Cardio-Thoracic Surgery Flashcards
which cholesterol is most indicative of coronary disease
LDL - low density lipo-protein
***what level do I want my LDL
low - under 100
***What level do I want my HDL
high - over 50 - increase with exercise
what is first ordered (within 24 hrs) for cardiac patients
full cholesterol panel
what happens in coronary artery disease
lipids build up in intima lining causing the vessel to get bigger so lumen stays the same, eventually lipids take over obstructing blood flow
at rest lumen is okay
with activity plaques release
how long does it take for plaques to develop
develop over time - collateral’s form
what does pt look like when vessel occludes
chest pain - hopefully calls 911
rapid respiration’s - SOB - decreased perfusion (body not getting enough oxygen, stimulates sympathetic nervous system)
when do we realize we have coronary artery disease
when more than 70% of vessel diameter is decreased
1st trt for suspected coronary artery disease
aspirin - chewable baby aspirin 325mg
what does aspirin do
prevents platelets from sticking together
when pt gets to ER what do we give to make the vessel wall bigger, initially
vasodilator - nitroglycerin under the tongue
oxygen - give 2L
if pt is having an MI what will the EKG show
ST changes
**how long do we have to trt pt with EKG changes (MI)
90 minutes - to get to cath lab and open up blood vessels
what population are we most worried about having an MI
young men - don’t think they’re having an MI - don’t have collateral circulation - die at home
women - don’t have same presentation - blow them off - die at home
men>45
women>55
why do we make a distinction for women >55 being at risk for MI
estrogen depletion - heart protecting
risk for promoting growth of breast cancer if given
risk fxrs for heart disease (MI)
family hx, diabetes, peripheral arterial disease, family hx of stroke
- smoking
- HTN - increases after-load (resistance of the blood vessel)
***total cholesterol should be under
200
***triglycerides should be under
150
why are HDL’s important
carry bad stuff back to liver
what do LDL’s do
go into intima lining and narrow blood vessels
tell me about smoking r/t the heart (3 facts)
stimulant - makes heart beat harder and faster
potent vasoconstricter - damaged for life**
changes oxygenation
what is a BNP
how much stretch is on the heart
in heart failure levels go up
normal BNP that indicates Heart Failure is
400
dx studies for suspected MI
EKG (ST elevation)
holter monitor (worn for days at home with diary)
stress test (goal HR 140-150) exercise or medication
cardiac cath
echo (u/s) tells ejection fraction (how much blood is pumped with each beat 65-70%)
trans-esophageal echo (requires sedation)
ElectroPhysiology study (cath which stimulates funky rhythm)
***most dx test for an MI
**cardiac cath
visualize blood vessels to see damage
not an intervention, diagnostic - doesn’t treat
venous vs arterial catheters in cardiac cath procedure
venous catheter - views pressures in heart - system that carries blood back to heart is the only one that allows me in to the heart - great iv for fluids
arterial catheter - goes to coronary artery - hooked to pressure bags to measure BP during procedure
prep for cardiac cath procedure
NPO from midnight
baseline HR, Vitals, electrolytes
consent (incl. OR backup)
20 or 18G IV in place
if diabetic what medication must you be off before having cardiac cath procedure
metformin - interaction w/dye has potential to shut down kidneys its permanent - at least 24 hrs before and 48 hrs after procedure
post cath please check
peripheral pulses - if no call Dr** groin (pressure system) flush with fluids - if not urinating may have shut down kidneys with the dye bed-rest for 6 hours, bed is flat immobilize leg monitor for bleeding/bruising
what medication may be given to diabetics to protect kidneys in cardiac cath procedure
mucomyst - given 24 hrs before and 48 hrs after procedure - protects kidneys
in an MI there is a discrepancy in the
oxygen i need vs what i have (supply and demand)
causes of MI
atherosclerosis
emboli
blunt trauma
spasm
types of MI
Q wave (at least 1/2 of the size of QRS) non Q wave
acute MI s/s
chest pain (can be severe) elephant on chest (can't get a deep breath) pale/diaphoretic dyspnea/tachypnea syncope (dizzy) n/v dysrhythmias
2 most common dysrhythmias of an MI
A Fib
PVC’s
dx of MI
12 lead EKG
cardiac enzymes
can an injury on an EKG be fixed
yes (fireman’s hat)
what cardiac enzymes do we screen for
CPK - can take 8 hrs to show damage
**troponin levels (standard) rise more quickly than CPK
goal of mgmt for acute MI
improve cardiac output/perfusion (oxygen demand/supply problem)
***pain relief (nitroglycerin sub-lingual)
check for dysrhythmia
slowly increase activity
relieve anxiety
place pt. on beta blockers/ace inhibitors
what do we check after giving sub-lingual nitro
blood pressure (potent vasodilator) low BP = High HR
what does an ace inhibitor do
prevent ventricular remodeling
what is TPA
a potent clot buster - no labs for 48hrs
what does heparin do
blood moves more smoothly around blockages
when must TPA be administered within
a 6 hour window from onset of pain
what must be in place before administering TPA
2 IV lines
who can’t have TPA
recent surgical procedure
what is the same procedure as a cardiac cath but in addition fixes where the blockage is
interventional angioplasty
will be on anti-coagulation therapy after the procedure
**who would get open heart (indications)
left main coronary occlusion >50% triple vessel disease unstable angina pectoris left ventricular failure lesions not amenable to PTCA PTCA failure chronic stable angina that is refractory to other therapies
process during traditional CABG
traditional incision - saw open sternum - open chest 2 catheters into heart (R/L) cool body to slow HR hook-up to coronary artery bypass (machine) reanastomos vessel (internal mammary) re-warm body defibrillator chest tubes pacer wires close incision
preparing for CABG
NPO before midnight extensive teaching (ventilator after surgery, weaned in 12 hrs) wires/tubes hooked up when returns within 12 hours out of bed walking within 24 hrs
goals post CABG
increase blood flow
watch/sternal and leg wound
relieve symptoms
what meds must a pt be off of prior to CABG
diuretics (few days prior)
aspirin (1 week)
anticoagulants (coumadin)
process of MID-CAB surgery
small incision
fix vessel while your own heart is still beating
much less invasive
must be certain blood vessels to do it
what does MID-CAB stand for
minimally invasive direct coronary artery bypass surgery
immediate (24hr) post-op care after CABG
monitor for hypo/hypertension - want normotensive
assess for dehydration - freq 0.5ml/kg/hr
rewarm pt during 1st 24hrs
wean from ventilator
watch wounds
pain relief
emotional support
increase activity
cough and deep breath w/hug me pillow (incentive spirometer)
***most common complication of CABG
dysrhythmias - A FIB most common
complications of CABG
dehydration - hypovolemia tamponade resp insufficiency renal impairment gi dysfunction impaired circulation infection dysrhythmia pain emboli death
sinus Brady
HR less than 60, everything else is normal
sinus tachy
HR above 100
what can make your HR go down (brady)
sleep
beta blockers
exercise
care for pt with Brady
give fluids
try atropine
may need pacer
what can make your HR go up
exercise fight or flight/stress low BP decreased cardiac output dehydration fever
care for pt with Tachy
**treat the cause
give fluids
possible beta blocker if nothing else has worked
SVT
HR over 150
difference between sinus tach and SVT
a narrow QRS complex
care for SVT
vagal maneuvers
try adenisine 6-12-12
if nothing works do cardio-version
how is adenisine given
6-12-12
what is cardio-version
slight sedation
synchronize to QRS - charge machine - defibrillation 50-100 jewels on the QRS
difference between cardio-version and defibrillation
cardio-version pt is awake - synchronize R waves - less jewels - controlled
***trt for v-tach
if awake/BP - cardio-vert
if not awake/no BP - defibrillator
trt for v-fib
give epi
defibrillator
trt for a-fib
anticoagulation - blood pools
a-flutter
saw-tooth waves
PVC’s (premature ventricular contraction)
a heart flutter - extra beat
first thing you should think of with a PVC
oxygenation and electrolytes
1st degree heart block
prolonged pr interval
2nd degree heart block
dropping QRS’s
what does QRS mean
perfusion
2nd degree mobitz II
PR gets long stays long and drop a beat
2nd degree wenkebach
pr gets longer
3rd degree heart block
p and qrs are not in sync, doing their own thing
treatment for 3rd degree heart block
pacer
who gets an implantable defibrillator
pt w/ejection fraction
pt with balloon pump - care
anti-coagulation
watch wave form to ensure placement of balloon
strict bed-rest with frequent turning
log rolled for turning
peripheral pulses every 30 minutes
experiences decreased pain increased output
monitor for bleeding
