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What is referred pain?
- Pain that is in another region other than where the injury or the source of where the injury actually is
- Normally associated with visceral organs
What is Orthopnea?
- Positional dyspnea
- Normally caused by :Angina, AMI, P.E.
What is Dyspnea?
What is Syncope?
- Loss of consciousness
- Brain isn't getting enough O2 or enough perfusion, Buroreceptor in the brain reading the perfusion pressure, this is what reads the pressure in the brain
What are Palpations?
- Extra beats
- Fluttery feeling
What is a Bruit?
Something we will hear in the carotid and listen for turbulent flow
What is pitting Edema?
- Excess fluid in the tissue
- Rated on a scale from +1-+4
- Normally caused by right sided heart failure
What is the most common cause of right sided heart failure?
Left sided failure
What is Ascites?
Excess fluid in the gut area
What is Hepatomelagy?
- Extended liver, tender upon palpation
- Normally caused by right sided heart failure
What is clubbing?
Inadequate blood flow to the extremities for a long period of time that changes the cells and capillaries
What is Orthostatics?
Checking BP in different positions (Lying, sitting and standing)
What is a positive orthostatic BP?
What is the ACLS ABC's?
- Differential diagnosis
What is the BLS ABC's?
What are the "Traditional" SXS of an AMI?
- Chest pain/heaviness
- Radiating pain
- Pale, cool, clammy
- Increased HR
- Sense of impending doom
What does P3AIN2E stand for?
- Paracardial tampanade
- Aortic dissection
- Esophageal rupture
What is PPPAINNE used for?
Reasins for chest pain
What is Paracarditis?
Swelling of the sac around the heart
What is Becks triad?
- Muffled heart sounds
- Narrowing pulse pressure
- Low BP
What 2 things dictate the name of a rhythm?
What are all the possible Single foci Genesis?
- Sinus (SA node)
- AV Junction (AV Node)
What is the of Kent?
- The bundle of Kent is an extra accessory conduction pathway between the atria and the ventricle in the heart.
- It is an Abnormal pathway, this pathway is a "bundle" of connective tissue that may be either between the right atrium and the right ventricle, or the left atrium and the left ventricle
- Causes WPW
What is WPW syndrome?
WPW Syndrome is a pre-excitation of the ventricles caused by the Bindle of Kent
What is the bundle of james, or james bundle?
- Pre-excitation of the ventricles do to an accessory pathway providing an abnormal electrical communication from the atria to the ventricles
- Causes LGL (Lown-Ganong-Levine syndrome)
What does a Ventricular genesis look like on lead II ECG?
- Wide QRS
- Questionable or inverted P-wave
What does a AV Junctional Genesis look like in lead II on the ECG?
- (-) or biphasic P-wave (Little up or little down)
- Narrow QRS
- 1:1 P/QRS
What does an atrial genesis look like in lead 2 on the ECG?
- (+) P-Wave
- P-Wave may be difficult to see
What is Bezold-Jarish Reflex?
- Involves a variety of cardiovascular and neurological protective precesses which cause hypopnea and bradycardia
- This happens when the SA node is not being fed well
- Normally caused by Right sided cardiovascular disease
What is an Agonal Rhythm?
Any Rhythm with a rate <20BPM
Explain Ventricular Escape.
Ventricular Escape is a rhythm genesis in the Ventricles with a rate between 20-40 BPM
Explain ACC Vent escape.
ACC Vent (Accelerated Ventricular) is a rhythm genesis in the ventricles with a rate above the normal rate for that foci between 40-100 BPM
Explain Uncontrolled Ventricular escape.
Uncontrolled Ventricular escape is a rhythm with a genesis in the ventricles with a rate above the max ACC Vent rate between 100-150 BPM
Explain VT w/RVR.
- VT with RVR is a rhythm genesis in the ventricles that is above the uncontrolled VT rate
- VT w/RVR has a rate 150 BPM<
Explain Junctional Bradycardia.
- Junctional Bradycardia is a rhythm with a genesis at the AV node with a rate below the "Normal" for the rate for that foci
- Junctional bradycardia rate is between 20-40 BPM
Explain Junctional escape.
Junctional escape is a rhythm with a genesis at the AV junctional with a rate between 40-60 BPM
Explain ACC Junctional Escape.
ACC Junctional Escape is a rhythm with a genesis at the AV junction with a rate 60-100
Explain Uncontrolled Junctional tachycardia.
Uncontrolled Junctional tachycardia is a rhythm with a genesis at the AV junction with an elevated rate between 100-150 BPM
Explain Junctional Tachycardia w/RVR.
Junctional Tachycardia w/RVR is a rhythm genesis at the AV Junctional with an elevated rate at 150 BPM<
Explain Sinus Bradycardia.
Sinus bradycardia is a rhythm with a genesis at the SA node with a decreased rate below 60 BPM
Explain Regular Sinus.
Regular sinus is a rhythm with a genesis at the SA node with a rate between 60-100 BPM
Explain Sinus Tachycardia.
Sinus Tachycardia is any rhythm with a genesis at the SA node with a rate 100 BPM<
What is the heart sound S1?
- The first heart sound
- Sounds like a "LUBB" caused by a sudden block of reverse blood flow due to the closing of the atrioventricle valves in the heart
What is the S2 heart sound?
- The second heart tone, or S2 forms the "DUB" sound in "LUBB-DUB"
- It is caused by the reversal of blood flow do to the closure of the Aortic and the pulmonary valves and the end of systole
- A split S2 can be associated with several different cardiovascular conditions
What is the third heart sound (S3)?
- S3 is rare and is also called preodiastolic gallop or ventricular gallop
- It occur at the beginning of diastole, and sometimes in pregnancy but if it re-emerges later in life it may signal a cardiac problem like failing left ventricle
- It is thought to be caused by blood passing back and fourth between the wall of the ventricles initiated by inrushing blood from the atria
- Distinguished between left and right, right side S3 will increase on inspiration, left side S3 will increase on expiration
What is the fourth heart sound S4?
- S4 is the sound heard at the end of diastole just after atrial contraction (Atrial kick) just before S1
- It is caused by the sound of blood being forced into a stiff/hypertrophic ventricle (During ventricular fill)
What does STEMI stand for?
ST Elevation Myocardial Infarction
What is Atherosclerosis?
Thickening, hardening, and loss of elasticity of the arterial walls
What is a Stenotic Lesion?
- Plaque begins to accolade the inner part of the vessel
- Stable angina
What is a Non-stenotic Lesion?
- Doesn't affect the inner part of the vessel plaque extends out
- More likely to cause AMI than a Stenotic Legion
What is a Thrombus?
A thrombus is a blood clot formed within the vascular system of the body and impeding blood flow
What is an Emboli?
a blood clot, air bubble, piece of fatty deposit, or other object that has been carried in the bloodstream to lodge in a vessel and cause an embolism
Port-a-cath is used for what?
Implantable access like a insulin pump
Subclaivian is used for what kind of access?
Central Venous canulation.
What are the 5 H's to assess the possible causes for cardiac arrest?
- Hypovolemia - A lack of blood volume
- Hypoxia - A lack of oxygen
- Hydrogen ions (Acidosis) - An abnormal pH in the body
- Hyperkalemia or Hypokalemia - Both excess and inadequate potassium can be life-threatening.
- Hypothermia - A low core body temperature
- Hypoglycemia or Hyperglycemia - Low or high blood glucose
What are the its?
- Tablets or Toxins
- Cardiac Tamponade - Fluid building around the heart
- Tension pneumothorax - A collapsed lung
- Thrombosis (Myocardial infarction) - Heart attack
- Thromboembolism (Pulmonary embolism) - A blood clot in the lung
What is the effects of Atherosclerosis?
- Disrupts intimal surface, causing loss of vessel elasticity and increase in thrombogenesis
- Decrease blood supple to the tissues
- Atheroma reduces diameter of vessel lumen
What is the MOST common cause of acute coronary syndrome?
Rupture of atherosclerotic
What are the perameters for a STEMI?
- ST elevation greater than 1mm
- (Has to be present in 2 or more concordant leads)
What are the perameters of a Non-STEMI?
- Depression of the ST segment of <0.5mm
- (Has to be present in 2 or more concordant leads)
What are the parameters of UA (unstable angina)?
- ST segment changes between 0.5mm-1mm
- (Has to be present in 2 or more concordant leads)
What are the "normal" parameters for the Q-wave?
- 0.04sec wide
- 5mm tall/deep
According to the Cardiologist when is Amioderone better to use?
- Better on non-ischemic tissue, so not on the emergent patient
- It also bubbles when you draw it up
According to Voss, when is a 12-lead ECG more valuable?
In the off hours, anytime other than 8am-5pm
Magnesium Cardiac Indications?
- Second-line antidysrhythmic in the treatment of ventricular fibrillation/pulseless ventricular tachycardia (refractory to lidocaine)
- VT refractory to lidocaine, Ventricular ectopy refractory to lidocaine
- First-line antidysrhthmic in the treatment Torsades de Pointes
What are the cardiac doses for magnesium sulfate?
- Ventricular ectopy refractory to lidocaine [2gm] SIVP
- Pulseless VF/VF refractory to lidocaine [2gm] IVP followed by DFib @ 360 - 400J
- VT or wide complex tachycardia unresponsive to lidocaine [2gm]SIVP
- Torsades de Pointes [2gm] IVP
Abnormal decrease in systolic BP (10-15mmHg) drops during inspiration compared to expiration
What is a pulse deficit?
When the radial pulse is less then the ventricular rate, indicates a lack of peripheral perfusion.
Arterial pulse wave form alternates strong/weak, indicates left ventricular systolic impairment, caries a very bad prognosis
Morphine Cardiac indication adult doses?
[2-10mg] SIVP until desired effect achieved (Use lowest effective dose to avoid complications)
Sodium Bicarbonate Indications?
- To correct metabolic acidosis found during prolonged cardiac arrest after initial interventions
- May be used as an adjunct in other causes of metabolic acidosis
- Overdose of TCA's or phenobarbital
Sodium Bicarbonate Indication dosing?
- Cardiac Arrest: [1 mEq/kg] IVP initially, then [0.5 mEq/kg] no more than 1 amp. Every 10 min until pulse is restored or as indication by ABGs.
- Other special circumstances, such as TCA OD: [1 mEq/kg IVP single dose per Dr order
What indicates a significant cardiac phenomenon with the ST segment?
ST elevation greater then 1mm indicates a significant cardiac phenomenon
What are some symptoms of Myocardial ischemia caused by Angina Pectoris?
- "Choking pain in the chest"
- Pressure/squeezing/heaviness/tightness in the chest (30% only feel chest pain) Some describe it as radiating to shoulders, arms, neck, jaw and through the back
- Usually associated with: Anxiety, SOB, N/V, Diaphoresis
What is the problem in Angina pectoris?
- Imbalance between myocardial O2 supply and demand
- Atherosclerotic disease of the coronary arteries, typically a stenotic lesion, may be a new onset MI
What causes pain in the myocardium/general tissue when ischemia is happening?
Accumulation of lactic acid and carbon dioxide, Metabolites irritate nerve endings and produce pain
What is Prinzmetal's angina?
- Also called Variant Angina
- Temporary occlusion due to coronary artery spasm with or without atherosclerosis
- Still a O2 supply/demand problem
- Common in Not well hydrated athletes, and high caffeine users
Define 3 features of "Classic" Stable angina?
- Discomfort thats squeezing, heavy or tight
- Precipitated by exertion or emotion
- Relieved by rest or nitro
Break down Typical, Atypical, Noncardiac "Classic" Angina by defined features.
- Typical Angina: All 3 features present
- Atypical Angina: 2 features present
- Noncardiac: 1 or no features present
Stable Angina Cause?
- Usually caused by physical exertion or emotional stress
- Pain last 1-5 min but may last as long as 15min
- Usually have "Attacks" of the same nature
- Always relieved by the same therapy (Rest, Nitro or O2)
What is Pleuritic pain?
Pain that gets worse when the breath
What features are not typical of MI?
- Pleuritic pain
- Primary middle/low abdominal pain
- Pain localized by tip of 1 finger (Somatic)
- Constant pain lasting hours to days thats not getting better or worse
- Brief episodes of a few seconds or less
- Pain radiating to distal extremities
What is Unstable Angina?
- New onset angina: (Any new Anginal chest pain)
- Rest Angina: (Lasting longer than 15-20min)
- Nacturnal Angina: (Awakens patient at night)
- Accelerating Angina: (Anginal pattern that has changed in its ease of onset, frequency, intensity, duration, or quality.
Unstable Angina Management?
- Place patient at rest: Administer O2 and aspirin (Per protocol)
- Monitor ECG (12-lead)
- Transport as soon as possible to an appropriate facility : IV therapy Pharmacology therapy (Nitro, Morphine)
- Fibrinolytic Screening
Define a Myocardial Infarction.
- Sudden and total occlusion or near occlusion of blood flowing through affected coronary artery
- Unlike Angina, MI causes tissue death
- The location of the occlusion effects the severity of the MI (Distal VS. Proximal)
In which direction does the heart depolarize?
The heart depolarizes from the inside out, slowly and in blocks in several phases, the endocardial cells start depolarizing first but finish last, the Pericardial cells finish depolarization first
What is Subepicardial or Transmural Ischemia?
Deep or through and through Ischemia: Recovery is delayed in the subepicardial layers, and the subendocardial muscle fibers seem to recover first (Abnormal depolarization, check the lead groups for T-wave inversion)
What is R-wave progression?
- R-Wave progression is the Progression of the R-Wave through the leads V1-V6
- V1 should have a little R-Wave and a big S-wave
- V2 should have a little R-Wave and a big S-Wave
- V3 Biphasic R wave, should have an R-Wave atleast 2mm tall for a healthy R-Wave progression
- V4 Biphasic R wave, should have an R-Wave atlas 2mm tall for a healthy R-Wave progression
- V1-V6 R-Wave gets larger and larger
What is Healthy R-Wave progression?
R-Wave progression must occur by V3 or V4 for a healthy R-Wave progression, can be early or late.
How is Subendocardial injury manifested on the ECG?
ST Segment Depression
How is Subepicardial or Transmural injury manifested?
ST segment elevation
What is Infarction?
- Cell death due to Anoxia. Most commonly caused by atherosclerosis
- NOT reversible
- Can be caused by: Thrombus, Embolus, Vasospasm (Variant MI)
What is the progression to Infarction?
- Anaerobic Metabolism
- Lactic acid production
- Decrease in ATP
- Electrolyte Imbalance
- Cell lysis
- Release of toxic byproducts
What is Q-Wave Infarction?
- AKA: Transmural Infarction
- Most characteristic finding of transmural myocardial infarction of the left venatical
- Prolonged Q-wave (longer than 0.04sec, and 5mm deep)
- Q-Wave change occurs when infarcted muscle is electrically inert
In what leads should the T-Wave always be positive?
- Leads: I, II, V3-V6
- Depression = Ischemia
- Elevation = Infarct
When is Non-Q Wave Infarction diagnosed?
Diagnosed in the presence of ST depression and T-wave abnormalities
What is an Ischemic Penumbra?
- Like an umbrella, showing various stages of myocardial damage of injury
- Progresses from center out, center being the most damaged
- Innermost: Zone of infarct
- Middle: Zone of injury
- Outer: Zone of ischemia
- Remember to treat the patient not the monitor!
How is the size of the infarction determined?
- Metabolic needs of the tissue supplied by the occluded vessel
- Collateral circulation
- Time until flow is reestablished (90min goal)
- The greater the number of leads showing indicative changes shows a larger MI
What is an Indicative change?
- A change in the rhythm in the leads, significant in 2 or more anatomically contiguous leads
- If they are Uninvolved in other leads they are Reciprocal changes a "Mirror Image" change
2 leads are contiguous if:
- They look at the same area of the heart
- They are numerically consecutive precordial leads
What is a Reciprocal change?
- It is a "Mirror image" looking at the posterior section of the heart,
- Posterior MI is a distal infarct
Where do Most AMIs occur?
- Most AMI's involve the left ventricle or Interventricular septum: Supplied by either of the major coronary arteries
- Some patients sustain damage to the right ventricle
What leads look at the inferior side of the heart?
Leads: II, III, aVF
What leads look at the Septal section of the heart?
What leads look at the Anterior side of the heart?
What leads look at the lateral side of the heart?
What three Ischemic Syndromes are based on rupture of unstable plaque in an epicardial artery?
- UA (Unstable Angina)
- NSTEMI (Non-ST-Elevation-MI)
What are some Myocardial tissue ruptures can cause Sudden Cardia Death?
- Papillary muscle
- Pain similar to angina (May radiate to arms, neck, jaw or back
- Sense of impending doom
AMI ECG Findings?
- STEMI: ST elevation >1mm in 2 adjacent leads, New onset LBBB
- High-risk UA/NSTEMI: ST segment depression >0.5mm lasting 20min, Transient ST elevation >0.5mm but <1mm, T-wave inversion with pain
- Normal or nondiagnostic ECG changes: Inconclusive changes, ST segment variation of <0.5mm
What are some AMI ECG Imposters?
- Left bundle brach block
- Some ventricular rhythms
- Left Ventricular Hypertrophy
- Ventricular aneurysm
- Early Repolarization
An Inferior Wall Infarction is involved with what artery? What leads will see it?
- Leads: II, III, aVF
- Involved with the Right Coronary Artery
If there is an Infarction in the septal wall, what leads would present it and what coronary artery would be Involved?
- Leads V1, V2 would present the Infarction
- The Left Coronary artery would be involved
If there is an Infarction on the Anterior wall of the heart what leads would present the infarction and what coronary artery would be involved?
- Leads: V3, V4 would present it
- The Left Coronary Artery would be involved
If there were an Infarction in the Lateral wall of the heart what leads would present it and what coronary artery would be involved?
- Leads: I, aVL, V5, V6
- The left coronary artery would be involved
If there were an infarction on the Right ventricle what leads would present the infarction and what coronary artery would be involved?
- Leads: V4R, V5R, V6R
- The right coronary artery would be involved
What is GIK?
- Glucose, Insulin, Potassium
- Studies have shown GIK can minimize heart muscle damage
What is CABG?
Coronary artery bypass graft
How many conduit branch bundles are on the left side of the heart?
2: Left Anterior Fascicle and the Left Anterior Fascicle
What does CARIE stand for and what is it used for?
- Irritability (Excitability)
- Elasticity (Contractility)
- This is used to remember the characteristics of the Myocardial Cells
What Myocardial Cell works as a working cardiac cell, but not a pacemaker cell?
What is a Solvent?
The Liquid in which a solute is dissolved to form a solution - A liquid, typically other than water, used for dissolving substances
What is a Solute?
The minor component in a solution, dissolved in the solvent
What (For our purposes) is a mEq/L? one thousandth of a gram (1mg) dissolved in 1cc of a normal solution
What is an ION?
Charged particles that are electrically (+) or (-)
What is an Cation?
What is an Anion?
What is the charge of the intracellular space?
(-) Relative to the outside
What is Potential energy?
Magnetic-like attraction gives separated particles (ions) of the opposite charges "Potential energy"
What is passive transport?
Diffusion/Osmosis, requires no energy
What is the active transport in the myocardial cells?
- Requires energy
What is Resting Membrane Potential?
- Cell in "Resting" State
- Inside the cell is negative compared to the outside of the cell membrane
What is electrical conduction = to?
What Foci of rhythm genesis takes the least energy to cause a change in the molecules?
What is the Permeability of the Myocardial cell membrane?
- Relatively permeable to K+ (Leaks out constantly)
- Less permeable to than it is K+, but more permeable than Na+ (Slow channel)
- Minimally permeable to Na+ (Channels open and close with changes in membrane potential - Fast channel)
What is the Sodium-Potassium Pump?
- The Sodium-Potassium Pump actively pumps sodium ions out of the cell and potassium into the cell
- Transports 3 Na+ out for every 2 K+ in
- Returns cell to "resting state"
What is Phase O of the Cardiac action potential?
- Fast Na+ channels open momentarily
- Rapid depolarization
What is Phase 1 of the Cardiac action potential
- Rapid Repolarization
- Fast Na+ channels close
- K+ leaves cell
What is Phase 1 of the Cardiac action potential?
- Slow Ca++ channels open
- K+ still leaving
What is phase 4 of the cardia action potential?
- Final Repolarization
- Slow Ca++ channels close
- K+ still leaving
What is phase 4 of the cardiac action potential?
- Sodium-Potassium pump is activated (K+ is pumped in, Na+ id pumped out 3Na+:2K+)
When is the Absolute Refractory period?
Between like 0.4-1.2 of the Cardia action potential
When is the Relative Refractory Period?
Between 1.2-3.4 of the cardiac action potential
What is the name of the interatrial bundle?
What does Ectopic mean?
Out of place
What are the 2 causes of Ectopic beats?
- Enhanced automaticity
What does Enhanced Automaticity result in?
- Acceleration in depolarization (Due to high leakage of the sodium ions into the cell)
- Cells reach threshold prematurely (Rate of impulse formation in potential pacemakers increases beyond their inherent rate)
- Causes dysrhythmias in Purkinje fibers and other myocardial cells
What is aspiration?
Pulling back on the plunger to ensure that the needle is not in a vessel
Tuberculin syringes are marked in what?
Per Voss, When administering medication IM, you must hold the skin how?
Hold the skin taut
After administering a med via the Nasogastric tube you must _____?
Flush the medication with 30cc of water
What is the best position to locate the Jugular vein?
Head down and turned away from you
What is the primary cardiac indication for Morohine?
Chest pain unresponsive to Nitro
Meds administers IM, IV or IO is called?
Sterilization is recommended for?
Instruments or devises that penetrate the skin
Is the heart a double sided pump?
What is the anatomical structure that holds the AV valves anchored to the Myocardium?
During the period between action potentials what in excess in the cell?
There is excess in the cell
Preload is defined as?
Ventricular end-Diastolic Volume
The visceral pericardium that covers the heart is called what?
What is the primary purpose of the Capillaries?
Allow for the exchange of nutrients and metabolic wastes
The Ventricles of the heart are innervated mainly by what kind of nerve fibers?
Sympathetic nerve fibers
Termination phase of rapid depolarization is what phase of the cardiac action potential?
What is the primary Intracellular cation?
What is the primary Extracellular Cation?
How deep should compressions be during CPR?
A group of nerves that innervate the atria and the ventricles is the?
A patient with Jugular Vein Distention (JVD) should position themselves how?
With the head elevated 45-degrees
What is the Tunica Intima made up of?
What is Tunica Media made up of?
Elastic tissue and Smooth muscle
What is the Tunica Adventitia made up of?
What is usual Q-T Interval?