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Sol's Cardiac Notes

MW Fall 11

P wave? atrial depolarization.
PR segment? time required for the impulse to travel through the AV node (where it is delayed) and through the bundle of His, bundle branches, and Purkinje fiber network.
PR interval? represents time required for atrial depolarization, and impulse travel through the conduction system and purkinje fiber network.
QRS complex? represents ventricular depolarization.
ST segment? early ventricular repolarization.
T wave? ventricular repolarization.
U wave? Late ventricular repolarization.
QT interval? total time required for ventricular depolarization and repolarization
J point? Junction where the QRS complex ends and the ST segment begins.
Where in the EKG is atrial systole? Beginning of the P wave to just before the high point of the R wave (QRS complex).
Where is isovolumetric contraction in the EKG? R to S
Ventricular ejection occurs where in the EKG? S wave to 2/3 through the T wave.
Isovolumetric relaxation occurs where in the EKG? Last 1/3 of the T wave.
Ventricular filling occurs where on the EKG reading? End of the T wave to the P wave.
Normal heart sounds (2)? S1 and S2
Abnormal heart sounds (3)? Splitting of S2, S3, S4.
What causes S1? The closing of the mitral and tricuspid valves (atrioventricular).
S1 marks the beginning of… Ventricular systole
S1 occurs where on the EKG? Just after the QRS complex.
What causes S2? The closure of the aortic and pulmonic valves (semilunar valves).
S2 marks the…? End of ventricular systole
S2 occurs where on the EKG? End of the T wave.
S3: aka, what? Aka ventricular gallop; heard after the normal S2 sound.
S3 caused by (2)? Early heart failure or ventral septal defect
S4: aka, what? Aka atrial gallop; heard before S1.
S4 caused by…(7)? 1.HTN 2.Anemia 3.Ventricular hypertrophy 4.MI 5.Aortic stenosis 6.Pulmonic stenosis 6.Pulmonary emboli 7.Loss of compliance with age
Gallops are caused by… Decreased compliance
New S3? Heart failure
New S4? MI
Murmurs: reflect what? Turbulent blood flow through normal or abnormal valves.
Systolic murmurs occur when? Between S1 and S2
Diastolic murmurs occur when? Between S2 and S1
Rub: when, sign of (3), 2 conditions? Occurs with heart beat; sign of infection/inflammation/infiltration; pericarditis, cardiac tamponade.
Walls of the heart are made of? Myocardium
Chambers of the heart are lined with? Endocardium
5 phases of the cardiac cycle in order? 1.Isovolumetric ventricular contraction 2.Ventricular ejection 3.Isovolumetric relaxation 4.Ventricular filling 5.Atrial systole
What do you lose during a fib? Atrial kick
Preload determined by? Left ventricular end dialstolic volume.
3 conditions that can lower preload? 1.Dehydration 2.Hypovolemic shock 3.CHF
5 meds to decrease preload? 1.Diuretics (lasix) 2.Venous/Vasodilators (Nitroglycerin) 3.Cardiac glycosides (Digoxin) 4.Beta blockers (metropolol) 5.Morphine
What do you not let your pt due who is on a nitro drip? Take a hot shower (d/t inc vasodilation)
Afterload? The pressure the LV must overcome to get blood out of the heart.
Two meds to decrease afterload? 1.Diuretics 2.ACE Inhibiitors 3.Other antihypertensives
Afterload and septic shock? Decerase in afterload
5 assessment factors outside of the heart? 1.Pulses 2.Blood pressure 3.Edema 4.Pain 5.EKG
PMI: where? Midclavicular, 5th ICS (mitral area at the apex of the heart).
3 reasons why one might have JVD? 1.Fluid overload 2.CHF 3.Dialysis
Auscultation mnemonic? APE TO MAN: Aortic Pulmonic Erb’s Point Tricuspid Mitral
Where is the SA node located? Wall of the RA
Big box numbers 1-8? 300, 150, 100, 75, 60, 50, 43, 38…
Left Main Artery branches into? Left Anterior Descending and the Left Circumflex Artery.
LAD perfuses? Portions of the LV, Ventricular Septum, Chordae Tendiane, Papillary muscle and to a lesser extent the right ventricle.
Left Circumflex perfuses? LA, lateral and posterior posterior portions of the interventricular septum.
Right Coronary Artery perfuses the? RA, RV, and Inferior portion of the LV.
SA Node BPM? (60-100 bpm)
AV Node BPM? (40-60 bpm)
Bundle of His? (40-60 bpm)
Purkinje Fibers? (20-40 bpm)
Systemic vascular resistance? A component of impedance; a combination of blood viscosity and arteriolar constriction.
Posture BP’s? Check BP/pulse while pt is lying supine (min 3 min). Check sitting pulse w/in 1-2 min. Have pt stand up, check BP and pulse within 1-2 minutes. Compare results.
Cause for concern in postural BP’s? A decrease of more than 20 mm Hg in systolic pressure, 10 mm Hg in diastolic pressure, as well as an increase in HR by 10-20% (10-20 beats) with any of the position changes may be indicative of dehydration or vasodilation.
ABI values? Normal Value: 1.0 or higer. <.80:Moderate Vascular Compromise. <.5:Severe Vascular Compromise.
Abnormal ABI’s? An abnormal ABI indicates vascular compromise and is can help identify peripheral vascular disease, and (more effectively in women) other CV disease such as CAD.
Where do you auscultate heart sounds (four anatomical locations)? Aortic area: 2nd ICS just right of the sternum. Pulmonic area: 2nd ICS just left of the sternum. Tricuspid area: fifth ICS at the lower left of the sternal border. Mitral area: fifth ICS at the apex of the heart/mid-clavicular line.
Systolic murmur: causes (2)? 1.aortic stenosis 2.mitral regurgitation.
Diastolic murmur: (2)? 1.mitral stenosis 2.aortic regurgitation.
Holosystolic murmur: what, causes (3)? Holosystolic murmurs begin with the first heart sound and extend to or through the second heart sound. 1.mitral regurgitation 2.tricuspid regurgitation 3.ventricular septal defect.
Friction rub: causes (3), heard in (3)?Caused by inflammation/infection/infiltration. Heard in pt’s with pericarditis resulting from MI, cardiac tamponade, or post-thoracotomy.
3 main cardiac markers? Troponin, Creatine Kinase MB, Myoglobin.
Most specific cardiac marker? Troponin
Troponin: rises in, peak, returns to normal? Rises 4-6 hrs after MI. Peaks in 12-14 hours. Returns to normal in 5-9 days.
Pt with troponin elevation but no MI on EKG will…? Still be treated aggressively.
CK-MB: specificity, rise, peak, return to normal? Most specific MI related CK test but not as specific as troponin. Rises in 3-6 hours. Peaks in 12-24 hours. Returns to normal in 3 days.
Myoglobin: specificity, rise, declines in..? Not a specific cardiac marker. Rises quickest of the 3: 2-3 hrs after injury. Declines in 7 hours.
When are cardiac markers measured? On admission, in 6 hrs, and 12 hrs after admission.
Non modifiable risk factors for CAD (3)? 1.Age 2.Heredity 3.Gender (men until age 80)
Most importat risk factor for developing CAD in women? Age
Primary factor in developing CAD? Atherosclerosis
Another major risk factor in CAD and PVD? Smoking
Non-modifiable risk factors in the development of CAD (8)? 1.Smoking 2.Obesity 3.Sedentary 4.Stress 5.Dietary habits 6.Diabetes 7.HTN 8.Hyperlipidemia
4 cigs a day = 2X the risk
20 cigs a day = 4X the risk
Ideal total cholesterol levels? <200
Ideal triglyceride levels? <150
Ideal HDL’s? >40
Ideal LDL’s? <70
Stage I HTN? 140/90 – 159/99
Stage II HTN? 160/100 – 179/109
Stage III HTN? >180/110
1st line tx for HTN? Diuretics: loop (furosemide/Lasix, Ethacrynic acid) Thiazides (HCTZ, Diuril) Potassim sparing (spironolactone,
2nd line of defense for HTN? Beta blockers.
Beta blocker action? block adrenergic impulses in the heart and peripheral vessels; lower HR (neg chronotropy), lower contractility (neg inotropy)
BB’s contraindicated in whom? Asthma/respiratory pts.
Examples of Beta Blockers? Propranolol, Atenolol, Nadolol, Metoprolol.
Adenosine: pharm class? Antiarrhymic
Uses for adenosine (2)? 1.Conversion of PSVT to sinus rhythm if vagal maneuvers do not work 2.Chemical stress test
Adenosine contraindicated in? 2nd and 3rd degree heart block
Adenosine dose? 0.5-1.0 mg with the end point being 0.04mg/kg
Albuterol classes? Adrenergic/Bronchodilator
Albuterol uses? Bronchodilator for bronchospasm
Albuterol is contraindicated in…d/t SE of…? Cardiac Dz/HTN: chest pain, palpitations, angina, arrhythmias, hypertension.
Amiodarone/Cordarone classes? ClassIII Antiarrhythmic
Amiodarone Uses? Pulseless Vtach, V Fib (when CPR and defib have failed). SVT (PO) and other lethal tachyarrhythmias.
Amiodarone contraindicated in? 2nd and 3rd deg heart block, cardiogenic shock, bradycardia.
Action of amiodarone? Inhibits adrenergic stimulation; vasodilates; slows sinus rate (prolongs QT and PR intervals).
Asprin classes? Non-opioid analgesic/salicylate
Aspirin uses? Prophalyactic tx of MI; mild to moderate pain.
Aspirin dose for suspected MI? 160mg STAT
Digoxin classes? antiarrhythmic/inotropic/digitalis glycoside
Digoxin uses? Heart failure, Atrial fibrillation/atrial flutter (slows ventricular rate), Paroxysmal atrial tachycardia.
Digoxin chronotropic and inotropic qualities? Slows heart rate (negative chronotropy), increases CO (positive inotropy).
Digoxin contraindicated in (2)? Uncontrolled ventricular arrhythmias, AV Block.
Digoxin and electrolyte imbalance? Can cause hypokalemia and hypomagnasesmia.
Hypokalemia during digoxin therapy can…? Greatly increase risk of digoxin toxicity.
Digitalizing dose? 0.5-1.0 gms given at 50% then 25% doses x2 at 6-12hr intervals.
Diltiazem: classes? Antianginal/antiarrhythmic/antihypertensives/ Calcium channel blocker.
Diltiazem antiarrhytmic use (2)? 1.SVT 2.Rapid ventricular rate of A Fib and A Flutter.
3 actions of Diltiazem? 1.Systemic vasodilation resulting in decreased BP 2.Coronary vasodilation resulting in decreased frequency and severity of attacks of angina 3.Reduction of ventricular rate in atrial fib/flutter.
Diltiazem contraindicated in (5)? 1. 2nd deg AV block 2. 3rd deg AV block 3.HypoTN 4.Recent MI 5.Pulmonary congestion
Enalapril classes? Anti-hypertensive/ACE Inhibitor
Enalapril uses (2)? Lowering of blood pressure in patients with hypertension. Increased survival and reduction of symptoms in patients with symptomatic heart failure.
SE of enalapril? 1.Cough 2.Hypotension 3.Dizziness
Heparin class? Anticoagulant/antithrombotic
Uses of Heparin (2)? Pulmonary emboli and Atrial fibrillation with embolization.
Labs to monitor in Heparin use? aPPT, Platelet count.
Isoproteronol classes? Antiarrhythmic, adrenergic, bronchodilator.
Uses of Isoproteronol (and action)? Bradycardia (positive inotropic and chronotropic effects)
Use Iso cautionsly in? HTN/CAD
Furosemide/Lasix class? Loop diuretic
Lasix uses (2)? Edema due to heart failure, Hypertension.
SE of lasix? Hypotension, electrolyte imbalances (hypokalemia among most others, dehydration, metabolic alkalosis).
Morphine class? Opioid analgesic
Morphine use? Pain associated with MI
Magnesium Sulfate use? Torsades de Pointe, hypomagnasemia, HTN.
Metoprolol classes? Beta blocker/anti-anginal/antihypertensive
Metoprolol uses? Hypertension, Angina pectoris, Prevention of MI and decreased mortality in patients with recent MI, Management of stable, symptomatic (class II or III) heart failure due to ischemic, hypertensive or cardiomyopathc origin.
Metoprolol contraindicated in (5)? Uncompensated CHF, Pulmonary edema, Cardiogenic shock, Bradycardia, heart block.
Nitroglycerin class? antianginal, nitrate
Nitro uses? Angina (acute: SL, chronic: PO, Transdermal), adjunt tx of CHF (PO)/MI(IV).
Nitro contraindicated in? pericardial tamponade, constrictive endocarditis.
4 common SE of nitro? 1.Dizziness 2.Headache 3.Tachycardia 4.HypoTN
Therapeutic uses of Nitro (3)? 1.Relief or prevention of anginal attacks 2.Increased cardiac output 3.Reduction of blood pressure
Procainamide classes? Class IA antiarrhythmic
Procainamide uses? 1. PAC 2.PVC 3.Vtach 4.PAT 5.Maintenance of normal sinus rhythm after conversion from atrial fibrillation or flutter
3 therapeutic uses of procainamide? Decreases myocardial excitability, Slows conduction velocity, May depress myocardial contractility.
Common SE of procainamide? diarrhea
Pt precautions for IV admin of procanamide? Have pt remain supine
Verapamil classes (4)? Antihypertensive, antiarrhythic, antianginal, calcium channel blocker.
Uses for verapamil (4)? Management of 1.hypertension 2.angina pectoris 3.vasospastic (Prinzmetal's) angina 4.supraventricular arrhythmias and rapid ventricular rates in atrial flutter or fibrillation.
Therapeutic uses for Verapamil (3)? 1.Systemic vasodilation resulting in decreased blood pressure 2.Coronary vasodilation resulting in decreased frequency and severity of attacks of angina 3.Reduction of ventricular rate during atrial fibrillation or flutter.
Verpamil contraindicated in (4)? 1.2nd- or 3rd-degree AV block 2.Systolic BP <90 mm Hg 3.CHF 4.Concurrent IV beta blocker therapy
Pt teaching for new Pacemaker()? 1.Rpt pulse lower than set on PM 2.Rpt any fever, redness, swelling, or drainage at insertion site 3.Keep cellular phones 6 in from generator w/ handset on ear opposite of PM 4.Avoid magnets/transmitters 5.No MRI’s 6.Medic bracelet/PM ID card
PM and pulse? Take daily at same time for 1 full minute and record rate in PM diary and any times you feel symptoms of a possible pacemaker failure.
More PM pt teaching? Avoid tight clothing/belts over PM (as well as pressure on the generator), inform other MD’s that you have a PM, do not operate electrical applicances over PM, do not lean over electrical/gas engines/motrs, be aware that antitheft devices can trigger PM.
MORE PM pt teaching? Inform airport personnel that PM will set off metal detector, stay away from arc welding equip, if you feel symptoms when near a device more 5-10 ft away and chk pulse, no sudden jerky movement for 8 weeks after PM installation.
Highest mortality rate of CAD associate with which CA? LAD (also 25% of all MI’s; perfused the aneriro wall and most of the septal wall of the LV.
Printzmetal’s angina sx (2), tx (3)? 1.Chest pain 2.Tachycardia 1.BB 2.CCB 3.Hydration
Q wave MI? More symptomatic than non Q wave MI.
Normal ejection fraction? 55-70% (problems when < 50%)
Most direct measure of CO? BP (takes VS as priority assessment)
Absolute contraindications to thrombolytics (7)? 1.Prior intracranial hemorrhage 2.Known cerebral vascular lesion 3.Known malignant intracranial neoplasm 4.Ischemic stroke w/in 3 months (except w/in 3 hours) 5.suspected aortic dissection 6.Active bleeding 7.closed head/facial trauma within 3 months
Glycoprotein inhibitors used for? continued patentcy of stents and angioplasty.
Shockable rhythms? V Fib, pulseless V Tach.
Tx for PSVT? Adenosine, Beta Blockers, Amiodarone, Cardizem.
3 regular rhythm, narrow QRS complex tachy’s? 1.Sinus Tachycardia 2.Atrial Flutter 3.PSVT
Tachy with wide QRS complex? Ventricular in origin
Tachy with narrow QRS complex? Atrial in origin
PSVT EKG characteristics (3)? 1.Reg rhythm 2.Narrow complexes 3.No visible P waves (P waves buried in T waves).
Interventions for narrow complex tachycardias (PSVT, Aflutter, Afib, Sinus Tachy)? 1.Assess ABC’s 2.O2 3.Monitor 4.IV Access 5.Vagal maneuvers 5.Adenosine 6.12-Lead EKG 7.Cadioversion
Dose of adenosine? 6-12mg
EKG characteristics for PVC’s? 1.Wide complex 2.come early 3.No p-wave 4.usually a compensantory pause
Multifocal PVC’s vs unifocal? different shapes (- and +)
Bigeminy PVC’s? A PVC every other complex (trigeminy every third)
Interventions for V Tach with a pulse? 1/Assess ABC’s 2.O2 3.Monitor 4.IV access 5.Rx: amiodarone/lidocaine (to calm the ventricular site) 6.Cardioversion
Sustained tachycardia? Longer than 30 seconds
Cardioversion used for (5)? 1.SVT 2.Atrial Tach 3.A Fib 4.A Flutter 5.V Tach w/ a pulse
How to identify V Fib? 1.Pt is unresponsive 2.No breathing, pulse, or BP 3.Disorganized pattern on EKG monitor 4.No P-Wave or QRS 5.No CO 6.Electrical and mechanical fxn’s are ineffective
% of LV muscle mass infarced during cardiogenic shock (pump failure)? >40%
ABG’s during cardiogenic shock? Mixed metabolic/respirtory acidosis, hypoxia
Rx for asytole? Epi
Rx for bradycardia? Atropine
Rx for V fib? Epi, lidocaine (shock, give meds, shock)
Causes of bradycardia? Athlete’s normal rate, excessive vagal stimulation (pain, bearing down), hypoxia, Inferior MI, Beta Blockers, CCBlockers, digitalis.
Tx bradycardia only if..? Symptomatic
Atropine doseing? 0.5-1mg; may repeat q5 min. Not to exceed a total of 2mg, or 0.04mg/kg,
Interventions for bradycardia (4)? 1.Atropine 2.Tx HypoTN w/ fluid or vasopressors (vasopressin, norepi/levophed, epi) 3.Withold bradycardic meds 4.Pacemaker
Interventions for PAC’s? 1.Rx quinidine, procainamide, propranolol, digoxin 2.Avoid stress 3.No cafeeine 4.observe for more serios arrhythmia
What’s harder to convert a fib or flutter? Flutter
Which has more hemodynamic consequences: a fib or a flutter? A fib.
Rx for a flutter? Digoxin, Calcium channel blockers (verapamil, diltiazem, -dipine), Ibutalide.
Problem with atrial fibrillation? No atrial contractions, atrial kick is lost.
Conrolled a fib vs uncontrolled? Controlled: normal range of ventricular beats (60-100).
Interventions for A fib? 1.Rx: heparin/enoxaprin, CCBlockers, digoxin, quinidine 2.Cardioversion 3.Ablation
Main characteristic of 1st degree AV block? PR interval of 0.20 or greater
Difference between Mobitz I (winkeback) and Mobitz II? In mobitz I the PR interval is progressively lengthened until a beat is dropped. In Mobitz II the PR remains constant (when it appears).
Characteristics of junctional rhythms (2)? 1.HR of 40-60 bpm w/ reg rhythm 2.Absent P wave
Causes of junctional rhythms (5)? 1.Sick sinus syndrome 2.Vagal stimulation 3.Digitalis toxicity 4.Inferior infarction 5.Rheumatic heart disease
What measurement can indicate mitral regurgitation? PAWP
Interventions for Junctional rhythm (5)? 1.Correct underlying cause 2.Tx symptomatic pts 3.Improve CO 4.Atropine 5.PM
Characteristics of an Idioventricular rhythm? 1.Regular rate of 20 to 40 bpm 2.Very wide QRS complex
5 causes of an idioventricular rhythm? 1.Myocardial ischemia 2.Myocardial infarction 3.Digitalis toxicity 4.Pacemaker failure 5.Metabolic imbalances
Tx for an idioventricular rhythm? Transcutaneous Pacing
Atrial kick accounts for how much % of ejection fractions? 30%
Three things to note on a paced rhythm? 1.Note the spike prior to QRS 2.Note what percentages are paced 3.Note wide QRS complexes
What is happening during PEA? Electrical conduction system is intact but mechanical pumping of the heart is not.
Tx for PEA? PEA: Problem-search for probable cause, Epi-1mg q 3-5 min, Atropine-if rate is slow up to 0.04 mg/kg
PATCH MD mneumonic for causes of PEA? Pulmonary embolus, Acidosis, Tension pneumothorax, Cardiac Tamponade, H(4) (Hypovolemia, Hyperkalemia, Hypothermia, Hypoxia), Massive MI, Drug overdose
Interventrions for PEA (7)? 1.Establish responsiveness 2.Assess ABC’s 3.Initiate CPR 4.Ensure IV access 5.Intubate 6.Underlying problem intervention 7.Drugs
Asystole: shockable? No
Interventrion s for asystole? 1.Chk in another lead 2.Transcutaneous pacing 3.Epi 4.Atropine (use meds to get a shockable rhythm).
Causes of Asystole (7)? 1.Acute MI 2.Severe electrolyte disturbances 3.Massive pulmonary emboli 4.Prolonged hypoxemia 5.Severe Acid-base disturbances 6.Electrical shock 7.Drug OD
8 interventions for Asystole? 1.Establish unresponsiveness 2.Assess ABCs 3.Initiate CPR 4.IV access 5.Intubation 6.Chk another lead 7.Transcutaneous pacing 8.Drugs
What is an aortic aneuresym? dilation or outpouching of the aorta.
Superior AA =? thoracic AA
Inferior AA? =? Abdominal AA (more common)
Risk factors for AA(8)? 1.Male 2.Adv age 3.HTN 4.Smoker 5.Connective tissue disorders 6.Diabetes 7.Trauma 8.Atherosclerosis
Sx of AA (3)? (most are asyptomatic until rupture is imminent) 1.Steady/gnawing pain of the abd, flank/back pain 2.Pulsation in the upper abd slightly left of the midline between xiphoid process and umbilicus 3.can auscultate a bruit
Sx of thoracic aortic dissection/rupture (7)? 1.Back pain 2.SOB/hoarseness 3.Sudden excruciating back pain 4.Neuro chgs 5.JVD 6.New murmur 7.Hypovolemic/hemorrhagic shock
Post op care for an AA (7)? 1.Assess for bleeding 2.Keep BP in normotensive range 3.Assess urine output 4.Monitor CO 5.Doppler of all extremities 6.Meticulous pulmonary hygiene
Risk factors for Arterial Occlusive Dz (7)? 1.Male 2.Smoking 3.Aging 4.HTN 5.Hyperlipidemia 6.Diabetes 7.Family Hx
Sx of acute occlusion (5)? Pain, Pallor, Pulseless, Paresthesia, Paralysis
Interventions for Arterial Occlusive Dz (6)? 1.Restore circulation 2.Embolectomy 3.Graft 4.Bypass graft 5.Balloon angioplasty 6.Stents
Created by: wvc 2