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What does PAINE mean?
- P-Pneumonia, P.E., pericardial tampanade
- A-AMI, Angina
- E-Esophageal rupture/issues
What does MONA Mean?
What is PAINE used for?
It is a pneumonic for the possible causes for chest pain
What is MONA used for?
It is a pneumonic used for the treatment of cardiac chest pain
What is PEA?
PEA is any organized pulses organized rhythm (besides VT)
What are some Cardiac Risk Factors?
- Family History
- High Cholesterol
- Cigarette smoking
- Preexisting Cardiac Disease
- Cocaine use
- Carbohydrate Intolerance
What does Parietal mean?
Parietal means most superficial, toward the outside
What does Visceral mean?
Visceral means deep, more interior.
What is the Endocardium?
The Endocardium is the layer of tissue in the heart that actually touches the heart
What is the Myocardium?
The Myocardium is the muscle of the heart
What is the Visceral pericardium (Epicardium)
The Epicardium is the serous membrane that covers the heart
What is the Parietal Pericardium
The Parietal pericardium is the serous membrane lines the fibrous pericardium of the heart
What is the Fibrous pericardium?
The Fibrous pericardium is the Fibrous outer layer of the heart
What are the layers of the Pericardium superficial to interior.
- Fibrous pericardium
- Parietal layer of serous pericardium
- Pericardial Cavity (Where the Serous fluid is held)
- Visceral layer of serous pericardium (Epicardium)
- Myocardium (Cardiac muscles)
What is the purpose of the pericardial fluid (serous fluid)
What are the Cardiac Veins
- 4 Pulmonary veins
- 2 Superior and inferior vena cavae
- 1 Coronary Sinus
What is the coronary sinus?
The Coronary sinus is a collection of veins joined together to form a large vessel that collects blood from the myocardium of the heart. It delivers deoxygenated blood to the Right atrium in conjunction with the superior and inferior vena cave.
What are the chambers of the heart?
- Right and Left atrium
- Right and Left ventricular
What is the division of the septum?
The septum of the heart is separated into 2 sections, the Interatrial septum and the Interventricular septum
What is the Interatrial septum?
The Interatrial septum is the wall of tissue that separated the right and left atrium of the heart.
What is the Introventricular septum?
The Introventricular septum is the stout wall separating the left and right Ventricles of the heart
What is the electrical conductivity of the septum of the heart?
The septum of the heart is an electrically inert area, its a tendon like substance
What are the valves of the heart in order the way blood flows.
- Mitral (Bicuspid)
How many Tricuspid valves are in the heart?
There are 3 tricuspid valves in the heart. The Tricuspid, the Pulmonary and the Aortic valves are all tricuspid in structure
When do the Coronary arteries fill?
The Coronary arteries fill during diastole of the contraction.
What are the Semilunar valves?
The Semilunar Valves are the Aortic and the Pulmonary Valve
What does the Semilunar Valves do?
The Semilunar Valves permit blood to be forced into the arteries, but prevent back-flow of blood from the arteries into the ventricles.
What is the flow of blood through the peripheral circulation in the order of hat a red blood cell would take?
- Inferior/superior vena cava
What is the layers of the arteries and veins from superficial to interior?
- Tunica Adventitia
- Tunica Media
- Tunica Intima
What is the Tunica Intima (Tunica Interna)?
The Tunica Intima is the most inner Smooth, slick tissue in the arteries and veins
What is the Tunica Media?
The Tunica Media is the muscular tissue of the arteries and the veins
What are the Tunica Adventitia (Tunica externa)?
The Tunica Adventitia is the Outermost layer of the Arteries and the veins (loose connective tissue)
What is after load?
After load is the amount of pressure is the heart pushes against
What is Pre-load?
Pre-load is the amount of pressure on the ventricles of the heart and determines the amount of stretch
What is the Tunica Intima (Interna) made up of?
The Tunica Interna is made up of Epithelial cells
How is the Tunica Media regulated?
The Tunica Media is regulated by Sympathetic vasomotor nerve fibers
What is the Tunica Adventitia (Tunica externa) made up of?
The Tunica externa is made up of Connective tissue which is used as reinforcement
What are the types of Arteries?
- Conducting (Large)
- Distributing (Small to Medium)
- Arterioles (Smallest)
Why do large veins have valves?
Veins have arteries because Veins pressure is often not grate enough to over come gravity and other forces to return to the heart
What is an Arteriovenous Anastomoses (AV Shunt) (Thoroughfare channel)?
The AV Shunt is where the blood bypasses the capillaries.
What is the purpose of the coronary arteries?
The coronary arteries supply arterial blood to the heart muscle
What Coronary artery carries the majority of the blood to the heart?
The LCA (Left Coronary Artery) carries about 89% of the blood supply to the myocardium. The RCA (Right Coronary Artery) carries the remainder.
What are the divisions of the LCA?
The LCA divides into the and circumflex arteries
What is the purpose of the Left anterior descending?
The LAD supplies blood to the: Anterior wall of the left ventricle and the INTRAVENTRICULAR SEPTUM
What does the Circumflex Supply?
The Circumflex supplies the: Lateral and posterior portions of the ventricle and part of the Right ventricle.
How can you tell which side of the heart is the dominant side?
The dominant side of the heart is the side which has the artery that goes down the farthest on the posterior side of the heart
Where does the Coronary Arteries Originate?
The Coronary Arteries originate above the aortic valve.
What is the thickness of the Right side of the heart?
The right side of the heart is normally between 3-5mm thick
What is the thickness of the left side of the heart?
The left side of the heart is generally 13-15mm thick
What does the Right coronary artery an the left anterior descending artery supply?
The Right coronary artery and left coronary anterior descending artery supply a portion of the right atrium and right ventricle and the Inferior aspect of the left ventricle
What provides collateral circulation?
Anastomoses provide collateral circulation.
What is the formula for CO (Cardiac output)?
CO=HR X SV
What is the Acute marginal artery?
- The Acute marginal artery is the first major feeder coming off the coronary artery.
- It is also called the Right marginal artery
What is the Oblique marginal artery?
- The Oblique marginal artery is the second major feeder coming off the coronary artery
- It is also called the Left marginal artery
What is another name for the Posterior descending artery?
What is another name for the Anterior descending?
What is the path blood takes in the Coronary veins?
The blood travels from the coronary veins and then empty into the coronary sinus
Cardiovascular problems usually deal with what structures?
- The Pump (The heart)
- The Tank (The body, 3rd spacing)
- The Pipes (Veins)
What are all the structures a red blood cells pass in the heart?
Blood comes in the right atrium from the Superior and inferior vena cave. Then the blood goes through tricuspid valve into the right ventricle, then goes through the Pulmonary valve to the lungs to get oxygenated. The blood then comes from the lungs into the left atrium, passe through the mitral valve into the left ventricle. Once the blood is in the left ventricle it passes through the aortic valve into the aorta and the rest of the body.
What feeds the heart?
70% of the heart is fed by gravity, the other 30% is supplied by Cardiac kick
What does Chronotropic mean?
Chronotropic is the Strength of contraction of the heart
What does Inotropic mean?
Inotropic means the strength of contraction of the heart
What does Dronotropic mean?
Dronotropic means the speed of conduction of the heart
What is Stroke Volume (SV)?
Amount of blood ejected with every heart beat
What are some factors that effect SV?
- Preload (Venous return) (Most important factor)
- Myocardial Contraction
What is the most important factor in SV?
Preload is the most important factor
What is normal end-diastolic ventricular volume?
- Ejection fraction - 60-70% of the blood volume
What is Starling's Law of the Heart?
- Its the rubber band principle
- Myocardial fibers contract more forcefully when stretching
What is Afterload?
Afterload is the Peripheral vascular resistance. It the pressure the Ventricular muscle must overcome to open the aortic valve and push blood through
What are some factors that affect afterload?
- Pressure in the peripheral vasculature
- Compliance of the aorta
- Viscosity of blood
What is ischemia?
Ischemia is lack of sufficient O2 to a specific area of tissue
What is Hypoxia?
Hypoxia is the lack of O2 to the body in general
Which nerve has parasympathetic control to reduce contractility?
The vagus nerve
What Neurotransmitter provides parasympathetic control to decrease contractility?
Which neurotransmitter provides sympathetic stimulation to increase contractility?
What hormones are secreted from the adrenal medulla to increase contractility?
Epinephrine and norepinephrine
What is the normal amount of blood pumped in one minute?
~4-6 L (About a gallon)
What are the ANS cardiac influences on the heart?
- Contractility (Inortopic)
- HR (Chronotropic)
- Conductivity (Dromotropic)
What is the Autonomic nervous system?
The ANS is the part of the nervous system that controls involuntary actions of the smooth muscles, heart and glands
What is the sympathetic nervous system?
The Sympathetic system is the Fight or flight. It prepares the body for action.
What is the parasympathetic nervous system?
- The Parasympathetic nervous system is the resting nervous system.
- Rest and remerge
What is the Valsalva maneuver and how is it performed??
The Valsalva maneuver is performed by holding your breath and "bearing down". This works by stimulating the Vagus nerve
What is the postganglionic neurotransmitter in the sympathetic nervous system?
What are the Norepinephrine effects on the Myocardium?
- + Inotropic
- + Chronotropic
- + Dromotropic
- Increased automaticity
- Dilation of the coronary arteries
What are the effects norepinephrine has on peripheral vasculature?
Generalized constriction of peripheral vessels )INcreased O2 demands of the heart met by increasing blood supply
What are the effects the Parasympathetic nerve has on the heart by the vagus nerve?
Inhibitory influence on the heart by decreasing HR and contractility via release of Acetylcholine
What are the effects Epinephrine has on the myocardium?
- Basically the same as Norepinephrine, it stimulates the heart:
- + Inotropic
- + Chronotropic
- + Dromotropic
- Increased Automaticity
- Dilation of the coronary arteries
What the difference between the neurotransmitter Norepinephrine and the administration of the medication?
The same effects except with the medication the effects last a little longer
What are the the electrolytes that influence cardiac function?
What are the functions Calcium (Ca2+) take on the myocardium?
- (Most abundant Cation in the body)
- Help contribute to the positive charge in the cells
- Required for Contraction of muscles
- Affects the strength of contraction
What are the functions Potassium (K+) has on the heart?
- Important in conduction of electrical impulses and muscles contraction
- affects rate of contraction
- (Normal blood value is 3.5 - 5.0 mEq/L)
- (Major intercellular cation)(Affects the cardiac system easily due to leaky channels)
What are the functions Sodium (Na+) has on the heart?
- Important in conduction of electrical impulses and muscle contraction
- Affects rate of contraction
- (Major extracellular cation)
What does Magnesium (Mg2+) do to the myocardium?
It mediates intracellular K+ replenishment
How does the the parasympathetic nervous system innervate the heart?
By the Vagus nerve
What lead is the standard monitoring lead?
Lead II remains the "Standard" monitoring lead
What "View" does lead II take?
Lead II looks through the left ventricle back toward the right atria
What is the first simple thing we need to see for rhythm recognition?
We need to know if the rate is fast, normal, or slow
What is the second thing we must see (know) for simple rhythm recognition?
Is the ventricular rhythm regular or irregular?
What is the third thing we must see/know for simple rhythm recognition?
Is there a "P" wave? (Atrial depolarization)
What is the fourth thing we must see/know for simple rhythm recognition?
What is the PRI width?
What is the fifth thing we must see/know for rhythm recognition?
What is the QRS width?
What is the sixth thing we must see/know for simple rhythm recognition?
What is the "P" to "QRS" ® ratio?
What is the seventh thing we must see/know for rhythm recognition?
Are there "T" wave &/or ST segment changes
What is the normal QRS width?
What is the PBBB QRS width?
What is the BBB QRS width?
If there is no p wave what do we Know?
If there is no P wave we can't call it sinus
What is normal PRI?
Normal PRI is 0.12-0.20
Waveforms moving away from the red lead will have what kind of deflection?
Waveforms moving away from the red lead will have a (-) deflection
Waveforms moving toward the red lead will have what type of deflection?
Waveforms moving toward the red lead will have a (+)/upright deflection
Where is the PRI interval?
The PRI interval is from the start of the P wave to the start of the QRS interval
What is bradycardia?
Bradycardia is when a rhythm is lower than the lower limit for the pacemaker site.
What is an accelerated rate?
An accelerated rate is a rate greater then the higher range of the pace maker site, but still lower then 100BPM
What is Tachycardia?
Tachycardia is any rate higher then 100BPM
What is the rate that the AV Junction can resume?
What is a junctional rhythm that is higher than 60BPM called?
ACC (Accelerated junctional rhythm)
What is the definition of ACC junction?
A junctional rhythm from 60-100BPM
What is ACC Vent?
A rhythm genesis originating in the ventricles that is 40-100BPM
What is the rate range for a rhythm originating in the ventricles?
What is Ventricular bradycardia called?
Agonal (Ventricular rhythm <20)
What is a concern with Atrial flutter?
We don't want to "reset" the rhythm because it can throw clots
The term "Uncontrolled" is commonly used with what rhythm?
Commonly used with any rate with a genesis other than the SA node 100-150 BPM
The term "Rapid Ventricle Response" (RVR) is used when?
- For any rhythm/rate with a genesis other than the SA node
- >150 BPM
- Start worrying about coronary fill
SVT is generic for what?
AVT is generic for all rhythms above the ventricles in origin and are fast, and usually reserved for regular-regular rhythms
What is an escape rhythm?
- An escape rhythm is a rhythm from the AV junction and Ventricles that are in there normal rate
- AV junction 40-60 BPM
- Ventricles 20-40 BPM
Why is the RR elevated in the cardiac patient?
The cells aren't aren't getting enough O2 so the respiratory increases to compensate
What is the timing for the littlest boxes on the ECG?
What does ischemia look like on an ECG?
- T-wave changes,
- Hyperacute T-waves
- T-waves can become inverted
- Reversible damage
- If continues long enough you may see an ST segment depression below baseline
What does Injury look like on an ECG?
Noted by ST elevation typically
What does Infarct look like on an ECG?
Pathological Q-wave (0.04 sec normal Q-wave (1 tiny box) no deeper then 5 mm)
Cardiac Indications for Dopamine?
- Primary Indication is Cardiogenic shock, but may be useful in other forms of shock
- Bradycardia refractory to atropine, and when pacing is unavailable
Dopamine Cardiac indication doses?
IV infusion ONLY - Mix 400mg in 250cc D5W or NS to produce 1600 mcg/mL. Infusion rates [2-20mcg/kg/min] titrate to effect. Microdrip/pump only
Epinephrine cardiac Indications?
- Cardiac arrest
- Symptomatic bradycardia
Epinephrine cardiac indication doses?
- Cardiac arrest: [1mg (1:10000)] q 3-5min IV/IO/ET
- Bradycardia: [1mg (1:1000)] in 250cc NS administer @ 2-10 mcg/min
Atropine Cardiac Indications?
- Symptomatic sinus bradycardia or A-V blocks
- Bradycardia associated with PEA
Atropine Cardiac Indication Doses?
- Bradycardia: [0.5mg] IV q. 3-5min: Max 3mg (0.04 mg/kg)
- Asystole/PEA <60bpm: [1mg] RIVP/IO/ET(Dilute 2-3mg in 10cc for ET) q.3-5min
- Pulseless VF/VT refractory to initial electrical therapy
- Unstable VT refractory to lidocaine and/or electrical therapy
Amiodarone Indication doses?
- Pulseless VT/VF: [300mg] initial bolus IVP/IO after epi, may rebels once with [150mg]
- Sustained VT: [150mg] over 10min, may rebels every 10 min as needed up to a Max 15 mg/kg/day
- Maintenance infusion: [0.5mg/kg], 540mg IV over 18hrs
Lidocaine Hydrochloride (Xylocaine) Cardiac Indications?
- Symptomatic ventricular dysrhythmias
- Sustained Ventricular Tachycardia
- Ventricular fibrillation/pulseless ventricular tachycardia
Lidocaine Hydrochloride (Xylocaine) Cardiac Indication adult doses?
- IV Bolus: Ventricular tachycardia [1-1.5 mg/kg] IV. If VT persists, [0.5-0.75 mg/kg] every 3-5min up to 3mg/kg start infusion if VT converts- VF and pulseless VT [1-1.5mg/kg] IV/IO/ET followed by defibrillation. If VF or VT persists - repeat [0.5mg-0.75mg/kg](up to 3mg/kg total) followed by defibrillation. Start lidocaine infusion if VF converts
- IV Drip technique: A. Mix 1gm of lidocaine in 250mL D5W/NS for a concentration of 4mg/mL - 1. If up to 2 mg/kg has been administered (Set drip at 2mg/min) 2. If 2 mg/kg< has been administered (Set drip at 3mg/min) 3. If 3mg/kg< has been administered (Set drip at 4mg/min) B. A second bolus after 10min may be given per physicians order
- IM: [200mg] if unable to start IV
Lasix (Furosemide) Indication adult doses?
- [20-40mg] SIVP or [0.5-1mg/kg] SIVP
- If currently taking double PO dose, may repeat PRN
Adenosine (Adenocard) Indications?
Paroxysmal SVT, including PSVT associated with Wolff-Parkinson-White syndrome
Adenosine (Adenocard) Indication adult doses?
[6mg] RIVP followed by 30cc flush, may repeat in 1-2min with [12mg] and a third with [12mg] all followed by 30cc flush RIVP
Myocardial Infarction patients, Including suspected AMI patients
162mg-325mg (81mg X 4)
- Chest pain, anginal pain
- Congestive heart failure with severe pulmonary edema
Nitroglycerine Indication adult doses?
- Sublingual: [0.3-0.4mg] Tablet. Repeat @ 3-5 min as needed to a total of three tabs (or more by MCEP order)
- Lingual Spray: [0.4mg] metered dose, spray directly under the tongue; additional 1-2 sprays q. 3-5 min for a total of three sprays
- Infusion: [5-20mcg/min]
Morphine cardiac Indications?
- Treatment for acute pulmonary edema
- Sedation procedures
What does Enhanced Automaticity Cause?
- Excess catecholamines
- Digitalis toxicity
- Myocardial ischemia/Infarction
- Increased venous return (Preload)
- Hypokalemia r electrolyte abnormalities
- Atropine Administration
What is Reentry?
Reactivation of myocardial tissue by same impulse
When does Reentry occur?
- When electrical impulse is delayed, blocked in segments of the heart's electrical conduction system
- Requires a closed system to send information back around
Reentry dysrhythmias can occur in?
- SA node
- AV Junction
- Bundle branches
- Purkinje Fibers
What can a delayed or blocked impulse be caused by?
- Myocardial Ischemia
- Certain drugs
During adult CPR, a tidal volume of _______ should be adequate?
A Monophasic AEDs should deliver shocks @ _____?
Studies in anesthetized adults (With Normal Perfusion) Suggest that a tidal volume of ________ maintains normal O2 and elimination of CO2.
What does DR. PATS (5 patient rights) stand for?
- D = Right drug
- R = Right Route
- P = Right Patient
- A = Right amount
- T = Right time
- S = Right Scribe
To promote absorption of a medication following injection you would do what (Per VOSS)?
Message the site briefly
Subcutaneous injections can be given with what size needle + Angle?
Clean techniques focus on?
Where is the most suitable location for venipuncture?
What medication must you push the "print" bottom?
How long can you use a Multi-dose vial after the seal is broken?
What medication must be drawn slowly (Or shaken) to avoid "Bubbles"?
In what cardiac arrhythmia may atropine not be effective in treating bradycardia?
WPW syndrome (Wolff-Parkinson-White Syndrome)
What is the J joint?
The junction between the end of the QRS and the beginning of the ST segment
What segment is the best reference to baseline?
- The TP segment
- Do not compare ST segment to the PRI, PRI can be depressed making the ST look elevated
Where are the leads: V1-V6 placed?
- V1: 4th intercostal space right of the sternum
- V2: 4th intercostal space, left of the sternum
- V3: 4th intercostal slightly inferior to lead V2
- V4: 5th Intercostal just medial and inferior to the patients nipple (Gender pending)
- V5: Lateral chest inferior to V4
- V6: Lateral chest lateral to V5
Development of a Pathological Q-wave indicates what?
MI, with irreversible damage
What does T-wave inversion indicate?