Cardiovascular system part 2

Question 1

Cardiac Evaluation- How well is this patients heart working?

Answer 1

-Past medical history
-general medical health
-physical evaluation
-ECG
-Type of sx planned

Question 2

Role of Medical Consultant- Good communication essential

Answer 2

-Medical clearance prior to sx
-Review available patient data, history, and his/her examination
-Communicate severity and stability of the patients cardiovascular status- and vet clearance in writing / faxed
-determine if patient is in optimal medical condition, given context of surgical illness

Question 3

Diseases of the cardiovascular system

Answer 3

“Cardio”
-Angina (chest pain)
-Myocardial infarction (MI- heart attack)
-Congestive heart failure (CHF)
-Valve damage
-cardiac dysrhythmias

“Vascular”
-Hypertension (high BP)
-Low BP
-cerebrovascular accident (CVA- Stroke)

Question 4

What parts of “cardio” leads to what diseases (plumbing pump circuitry)

Answer 4

• The Plumbing: Diseases of the coronary arteries leads to angina pectoris
• The pump: Diseases of the myocardium and valves leads to congestive heart failure (CHF) and valve damage and malfunction
• The Circuitry: Diseases of the conducting system leads to irregular heart beats- dysrhythmias

Question 5

Cardiac diseases- Ischemic heart disease

Answer 5

-Definition: Ischemia is a restriction in blood supply, generally due to partial or complete occlusion of the blood vessels, with resultant damage or dysfunction of tissue.
-Insufficient blood flow to heart muscle from narrowing of coronary artery may cause chest pain, narrowing caused by plaque in coronary artery

Question 6

Classification of Ischemic Heart disease usually results in __ and this encompasses ___ and ___.

Answer 6

classification of ischemic heart disease usually results in acute coronary syndrome and this encompasses angina pectoris and myocardial infarction

Question 7

Acute coronary syndrome sequence of disease

Answer 7

-early plaque begins. plaque is made up of fat cholesterol calcium and other substances found in blood
-significant plaque begins to partially occlude arteries walls. when plaque partially occludes blood flow to muscle result is angina
-thrombus- plaque beginning to rupture. Plaque can crack off which causes blood clot
-Infarction- thrombus totally occludes coronary artery blocking blood flow
-results in death/necrosis of muscle/results in heart attack (MI)

Question 8

Angina pectoris definition

Answer 8

Definition: A primary symptom of coronary heart disease which occurs when myocardial oxygen demand exceeds supply.

-chest pain that occurs in coronary heart disease caused by inadequate oxygenation of cardiac muscle

Question 9

Angina pectoris

Answer 9

-crushing substernal pain (under sternum/middle chest)
-pain radiating to jaw, arm, back
-caused by ischemia (lack of blood supply to heart)
-if ischemia is relieved and blood supply is restored, angina should resolve

Question 10

angina - pathophysiology

Answer 10

-starts in coronary arteries by build up of plaque
-available space for blood to flow is narrowed

Question 11

angina pectoris- diagnosis

Answer 11

diagnosis- history
-when was the last attack?
-how frequently do the attacks occur?
-what exercise level leads to the attacks?
-angina pectoris associated with pain during g exertion

Question 12

Acute coronary syndrome - treatment

Answer 12

-early plaque + significant plaque= angina
-tx is focused on restoring oxygen to heart muscle remember MONA
-Morphine is given to relive pain
-Oxygen is given to minimize O2 delivered
-Nitroglycerin is a med that dilates arteries to increase blood flow to heart
-Aspirin is given to thin blood

Question 13

Angina pectoris - treatment

Answer 13

If Angina occurred during intraoperatory treatment would be to
-terminate surgery
-suction, pack surgical site
-100% O2 by mask
-semi recumbent positio.
-loosen clothing
-nitroglycerin sublingually (tablet or spray)
-monitors (BP, HR, EKG, Pulse Ox)
-Nitroglycerin 2nd and 3rd dose q 5 min prn
- If no relief after 3rd dose assume MI and call 911

Question 14

Myocardial Infarction - the second component of the acute coronary syndrome

Answer 14

Definition: Necrosis or death of heart muscle precipitated by decreased oxygenation from partial or complete blockage of blood flow in the coronary arteries

• Area of infarction with death of the myocardial tissue

Question 15

Myocardial infarction signs and symptoms

Answer 15

-crushing chest pain not relieved by nitroglycerin
-pain radiating to the arm shoulder or jaw
-sweating, pallor (pale)

Question 16

Myocardial Infarction vs angina

Answer 16

Heart attack vs coronary

MI is irreversible with cell death
Angina is an injury

Angina is deprived of oxygen- injured but reversible event. restoration of blood flow and oxygen will resolve pain.

Question 17

Radiation of chest pain in myocardial infarction (MI)

Answer 17

Just as in angina..
-pain may radiate to jaw, shoulder, arm
-jaw pain my be mistaken for tooth pain

Question 18

Myocardial infarction- diagnosis

Answer 18

-weakness, anxiety, and feeling of impending doom
-crushing chest pain but no response to NTG
-Cardiac dysrhythmias
-Hypotension
-systemic symptoms: nausea/vomiting, pallor (pale), Diaphoresis (sweaty)

Question 19

Thrombus

Answer 19

-partially restricted blood flow due to plaque in arterial wall
-if plaque ruptures then thrombus forms and may grow and occlude the vessel, thrombus detaches causing embolism obstructing blood flow through artery
-supply of blood obstructed=MI cells ischemic resulting in damage to heart muscle
-Coronary arteries supply constantly alive heart muscle with blood
-MI symptoms: short breath, tightness in chest, intense prolongs chest pain, nausea, fainting, sweating, pain in left shoulder arm jaw and back

Question 20

Myocardial infarction is induced by and caused by what

Answer 20

-induced by exercise, emotion, heavy meal, stress, surgery
-caused by inadequate coronary circulation leading to permanent muscle damage

Question 21

Medications used to manage ischemic heart disease

Answer 21

-Remember sympathetic nervous system
-Beta blockers- decrease myocardial oxygen requirements (atenolol, lopressor) lowers blood pressure and heart rate

-Nitrates- vasodilation (nitroglycerin) side effect of a headache

-calcium channel blockers- reduction in cardiac contractility (Adalat, procardia)

-Aspirin- reduction of clumping of blood platelets which can lead to clot formation

-Lipid-lowering drugs- reduce plaque formation (lipitor)

Question 22

Treatment considerations for patients with a history of Myocardial Infarction

Answer 22

-oxygen during the procedure
-stress reduction
-sedation

Question 23

Anesthetic considerations and intraoperative management

Answer 23

-for minimally invasive procedures normally performed in an office setting, moderate (“conscious”) sedation may be considered for a patient with significant history of cardiovascular disease

-for more complex procedures requiring general anesthesia, consider an operating room with an anesthesiologist monitoring the patient

Question 24

Myocardial infarction treatment

Answer 24

MONA (Morphine, Oxygen, Nitroglycerin, Aspirin)
When MI suspected call 911 at outset and be prepared to transfer care to EMTs

Question 25

Myocardial infarction treatment summary

Answer 25

-terminate surgery -100% O2 -Call 911 -Start flow sheet and place patient in comfortable position and loosen clothing -monitor vital signs if not on ECG, place leads -establish IV early on because if heart fails BP will drop and all blood vessels will collapse and hard to start IV -Medicare for pain (Morphine, fentanyl) -Give ASA (aspirin)

Question 26

Myocardial infarction prevention

Answer 26

-thorough medical history -100% O2 throughout procedure -Oral premedication or sedation -profound local anesthesia

Question 27

Valve abnormalities

Answer 27

-stethoscope normal sound: lub dub sound -sounds are made by valves closing -first sounds are mitral and tricuspid valves closing and the second sounds is aortic and pulmonic valves closing -murmur sounds like luh bish dub -murmur is turbulent blood flow across an abnormal valve -cardiac valves: mitral aortic tricuspid and pulmonic (mercedes signs)

Question 28

Murmurs- Dysfunction of valves described as

Answer 28

-Stenosis: valve is stiff and rigid. valves don’t open all the way -prolapse: “floppy” valves flex backwards -regurgitation: valves do not close all the way. Blood will shoot back from chamber which it came

Question 29

Considerations with valve abnormalities

Answer 29

-sub-acute bacterial endocarditis -congestive heart failure -poor cardiac reserve -predispose for cardiac dysrhythmias -whichever dysfunction the heart has to work harder and more forcefully to push blood through

Question 30

Bacterial endocarditis - what is it? who gets it? what causes is? what actually happens?

Answer 30

-It is an infection of the lining of the heart chambers and heart valves caused by bacteria -usually people who have underlying heart disease or valvular disorders will get it -A bacteremia (bacteria in the blood) which can happen during dental, upper respiratory, urologic and lower GI diagnostic and surgical procedures. As it travels through blood it’ll go to the heart. -The infection can cause growths on the heart valves, the lining of the heart or the lining of the blood vessels These growths may form clots that break off and travel to the brain, lungs, kidneys or spleen. It stays at the heart and settles there. -The growths are called regenerations. If it breaks off it can cause thrombus which can travel to brain lungs kidney spleen.

Question 31

Congenital Heart Disease

Answer 31

-present from birth -poorly formed valves, chambers -abnormal communications between vessels or chambers

Question 32

Antibiotics required

Answer 32

Patients at the greatest danger of bad outcomes from endocarditis and for whom preventative antibiotics are worth the risks include this with: -artificial heart valves -hx of having had endocarditis -cardiac transplant which develops a problem in a heart valve -unrepaired congenital defects -a completely repaired congenital heart defect with prosthetic material or device during the first six months of after the procedure -any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or prosthetic device

Question 33

AHA guidelines for abx prophylaxis

Answer 33

standard regimen: amoxicillin: Adults 2.0g; Child: 50 mg/kg one hour prior to procedure allergy to penicillin: -clindamycin adults 600mg child 20 mg/kg one hour prior to procedure PO or IV -azithromycin adults 500mg child 15 mg/kg one hour prior to procedure

Question 34

cardiac diseases

Answer 34

congestive heart failure (pump failure of heart) -A clinical syndrome in which the heart fails to maintain an adequate output, resulting in diminished blood flow to the tissues, and congestion in the pulmonary and/or the systemic circulation. -2 kinds of failure- right and left -if left side can’t pump forward where does pump to? Lungs -blood goes from right atrium to right ventricle and then where? to the lungs and then gets backed up

Question 35

Congestive heart failure- left sided heart failure

Answer 35

-poorly functioning left ventricle -fluid builds up into lungs- pulmonary edema, shortness of breath (SOB) -Symptoms: -orthopnea- difficulty lying down -paroxysmal nocturnal dyspnea (PND) when patient goes to sleep they wake up gasping for air -blood and fluid in lungs patient coughing and pink frothy sputum

Question 36

congestive heart failure- right sided heart failure

Answer 36

-poorly functioning right ventricle -fluid backs up into body tissues- peripheral edema and ascites (abdominal swelling from fluid accumulation) -if right side can’t pump blood forward where does it go? systemic circulation in rest of body swelling of ankles, feet (pitting edema) due to fluid and belly swelling up (ascites) -when you press on swelling due to fluid it “pit” or leave indentation

Question 37

Manifestations of congestive heart failure

Answer 37

-with time the heart becomes enlarged (cardiomegaly) -left sided heart failure often leads to right sided heart failure and the patient develops symptoms of both

Question 38

Treatment of CHF

Answer 38

Medications: -Digitalis- Improve force of contraction, pumping action -Diuretic- flush fluids ex furosemide (Lasix) pt pee’s extra fluid Management: -Don’t lay pt down, keep in a comfortable semi-fowlers position -short procedures -Low IV fluid rate -supplemental oxygen -Remind pt to uncross legs