CARDIO PACKET 4 TX Flashcards
Cardiogenic shock/hypovolemic shock
Based on prompt diagnosis and accurate appraisal of inciting conditions
Initial management
• Basic life support: _____, _______, airways
• Main entail airway _______ and mechanical ventilation
• Ventilatory failure should be anticipated in patients with severe _______
• Unresponsive or minimally responsive patients should have glucose checked
o Low glucose; 1 ampule of 50% dextrose IV
• IV access and fluid resuscitation
• Cardiac monitoring and assessment of hemodynamic parameters such as blood pressure and heart rate
• Arterial line for continuous blood pressure measurement
• Foley catheter for urine output measurements
• Cardiac monitoring can detect myocardial ischemia or malignant arrhythmias
o Treated by ACLS protocols
Central Venous Pressure
• Consideration of placement of a central venous catheter for infusion of ____ and medications and for hemodynamic pressure measurements
• CVP greater than __ mm Hg suggests volume overload, cardiac failure, tamponade, or pulmonary hypertension
• May place Pulmonary artery catheters to measure the pulmonary artery pressure
• A CVP of less than _ mm Hg suggests hypovolemia
• Treatment is directed at maintaining a DVP of 8-12 mm Hg, a mean arterial pressure of 65 mm Hg or higher a cardiac index of 2-4 L/min/m2 and a ScvO2 greater than 70%
Volume Replacement
• Initial management of shock
• Hemorrhagic shock is treated with immediate efforts to achieve hemostasis and rapid infusions of blood substitutes such as type specific or type O negative packed red blood cells (PRBCs) or whole blood
• Hypovolemic Shock secondary to dehydration is managed with rapid boluses of _______ (0.9% saline or lactated Ringer solution) usually in 1 liter increments
• Cardiogenic Shock requires_____ fluid challenges usually in increments of 250 ml
Early Goal directed therapy
• Early treatment before the development of organ failure results in improved survival and patients who respond well to initial efforts demonstrate a survival advantage over nonresponders.
Medications
• After adequate fluid resuscitation
• Choice of vasoactive therapy depends on the presumed etiology of shock as well as cardiac output Continued hypotension with evidence of high cardiac output after adequate volume resuscitations
o Vasopressor support is needed to improve vasomotor tone
• Evidence of low cardiac output with high filling pressures
• Inotropic support is needed to improve contractility
Vasodilatory shock
• Vasoconstriction is needed to maintain adequate perfusion pressure
• Alpha adrenergic catecholamine agonists are generally used
• Norepinephrine is both alpha adrenergic and beta adrenergic agonist
o Preferentially increases mean arterial pressure over CO
o Initial dose 1-2 mcg/min as IV infusion titrated to maintain the mean arterial blood pressure at 65 mm Hg or higher; maintenance dose is 2-4 mcg/min IV
• Epinephrine
o Used in refractory shock
o Severe shock and during acute resuscitation
o 1 mcg/min as continuous IV infusion and titrated to hemodynamic response
Vasoactive therapy:
• Dopamine
Cardiogenic Shock
• Insufficient evidence to recommend a specific vasopressor to use in cardiogenic shock
• Expert opinion suggests that either _______ or _______ be used as a first line agent
o Dobutamine is predominantly a beta-adrenergic agonist, and increases contractility and decreases afterload
o Used for patients with low cardiac output and high PCWP (pulmonary capillary wedge pressure)
o Or if there are signs of hypoperfusion despite adequate volume resuscitation and adequate mean arterial pressure
o Initial dose is .1-.5 mcg/kg/min as continuous IV infusion and titrated to hemodynamic effect
o Tachyphylaxis (acute and sudden decrease in response) can occur after 48 hours secondary to the down regulation of beta adrenergic receptors
o Amrinone and milrinone are phosphodiesterase inhibitors
Can be substituted for dobutamine
Vasodilation is a side effect
circulation, breathing
intubation
metabolic acidosis
fluids
18
5
isotonic crystalloid
smaller
norepinephrine, dopamine
aortic aneurysms
AAA:
Surgical repair is indicated for AAA >___ cm in diameter or any size AAA with rapid growth
Elective repair:
• AAAs > 5.5 cm in diameter or rapid expansion (> .5 cm in 6 months)
• Symptoms of pain and tenderness indicate impending rupture: ____ repair
Thoracic aortic aneurysm
• >_cm: consider repair
• Descending thoracic aorta: often endovascular grafting
• Proximal aortic arch or ascending aorta: difficult; open procedure
• 4-10% rate of paraplegia following repair of thoracic aneurysm endovascularly
5.5
urgent
6
aortic dissection
Medical
• Aggressive measures to lower__ immediately
• Bring down to 100-120 systolic
• First line therapy: _______ IV (labetolol) or esmolol
• Nitroprusside IV is used in patients where Beta blockade does not adequately bring down BP
• Goal heart rate: 60-70 bpm
Surgical:
• Urgent surgical intervention is required for all Type _ dissections
• Transfer facilities if necessary
• Type _: early thoracic stent repair
• Untreated Type A’s: 90% mortality at 3 months
• Uncomplicated Type B’s: with BP control may have long term survival without surgery: aneurysms develop: need yearly CT scans
BP
beta blockers
A
B
lymphedema
- Due to the progressive nature, very difficult to treat!
- Treat any ______ causes
- Refer to specialty wound care center if possible
- _______ legs as much as possible
- Graduated elastic ________ stockings or lymphedema wraps
- Pneumatic pressure devices
- Meticulous skin care to avoid cellulitis
- Once infection starts, treat with abx to cover Staph and Strep (______ 500 mg QID x 7-10 days)
underlying
elevate
compression
Cephalexin
lymphagitis
- Heat to affected area
- Elevation
- Immobilization
- Analagesia
- Antibiotic therapy to cover Staph and Strep infections
- _______ 500 mg QID x 7-10 days
- ______ 750 mg BID x 7-10 days
- If MRSA suspected use Bactrim (TMP-SX) 2 tabs DS BID x 7-10 days
- Meticulous wound care to the site of bacterial entry
- May need debridement
- Prognosis – with prompt and appropriate care infection generally resolves quickly. Delays in care can result in tissue loss, sepsis
- All patients with lymphangitis should be admitted to hospital to start abx and monitor responsiveness to therapy
cephalexin
augmentin
acute arterial occlusion
the 5 P’s
- _______: constant and aggravated by movement
- _____: occurs initally, followed by cyanosis
- __________: with cold limb
- _______: caused by anoxia to peripheral nerves
- ______: necrosis of muscles
• Time critical factor • Consult vascular surgery!! • Unless that is a contraindication, immediate anticoagulation with heparin should be started to prevent further propagation of the clot o \_\_\_\_\_\_: IV bolus 5,000- 10,000 U o 1000 U/h to 1500 U/h o •TT: 1.5-2 times normal range
- Patient remains heparinized until etiology established
- If cardiac emboli the source: long term management with oral anticoagulants (warfarin) needed.
- Will still need operative intervention
- Endovascular
- Surgical intervention
pain pallor pulselessness parathesias paralysis
heparin
superficial venous thrombophlebitis
• Mainly symptomatic tx o Analgesics o Warm compresses • If septic thrombophlebitis o Remove any \_\_\_\_\_\_ o IV antibiotics (vancomycin PLUS ceftriaxone)
lines/catheters
DVT
• Anticoagulant: first line
o LMWH, ______
• _____: for recurrent DVT/PE despite adequate anticoagulation or stable patients in whom anticoagulation is contraindicated
warfarin
IVC filter
varicose veins
• Non-surgical management – elastic graduated ______ stockings
• Stockings worn daily
• Elevate legs at night
• Sclerotherapy – sclerosing agent injected into the veins
• Induces fibrosis and obliteration into the target vein
Surgical
• ________ (laser or radiofrequency)
• Vein stripping
compression
thermal ablation
chronic arterial insufficiency
PAD treatment 1: • Cardiovascular risk factor reduction • Smoking cessation • Lipid and blood pressure management • Weight loss • Antiplatelet therapy 2: structured exercise program
• All symptomatic patients should be on antiplatelet agent
o ______ 81 mg daily
• High dose statin – ________(Lipitor) 80 mg daily
• Trial of Cilostazol (Pletal) 100 mg BID improves walking distance in patients with disabling claudication
• A program of daily walking to point of claudication followed by rest period should be repeated several times daily
o Enhances development of collateral circulation and improves circulation
o Patients should try to “walk through their claudication” a little more each day
Other treatments:
• Vascular reconstruction or angioplasty and stenting : indicated for patients with debilitating claudication, rest pain or evidence of severe occlusion
• Arterial grafts (prosthetic or saphenous vein) used to bypass occluded vessel
aspirin
atorvastatin
buerger disease
- Stop ________!!
- Usually halts the disease
- Since the distal arterial tree is occluded, patient cannot be revascularized
- If patient will not stop smoking, ______ of both upper and lower extremities is the eventual outcome
smoking
amputation
giant cell arteritis
_______ 60 mg qd x one month
•After one month, trial of steroid tape
•Monitor ESR and patient sxs on steroid taper
prednisone