Cardiac Flashcards
What eligibility criteria is required to diagnose a STEMI?
ST elevation in 2 or more contiguous leads or new LBBB
chest pain onset <12hrs
Chest pain 30 minutes in duration
Chest pain unresponsive to SL NTG
What patient care management is required if your patient s/p PCI has a vasovagal reaction?
Give fluids and atropine
(Hypotension <90 SBP w/ or w/o bradycardia, absence of compensatory tachycardia)
Associated symptoms pallor, nausea, yawning, diaphoresis
What are absoltue contraindications for fibrinolytic therapy in a treatment of STEMI?
- Prior intracranial hemorrhage
- known structural cerebrovascular lesion
- Malignant intracranial neoplasm
- ischemic stroke within 3 months except ischemic stroke within 3 hours
- Suspected aortic dissection
- active bleeding
- Significant closed head trauma within 3 months
True or false
Marked elevation of troponin and CK-MB are evidence of reperfusion s/p PCI?
True
This is due to myocardial stunning when the vessels open
What are potential arrhythmias s/p reperfusion of a PCI and why?
VT, VF, accelerated idioventricular rhythm
Because of myocardial stunning when the vessel opens
If a patient who is experiencing a NSTEMI and is considered high risk and showing signs of instability, what type of medication would you start and what procedure would your prepare for?
GP IIb/IIIa inhibitors (Intergrillin, Reopro)
Prepare for a diagnostic cardiac cath within 24 hours
What are some common arrythmias seen with an MI and how would you treat them?
- VF or VT
- Defibrillate VF
- drug therapy for stable sustained VT and to prevent recurrent VF
- synchcronized cardioversion for unstable sustained VT
- A. Fib
- Bradycardia
- Heartbroken, sick sinus syndrome
What are complications of a PCI?
- Stent thrombosis ( most incidents occur within 24hrs or subacutely within the first 30 days)
- retroperitoneal bleed (Grey Turner’s sign)
During a sheath removal your patient experiences a vasovagal response, what nursing management interventions are required?
- Hold nitrates
- Atropine 0.5mg IV, even in the absence of bradycardia
- IV fluid bolus of 250ml if patient does not respond to atropine
- Assess of pain/anxiety as contributing factors
What is the difference between a hypertensive crisis and a hypertensive urgency?
A crisis/emergency is an elevated BP with evidence of end organ damage (brain, heart, kidney, retina) and needs critical care admission
An urgency is an elevated BP without evidence of end organ damage
What is the treatment for a hypertensive crisis and what is the greatest risk for this patient?
- Nitroprusside ( preload and afterword reducer)
Watch out for cyanide toxicity- s/s change in LOC, tachycardia, seizures, unexplained metabolic acidosis - Labetolol
Max dose 300mg
Duration of effect persists for 4-6hrs after discontinuation of med
GREATEST RISK IS STROKE!!
What are the 6 P’s of peripheral arterial disease?
- Pain
- Pallor
- Pluse absent or diminished
- Parasthesia
- Paralysis
- Polkiothermia ( loss of hair on extremities and glossy cool dry skin)
What is the normal range for an ankle brachial index?
Normal >0.90
True or false
When taking care of a PAD pt, it is important to place them in trendelenburg or to elevate the extremities.
False
Place them in reverse trendelenburg. Do not elevate the extremities because it decreases the perfusion
What is the gold standard for diagnosing a patient with carotid arterial disease and what are potential treatments?
Angiography
Carotid endartectomy
Carotid stenting
Aspirin
Statin therapy
What should you monitor for after a carotid stenting or carotid endarterectomy?
- change in LOC
- change in BP ( hyper or hypotension)
Hypoperfusion syndrome with signs of a headache ipsilateral to the revascularized carotid artery, focal motor sz, and/or intracerebral hemorrhage
-bleeding
-loss of airway
A patient with WPW complains of dizziness, chest pain, SOB, and syncope. The ECG on the monitor illustrates supraventricular tachycardia and a BP of 72/30. What nursing interventions should you prepare for?
For unstable SVT: perform synchronized cardioversion or administer adenosine (6mg IVP first dose, 12mg second dose)
Which pacemaker paces both the atria and the ventricles, senses both the atria and the ventricles and can inhibit and trigger in response to sensing?
DDD
Which pacemaker paces the ventricles, sense the atria and inhibits pacing in response to sensing?
VAI
B-type natriuretic peptide (BNP) is released when and causes what?
It’s released when the ventricle wall is under stress and attempts to dilate and decrease the ventricles pressure
What are signs of systolic heart failure and what type of cardiomyopathies can it lead to?
Signs: EF less than or equal to 40% Pulmonary edema d/t poor ventricular emptying Dilated left ventricle Valvular insuffiency S3 heart sound
This can lead cardiomyopathies that result in systolic HF (Dilated). An example of this is Takotsubo Cardiomyopathy, which is also known as Broken Heart Syndrome
What types of medications are contraindicated for systolic heart failure?
Negative inotropes ( calcium channel blockers and in acute phase beta blockers)
What are signs of diastolic heart failure and what cardiomyopathues can they lead to?
Signs:
S4 heart sounds with HTN
Normal EF
Thick ventricular wall and/or thick septum
They can lead to hypertrophic cardiomyopathy, restrictive, idiopathic hypertrophic subaortic stenosis (IHSS)
What medications and situations are contraindicated for diastolic HF?
Positive inotropes
Dehydration
Tachyarrhythmias decreasing filling time
What are causes of right sided HF?
- RV infarction
- massive PE
- septal defect
- pulmonary stenosis or regurg
- COPD
- pulmonary HTN
- LV failure
What are causes of left sided HF?
- coronary artery disease, ischemia
- MI
- cardiomyopathy
- Fluid overload
- Chronic, uncontrolled HTN
- aortic stenosis/regurg
- mitral stenosis or regurg
- cardisc tamponade
Signs of right sided HF?
Hepato and splenomegaly Dependent edema Venous distention Elevated JVD/CVP Tricuspid insufficiency Abdominal pain
Signs of left sided HF?
Orthopnea, dyspnea, tachyon Hypoxemia Tachycardia Crackles Cough with pink frothy sputum Elevated PAOP/PA diastolic Diaphoresis Anxiety or confusion
During the compensatory stage of cardiogenic shock, what is your pulse pressure like ( narrow or wide) and why?
Narrow
Because your cardiac output and stroke volume decrease secondary to systolic dysfunction thus dropping your SBP.
And in order to maintain a normal blood pressure vasoconstrictive compensatory mechanisms occur thus elevating the SVR.
DBP is an indirect measurement of the SVR.
In the progressive stage of shock, how would your patient present clinically?
Hypotension Worsening tachycardia, tachypnea Worsening crackles and hypoxemia Oliguria Metabolic acidosis Skin is clammy and mottled
What is cardiogenic shock?
When compensatory mechanisms fail to maintain the cardiac output and the most extreme end of the continuum is cardiogenic shock.
What is the treatment for cardiogenic shock?
Identifying and treating the cause.
Manage arrhythmias that may contributing to a decrease in cardiac output
Reperfusion if STEMI
Emergent surgery if mechanical problem (ie- ruptured papillary muscle or VSD)
***Enhance effectiveness of the pump: (+inotropes dopamine, dopamine, milrinone) levo, vasodilators may be used in conjunction with IABP therapy if patient is in progressive stage with hypotension
***decrease demand on pump: preload and afterword reducers, optimize O2, treat pain, IABP for short term therapy, ventricular assist device for longer period of time
IABP therapy is used for management of left ventricular HF, cardiogenic shock, and cardiomypopathies. What is the benefit of this therapy?
Increases coronary artery perfusion and decreases afterload
Post op complications of a CABG include tamponade, pericarditis, and CT management. The only times it is indicated to clamp the CT are when:
Changing the drainage system
There is a system disconnect.
*if there is >100ml for 2 consecutive hours it requires intervention
Transcatheter aortic valve replacement (TVAR) is ideal for those with severe aortic valve disease that are considered high risk for open surgery.
What are complications of this procedure?
Vascular complications associated with femoral access ( similar to PCI - hematoma, retroperitoneal bleeding, arterial occlusion) heart block, AKI, paravalvular regurgitation
What are some signs and symptoms of cardiac tamponade?
Elevated JVD
Equalization of the CVP, PAOP, Pulmonary artery diastolic pressure
**Narrowed pulse pressure
***pulsus paradoxus ( excessive drop in SBP, greater than 12 mmhg, during inspiration)
What are some difference between myocardial contusions and pericarditis?
Pericarditis:
S/S- ST elevation in all leads, cardiac tamponade, post MI, Dressler’s syndrome
Etiology- viral, after MI, post cardiac surgery radiation, Dressler’s syndrome
Myocardial contusions:
Etiology- trauma
Abdominal aortic aneurysms are 75% of all CV related aneurysms, whereas THORACIC are 25%. What are s/s of thoracic aortic aneurysms?
Sudden tearing or ripping of chest that radiates to shoulder, neck and back
Dysphagia
Dyspnea
Dizziness, difficulty walking and speaking
Widening of the mediastinum on CXR
What is the treatment for aneurysms?
<5cm produce no symptoms
- monitor and tx HTN with beta blockers
- people with Marfan syndrome treat sooner
> 6cm of thoracic aortic aneurysms that cause symptoms
- surgery
- dissection - surgery
- aggresive treatment of HTN and HR control- labetolol drip
