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What is the cardiac response to ↓ Contractility?
↑ HR
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What is the cardiac response to hypoxia?
Pulmonary arteries constrict (pulmonary hypertension)
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What is the cardiac response to ↓ systemic perfusion?
- Blood vessels constrict
- Except in neurogenic, spinal, septic, & anaphylactic shock!
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With systemic ↑ in vasoconstriction what will happen to cardiac output?
↓
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What is normal CO (Cardiac Output) and what is the equation to find this?
- Normal CO is 4-8 L/min
- CO=HR X SV
- Lung minute volume (Ve) is also 4-8 L/m
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What effects SV (Stroke Volume)?
- Preload
- Contractility
- Afterload
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What is Preload?
- The load that stretches cardiac tissue BEFORE contraction
- Amount of blood returned to the right heart from the body
- Amount of blood returned to the left heart from the lungs.
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What is Contractility?
The intrinsic ability of the heart/myocardium to contract
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What does Frank-Starling law state?
- Stroke volume from the heart increases to an increase of the volume of blood filling the heart.
- Bigger stretch... Bigger contraction.
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Define Afterload.
The degree of vascular resistance to ventricular contraction
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What affects right heart afterload?
Pulmonary Arteries (PVR)
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What affects left heart afterload?
Systemic vascular resistance (SVR)
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What does Systemic Vascular Resistance measure?
Afterload of the heart
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What is the normal Systemic Vascular Resistance (SVR) measurement?
800 - 1200 dynes
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What conditions are associated with ↑ SVR?
- Hypothermia
- Hypovolemic shock
- Decreased CO
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What conditions are associated with ↓ SVR?
- Anaphylaxis
- Neurogenic (distributive) Shock
- Septic Shock
- Vasodilating drugs
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What are your S1 & S2 heart sounds?
- S1: Lub
- S2: Dub
- This is normal heart sounds
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What is associated with S3 heart sounds? What is a common cause of this?
- S1: Ken
- S2: Tuck
- S3: Y
- Congestive Heart Failure
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What do we associate with S4 heart sounds? What is a common cause?
- S4: Tenn
- S2: E
- S2: See
- Myocardial Infarction
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What does the Right Coronary Artery (RCA) supply?
- Right Ventricle
- 60% of populations SA Node
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What tripe of MI is associated with the RCA?
Inferior MI
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Why is bradycardia associated with an Inferior MI?
Due to SA node involvement
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Why is a complete blockage of the LCA called the "widow maker"?
Because it would occlude both the LAD and LCX.
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Define a STEMI.
ST elevation in 2 contiguous leads > 2mm
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What is often associated with a new onset LBBB?
STEMI
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Will a STEMI have (+) cardiac markers/enzymes?
Yes
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Will a Non-STEMI have (+) cardiac markers/enzymes?
Yes
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Define a Non-STEMI.
ST depression or dynamic T wave changes in 2 contiguous leads
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What causes ST wave depression?
lack of O2 (either now or an old infarct)
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What are dynamic T waves?
T wave inversion
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Define Unstable Angina.
Angina NOT relieved by rest, nitro, or has different qualities than pt "normal" chest pain.
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What leads would show Inferior MI?
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What leads would show Anteroseptal MI?
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What leads would show Lateral MI?
- I
- aVL
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Define PAILS
- Posterior
- Anterior
- Inferior
- Lateral
- Septal
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What EKG leads are associated with the posterior location?
- Reciprocal changes in:
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What EKG leads are associated with the anterior location?
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What EKG leads are associated with the Inferior location?
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What EKG leads are associated with the lateral location?
I, aVL,
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What EKG leads are associated with the septal location?
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What vessel is affected in a posterior MI?
Left Circumflex (LCX)
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What vessel is affected in a anterior MI?
Left Anterior Descending (LAD)
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What vessel is affected in a inferior MI?
Right Coronary Artery RCA
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What vessel is affected in a lateral MI?
Left Circumflex (LCX)
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What vessel is affected in a septal MI?
Left Anterior Descending (LAD)
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What is the treatment for a posterior MI?
MONA
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What is the treatment for an anterior MI?
MONA
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What is the treatment for an inferior MI?
- 2L Fluid Challenge
- NO Nitro! NO Beta Blockers!
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What is the treatment for a lateral MI?
MONA
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What is the treatment for a septal MI?
MONA
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Which lead do we look for Bundle Branch Blocks?
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What will a RBBB look like in ?
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What will a LBBB look like in ?
- DOWN
- QRS > 0.12
- Rabbit Ears
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What is associated with a new onset LBBB?
AMI
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What do I want to check with LBBB?
Cardiac markers/enzymes
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What do Beta Blockers do in treating an MI?
- Reduce HR
- Reduces myocardial O2 Demand
- Do not use for bi-fasicular blocks or BBBs
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What is Adenosine used for in ACLS? What is the dose?
- Narrow complex SVT
- Dose: 6mg/12mg
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What is Amiodarone used for in ACLS? What is the dose?
- V/F & Pulseless V-Tach
- 300mg (1st dose)/150mg (2nd dose)
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What is Dopamine used for in ACLS? What is the dose?
- Second line for bradycardia & hypotension
- 2-20mcg/kg/min
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What is Vasopressin used for in ACLS? What is the dose?
- Alternate pressor to Epi/Septic Shock
- 40 Units (only 1 dose)
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Name 3 Sodium Channel Blockers. What do they do?
- Lidocaine, Phenytoin, Procainamide
- Interferes with Sodium (Na+) Channels
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Name 6 Beta Blockers.
- Carvedilol
- Labetolol
- Propanolol
- Timolol
- Esmolol
- Metoprolol
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What two cardiac issues would you not use a Beta Blocker?
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What electrolyte does Amiodarone affect?
Potassium (K+) efflux
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What drug is used for patients in profound hypotension?
Levophed (NorEpi)
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What does Nitroprusside do? What can it cause?
- Reduces preload and after load by dilation
- Can cause cyanide toxicity
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What affects do Levophed have on the vascular?
- Increase SVR
- Vasoconstricts
- increases preload
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What affect does Nitroprusside (Nipride) have on the vasculature?
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What drugs decrease preload (vasodilator)
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What is the main absolute contraindication to Fibronolytics?
Non-compressible hemorrhage
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What is PTCA?
- Percutaneous
- Trans
- Luminal
- Coronary
- Angioplasty
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What is a GP2B3A inhibitor?
- Prevents platelet activity.
- Can be titrated
- Half-life of 8 hours
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What are 3 examples of GP2B3A inhibitors?
- Reopro
- Integrilin
- Aggrastat
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What do we do after cardiac catheter is removed?
Keep leg straight and hold pressure for 30 minutes.
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What is a CABG?
- Cardiac
- Artery
- Bypass
- Graft
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What is variant angina?
- Chest pain at rest, has circadian rhythm (mostly in the morning)
- Most often seen in women
- Treated with Nitro and CCBs
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What is Silent angina?
- No pain
- Evidence of ischemia on EKG (ST depression)
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What should be done if a heart transplant patient is decompensating?
- Immediate cardioversion
- Normal Saline & Dopamine with bradycardia
- NO Atropine (it won't work)
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What is Endocarditis?
Inflammation on the inside of the heart
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What is the #1 cause of Endocarditis?
IV drug use
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What are signs of Endocarditis?
- New Murmur
- Osler Nodes (painful red fingertips)
- Janeway Lesions (Red lesions on palm and soles)
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What is pericarditis?
- Inflammation on the outside of the heart
- Substernal chest pain when breathing or laying supine (pericardium rubs against the sternum)
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What is the most common cause of pericarditis?
Idiopathic (80%)
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When do you see Uremic Pericarditis?
Pt who is undergoing dialysis due to renal failure
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What is Dressler's Syndrome?
Pericarditis occurring post MI/ post cardiac surgery
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What EKG finding is true of Pericarditis? What do we use to treat it?
- Global ST Elevation
- NSAIDS (IndocinColchicine)
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How do CHF pts present?
- progressive dyspnea
- coughing up pink frothy sputum
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What is the most common cause of right heart failure?
Left heart failure
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What would you see on a CHF pts X-ray?
Butterfly pattern/ Kerley B Lines, Bilateral Diffuse Infiltrates
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What will you see on a CHF pt blood work?
- BNP (B-type Natriuretic Peptide) increase
- BNP = CHF
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What is the most important drug therapy for the CHF pt?
Lasix
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What is the tell tale description of an Aortic Dissection?
- Ripping or Tearing between shoulder blades
- Could also present in stomach or chest
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Where is the most common site for an aortic dissection?
Ascending Aorta
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What would a pt X-ray show in an Aortic Dissection?
- Widened mediastinum
- Loss of aortic knob
- pleural effusion
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What is the drug treatment for Aortic Dissection?
- 1st with Beta Blockers (Labetalol)
- 2nd with Vasodilators (Nitroprusside)
- Pain Meds (Morphine, Fentanyl, Ketamine)
- Restrict fluids unless hypotensive
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What does a Swan-Ganz catheter used to measure?
How much pressure blood is under when it enters the Pulmonary artery.
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What part of the Swan-Ganz catheter is used to measure pressures?
Distal tip
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How much air is in the distal cuff of the Swan-Ganz catheter?
1.5cc of air
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How long can we take wedge pressure readings?
No longer than 15 seconds or 3 breaths
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When do we take our PAWP readings?
At the end of respirations
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When transporting a pt with a PA cath what should we do with the distal cuff?
Prevents inadvertent wedge pressure
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What is the difference between PAWP, PAOP, & PACP?
Nothing. They are the same thing.
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What is CVP (Central Venous Pressure)? What is the normal value?
- Right atrial pressure
- 2-6 mmHg
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What is RV (Right Ventricular)? What is the normal value?
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