Cardiac Patient Assessment

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Cardiac Patient Assessment Treatment
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Review

• Cardiac Output
• 5000-6000 ml/min.
• HR or SV CO
• Sympathetic effects
• HR and SV
• Parasympathetic
• Slows HR
• Little effect on SV

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Review

• SV pressure in ventricle
• Frank Starling effect
• Peripheral vascular constriction increases venous
  return
• Increased RV output.
• Vasodilation of arteries decreases PVR and
  diastolic pressure
• Increased CO.

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Vital Signs

• Normal B/P is 120/70 mmHg
• Increases with age
• General
• Systolic 100 age up to 140
• At age 50 usually 140 mmHg
• Increases 1 mmHg/yr after 50.

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Abnormal Cardiac Function

• Dispatched as
• Man down
• Chest pain
• Heart attack
• SOB
• Fainted
• Dizzy

• Passed out
• Choking
• Stroke
• DFO
• DRT

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Initial Assessment

• Brief History
• Onset
• Provoking factors
• Quality
• Radiation
• Severity
• Time
• BP changes

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Initial Assessment

• Meds
• Cardiac rhythm
• Abnormal breathing
• Edema
• Rales
• Changes in skin color and moisture

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Acquired heart diseases (Not Congenital)

• Angina Pectoris
• Myocardial Ischemia
• Myocardial Infarction
• Cardiogenic Shock
• Cor Pulmonale
• Hypertension

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Angina Pectoris

• Physiology
• Myocardial Demands not met
• Stable
• Onset with exertion
• Subsides with rest within 5 minutes
• If onset with stress, pain may last 15 min.

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Angina Pectoris

• S/S
• Heavy squeezing pressure with radiation
• Anxious
• Diaphoretic
• Clammy
• SOB

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Angina Pectoris

• Unstable
• In patients with previously stable angina
• Frequency, Severity Duration
• Pain with less activity or at rest.
• More resistant to relief with NTG.

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Myocardial Ischemia

• Physiology
• Similar but worse
• Occurs anytime
• Can last 30-60 minutes
• Not permanent damage
• May fail acutely or fibrillate

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Myocardial Ischemia

• S/S
• Tachycardia
• Elevated systolic BP
• Transient (Brief) ST depression
• Possible T wave inversion
• Precursor to

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Myocardial Infarction

• Physiology Coronary ThrombusArteriosclerosis /
  Atherosclerosis
• History ()
• CP
• Possible Radiation
• Sweating
• Nausea
• SOB
• Pallor

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AMI - Another Rhythm?

• Circadian rhythm
• 3x more likely in AM
• Usually 3-4 hrs. after awakening.
• CP awakened from sleep

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AMI

• Note
• Elders Diabetics often have no pain
• History
• General Malaise
• Burning
• Syncope
• Dizziness

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AMI History

• Nausea
• Diaphoresis
• Weakness, unknown fatigue
• Hot flash
• Nonspecific chest discomfort
• CHF rales

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AMI History

• Intermittent sx
• Seasonal - fall and winter
• MI at rest - no precipitating factors

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AMI HUGE Risk Factors

• 2x more likely to die in 1st year post MI
• Increased stroke risk
• 1/2 gt 75 y/o
• PMHx HTN, Diabetes

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AMI Little Known Fact-Cliff Claven

• Socialization key clue (Females)
• Significantly less likely to be referred to
  cardiac cath lab, thrombolytics, or angioplasty
• Increase index of suspicion

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Treatment of AMI

• Treatments, as always, are based on Symptoms
• Ectopy
• Pain
• Coronary Perfusion
• Container Problem
• Fluid (mis)placement problem

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Hospital Assessment of AMI

• Cardiac Enzymes
• Qualitative CPK (Creatine phosphokinase)
• CK-MB 0 4
• PEAK 12-24 H
• Troponin 0 0.1
• ONSET 1 4 H
• PEAK 12-24 H
• Significant ECG Changes
• Symptoms within 24 hours
• History (Surgeries)
• Candidate for Thrombolytics?

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Acute Left Ventricular Failure

• Acute LVF from heart disease
• 1 cause of heart failure.
• Assume the worst, hope for best
• Pt. with CAD w/ hx of MI (new or old)
• May develop LVF.
• Frequently LVF is only manifestation of AMI.

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LVF

• Common causes
• Systemic HTN
• Afterload
• Coronary artery disease
• Arteriosclerosis/atherosclerosis
• Ischemia
• Local/temporary occlusion

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LVF

• Common Causes
• Infarction
• Permanent, necrosis
• Significant Sized Infarct
• Decrease effective wall motion
• Decreased stroke volume
• Cardiomyopathy
• Diseased heart muscle tissue
• ETOH
• Enlargement

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LVF

• Causes
• Volume overload
• Bag of Potato Chips
• Severe anemia
• Hypoxemia

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LVF and Pulmonary Edema

• Incidence of CHF doubles per decade of life
• CO falls and pulmonary capillary pressure rises.
• Fluid move (interstitial alveolar)
• Lymphatic system fails to remove/filter.

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CHF

• Acute CHF
• Rapid
• Chronic CHF
• Slow
• Midnight shoppers

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Pulmonary edema results from

• CVA
• Pulmonary embolism
• Infection - Sepsis
• Allergy
• Inhalation of fumes
• Narcotic abuse
• Especially Inhaled (Heroin)
• Altitude sickness.

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Pulmonary Edema S/S

• Generalized weakness
• Fatigue
• Dyspnea
• Cyanosis
• Tachycardia

• JVD Indirect
• Increase B/P Pulse
• Chest pain
• Agitation
• Anxiety

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Pulmonary Edema S/S

• Tachypnea
• Orthopnea
• Paroxysmal Nocturnal Dyspnea
• Elevation of pulmonary venous cap pressures
• Wakening from sleep

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Pulmonary Edema S/S

• Noisy Labored Breathing
• Rales
• Wheezes
• Reflex airway spasm
• Cardiac asthma
• Rhonchi (larger airways)

• Coughing
• Blood Tinged Sputum
• Pink Frothy

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Cardiogenic Shock

• LV function compromised and CO falls
• S/S - Decompensating
• Systolic BP lt 80 mmHg
• Usually semiconscious
• Cold, clammy skin
• Mild to moderate cyanosis of lips and nail beds.
• EKG usually sinus tach

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Cardiogenic Shock

• Note If pt appears dehydrated
• (neck veins flat)
• Suspect hypovolemia.
• Fluid Resuscitation? Or Not?
• Hmmmmmmmmm.

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Right Ventricle Failure

• Leading Cause
• LVF
• MIs HTN mostly affect LV
• Isolated RVF
• Pulmonary HTN Cor Pulmonale
• RA / RV Infarct (Rare)
• Pulmonary and Mitral valve stenosis
• Pulmonary vascular HTN

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RVF Physiology

• Preload High
• RV cannot keep up
• Increased pressure in Big Veins
• Max stretch density reached
• Backflow in systemic circulation
• Fluid forced to interstitial spaces

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RVF S/S

• Neck Veins
• Semi-fowlers position (45 Degrees)
• Peripheral Edema
• Dependent edema
• Pitting edema
• Sacral (bedridden)
• Fluid Collection
• Ascites
• Pleural Effusion
• Pericardial Effusion

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RVF S/S

• Clubbing of fingers
• Chronic Hypoxia with RHF
• Most of the other LVF S/S also
• Cor Pulmonale
• SOB
• Tachypnea
• Anxiety
• Etc

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RVF S/S

• Liver Engorgement
• Big Belly (uneven to the right) Suspect
• Hx of MI
• Lasix
• Digoxin
• Enlarged Heart
• Weak Heart
• Bum Ticker

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Cor Pulmonale

• Hypertrophy of RV 2nd to Resp Disorder
• Acute PE 2nd to clot (R Heart)
• Clot / Occlusion
• Increase in pulmonary vascular resistance
• COPD Patients
• (High Right Heart Workload, High Risk)

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Cor Pulmonale S/S

• Sudden onset unexplained SOB
• Difficulty breathing
• HR elevated
• Chest pain with cough
• Dyspnea not aggravated by lying flat
• Cold
• Diaphoretic
• Cyanotic
• Neck veins may be distended

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Cor Pulmonale Case

• 58 yo male
• Hx of chronic bronchitis or emphysema
• Typical S/S of bronchitis
• Progression
• Deterioration of pulmonary capillaries
• Alveolar fibrosis
• Chronic hypoxemia

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Cor Pulmonale Case

• Progression
• Increase in pulmonary artery pressures
• Result RV afterload increase
• RV ill equipped
• RV Enlarges (Hypertrophy)
• Chronic RH HTN leads to RVF

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Cor Pulmonale Case

• Patient displays all signs of
• RVF
• Initial cause was pulmonary condition

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Hypertension

• Defined as BP gt 150/90 mmHg.
• Precise cause unknown for 90 pt.
• Acute Life-threatening Hypertension

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S/S Hypertensive Crisis

• Recent onset of H/A
• Altered mental status
• Signs of CHF
• BP usually gt 200/120

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So, What to do?

• Decide Sick/NotSick?
• Vitals
• Look
• Skin wet/dry, color, temp
• JVD
• Peripheral edema
• Subtle signs

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• Listen
• Breath sounds
• Bruit
• Pulse x 6
• Skin

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Treatment

• OMI
• Oxygen, Monitor, IV
• MONA - if appropriate
• Morphine, Oxygen, Nitro, ASA (Not in that order)
• Dont let patient walk!
• Position of comfort
• Reassure

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Treatment (cont.)

• IV Ntg, Nitroprusside if BP gt100 mmHG
• Dobutamine 2-10 ?g /kg/min if BP lt100
• Positive Pressure Ventilations
• Thrombolytics
• Dig if A-fib
• Angioplasty
• Bypass

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Treatment of RVF LVF

• CHF a circumstance not a Dx
• Treatment objectives
• Decrease myocardial
• Workload
• Oxygen demand
• Increase force efficiency of contraction
• Reduce fluid retention

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Treatment

• Decrease Workload
• No Physical activity
• Sitting upright
• Oxygen
• Pt may tolerate BVM
• CPAP
• BiPAP

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Treatment

• Vasodilatory Therapy (Nitrates)
• AMI reperfusion
• Container expansion reduces preload
• Morphine ?
• Reduce Fluid Retention
• Diuretics
• Lasix
• Bumex

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Treatment

• Increase Contractility
• Shock algorithm directs
• Dopamine
• Dobutamine
• Norepinephrine

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Acute Pulmonary Embolism
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Acute Pulmonary Embolism
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Defined

• Blockage in pulmonary artery
• Blocks pulmonary artery flow
• Supplied area ceases to function
• Decreased gas exchange
• V/Q mismatch

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Defined

• Typically a clot forms in deep veins of thighs
• Can also be fat or air

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History

• Anticoagulation therapy
• Heparin 1930s
• Streptokinase 1930
• Urokinase 1951
• 1960s Large study of clot resolution
• Recently TPA

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Incidence

• Unknown, range from 50,000-100,000/yr
• Higher than diagnosed, most diagnosed postmortem
• 8 death rate with heparin tx
• 1/3 will die within 1 hour

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Risk Factors

• Deep vein thrombosis
• Prolonged immobilization
• Surgery
• Trauma
• Pelvic or femur fractures
• Late pregnancy

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Risk Factors

• Thrombophlebitis
• Certain meds
• Oral contraceptives
• Atrial fibrillation
• Smoking
• Unknown

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Increasing Frequency

• Older population
• Malignancies
• More sedentary
• Heart failure
• COPD
• Surgical procedures

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Presentation

• Variable and Non-specific
• Dyspnea
• Pleuritic chest pain
• Syncope
• Hemoptysis
• RHF
• Tachycardia

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Presentation

• No physical findings significantly accurate
• Deep venous thrombosis in proximal lower ext.
  helpful for Dx
• Only about ½ source known

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Why doesnt lung tissue die from emboli like
heart muscle?

• Lung has two blood supplies
• Pulmonary and Bronchial
• Share capillary beds

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Pre-hospital Treatment

• Good Physical Exam and History
• Index of suspicion
• Airway
• High flow O2
• IV
• Rapid Transport

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Treatment ???

• Heparin
• Thrombolytic agents
• Streptokinase
• TPA
• Catheter fragmentation
• Catheter embolectomy
• Open-chest embolectomy

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Definitive Diagnosis

• ????
• Angiographic
• V/Q scan (venous/perfusion mismatch)
• Operative
• Multiple sources of evidence

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Differential Diagnosis

• Pneumonia
• Herpes Zoster
• Pleurisy
• COPD
• Rib fracture
• Asthma
• Angina
• MI
• Pneumothorax
• Pancreatitis
• Hepatitis
• Salicylate OD

• Bronchitis
• Hyperventilation
• Lung carcinoma
• Sepsis
• TB
• Muscle pain
• Costochondritis
• CA
• Pericarditis
• CHF
• Percardial tamponade

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Watch Out

• Extraordinarily difficult to diagnose
• Watch out for hyperventilation
• Young women

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GENERAL TREATMENT PLAN
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Fix any Volume Problem

• Fluid challenge
• 250-500 cc
• Any Change?
• Go to Meds

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Fix BP next

• lt70mmHg - Dopamine
• 70-100 mmHg - Dopamine, if D gt20 ?g, BP 90 can
  start Dobutamine
• 70-100 mmHg no shock sx, 250-500 cc then Dopamine
• gt100 mmHg in Pulmonary Edema, Ntg or
  Nitroprusside

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Fix Pulmonary Edema last

• Sit up
• High Flow O2, Intubation if needed
• Ntg, Ntg, Ntg
• MS
• Lasix, 0.5-1.0 mg/kg

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Summary

• AMI
• Pulmonary Edema
• LVF
• RVF
• Hypertensive
• What a mess!!!
• This is going to be confusing
• Differential Diagnosis is the key
• Treat/assume the worst hope for the best