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86 Cards in this Set
- Front
- Back
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What is Coronary Artery Disease (CAD)?
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The most common form of heart disease and the leading cause of death in Canada.
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What happens?
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The coronary arteries become narrowed and deprive the myocardium of the oxygen it needs to function. The tissue then becomes ischemic and eventually under go infarction.
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What is atherosclerosis?
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Small amounts of fat are deposited on the inner wall of arteries. This leads to them becoming narrowed. Blood clots or a thrombus can form here and may lead to the total occlusion of the vessel.
Calcium can also be deposited which reduces the elasticity of the arteries. |
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What is Angina Pectoris?
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Angina occurs when the supply of oxygen to the myocardium is insufficient to meet the demand.
As a result the cardiac muscle becomes ischemic. |
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Why is supply and demand the key?
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A person with heart disease may have adequate supply of O2 at rest but under stress or exercise this may not be the case.
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What is it important to determine when asking history questions?
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Try to determine if the patient has stable angina or unstable angina.
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What is stable angina?
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Follows a recurrent pattern. IE pain after a certain amount of exertion.
Patients with stable angina often take nitro for relief of anginal pain. |
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What is unstable angina?
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Much more serious as it implies that there is a greater degree of obstruction of the coronary arteries.
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How does a patient with unstable angina present?
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Patient may report that changes in frequency, severity and duration of pain. Perhaps occur without stress.
Such attacks are often a warning sign of an impending MI. |
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What is an Acute Myocardial Infarction?
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When a portion of the cardiac muscle is deprived of blood flow long enough that portions of the muscle die.
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How can blood flow can be diminished?
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Blood clots
Spasm of coronary artery Shock Arrhythmias Pulmonary Embolism |
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How are infarcts located?
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Depends very much on which coronary artery is blocked and where on the length this takes place.
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What is the classic symptom on an AMI?
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Chest pain. Similar to angina but more severe and lasting more than 15 minutes.
Patients with chronic angina will be aware that something different is happening. |
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How and where is the pain felt, describe its quality?
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Typically felt just beneath the sternum and often described as heavy, crushing or tight.
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Where can the pain radiate to?
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The pain can radiate to the arms, most often the left arm. Also the neck, jaw, upper back or epigastrium.
The pain can sometimes be mistaken for indigestion. |
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Do all AMI patients experience chest pain?
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10-20% of patients with AMI do not experience any chest pain.
Diabetics, older people, and heart transplant patients generally do not present with chest pain. |
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What about women?
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Women with AMI may present differently to men with the same condition.
May be nausea, light headedness, epigastric burning, sudden onset of weakness or unexplained tiredness. |
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What are some symptoms of AMI?
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Diaphoresis
Dyspnea Anorexia Weakness Dizziness Palpitations Feeling of Impending doom |
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What are signs of Left Sided heart failure?
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Wheezes and crackles
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What are signs of right sided heart failure?
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Distended neck veins
Pedal edema |
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What is a typical patient with an AMI?
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Very apprehensive, with ashen grey pallor and cold wet skin. He or she looks scared. The pulse may be rapid unless some kind of heart block has occurred.
Blood pressure can be decreased as a result of damage to the heart or it can be increased due to pain and anxiety. |
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What are the goals of pre-hospital care for ACS?
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Limit the size of the infarct, decrease the patients fear and prevent the development of serious cardiac arrhythmias.
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What is the first stage of treatment?
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Place the patient at physical and emotional rest.
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Why is this important?
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The stress response causes a surge of catecholamines which can send the heart racing.
The peripheral circulation can be vasoconstricted. This makes the heart work faster but also harder against increased afterload. The hearts demand for oxygen soars at a time when it is in a state of oxygen deprivation. |
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What can this cycle lead to?
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Arrhythmias and death.
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How can you reduce the load on a patient?
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Make sure the patient does not do anything physical.
Put the patient in a position in which cardiac work is minimal. This is the semi-fowlers position - about 30 degrees |
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Why is oxygen given to the patient?
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Oxygen may limit ischemic myocardial injury and reduce the amount of ST elevation.
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What is the recommended for O2 therapy?
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Nasal Cannula @ 4-6L/min
or Non-rebreather @ 12-15 is ok as well Monitor spO2 levels and try to ensure that they stay above 90% |
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Why give the patient aspirin?
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Aspirin will prevent the clot from building and will inhibit the action of platelets.
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What are contraindications for aspirin?
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Allergy
Gastrointestinal Bleed |
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What pain relief can be provided?
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You can provide nitro but you need to be sure that the patients blood pressure is adequate prior to administration.
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What is it imperative that you ascertain before giving Nitro?
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Ensure that the patient is not on any erectile dysfunction medication.
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How does Nitro work?
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It dilates the blood vessels.
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What if the patient is experiencing an AMI?
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The pain is unlikely to go away. It may however help to reduce the size of the infarction.
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When should you not give nitro?
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When the patient is
Hypotensive Bradycardic Having epigastric symptoms (indigestion or hiccups). |
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What is congestive heat failure?
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Occurs when the heart is unable for any reason to pump powerfully enough or fast enough to empty its chambers.
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What happens?
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Blood backs up into the systemic circuit, the pulmonary circuit or both.
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How can CHF develop?
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As a result of damage from an AMI, Trauma or a patient with chronic high blood pressure among others.
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Why can left sided heart failure occur?
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The left ventricle is the most commonly damaged in an AMI. In chronic hypertension the left ventricle tends to suffer from having to pump against an increased afterload.
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What happens?
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The blood backs up behind the left ventricle and pressure in the left atrium and pulmonary veins increases.
As the veins become engorged with blood serum is forced out of the pulmonary capillaries and into the alveoli. The serum mixes with air to produce foam (pulmonary edema) |
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What happens when fluid occupies the alveoli?
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Oxygenation is impaired which the patient experiences as dyspnea.
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What does the patient do to compensate?
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The patient will increase the respiratory rate and effort to get more air.
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What else can fluid from the pulmonary vessels do?
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Leak into the interstitial spaces.
This causes narrowing of the bronchioles. |
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What are signs of this pulmonary edema?
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Air passing through narrowed bronchioles creates wheezing noises.
Air bubbling through fluid filled alveoli produces crackles. Edema may be coughed up in the form of blood tinged sputum. |
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How does the cycle develop?
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As airways narrow and the lungs grow heavier from the accumulation of fluid the work of breathing increases putting more strain on the heart.
Dyspnea and hypoxemia induce a state of panic causing a release of epi. This causes peripheral vasoconstriction and increased work rate of the heart at a time when oxygen is already at a premium. |
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How can a patient present?
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They may become frantic from air hunger. They may pace or thrash or become combative as less O2 reaches the brain.
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What can be the end result?
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Cardiac arrest will follow if the hypoxemia is severe enough.
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What are the goals of managing left sided heart failure?
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Aimed at improving oxygenation, decreasing the workload of the heart and reducing the volume of venous blood returned to the heart.
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How is O2 administered?
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100% supp O2 via non-rebreather and monitor with pulse oximetry.
For a person in severe distress preferably done via a BVM with an attached PEEP valve. |
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What about CPAP?
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Continuous Positive Airway Pressure.
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What does positive airway pressure do?
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Reduces work for the heart leading to an improved stroke volume and improvement of heart failure symptoms.
It drives fluid out of the alveoli. |
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When should CPAP be used?
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When the patient suffering from severe pulmonary edema and hypoxemia is not responding to a non-rebreather mask.
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How should a patient be positioned?
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Sitting up with the feet dangling if possible. This encourages venous pooling in the legs and reduces venous return to the heart.
The sitting position also helps a patient in respiratory distress. |
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What about IV's and ECG's
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Start an IV with normal saline @ TKVO
Attach cardiac monitoring electrodes as CHF patients are prone to arrhythmias |
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How is nitroglycerin used?
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It can reduce mortality, intubation rate, and AMI rate.
It is used as a spray under the tongue. |
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What does the nitro do?
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The first effects are to cause venodilation and at higher doses arterial dilation.
This indirectly may lead to a reduction of cardiac work and an improvement in output. Venodilation may result in pooling reducing the amount of edema being produced. |
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What does the arterial dilation do?
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It reduces the afterload which takes the strain off the heart and improves cardiac output.
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What must you perform when administering nitro?
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Frequent blood pressure checks.
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What causes right sided heart failure?
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Most commonly it is caused by left sided heart failure.
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How does this occur?
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Blood backs up from the left side of the heart into the lungs. This makes the right side have to work harder to pump blood into the engorged pulmonary vessels.
Eventually the right side of the heart is unable to keep up with the increased workload. |
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What else can right sided heart failure be a result of?
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Pulmonary Embolism or long standing COPD especially chronic bronchitis.
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How can you tell if the failure is secondary to left sided failure?
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The presence of pulmonary edema on physical exam.
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What happens when right sided failure occurs?
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Blood backs up behind the right ventricle increasing pressure in the systemic veins. This can be seen with JVD.
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What happens over time?
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As pressure within the systemic veins inceases serum is forced out of the veins and into the surrounding tissues.
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How does this present?
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Edema is most likely visible in the feet of a sitting or standing patient or the lower back in a bed ridden patient. Edema can also be present in parts of the body that are not visible.
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What is a cardiac tamponade?
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Occurs when excess fluid accumulates in the pericardium.
When this happens the hearts ability to fully expand is compromised resulting in decreased CO. |
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What can cause a cardiac tamponade?
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Tumours
Pericarditis (inflamatory or infectious process leading to excessive fluid buildup) Blunt or penetrating trauma |
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What are the signs and symptoms of cardiac tamponade?
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With a gradual onset can be dyspnea and weakness. A traumatic cause might be chest pain.
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What about vital signs?
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The stroke volume will decline leading to a drop in blood pressure.
The diastolic will slowly rise giving a narrowing pulse pressure. Heart may be tachycardic Heart sounds may be muffled or quieter than usual due to buildup of fluid. May be visible JVD due to backup on right side of the heart. |
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What is Becks Triad?
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Narrowing pulse pressure (hypotension)
JVD Muffled heart sounds |
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What is Cardiogenic Shock?
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Cardiogenic shock occurs when the heart is so severely damaged that it can no longer pump a volume of blood sufficient to maintain tissue perfusion.
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How is cardiogenic shock managed?
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Improve oxygenation and peripheral perfusion without adding to the work of the heart.
This should be 100% O2. If the patient is comatose then an advanced airway may be needed. |
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What the there is pulmonary edema?
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You can use a PEEP valve with an adanced airway or a CPAP mask delivery system.
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How should the patient be placed?
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Patient should be placed supine unless pulmonary edema is present in which case they should be placed in the semi fowlers position.
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What is an acute dissection of the aorta?
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Over time damage can occur to the intermost layer of the aorta.
This affects blood flow and can also affect the heart valves. |
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What is the typical patient with Acute dissection of the aorta?
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Middle aged or older man with chronic hypertension.
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What is the most common complaint?
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Chest pain, worst ever felt, ripping tearing sharp pain, like a knife.
Pain is very sudden and may radiate into the posterior chest, back or abdomen. |
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What is a AAA?
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Abdominal Aortic Aneurysm
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What is the typical patient?
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Man in late 50's or 60's
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What happens when the aneurysm begins to expand?
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The patient becomes symptomatic with sudden onset of abdominal or back pain.
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What is the most characteristic physical finding?
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A pulsatile mass palpable in the abdomen.
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What is treatment for a AAA?
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Adminsiter O2
Transport without delay Insert an IV line en route (large bore TKVO unless signs of shock) |
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What is the key with AAA?
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Maintain a high index of suspicion whenever a middle aged person presents with sudden onset back pan and a pulsatile abdominal mass.
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What is most hypertension a result of?
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atheriosclerosis (Hardening of the arteries)
arteriosclerosis (refers to a stiffening of arteries) |
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What are some complications of hypertension?
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Renal damage, stroke and heart failure.
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What can happen to the brain at very high blood pressures?
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Fluid can leak causing increased ICP.
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