Arterioles (Smallest)

Veins have arteries because Veins pressure is often not grate enough to over come gravity and other forces to return to the heart

The AV Shunt is where the blood bypasses the capillaries.

The coronary arteries supply arterial blood to the heart muscle

The LCA (Left Coronary Artery) carries about 89% of the blood supply to the myocardium. The RCA (Right Coronary Artery) carries the remainder.

The LCA divides into the and circumflex arteries

The LAD supplies blood to the: Anterior wall of the left ventricle and the INTRAVENTRICULAR SEPTUM

The Circumflex supplies the: Lateral and posterior portions of the ventricle and part of the Right ventricle.

The dominant side of the heart is the side which has the artery that goes down the farthest on the posterior side of the heart

The Coronary Arteries originate above the aortic valve.

The right side of the heart is normally between 3-5mm thick

The left side of the heart is generally 13-15mm thick

The Right coronary artery and left coronary anterior descending artery supply a portion of the right atrium and right ventricle and the Inferior aspect of the left ventricle

Anastomoses provide collateral circulation.

CO=HR X SV

• The Acute marginal artery is the first major feeder coming off the coronary artery.
• It is also called the Right marginal artery

• The Oblique marginal artery is the second major feeder coming off the coronary artery
• It is also called the Left marginal artery

Posterior Interventricular

Anterior Interventricular

The blood travels from the coronary veins and then empty into the coronary sinus

• The Pump (The heart)
• The Tank (The body, 3rd spacing)
• The Pipes (Veins)

Blood comes in the right atrium from the Superior and inferior vena cave. Then the blood goes through tricuspid valve into the right ventricle, then goes through the Pulmonary valve to the lungs to get oxygenated. The blood then comes from the lungs into the left atrium, passe through the mitral valve into the left ventricle. Once the blood is in the left ventricle it passes through the aortic valve into the aorta and the rest of the body.

70% of the heart is fed by gravity, the other 30% is supplied by Cardiac kick

Chronotropic is the Strength of contraction of the heart

Inotropic means the strength of contraction of the heart

Dronotropic means the speed of conduction of the heart

Amount of blood ejected with every heart beat

• Preload (Venous return) (Most important factor)
• Afterload
• Myocardial Contraction

Preload is the most important factor

• 120-130mL
• Ejection fraction - 60-70% of the blood volume

• Its the rubber band principle
• Myocardial fibers contract more forcefully when stretching

Afterload is the Peripheral vascular resistance. It the pressure the Ventricular muscle must overcome to open the aortic valve and push blood through

• Pressure in the peripheral vasculature
• Compliance of the aorta
• Viscosity of blood

Ischemia is lack of sufficient O2 to a specific area of tissue

Hypoxia is the lack of O2 to the body in general

The vagus nerve

Acetylcholine

Norepinephrine

Epinephrine and norepinephrine

~4-6 L (About a gallon)

• Contractility (Inortopic)
• HR (Chronotropic)
• Conductivity (Dromotropic)
• Automaticity

The ANS is the part of the nervous system that controls involuntary actions of the smooth muscles, heart and glands

The Sympathetic system is the Fight or flight. It prepares the body for action.

• The Parasympathetic nervous system is the resting nervous system.
• Rest and remerge

The Valsalva maneuver is performed by holding your breath and "bearing down". This works by stimulating the Vagus nerve

Norepinephrine

• + Inotropic
• + Chronotropic
• + Dromotropic
• Increased automaticity
• Dilation of the coronary arteries

Generalized constriction of peripheral vessels )INcreased O2 demands of the heart met by increasing blood supply

Inhibitory influence on the heart by decreasing HR and contractility via release of Acetylcholine

• Basically the same as Norepinephrine, it stimulates the heart:
• + Inotropic
• + Chronotropic
• + Dromotropic
• Increased Automaticity
• Dilation of the coronary arteries

The same effects except with the medication the effects last a little longer

• Calcium
• Potassium
• Sodium
• Magnesium

• (Most abundant Cation in the body)
• Help contribute to the positive charge in the cells
• Required for Contraction of muscles
• Affects the strength of contraction

• Important in conduction of electrical impulses and muscles contraction
• affects rate of contraction
• (Normal blood value is 3.5 - 5.0 mEq/L)
• (Major intercellular cation)(Affects the cardiac system easily due to leaky channels)

• Important in conduction of electrical impulses and muscle contraction
• Affects rate of contraction
• (Major extracellular cation)

It mediates intracellular K+ replenishment

By the Vagus nerve

Lead II remains the "Standard" monitoring lead

Lead II looks through the left ventricle back toward the right atria

We need to know if the rate is fast, normal, or slow

Is the ventricular rhythm regular or irregular?

Is there a "P" wave? (Atrial depolarization)

What is the PRI width?

What is the QRS width?

What is the "P" to "QRS" ® ratio?

Are there "T" wave &/or ST segment changes

0.10-0.12 sec

>0.12sec

If there is no P wave we can't call it sinus

Normal PRI is 0.12-0.20

Waveforms moving away from the red lead will have a (-) deflection

Waveforms moving toward the red lead will have a (+)/upright deflection

The PRI interval is from the start of the P wave to the start of the QRS interval

Bradycardia is when a rhythm is lower than the lower limit for the pacemaker site.

An accelerated rate is a rate greater then the higher range of the pace maker site, but still lower then 100BPM

Tachycardia is any rate higher then 100BPM

40-60BPM

ACC (Accelerated junctional rhythm)

A junctional rhythm from 60-100BPM

A rhythm genesis originating in the ventricles that is 40-100BPM

40-60BPM

Agonal (Ventricular rhythm <20)

We don't want to "reset" the rhythm because it can throw clots

Commonly used with any rate with a genesis other than the SA node 100-150 BPM

• For any rhythm/rate with a genesis other than the SA node
• >150 BPM
• Start worrying about coronary fill

AVT is generic for all rhythms above the ventricles in origin and are fast, and usually reserved for regular-regular rhythms

• An escape rhythm is a rhythm from the AV junction and Ventricles that are in there normal rate
• AV junction 40-60 BPM
• Ventricles 20-40 BPM

The cells aren't aren't getting enough O2 so the respiratory increases to compensate

0.04sec

• T-wave changes,
• Hyperacute T-waves
• T-waves can become inverted
• Reversible damage
• If continues long enough you may see an ST segment depression below baseline

Noted by ST elevation typically

Pathological Q-wave (0.04 sec normal Q-wave (1 tiny box) no deeper then 5 mm)

• Primary Indication is Cardiogenic shock, but may be useful in other forms of shock
• Bradycardia refractory to atropine, and when pacing is unavailable

IV infusion ONLY - Mix 400mg in 250cc D5W or NS to produce 1600 mcg/mL. Infusion rates [2-20mcg/kg/min] titrate to effect. Microdrip/pump only

• Cardiac arrest
• Symptomatic bradycardia

• Cardiac arrest: [1mg (1:10000)] q 3-5min IV/IO/ET
• Bradycardia: [1mg (1:1000)] in 250cc NS administer @ 2-10 mcg/min

• Symptomatic sinus bradycardia or A-V blocks
• Bradycardia associated with PEA
• Asystole

• Bradycardia: [0.5mg] IV q. 3-5min: Max 3mg (0.04 mg/kg)
• Asystole/PEA <60bpm: [1mg] RIVP/IO/ET(Dilute 2-3mg in 10cc for ET) q.3-5min

• Pulseless VF/VT refractory to initial electrical therapy
• Unstable VT refractory to lidocaine and/or electrical therapy

• Pulseless VT/VF: [300mg] initial bolus IVP/IO after epi, may rebels once with [150mg]
• Sustained VT: [150mg] over 10min, may rebels every 10 min as needed up to a Max 15 mg/kg/day
• Maintenance infusion: [0.5mg/kg], 540mg IV over 18hrs

• Symptomatic ventricular dysrhythmias
• Sustained Ventricular Tachycardia
• Ventricular fibrillation/pulseless ventricular tachycardia

• IV Bolus: Ventricular tachycardia [1-1.5 mg/kg] IV. If VT persists, [0.5-0.75 mg/kg] every 3-5min up to 3mg/kg start infusion if VT converts- VF and pulseless VT [1-1.5mg/kg] IV/IO/ET followed by defibrillation. If VF or VT persists - repeat [0.5mg-0.75mg/kg](up to 3mg/kg total) followed by defibrillation. Start lidocaine infusion if VF converts
• IV Drip technique: A. Mix 1gm of lidocaine in 250mL D5W/NS for a concentration of 4mg/mL - 1. If up to 2 mg/kg has been administered (Set drip at 2mg/min) 2. If 2 mg/kg< has been administered (Set drip at 3mg/min) 3. If 3mg/kg< has been administered (Set drip at 4mg/min) B. A second bolus after 10min may be given per physicians order
• IM: [200mg] if unable to start IV

Pulmonary edema

• [20-40mg] SIVP or [0.5-1mg/kg] SIVP
• If currently taking double PO dose, may repeat PRN

Paroxysmal SVT, including PSVT associated with Wolff-Parkinson-White syndrome

[6mg] RIVP followed by 30cc flush, may repeat in 1-2min with [12mg] and a third with [12mg] all followed by 30cc flush RIVP

Myocardial Infarction patients, Including suspected AMI patients

162mg-325mg (81mg X 4)

• Chest pain, anginal pain
• Congestive heart failure with severe pulmonary edema

• Sublingual: [0.3-0.4mg] Tablet. Repeat @ 3-5 min as needed to a total of three tabs (or more by MCEP order)
• Lingual Spray: [0.4mg] metered dose, spray directly under the tongue; additional 1-2 sprays q. 3-5 min for a total of three sprays
• Infusion: [5-20mcg/min]

• Treatment for acute pulmonary edema
• AMI
• Sedation procedures

• Excess catecholamines
• Digitalis toxicity
• Hypoxia
• Hypercapnia
• Myocardial ischemia/Infarction
• Increased venous return (Preload)
• Hypokalemia r electrolyte abnormalities
• Atropine Administration

Reactivation of myocardial tissue by same impulse

• When electrical impulse is delayed, blocked in segments of the heart's electrical conduction system
• Requires a closed system to send information back around

• SA node
• Atria
• AV Junction
• Bundle branches
• Purkinje Fibers

• Myocardial Ischemia
• Certain drugs
• Hyperkalemia

6-7 mL/kg

360J

8-10 mL/kg

• D = Right drug
• R = Right Route
• P = Right Patient
• A = Right amount
• T = Right time
• S = Right Scribe

Message the site briefly

• 25g
• .5"
• 45-degree angle

Destroying pathogens

Most distal

Adenosine

30 days

Amiodarone

WPW syndrome (Wolff-Parkinson-White Syndrome)

The junction between the end of the QRS and the beginning of the ST segment

• The TP segment
• Do not compare ST segment to the PRI, PRI can be depressed making the ST look elevated

• V1: 4th intercostal space right of the sternum
• V2: 4th intercostal space, left of the sternum
• V3: 4th intercostal slightly inferior to lead V2
• V4: 5th Intercostal just medial and inferior to the patients nipple (Gender pending)
• V5: Lateral chest inferior to V4
• V6: Lateral chest lateral to V5

MI, with irreversible damage

Myocardial ischemia