Chapter 18 Cardiology Flashcards
Sudden narrowing or complete blockage of coronary artery causes myocardial tissue death is called what?
Acute Myocardial Infarction (AMI)
The cessation of cardiac mechanical activity is called what?
Cardiac Arrest
Heart rhythm disturbances
Dysrhythmias
The right atrium receives blood from where?
Superior vena cava, inferior vena cava, and the coronary sinus.
Which part of the heart receives oxygenated blood from the pulmonary veins?
Left Atrium
The ___________________ has much thicker walls than the ______________________.
Ventricles have much thicker walls than the atrium.
Which part of the heart pumps deoxygenated blood to the lungs?
Right Ventricle
What does the left ventricle pump blood to?
The entire body
The L ventricle rotates forward as it contracts. PMI is the POINT OF MAXIMUM IMPULSE, where the heartbeat is most strongly felt. Where on the body can you feel the PMI?
Left anterior part of the chest, 5th intercostal space, midclavicular.
What separates the heart into 2 functional pumps?
Septa
Which is the “low pressure” side of the heart? Which is the “high pressure” of the heart?
Right is low pressure, as it pumps to lungs.
Left is high pressure, as it has to pump blood through the entire system.
What is responsible for cardiac contraction and efficient ejection of blood from the heart?
Myocardium
What supplies blood to the tissues of the heart?
Coronary arteries
Which artery is the largest in diameter, shortest, and divides off into the LAD (Left Anterior Descending Artery) and the CX (Circumflex Artery)?
Left Main Coronary Artery (LMCA)
Where does the LAD supply blood to?
L ventricles anterior, posterior, lateral, septum.
The Cx artery supplies blood to the what?
Lateral and posterior of L ventricle and L atrium
What supplies blood to the walls of the R Atrium and ventricle, a portion of the inferior part of the L ventricle, and portions of the conduction system (SA node and AV bundle)?
Right Coronary Artery (RCA)
Four main components of the Cardiac Cells?
Automaticity
Excitability
Conductivity
Contractility - Calcium
Name the components of the cardiac conduction system.
SA Node
AV Node
Bundle of His
R & L Bundle Branches
Purkinje Fibers
A series of cardiac conditions caused by an abrupt reduction in blood flow through a coronary artery is called what?
Acute Coronary Syndromes
The 3 major Acute Coronary Syndromes.
Unstable Angina
NSTEMI
STEMI
Common chief complaints of someone experiencing ACS.
Chest pain/discomfort
Dyspnea
Fainting
Palpitations
Fatigue
Best assessment technique for assessing cardiac related complaints.
O - Onset
P - Provocation
Q - Quality
R - Radiation
S - Severity
T - Timing
What cause Angina Pectoris?
Ischemia, when the heart muscle does not receive enough O2.
Left Ventricular Failure cause fluid to build up where?
Lungs
(Left to Lungs, the rest is from Right)
Sudden onset of difficulty breathing in which the pt is suddenly woken from sleep, often associated with L sided heart failure.
Paroxysmal Nocturnal Dyspnea, often accompanied by coughing, wheezing, and sweating. Usually improves within 15-30 mins after sitting upright or standing.
A brief loss of consciousness caused by a temporary decrease in blood flow to the brain.
Syncope (fainting)
Common cardiac meds to ask about during assessments.
Antidysrhythmics - Digoxin, Amiodarone, Verapamil
Anticoagulants - Lovenox (enoxparin), Coumadin (warfarin), Plavix (clopidogrel)
Angiotensin converting enzyme inhibitors - (PRIL DRUGS) Lisinopril, Enalapril, etc
Beta Blockers - (LOL DRUGS) Atenolol, metoprolol, propranolol
Lipid lowering agents - (STATIN DRUGS) Lovastatin, Pravastatin, Rosuvastatin, etc
Diuretics - Lasix (Furosemide) Hydrochlorothiazide (HCTZ)
Vasodilators - Nitro, Isordil
Specific Diagnoses to inquire about during assessments.
Aneurysm
Atherosclerotic Heart Disease (MI, HTN, angina, heart failure)
Congenital Anomalies
CAD
DM / Renal Disease
Inflammatory Heart Disease
Previous heart surgeries/grafts/valve replacements
Pacemaker/Defibrillator
Pulmonary Disease
Valvular Disease
Vascular Disease
Bilateral pitting edema is a sign of what?
Right Ventricular Failure
Pitting edema to one side of the body is an indication of what?
A blockage in a major vein.
What occurs when the SBP drops 10 mm hg or more w/inspiration?
Pulses Paradoxus
What conditions could you find Pulses Paradoxus in?
AMI, Cardiogenic Shock, Cardiac Tamponade, and Constrictive Pericarditis
A beat-to-beat difference in the strength of a pulse is called what? Could be a sign of severe ventricular failure.
Pulsus Alternans
Heart sound on systole, when the tricuspid and mitral valve open.
S1
Louder S1 sounds can be heard in pts with what? Due to the valves opening when the ventricles contract.
Fever, Anemia, or hyperthyroidism
How many Amps of electricity does sit take to stop the heart?
O.5 amps
Treatment for R sided MI
Fluids - Improve Preload
NO NITRO!! Will kill them!!
Treatment for L sided heart failure
Nitro
NO FLUID!! Do not want to overload them!!
How many joules do you use to cardiovert a ped pt?
Start w/2 joules, can go up to 10.
Average Adult Stroke Volume
70ml
Hypothermic CPR Rules
CPR, 1 shock, transport, NO DRUGS!!
Cold Blood doesn’t…..
Clot
CPR Pyramid
Early Recognition
CPR
AED
Airway
Drugs
How to treat SVT, VF, VT, AFib, A Flutter
1.) Narrow Complex, Start w/Vagal Maneuver/Cardioversion
A.) Shock at 50 Joules, up to 200J as needed
B.) PEDS - 0.5J per kg
2.) Wide Complex, Shock
A.) Shock at 100 Joules, up to 200J as needed
B.) PEDS - 1J per kg
Treatment for Sinus brady
1.) Atropine (if that doesn’t work)
2.) Epi (If that doesn’t work)
3.) Pace
A “widow maker” is a complete occlusion of which artery?
Left Anterior Descending Artery
What part of the heart does V1 capture?
Septum
Which artery supplies blood to the septum and anterior part of the heart?
Left Anterior Descending Artery
Which artery supplies blood to the lateral part of the heart?
Circumflex Coronary Artery
Which artery supplies blood to the inferior part of the heart
Right Coronary Artery
V1 and V2 capture which part of the heart?
Septum
V3 and V4 capture which part of the heart?
Anterior
Which part of the heart does V5 & V6 capture?
Lateral
An abnormal whooshing sound that is associated with turbulent blood flow through valves.
Murmur
A sequence of changes in the membrane potential that occurs when an excitable cell is stimulated.
Action potential
The process of discharging resting cardiac muscle fibers by means of an electrical impulse that stimulates contraction.
Depolarization
Cardiac Action Potential Phases
Phase 0 - Cardiac muscle receives impulse. The cell depolarizes and contracts. QRS complex on EKG.
Phase 1 - Inward sodium channels close and the cell begins to repolarize.
Phase 2 - Plateau Phase. Corresponds to the ST segment on EKG.
Phase 3 - Final phase of repolarization. Becomes increasingly negative. T wave on EKG.
Phase 4 - Resting Phase. Sodium and Potassium swap out in preparation for the next depolarization.
What cells are found in the tissue of the SA node, AV node, bundle of His, and Purkinje Fibers?
Pacemaker Cells
Depolarization of Atria. Normal duration is 0.08-0.11 secs (2-3 small boxes) and less than 2.5mm tall.
P wave
Distance from a P wave to the beginning of a QRS complex, indicates the amount of time it took for the impulse to traverse the atria and AV junction. Normal range is 0.12-0.20 secs (3-5 small boxes). Prolonged ones can indicate a heart block.
PR Interval
Represents ventricular depolarization. Should be narrow w/a duration of 0.08-0.11 secs.
QRS wave
1st negative deflection, indicates conduction through the interventricular septum. Should last no more than 0.04 secs.
Q wave
Wave that represents depolarization of the R & L ventricles (squeeze of heart).
R & S wave
Begins at J point, ends at T wave. Represents early ventricular repolarization. Period between ventricular depolarization and beginning of repolarization.
ST Segment
Represents ventricular repolarization. Upright, flat, or inverted wave following the QRS complex. Should be asymmetric and half the overall height of the QRS complex.
T wave
Time between 2 successful ventricular depolarizations.
R-R Interval
Represents all electrical activity of one complete ventricular cycle. Generally measures 0.40 & 0.44 secs.
QT Interval
Considered prolonged if longer than 0.47 in men and 0.48 in woman.
Elevated T wave indicates what?
Hyperkalemia
Decreased T wave indicates what?
Hypokalemia
Lead 1 provides tracing between what?
LA & RA
R Arm lead is always…..
Negative
L leg is always……
Positive
L Arm can be ______________ or _______________, depending on what?
Negative or Positive, depending on the lead and which part of the heart its trying to capture.
Lead 1: Tracing between RA & LA, L arm is positive, because R arm is always negative.
Lead 2: Tracing between RA & LL, L leg is positive, because R arm is always negative.
Lead 3: Tracing between LA & LL, L arm is negative, because L leg is always positive.
4 Leads Placement
R arm/Shoulder is white
R torso/leg is green
L arm/shoulder is black
R torso/leg is red
R arm is referenced against combination of L arm and L leg.
AVR
L arm referenced against combination of R arm and R leg.
AVL
Combination of L arm and R arm
AVF
1,500 method of determining HR
Count # of small boxes between any 2 QRS complexes. Then divide 1,500 by that number = HR
Sequence Rate Method of determining HR
R wave to R wave. R wave on line, next big box is 300, next big box is 150, next big box is 100, next is 75, next 60, next 50. Wherever the next R wave is, is where you get your HR.
Rules that determine a NSR
Rate: 60-100BPM
Regularity: Regular
P Wave: Present
P:QRS ratio: 1:1
PRI: Normal/Regular
QRS width: Normal
Grouping: None
Dropped Beats: None
This rhythm has all the normal qualifications of NSR, except it may be irregular d/t respirations.
Sinus Arrythmia
This rhythm has all the normal rules for NSR, except it has a rate of less than 60BPM.
Sinus Bradycardia
Rhythm that presents with 100BPM or higher, other rules fall within sinus rhythm.
Sinus Tachycardia
Varied Rate
Regular, except for area of dropped beat
P wave, except in areas of pause/dropped beats
P:QRS ratio 1:1
Normal PRI
Normal QRS width
Sinus Pause/Sinoatrial Block
Approx 100bpm
Irregularly irregular
3 different morphologies of P waves
PRI varies
Wandering Atrial Pacemaker
Greater than 100bpm
Irregularly Irregular
At least 3 different morphologies of P waves
PRI varies
Multifocal Atrial Tachycardia
Commonly 250-350bpm (ventricle rate 125-175)
Usually regular
“Saw tooth” appearanced P waves
P:QRS ratio 2:1
Atrial Flutter
Rate: Variable, can be slow or fast
Irregularly Irregular
P Wave: none or chaotic activity
PRI: None
Atrial Fibrillation
Rate depends on underlying rhythm
Irregular
Variable; P waves on regular beat, none on early beat
PRI: None or shortened
Premature Junctional Contraction
No P Wave
Irregular
No PRI
Dropped Beats
Junctional Escape Beat
No P wave
No PRI
HR 60-100
Accelerated Junctional Rhythm
Irregular Beat
No P Waves
Wide QRS
Premature Ventricular Contraction
Irregular
No P Wave / No in PVC
Wide QRS
Later than expected beat
Ventricular Escape Beat
HR 20-40 BPM
No P Wave
No P: QRS Ratio
No PRI Interval
Wide QRS
Idioventricular Rhythm
HR 40-100
P Wave None
P:QRS ratio: None
PRI Interval: None
QRS Wide
Accelerated Idioventricular Rhythm
HR 100-200
No P Wave
Wide QRS
Ventricular Tachycardia
200-250HR
Irregular
No P Wave
No P:QRS ratio
No PRI Interval
Tornadoes de Pointes
200-300HR
Regular
No P Wave, P:QRS ratio, or PRI
Ventricular Flutter
Indeterminate Rates
Chaotic Rhythm
No P wave, QRS ratio, no PRI
V-Fib
Which rhythm do you check lead placement before treatment?
Asystole
PRI consistently prolonged
1st degree heart block
Regularly Irregular
P:QRS ratio: Variable
PRI: VARIES
Dropped Beats
Type 1 2nd degree heart block
Rate varies
Regularly Irregular
P:QRS ratio: Varies
Dropped Beats
Type 2 heart block
P:QRS ratio: varies
PRI: Varies, no pattern
P waves does not match QRS
3rd degree heart block
If the R is far from P, you have a…..
1st degree a
Long PRI, longer PRI, longer PRI, dropped QRS, you have a……
Type 1 2nd degree heart block
P-P stays the same, dropped QRS waves
Type 2 2nd degree heart block
R-R Intervals match
PRI’s vary
Dropped QRS Waves
3rd Degree Heart Block
How to treat Sinus Brady?
Scene Safe/BSI
ABC’s
Cardiac Monitor/IV/O2
Hx - Pacemaker? Beta Blocker?
Fluid Bolus
Asymptomatic - Atropine 1-1.5mg up to 3mg
Epi 2-10mcg/min titrate to effect
Symptomatic - Hemodynamically unstable - Not perfusing - Pace starting at 50ma, can increase by 10ma until you have capture (Electrical capture when pacer spike hits QRS) then increase 10ma until i have mechanical capture (when you can feel a radial pulse) Once mechanical capture has been obtained, increase 10ma and set it.
How to treat Sinus Tach? Concern is decreased preload.
Scene Safe/BSi
ABC’s
Vitals / O2 SAT
Cardiac Monitor/IV/O2
Find the underlying cause and treat it (H’s & T’s)
How to treat Sinus arrhythmia? Common is children & young adults, until hormones balance out.
Scene Safe/BSI
ABC’s
Vitals / O2 SAT
Cardiac Monitor/IV/O2
If you can link it to respirations, supportive care.
Monitor pt for underlying, worsening condition, and treat.
How to treat Sinus Arrest & Sinotrial Break?
Scene Safe/BSI
ABC’s / O2 SAT
Cardiac Monitor/IV/O2
Supportive Care & Monitor.
How to treat PAC’s? Premature Atrial Contraction. Irregular looking P wave.
Scene Safe/BSI
ABC’s / O2 SAT
Cardiac Monitor/IV/O2
Treat underlying H&T’s
How to treat PVC’s? Premature Ventricular Contractions
Scene Safe/BSI
ABC’s / O2 SAT
Cardiac Monitor/IV/O2
Supportive Care & Monitor.
How to treat SVT? Supraventicular (above the ventricles) Tachycardiac. No P waves d/t accelerated rate, but has narrow QRS complex, so it originates in the atria.
Scene Safe/BSI
ABC’s / O2 SAT
Cardiac Monitor / large bore IV / O2 / Vitals
Vagal Maneuver
Adenosine 6mg Fast IVP, flush w/20ml nacl. Can repeat once at 12mg.
Sedate w/Versed 1-2mg IV, up to 10mg, if BP is WNL.
Cardiovert: Apply 4 leads and pads, change to Lead 2 for better overall picture of heart. 50J, sync. Charge/Shock. Increase Joules as needed.
Pre-Excitation - Wolf Parkinson White Syndrome
SA fires and Bundle of Kent -fires at the same time. It reenters into the AV node, giving another electrical impulse too soon. Slurred QR wave (called a Delta wave). If you see a Delta wave, DO NOT TREAT WITH ADENOSINE!!
Lown-Gangong-Levine syndrome
Reentry problem. Causes pre-excitation. Reenters into AV node from Bundle of Kent. Predisposed to tachy dysrhythmias. Do not treat with AV blockers, Adenosine. If you see a Delta Wave, DO NOT TREAT W/ADENOSINE.
How to treat A-Fib? Irregular Rhythm, No P Waves.
Scene Safe/BSI
ABC’s / O2 SAT
Vitals
Cardiac Monitor / large bore IV / O2 / Vitals
Vagal Manuever
Cardioversion.
Supportive Care, Transport.
How to treat A Flutter? Saw tooth pattern (F Waves)
Scene Safe/BSI
ABC’s / O2 SAT
Vitals
Cardiac Monitor / large bore IV / O2 / Vitals
Cardioversion.
Supportive Care, Transport.
How do you treat Wandering Atrial Pacemaker? Impulse is coming from different parts of the atria. 3 different looking P waves. Narrow QRS. Children and Athletes, d/t increased vagal tones.
Scene Safe/BSI
ABC’s / O2 SAT
Vitals
Cardiac Monitor / large bore IV / O2 / Vitals
Only treat symptomatic, bradycardiac.
Atropine 1mg IVP, up to 3mg.
Supportive Care and transport.
How to treat Multifocal Tachycardiac? WAP rhythm w/an accerlated rate.
Scene Safe/BSI
ABC’s
Vitals
Cardiac Monitor / IV / O2
Supportive Care and Transport.
How to treat Premature Junctional Contraction? Inverted P waves w/QRS, imbedded in a normal rhythm.
Scene Safe/BSI
ABC’s
Vitals
Cardiac Monitor / IV / O2
Supportive Care and transport.
How to treat Junctional Rhythm? No P wave or inverted. Does not return to normal rhythm. 40-60HR
Scene Safe/BSI
ABC’s
Vitals
Cardiac Monitor / IV / O2
Atropine 1mg IVP.
Pacing.
How to treat Accelerated Junctional Rhythm? Most often associated with Digoxin poisoning. 60-100HR
Scene Safe/BSI
ABC’s
Vitals
Cardiac Monitor / IV / O2
Supportive Care and Transport.
How to treat Junctional Tachycardia? HR over 100
Scene Safe/BSI
ABC’s
Vitals
Cardiac Monitor / IV / O2
Treat underlying condition.
Depending on rate.
Adenosine, Cardioverting
How to treat Premature Ventricular Contraction? Wide Complex ventricular beat within a normal rhythm. Usually benign, until they begin coupling. Then they become Bigeminy, Trigiminy, or runs of V-Tach.
Scene Safe/BSI
ABC’s
Vitals
Cardiac Monitor / IV / O2
Supportive Care and Transport.
How to treat Idioventricular rhythms? 20-40HR, no P waves, wide QRS.
Scene Safe/BSI
ABC’s
Vitals
Cardiac Monitor / IV / O2
Pace
Prepare for CPR.
How do you treat Acceralted Idioventricular Rhythm? 40-100HR, no P wave, wide QRS.
Scene Safe/BSI
ABC’s
Vitals
Cardiac Monitor / IV / O2
Prepare for CPR
How to treat Torsades de Pointes? 200-250HR. If they have a pulse, they won’t for long.
Scene Safe/BSI
ABC’s
Vitals
Cardiac Monitor / IV / O2
Magnesium 1-2mg IVP
Defibrillate.
CPR
How to treat Ventricular Tachycardia? With a pulse.
Scene Safe/BSI
ABC’s
Vitals
Cardiac Monitor / IV / O2
Amiodarone 150mg in 100ml nacl, adm 10ml/min.
Cardioversion if needed.
How to treat Ventricular Fibrillation? Will not have a pulse.
Scene Safe/BSI
ABC’s
Cardiac Monitor / IV / O2
Defibrillate at 200 Joules, move up to 360 Joules if needed
CPR
How to treat 1st degree AV block? There is a block between SA node to AV node. Consistent, PRI will exceed 0.20 sec or 5 small boxes. Narrow Complex.
Scene Safe/BSI
ABC’s
Vitals
Cardiac Monitor / IV / O2
Supportive Care and transport.
How to treat Type 1 2nd degree heart block? A block keeping the ventricles from contracting, means you lose a QRS. Long, Long, longer PRI, drop’s QRS, then starts over at the beginning.
Scene Safe/BSI
ABC’s
Vitals
Cardiac Monitor / IV / O2
Treatment depends on HR.
Atropine 1mg every 3-5mins, up to 3mg.
Supportive Care and Transport.
How to treat Type 2 2nd degree block? Block is in the Bundle of HIs or Bundle braches, does not block every conduction. Normal PRI, w/dropped QRS’. Impulse from SA did not make it through the ventricles.
Scene Safe/BSI
ABC’s
Vitals
Cardiac Monitor / IV / O2
Will typically present w/low HR.
Pace.
Atropine will not work.
How to treat 3rd degree heart block? Complete heart block. SA impulse is not going to ventricles at all. PRI varies.
Scene Safe/BSI
ABC’s
Vitals
Cardiac Monitor / IV / O2
Pace.
Atropine won’t work.
Chest pain that is relieved w/rest or Nitro. Caused by myocardial ischemia.
Stable Angina
Varies in intensity. Not relieved w/rest or Nitro. Needs treatment.
Unstable Angina
Where does fluid build up in body in R sided heart failure?
Extremities and Abdomen
Where does fluid build up in body in L sided heart failure?
Lungs
Primary cause of R sided heart failure
L sided heart failure
R sided heart failure that is caused by chronic lung dz?
Cor pulmonale
Decreased blood flow from the kidneys stimulates the sympathetic nervous system, that stimulates RAAS, Renin Angiotensin Aldosterone System. Is system reaction for what?
To retain fluid, and sodium for better cardiac output.
Muffled heart sounds
JVD
Hypotension
Beck’s Triade - Cardiac Tamponade
Hypotension
Bradycardia
Cool/Clammy
Cardiogenic Shock - MI
Acute BP of 180/120 or higher BP, w/evidence of other organ damage (renal dz, heart dz)
Hypertensive Emergency
Infection of endocardium, caused by bacteria.
Endocarditis
Pain, cramping, muscle tightness, fatigue or weakness of the legs when walking or during exercise.
Claudication
Firing rate for SA node
60-100
Firing AV Junction rates
40-60
Firing rates for ventricles
Takes about 0.08 seconds from impulse to spread from Bundle of His across ventricles. 20BPM
Depolarization of atria. Duration?
P wave - 0.08-0.12 secs
Cations are half filled again, and can fire again, though will not be efficient if it does. Phase 3.5-4. Halfway through the T wave to the beginning of P wave.
Relative Refractory Period
Cations returning back to starting period, but has not made it to destination, nothing is able to fire again. Phase 0-3.5. Beginning of P wave to halfway through the T wave.
Absolute Refractory Period
Cations returning back to starting period, but has not made it to destination, nothing is able to fire again. Phase 0-3.5. Beginning of P wave to halfway through T wave.
Absolute Refractory Period
Positively charged ion, sits outside of cell, waiting to go in, more than Potassium. Starts depolarization, sends impulses to the Calcium.
Sodium
Controls contractility of the heart muscle.
Calcium
Moves to outside of cell, to move opposite of sodium to keep cell balanced (polarity).
Potassium
Helps w/cell permeability, stabilizes cell membrane. Works in conjunction w/Potassium, opposes the action of calcium.
Magnesium
Distance from the beginning of P wave to the beginning of QRS complex. Represents the amount of time required for impulse to traverse the atria & AV junction.
PRI - 0.12-0.20
Represents ventricle depolarization.
QRS - 0.08-0.12
Indicates conduction through the Septum. Lasts no more than 0.04 secs.
Q wave
Represents depolarization of R & L ventricles.
R & S Wave - should be 0.08-0.12
Represents early ventricular repolarization. Period between ventricular depolarization and beginning of repolarization.
ST
Represents ventricular repolarization.
T wave
Represents all electrical activity of one complete ventricular cycle. Considered prolonged if over 0.47/0.48
Q-T
Time between 2 successive ventricular depolarizations.
R-R Interval
AV node
Receives SA signal, delays signal by about 0.12 seconds, to allow atria to fully empty blood into ventricles, then sends signal to Bundle of His.
Rhythm’s you treat with Amiodarone
Cardiac Arrest
Ventricular Fibrillation
Ventricular Tachycardia
Stable wide complex tachycardia
When do you not use Amiodarone?
Cardiogenic Shock
Bradycardia
Heart Blocks
Zofran usage (prolongs QT interval)
Dosages for Amiodarone
Cardiac Arrest, VT/VF: 300mg IVP. May repeat 150mg IVP, once in 3-5 min, if no effect from 1st dose.
Stable Wide Complex Tachycardia: 150mg IVP (mix150mg in 100ml, run at 10ml/min)
What rhythms do we treat with Atropine?
Bradycardia
Dosage for Atropine
0.5mg-1mg IVP every 3-5mins, up to 3mg.
What is Adenosine used to treat?
Narrow Complex Tachycardia rate over 150, or SVT
Dosage for Adenosine
6mg rapid IVP, flush w/20ml NACL, elevate arm. If no effect in 1-2 mins, may repeat once @12mg.
When do we not use Adenosine?
Heart Blocks
Lung Disease
Drug induced tachycardia
AFIB w/WPWS
When do we not use Atropine?
Hypothermic Bradycardia
Hypotensive from hypovolemia
What do we use Lidocaine for?
Cardiac arrest
Ventricular Tachycardia
Ventricular Fibrillation
When do you not use Lidocaine?
Hypotension
Heart Blocks
Dosages for Lidocaine
Cardiac Arrest, VT/VF: 1-1.5mg/kg IVP. May repeat twice with 0.5-0.75mg/kg IVP every 5-10mins. Max dose 3mg/kg.
Stable VT: 1-4mg/min (after loading dose) (mix 1g in 250ml of D5W)
PVC’s: 0.5-0.75mg/kg
How long is each wave?
P- 0.08-0.11 secs - 2-3 small boxes
PRI- 0.12-0.20 secs 3-4 small boxes
QRS - 0.08-0.11 secs 2-3 sm box
QT - 0.40-0.44 secs 10 sm boxes
Strength of a cardiac contraction
Isotropic
The rate of muscle contractions
Chronotropic
Speed of cardiac muscle contractions
Dromotropic
Most HTN is the result of what?
Atherosclerosis or Arteriosclerosis, which narrows the lumen of the arteries and reduces their elasticity.
Stimulus that raises the pressure at which blood is ejected from the heart, in reaction to high after load on the heart from narrowed arteries.
Frank Starling Reflex
The hearts ability to spontaneously create & send electrical impulses w/o being told to by another source
Automaticity
Ability of heart to respond to stimuli
Excitability
How well the cells can conduct electricity
Conductivity
How hard and long the heart muscle can contract
Contractility
What vessel transports blood from the heart to the lungs?
Pulmonary Artery -
Blood goes from R ventricle, through the pulmonary artery, to the lungs.
Which phase does the heart receive blood?
Diastolic, Resting, Phase 4.
What is one thing a Cardiac monitor or EKG unable to measure?
Perfusion, which beats on EKG are actually perfusing
Mechanical function of heart
Imaging of heart
Where does the endocardium receive its blood flow?
From the blood it’s pumping
How does the endocardium return the blood it’s pumping?
Through the coronary sinus
What cells transmit signals from cell to cell?
Intercalculated Disks
Blood flow through heart
R atrium from Superior & Inferior Vena Cava, & Coronary Sinus
R atrium through Tricuspid Valve into the R Ventricle
R Ventricle through the Pulmonary Valve, into Pulmonary Artery, to the lungs
Lungs through the pulmonary veins, into the L atrium
L atrium through Mitral valve into L ventricle
L ventricle through the aortic valve into the aorta
Neurotransmitter of the parasympathetic nervous system
Acetylcholine
Cardiac causes of syncope
Dysrhythmias
Increased Vagal Tones
Heart Lesions
Acute onset rapid heartbeat, no known underlying cause
SVT
Rapid HR that should have an underlying, treatable cause
Sinus Tach
1 cause of chronic HTN
Atherosclerosis
Where does the S1 heart sound come from?
“Lub”
From the closing of the Mitral and Tricuspid valves
Where does the S2 sounds come from?
“Dub”
From the pulmonary & aortic valves closing (semilunar valves)
What does S3 sound like and what is it an indication of?
“Kentucky”
CHF
What does S4 sound like and what is it an indication of?
“Tennessee”
L ventricular Hypertrophy
S/S of R Sided Heart Failure/CHF
Pitting Edema
Pink Frothy Sputum
JVD
HTN
Crackles
Where would you listen for aortic stenosis?
Valves - R side of sternum, 2nd intercostal space
Stage 2 HTN reading
140/90
What is a late stage sign of shock?
Widened Pulse Presure
Narrowed Pulse Pressure is an indication of what?
Cardiac Tamponade
Cation responsible for depolarization.
Sodium (positively charged ion)
Lives outside of cell
Goes through Sodium/Potassium Channel, into cell, to begin depolarization.
What maintains baseline charge for cell?
Sodium/Potassium pump
What is a Q wave infarct?
A Q wave infarct is a type of myocardial infarction characterized by the presence of Q waves on an electrocardiogram (ECG).
Q waves indicate that there has been significant damage to the heart muscle.
Is the cell negative or positive during resting phase?
Negative
-70 to -90
Which phase takes cell from positive to negative
Phase 4, resting phase
Phase 1 (can’t be seen on EKG)
Inward sodium channels close and the cell begins to repolarize.
Phase 2:
Phase 2 - Plateau Phase. Corresponds to the ST segment on EKG. Depolarization is continuing. Cells used are still repolarization.
This phase is where Sodium+ and Calcium++ enter the cell, and Potassium+ goes out of the cell.
Taking cells from a negative state w/cations swapping, making it positive.
Depolarization
SA Node receives its blood from the…..
RCA
AV Node initiated impulses
40-60BPM
P Wave
Narrow QRS
Which nervous system transmits commands by releasing Norepinephrine? Fight or Flight, increases HR.
Autonomic Nervous System
Which nervous system transmits commands by releasing Acetylcholine, sending messages through the vagus nerve, decreasing HR?
Parasympathetic Nervous System
Lead 1 reads from what to what?
R Arm (-) to L Arm (+)
Lead 2 reads from what to what?
R Arm (-) to LL (+)
Lead 3 reads from what to what?
LL (+) to LA (-)
Which electrode will be the “camera”?
The positive electrode
Precordial (Unipolar) Leads
V1-V6
Augmented (Bipolar) Leads
AVR (checks lead placement)
AVL - Lateral Side of Heart
AVF - Inferior side of heart
How much time is each little box?
0.04
How much time is each bog box?
0.20 secs
How many big boxes does it take to make 6 seconds?
30
P wave is how long?
0.04 - 0.11 secs (2-3 sm boxes)
Time of normal PRI
0.12-0.20 (3-5 sm boxes)
What does inverted T waves indicate?
Ischemia
Time of QT Interval - All electrical activity in 1 completed ventricular cycle.
0.40-0.44secs or 390-460ms
Long QT Intervals can lead to ….
Dysrhythmias and cardiac arrest
What is the most common cardiac cause of hospitalizations in patients 65 and over?
Heart failure
Which type of artifact will make a paced rhythm unidentifiable?
Muscle Artifact
Most common cause of death from cardiogenic shock?
Myocardial Infarction
From a list what med he between the ages of 60-70 is seen 10x more in men than women?
AAA
is a type of chest pain caused by a spasm in the coronary arteries, leading to reduced blood flow to the heart muscle. It typically occurs at rest and is often cyclical, happening at the same time each day.
Prinzmetal Angina, AKA a variant angina
a type of chest pain caused by spasms in the coronary arteries. These spasms temporarily reduce blood flow to the heart muscle, leading to chest pain.
Vasospastic angina
Muscle cramps or spasms - Tingling in the fingers or around the mouth - Seizures - Fatigue - Anxiety or irritability - Tetany (involuntary muscle contractions)
Are S/S of what?
Hypocalcemia
Hypertension and arrhythmias, such as a shortened QT interval on an ECG.
Are S/S of what?
Hypercalcemia
Cardiac Tamponade - Beck’s Triad
Narrowed Pulse Pressure
Hypotension
JVD
Muffled Heart Sounds
How would you BEST describe cardiogenic shock
Condition in heart muscle function is severely impaired, decreasing cardiac output, inadequate tissue perfusion. S/s: Hypotension, Brady/tachycardia, JVD, narrowed pulse pressure, AMS, skin changes.
Called to assist patient with unilateral limb pain. You suspect a patient is having a peripheral vascular emergency. What would best support your field determination.
Abnormal pulse on one side
Sign of thrombosis in the affected limb
Claudication - pain/weakness
Hx of afib
Or recent surgery
What is included in the Secondary Assessment?
Cardiac Monitor, Waveform Capno, SPO2, Vitals, HX
Normal QRS, normal P wave, PRI of 0.28, what rhythm?
1st degree heart block (consistent prolonged PRI)
specialized junctions that connect adjacent cardiac muscle cells (cardiomyocytes) in the heart
Intercalated Disks
Potassium (K+), Sodium (Na+), Calcium (Ca2+), Magnesium (Mg2+)
Electrolytes
specialized nerve fibers found in the heart that play a crucial role in the electrical conduction system of the heart, end of the bundle branches
purkinje fibers-
Which of the following would a 3 lead be the most useful, in what circumstances
patient with suspected heart disease.
Use of a defibrillation pad to obtain a single lead view is best used in which of the following circumstances?
When a quick assessment of heart rhythm is needed
Least likely to start resuscitative efforts-
obvious signs of death or major traumas(obvi sign of death) or a pt that has a pulse.
APE- acute pulmonary edema, what is it, what’s happening-
acute onset fluid in lungs, can appear suddenly, causes mild to severe difficulty breathing, cough, chest pain, and fatigue
a type of heart attack where the damage extends through the entire thickness of the heart muscle (myocardium) Infarct that extends through the entire ventricular wall
Transmural infarct-
a type of infarct in the coronary artery.
Coronary Infarction
infarct that affects only the inner layer of the heart muscle
Subendocardial infarction
Cyanosis, blue/gray tint of skin caused by….
Hypoxia, decreased O2
Flushing of skin can be caused by….
Fever, HTN, Burns, Allergic reactions, alcohol, carbon monoxide
Pallor/Pale skin can be caused by….
blood loss, anaphylaxis, hypoglycemia, anxiety
Cardiovascular (shock) embarrassment, decreased intra vascular coagulopathy can cause skin to look……
Mottled
What would account for bp differences between arms?
blood pressure difference between arms can be due to peripheral artery disease, anatomical variations, or the presence of atherosclerosis. Can also be caused by muscle compression or Aortic arch dissection.
Pathological Q wave
30% height of R wave (Infarct or Ischemia)
Physiological Q Wave
1/3 of the QRS height
Treatment for CHF
In the EMS setting, treatment for congestive heart failure includes ensuring ABCs, administering oxygen (CPAP), positioning the patient properly, establishing IV access, administering nitroglycerin and diuretics if indicated, monitoring vital signs, and transporting the patient to the hospital
Treatment for DKA
The treatment for DKA (Diabetic Ketoacidosis) includes fluid replacement, electrolyte correction, and insulin therapy
Treatment for Pulmonary Edema
Oxygen, nitrates, diuretics, and possibly CPAP.
Treatment for Hemorrhagic Stroke
-Supportive care, including stabilizing the airway, breathing, and circulation. Monitor vital signs, provide oxygen as needed, elevate the head of the bed to 30 degrees if tolerated to reduce intracranial pressure, and transport to an appropriate facility for further care. Avoid anticoagulants and antiplatelet drugs.
Treatment for Ischemic Stroke
Place patient in supine position. Ensure rapid transport to a stroke center for fibrolynic therapy, provide supportive care, and monitor vital signs. Administer oxygen if needed and establish IV access.
when does the coronary artery get fed, systole or diastole
Diastole
Which of the following degree of artifact will make paced rhythm virtually impossible to identify?
Muscle artifact
Why would it be a good idea to provide o2 to pt with an MI?
May improve o2 delivery to ischemic myocardial tissue
you arrive on scene w/ a family member telling you the pt is in cardiac arrest. Priority by pt side.
Determine if the pt is unresponsive and PULSELESS,
AAA what symptom would you expect
Urge to defecate along w/ back pain, abdominal pain
Pt 65 and over- leading causes of hospitalizations?
Heart Failure
RBBB
RBBB charaterized by widened QRS over 0.12 and a terminal r wave in V2. Rsr complex(R-prime). Terminal S wave in 1, aVL, and V6
LBBB
LBBB charaterized by widened QRS, >0.12, terminal S wave in V1. Terminal R wave seen in 1, aVL, and V6.
Anterior Block
Anterior block- characterized by rS complexes in leads 2, 3, and aVF and by qR complexes in leads 1 and aVL.
Posterior Block
Posterior block- rare and requires a DX of exclusion. Characterized by qR complexes in lead 2, 3, and aVF, and by rS complexes in lead 1.
FONA/ MONA
Fentanyl, O2, Nitro, ASA
Morphine, O2, Nitro, ASA
Asynchronous Cardioversion
Asynchronous- aka defibrillation, is a process in which enters may be delivered at any point in the cardiac cycle
which of the following ecg findings would confirm the conclusion that your pt is having angina?
ST depression
CHF patient takes potassium supplements, what other drugs would you expect the patient also have in their history?
Beta blockers (-lols) diuretics (lasix, hctz, Lozol) ACE inhibitors (-prils), angiotensin 2 receptor blocker- similar to ace inhibitor but don’t cause cough, digoxin- slows heart rate, helps w/ a fib, vasodilators- relax blood vessels, anticoagulants- prevent blood clots, statins- a gene cholesterol levels
Vasculitis
vascular inflammation.
Synchronized Cardioversion
Synchronous- aka synchronized cardioversion, delivers timed bursts of electrical energy and identifies the r waves.
claudication
pain, cramping, muscle tightness, fatigue weakness in legs during physical activity- sign of PAD
Arteriosclerosis
hardening of the arterial walls
atherosclerosis
narrowing of the arteries typically from a build up of plaque from diet, or clots
Lead 1
Looks at…
Is fed by…
High lateral
Circumflex Artery
arterial occlusions
Sudden disruption of arterial blood flow caused by many things, use your head.
Lead 2
Looks at…
Is fed by…
Inferior
Right coronary or circumflex
S/s of cardiogenic shock
hypotension, decreased hr first, then increased hr decreased cardiac output, pale cool clammy, crackles
S/s of anaphylactic shock
hypotension, tachy, warm flushed skin, wheezes
Lead 3
Looks at…
Is fed by…
Inferior
Right coronary or circumflex
S/s of hypovolemic shock
hypotension, tachy, pale cool clammy, clear lung sounds
S/s of neurogenic shock
hypotension, Brady, flushed dry warm skin, clear lungs
S/s of distributive shock
wide spread vasodilation
Junctional rhythm/junctional escape
No, inverted or retrograde p wave. Normal QRS complexes, regular, rate 40-60
Accelerated junctional rhythm
No, inverted, or retrograde p waves, regular QRS, regular, rate greater than 60 less than 100
AvR
Which Leads?
Looks at…
Is fed by…
R lead reflection between the LA and LL lead
Looks at nothing
Junctional tachycardia
No, inverted, or retrograde p waves, regular QRS, regular, rate greater than 100.
Premature junctional complex(PJC)
An early complex that appears within another rhythm. No, inverted, or retrograde p wave, narrow QRS.
EKG changes associated with cardiac tamponade
electrical alternans: beat to beat variation in the amplitude and axis of QRS complex, low voltage QRS, tachycardia
AvL
Which Leads?
Looks at…
Is fed by…
Reflection of the LA between the RA and LL
High lateral
CX artery
AvL
Which Leads?
Looks at…
Is fed by…
Reflection of the LA between the RA and LL
High lateral
CX artery
EKG changes associated with pulmonary embolism
sinus tach, t wave inversion, right axis deviation
EKG changes associated with AAA
ST elevation, ST depression, changes in polarity/morphology of T wave
Heart Blocks
1st degree - Consistently prolonged PRI
Type 1 2nd degree - Variable PRI w/dropped beats
Type 2 2nd degree - Normal PRI w/dropped beats
3rd degree - Irregular PRI’s w/extra P waves
AvF
Which Leads?
Looks at…
Is fed by…
Reflection of the LL between the RA and LA
Inferior
RCA or cx
EKG changes associated with tension pneumo
PR segment elevation in inferior lead, PR segment depression in aVR lead, St depression, elevation, or other changes
V1 & V2
Looks at…
Is fed by…
Septum
LAD
V3 & V4
Looks at…
Is fed by…
Anterior
LAD
EKG changes associated with hypokalemia
T wave amplitude decreases, diffuse ST depression, T wave inversion,
EKG changes associated with hyperkalemia
tall peaked T waves, widened QRS
V5 & V6
Looks at…
Is fed by…
Low Lateral
CX
V5 & V6
Looks at…
Is fed by…
Low Lateral
CX
AAA
AAA- Abdominal Aortic Aneurysm
present w/ back pain and abdominal pain, urge to defecate
”worst headache ever”- sign of cerebral bleeding from aneurysm
Difficulty swallowing/horseness can indicate thoracic aortic aneuryms
Thrombotic therapy
involves administering medications that convert Boyd’s clot dissolving enzymes from it’s inactive form (plasminogen) to it’s active form (plasminogen). Breaks down fibrinogen and fibrin clots. Can not be limited to coronary arteries and can cause uncontrolled bleeding.
Traumatic aortic disruption
inside wall of the artery becomes torn allowing blood to collect between the arterial wall layers. can occur w/ trauma or sustained hypertension, particularly when AAA is present. Thoracic dissection can produce chest pain that is difficult to differentiate from cardiac ischemia. Obtain BP in both arms and palpate HR in both arms. Systolic BP change of 15mmhg between arms suggest thoracic dissection
Contraindications with thrombotic therapy
bp 180-200/100-110, right/left arm bp change of 15mmhg, stroke longer than 3hrs or shorter than 3mo, trauma/blood loss/surgery, close head trauma in last 3mo, gi bleeding in last 2-4wks, other serious systemic disease like cancer liver or kidney disease, any prior history of brain bleed, pregnancy
Oxygenated blood reaches the heart through..
Coronary arteries
Oxygenated blood reaches the heart through..
Coronary arteries
Main coronary arteries
Left and Right coronary arteries
Left Coronary Ateries
Left Anterior Descending & Circumflex
LAD & Circumflex feeds what…
Left ventricle anterior and posterior, septum, lateral, part of R ventricle
Left= PALS
Right Coronary Artery
Where?
Feeds?
Travels between r atrium and r ventricle
Feeds R atrium, r ventricle, portions of L inferior ventrical, and parts of conduction system
R= RIP
Conduction system of the heart
SA, AV, BUNDLE OF HIS, BUNDLE BRANCHES R&L, PERKINJIE FIBERS
LEFT- ANTERIOR AND POSTERIOR FASICLES
