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BC3 CARDIO MI 1/30
BC3 CARDIAC LECTURE MI 1/30/08
| Question | Answer |
|---|---|
| modifiable risk factors OF MI | Obesity; Diet and exercise;behavioral changes ; |
| stable angina | predictable angina; knows that if he is going to go chop wood he is going to get chest pain. What relieves it? I sit down, I rest, I take it easy for awhile and it goes away…predictable.;from 2 things – physical stress and emotional stress |
| Unstable angina | called pre-infarct angina or crescendo angina. it’s just there. It’s not predictable; needs to be treated immediately as an acute MI; comes in, says he has angina, if unstable he will have stenting – 90 minutes door to balloon. |
| Variant angina is | Prinzmetal’s angina and that is usually treated with a calcium channel blocker and we look at that as a vaso-spastic angina.patient is ischemic ; occurs at rest, MORE IN WOMEN |
| acute coronary syndrome | or ACS is known collectively as unstable angina and an MI. |
| how treat the angina? | Management is #1 Risk reduction;stop smoking, lifestyle changes, diet, weight loss, exercise, medications to control cholesterol, hypertension and diabetic management. |
| what does angina come from | Lack of oxygen ;Give them oxygen.give them nitroglycerin for coronary vaso artery dilation;give them beta blockers, calcium channel blockers, and you can give them an aspirin |
| Most research says….TAKE an aspirin | 325; 81 mg is enough – that’s NOT the right answer |
| Invasive treatment OF MI | angioplasty;balloon angioplasty, PTCA, stent placement, intra-aortic balloon pump and CABG – those are all treatment for angina |
| Inversion of the T wave means | ischemia. |
| Depression of the ST segment MEANS | ischemia. |
| MI is due to inflammation; rupture of the atherosclerotic plaque | (blank) |
| inflammation; monitored with | C-reactive protein |
| if you have high C-reactive protein – what is the treatment for that? | an aspirin every day |
| plaque ruptures and when that plaque ruptures it attracts | cytokines?an inflammatory; response;. As a result,a thrombus forms;you have occlusion of that coronary artery.ischemia |
| ST elevation indicates | acute MI |
| types of MI; infarct expansion | patient has new necrosis;failure to treat within 6 hours |
| What does a thrombolytic do? | opens up the vessels |
| see prior to giving the thrombolytic | elevated CPK obviously. Or elevated enzymes |
| wash-out effect | enzyme that was there previously, is occluded behind that clot. I opened up that vessel, what happened? Oh…that enzyme came rushing through – ran up, came back down, went back down to baseline |
| re-perfusion dysrhythmias | (blank) |
| metabolism (?) anaerobic, what happens? | Acidosis.heart in an acidotic state? Dysrhythmias – it doesn’t contract well. |
| who uses tPA | Hospitals that don’t have a cath lab or access to a helicopter ;$3000 for an injection. |
| infarct expansion | if that infarct is not treated and that area is not opened up to perfuse the area, areas of necrosis continue to creep out and that area of necrosis gets bigger and bigger. |
| Infarct extension means | muscle thins and dilates in the infarct zone, so that area that has been infracted, the muscle gets very thin and becomes very dilated. Again, affecting contraction on systole. |
| remodeling is | change in ventricular muscle diameter –where you get thin and thick fibers. |
| two things that you have following an MI | infarct expansion, infarct extension and remodeling |
| EKG progression of an MI | usually come in with very tall T waves – |
| male MI symptoms? | crushing chest pain, this is Levine sign by the way (FIST OVER CHEST);pain is sternal – radiates to the left arm up to the left jaw |
| women MI symptoms? | GI;little short of breath, you are a little queasy in the stomach/GI upset, just haven’t felt too good…tired… |
| hyper acute T waves, (tall t waves) | sign of MI |
| get inverted T waves | identify ischemia |
| ST elevation will last | hours to days, unless you give a thrombolytic |
| Q wave | 1-2 days to develop that Q wave, IF they are having a Q wave MI. |
| A Q wave MI is | retrosternal chest pain, left arm, up into the jaw. Who gets Q wave MI – MEN. full infarct of the wall of the heart, all three walls are affected. |
| non-Q wave | women tend to get;part of that muscle has been infracted, so it could be a sub endocardial – affecting only the endocardial wall |
| Non-Q wave MI’s tend to return to | your ED with a fatal MI |
| EKG changes after an MI | ST segment decreases, goes back to the isoelectric line ; don’t see it unless you use thrombolytics; T waves may be inverted for weeks after an MI; and Q waves will always, always, persist. |
| complications w/ MI / Cardiogenic shock | heart fails; left ventricle not putting out cardiac output |
| hemodynamics of Cardiac shock | pulmonary artery wedge pressure will be greater than 18/ an elevated pulmonary artery wedge pressure/ If wedge pressure is < 18 patient is hypovolemic, |
| Other signs of Cardiac shock | decreased blood pressure, decrease PaO2, a mean arterial pressure of less than 65; and cardiac index of less than 2.2. |
| what are the autonomic symptoms they have? women, | Diaphoresis, nauseated |
| women complain of pressure | not pain, ppressure; changes of the left arm pain, sternal pain and jaw pain, they have autonomic symptoms as well |
| arms arterial pulses 3 locations | brachial,above the bend of the elbow ;radial ,flexor surface of the wrist laterally ;ulnar,flexor surface of the wrist medially |
| legs, arterial pulses 4 locations | femoral in groin, popliteal behind knee; dorsalis pedis dorsum of the foot ;posterior tibial behind the medial malleolus of the ankle, |
| Veins, | carry blood back to the heart |
| Deep leg veins include | femoral veinmedial to the femoral artery below the inguinal; |
| Superficial leg veins include | great saphenous vein, orsum of the foot to the groin;small saphenous vein ,side of the foot to the back of the knee. |
| If you suspect arterial insufficiency in an arm or hand, feel for the ulnar. The pulse | pulse of a normal ulnar artery may not be palpable |
| To help determine patency of the ulnar aterty, | perform the Allen Test |
| the Allen Test (repeat steps for radial artery) on reverse side | thumbs lightly over the radial & ulnar arteries ;clench his fist tightly; firmly depress both arteries between thumbs & fingers; open & relaxed hand;color of palm & fingers,should be pale;release pressure over ulnar ; artery patent = palm pink 3-5 sec, |
| assess the brachial pulse | Flex the patient elbow slightly;antecubital crease just medial to the biceps tendon; 3cm above the medial epicondile |
| exam the legs; lying down ; legs are fully exposed | skin temperature w/ backs of fingers; palpate the femoral pulse; superficial inguinal nodes ; obese, you may need to place one hand on top of the other |
| palpate the femoral pulse | fingers midway between the anterior superior iliac spine and the symphysis pubis and press it deeply below the inguinal ligament. Just medial to the femoral pulse |
| popliteal pulse | slightly flex the patient's knees; slightly lateral to the midline.more difficult / deeper and more diffuse |
| dorsalis pedis pulse | palpating the dorsum of the foot, just lateral to the extensor tendon of the big toe.may be congenitally absent |
| posterior tibial pulse | curving your fingers behind and slightly below the medial mallelous of the ankle |
| inspect the saphenous system for varicosities | ask your patient to stand;Look for redness or discoloration ;feel for tenderness |
| examination of the peripheral vascular system involves | assessment of the arteries, veins, and lymph nodes in the arms and legs. |
| CABG, coronary artery bypass graph surgery | Uses native vessels, such as the saphenous vein.harvest from leg, left internal mammary artery; |
| Now, the advantage of using the LIMA (left internal mammary artery) for CABG | it is an artery; lasts longer, it does not re-stenosis;does not have atherosclerotic plaquing as early as what the saphenous vein does; greater graph patency over a 10 year period; |
| Off-pump CABG | heart does not stop; device that is called the octopus; find the vessel that you need to bypass, you put this tube, it’s like two popsicle sticks that have suction cups on bottom of it and u stick it to area where you want to graph.stabilizes heart |
| profusionist | someone who runs the bypass machine |
| so off-pump – it is | limited in use simply because your visibility is limited, so anyone who needs by pass x 5 and up have off-pump |
| How do you stop the heart | Potassium |
| how do you start the heart | You shock them; Usually a couple of times |
| neurological complications that we find from the cardiopulmonary bypass machine | stroke, because of the platelet disruption, |
| off-pump | decreased length of stay if they are off-pump; similar stroke rate with pump bypass; stroke will occur 24-72 hours;on pump bypassstroke occurs immediately |
| off-pump people need to be monitored longer for CVA than cardiopulmonary bypass. | (blank) |
| systemic inflammatory response syndrome | Strokes do occur due to SIRS ;and micro-emboli formation during the surgery, therefore they tend to use plavix, they use heparin after the OR and you are always monitoring for a change in level of consciousness. |
| Why would you want epicardial pacer wires in a post-op CABG? | with the pacer wires, you can pace the patient and you have direct access to the heart, so what you are trying to do is prevent a complication from the pump |
| care of open heart patient. | You can have stenosis, you can have insufficiency. |
| with stenosis | stenosis, and looking at number 1, mitral stenosis, it decreases forward flow of the blood from the left atrium to the left ventricle;result of that;loss of forward flow, you have decreased cardiac output. |
| . What causes mitral stenosis? | rheumatic heart disease; a-fib, pulmonary hypertension,look at the echo ,at the gradientgreater than 15-20 and what that means is the left atrial pressure is greater than 15-20mmHg higher than the left ventricle. blood is not leaving the left atrium |
| left atrial pressure is greater than 15-20mmHg higher than the left ventricle. | reason for that is the blood is not leaving the left atrium. It is not going forward – it is being retained in the left atrium, so you left atrial pressure is 15-20 mmHg higher than the left ventricle due to failure of the blood to go forward |
| Normal mitral valve area is | 4-6 and you can find that out with a cardiac cath;If it is less than 1.5, you have severe mitral stenosis;what happens to the lung? keeps going back in to the lungs; CHF, R vent enlarge |
| pulmonary signs and symptoms | dyspnea, fatigue, shortness of breath, crackles |
| Aortic stenosis | gradient is greater than 50 ; The normal valve area is 2.6-3.5cm2 ;less than 1, you have severe AS (aortic stenosis |
| cause of aortic stenosis | rheumatic fever and calcification with age |
| Insufficiency is the same as | regurge; mitral insufficiency, or mitral regurge, and aortic insufficiency or aortic regurge. |
| with Mitral insufficiency we find? | thickening or stretching of the leaflets;result ,loss of forward flow ,bloodregurgitates into the left atrium |
| acute mitral insufficiency after an MI | due to the papillary? Muscle that may rupture after and MI. Treatment for that is emergency valve replacement. |
| cause of Aortic insufficiency | rheumatic heart disease; aneurysm of the ascending aorta;Corrigan’s pulse due to an acute injury as well, such as, steering wheel to the chest;rupture the ascending aorta |
| Corrigan’s pulse or a or a water-hammer pulse | patient is low diastolic pressure with a widening pulse pressure |
| insufficiency | mitral valve; don’t close completely. What these lead to is regurgitation and backwards flow of the blood |
| different kinds of replacement valves that we can use | tissue valves, we can use metal valves; reconstruction is largely preferred over valve replacement; decreased mortality; decreased thromboembolic events;no need for long-term anticoagulation ; decreased risk of endocarditis |
| complication of a MVR | endocarditis |
| different replacement valves | tilting; ball and cage; and tissue |
| biological valves can be | pig or cow valves. They last about 6-10 years. They are not used for a patient with a long life expectancy – why? Because they don’t last long – they have to be replaced – patient would be going in for another valve every 6-10 years. |
| tissue valves are good for | patient’s who are non-compliant with anticoagulant therapy. But the other patient who is confused who may take too much Coumadin or may not take the Coumadin, the choice may be a tissue valve compared to a metal valve. |
| childbearing age, very young women, should not take Warafin - what’s warafin – Coumadin | crosses the placental barrier.22 year old who needs a valve replacement;best choice? Tissue;do not have to take the anticoagulant therapy. |
| cardiopulmonary bypass | This is the pump that moves the oxygenated blood around body during open heart surgery.protects the organs too; hypothermic state, they have decreased neurological symptoms; preventsischemic which is a complication of bypass |
| cardioplegia | the solution that is used; causes asystole; protects the heart from ischemia; Ice slush the cardioplegia will not reach all the areas of the heart |
| some of the complications that we find with cardiopulmonary bypass machine: | 1. Increased capillary permeablilty;2. Hemodilution;3. platelet aggretaion problems – or altered coagulation; 4. damage to the red blood cells; 5. microembolization |
| What would cardioplegia do to your oxyhemoglobin association curve? | Shift it to the left. |
| perfusionist manages machine that?,.... | deoxygenated blood leaves the heart, comes down to this reservoir, you have an oxygenator and a heat exchanger, you have roller clamp in here and a bubble catcher and a heat exchanger and filter and then it is returned into the aorta by canula. |
| complications of cardiopulmonary bypass | arrhythmias, sinus tach is due to hypovolemia, fever and pain ;sinus brady cardia due to the pre-op beta blockers; PAC’s due to changes in electrolytes; a-fib |
| sympathomemetic drugs that cause sinus tach | dopamine, epinephrine |
| treat a-fib with | amiodorne |
| complications of cardiopulmonary bypass | . Fluid resuscitation , so use a swan to identify a volume usually less than2.5,pulmonary artery wedge pressure of less than 14 -18 indicates hypovolemia secondary to fluid shift to the interstitial spaces |
| SIRS (Systemic Inflammatory Response Syndrome) | a pulmonary artery wedge pressure of less than 14 -18 indicates hypovolemia secondary to fluid shift to the interstitial spaces that occurs with SIRS (Systemic Inflammatory Response Syndrome) so your monitor will tell you if your patient needs fluid or no |
| complications of cardiopulmonary bypass | Decreased cardiac output – we treat that with sympathomemetic drugs; and you are always looking at the cardiac index |
| complications of cardiopulmonary bypass | Control of the blood pressure – you need a mean arterial pressure of 70 to perfuse the organs or a systolic greater than 120 without any alpha stimulation. And what if your patient is hypertensive, what drug would you use? Nitroglycerin – we usually han |
| complications of cardiopulmonary bypass | Respiratory problems ; |
| on ventilators after the surgery Respiratory problems ; | FI02 of greater than what? 21; a Sat of greater than? 90-91%; check your ABG’s; patient will most likely be on PEEP; they will start in an assist control mode and move to an SIMV mode if they are weaned off, they may have to go to CPAP. |
| on ventilators after the surgery Respiratory problems | assist control, SIMV and then CPAP |
| concentrate your assessment in a CABG patient in | left lower lobe; often we find phrenic nerve damage due to the cooling that has occurred during surgery;most of your CABG patient’s will have a left effusion. Go over your chest x-rays and look for a left pleural effusion. |
| Post-op bleeding – chest tube drainage after CABG | greater than 200cc/hour they bought themselves a ride back to the OR; bleeding somewhere and has to be treated surgically |
| Post-op bleeding is treated with | Protamine sulfate to reverse the heparin |
| what reverses heparin? | Protamine sulfate |
| Often theCABG patient’s will require platelets because of | the platelet problem that occurred into the bypass machine |
| warm post op CABG patient to ? | get the coagulation cascade working again |
| Coagulation cascade does not work in ...?.... | cooling states, so you have to warm the patient up to get them back to their normal coagulation cascade. They can have cryoprecipitate (FYI pg 467), DDAVP which is called vasopressin (book says desmopressin |
| the thing that you really want to avoid in this patient who is bleeding is | Cardiac tamponade occurs whenever the blood surrounds the pericardium. If the blood surrounds the pericardium, you end up with signs such as Beck’s Triad – |
| Beck’s triad is : | 1. Muffled heart sound; 2. Hypotension ;3. Increased JVD; |
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goryan
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