Emergency Care In The Streets: Chapter 27 Cardiovascular Emergencies Part 2 Of 5

Front 1

Coronary artery disease (CAD)

Back 1

A pathologic process caused by atherosclerosis that leads to progressive narrowing and eventual obstruction of the coronary arteries.

Hint 1

27.89

Front 2

What are the modifiable risk factors of CAD?

Back 2

Cigarette smoking
HTN
Cholesterol
Lack of exercise/obesity

Hint 2

27.27

Front 3

What are the nonmodifiable risk factors of CAD?

Back 3

Family hx and male gender

Hint 3

27.27

Front 4

bruits

Back 4

"Swishing" sound heard with the stethoscope over the carotid arteries which signifies presnece of atherosclerosis and contraindicates carotid massage.

Hint 4

27.28

Front 5

phlebitis

Back 5

Swelling and pain along the veins that can lead to formation of blood clots (thrombophlebitis).

Hint 5

27.28

Front 6

Risk factors for peripheral vascular disorders like pulmonary embolism include:

Back 6

Age, oral contraceptive use, smoking, recent surgery, recreational IV drug use, trauma, and extended immobilization.

Hint 6

27.28

Front 7

Signs of peripheral vascualr occlusion includes:

Back 7

Pain, redness, swelling, warmth, and tenderness in the ext.
However these signs are present in only about half of all cases.

Hint 7

27.28

Front 8

Acute coronary syndrome

Back 8

The term used to describe any group of clinical symptoms consistent with acute myocardial ischemia. Most common being chest pain.

Hint 8

27.28

Front 9

What is the principal symptom of coronary artery disease?

Back 9

Angina pectoris, literally means "chocking in the chest." Occurs when the supply of oxygen to the myocardium is insuffient to meet the demand.

Hint 9

27.28

Front 10

Stable vs unstable angina

Back 10

Stable angina is chest pain that is predictable, ie caused by excertion and goes away with Nitro.
Unstable is chest pain that is unpredictable, signals an impending MI.

Hint 10

27.90

Front 11

Inferior wall infarts are usually a result of what coronary artery?

Back 11

RCA

Hint 11

27.29

Front 12

Classic "textbook" AMI chest pain

Back 12

Felt just beneath the sternum describe as heavy, squeezing, crushing, and/or tight. Pt may unconsciously clench fist when decriging the pain. Levine sign, to convey squeezing nature. 25% of the time it radiates to an arm, often the left side, and into the neck, jaw, upper back, or epigasteium. The pain of an AMI is not influenced by coughing, deep breathing, or other body movements.

Hint 12

27.29-30

Front 13

Who is more prone to "silent MI", AMI without chest pain?

Back 13

Diabetics, older people, and heart transplant pts.
Usually have symptoms related to reduce cardiac output.

Hint 13

27.30

Front 14

Women with an AMI may experience

Back 14

N/V, lightheadedness, epigastrium burning, sudden onset of weakness or tiredness.

Hint 14

27.30

Front 15

Ways to confirm Nitro still has theraputic effects?

Back 15

Burning sensation under tongue pt feels flushed, and has a headache.

Hint 15

27.30

Front 16

Managemtn of chest pain/AMI

Back 16

1) Place pt at physical and emotional rest (semi fowler or shock position)
Increasing heart rate, increases work load.
2) MONA but not in that order. Should be Oxygen, ASA, Nitro, than Morphine.

Hint 16

27.31

Front 17

Before administering Nitro chekc with pt that...

Back 17

They are not taking any phosphodiesterase-5 (PDE-5) inhibitors for erectile dysfunction. The combine effects will drastically drop BP. These include but are not limited to Viagra (4 hrs), Levitra (4 hrs), and Cialis (36 hrs).

Hint 17

27.31

Front 18

Dose of Nitro

Back 18

0.4 mg

Front 19

Contraindications for Nitro

Back 19

Hypotension (below 100 systolic), bradycardia, epigastric symptoms "indigestion" or hiccups.

Hint 19

27.31

Front 20

Contraindications for morphine

Back 20

Hypotension (below 100 systolic), dehydration, or suspected inferior AMI.

Hint 20

27.32

Front 21

Fibrinolytic therapy

Back 21

Medications used to dissolve the occluding blood clot. Indicated during the early hours of an AMI. It actions are to active the body's fibrinolytic system to dissolve the clot in the coronary arteries. However the action is not limited to the coronary arteries, thus may lead to bleeding elsewhere. Weight risk!

Hint 21

27.32

Front 22

Common fibrinolytic therapies

Back 22

Altepase/Activase, streptokinase/Streptase, Reteplase/Retavase.
All work by converting the body's clotting enzyme from its inactive form, plasminogen, to its active form, plasmin.

Hint 22

27.34

Front 23

Percutaneous interventions

Back 23

Passing ballons, stents, or other devices through a 2-mm-diameter catheter via a peripheral artery to recanalize and keep the block coronary artery open.

Hint 23

27.34

Front 24

Congestive heart failure

Back 24

Also known as chronic heart failure occurs when the heart is unable, for any number of reasons, to pump powerfully enough to empty chambers causing backflow.

Hint 24

27.34

Front 25

Left sided heart failure

Back 25

Often cause from HTN due to increase afterload causing backflow in the pulmonary circulation. End result being pulmonary edema.

Hint 25

27.34

Front 26

S/S of left sided heart failure

Back 26

Extreme restless and agitation, confusion, sever dyspnea and tachypnea, tachycardial, increase BP, crackles and possible wheezes, and frothy pink sputum.

Hint 26

27.34

Front 27

What is the goal of prehospital treatment of left sided heart failure?

Back 27

Improve oxygenation and decrease the workload of the heart, chiefly by reducing the volume of venous blood returned to the heart (the preload), so that the left ventricle is less overburdened.

Hint 27

27.36

Front 28

Medicaitons for left sided heart failure (besides oxygen)

Back 28

Nitro in order to creast vasodilation for venous pooling, decrease workload on the heart.
Lasix/furosemide with two positive effects. Initally within 5 to 10 minutes venodilating, increase peripheral pooling of blood. Later removes excess fluid from the body by promoting excretion by the kidneys.
Morphine causing vasodilation, increase peripheral pooling. Along with a calming effect on the pt. Recommended dose being 3mg at a time, than reassessing.
Consider bronchodilators to counteract bronchoconstriction from the excess fluid.

Hint 28

27.36

Front 29

Dose for Furosemide

Back 29

20 to 40 mg or 0.5 to 1mg/kg IV bolus. Administer slow!

Hint 29

27.36

Front 30

What is the most commonly cause of right sided heart failure?

Back 30

Left sided heart failure because work increases on the right side since the left side has failed. May also occur as a result of pulmonary embolism, long standing COPD, especially chronic bronchitis.

Hint 30

27.36

Front 31

S/S of right sided heart failure

Back 31

Edema, hepatomegaly-painful liver which is engorged, JVD

Hint 31

27.36

Front 32

Cardiac tamponade

Back 32

When excessive fluid accumulates within the pericardium, limiting the heart's ability to expand fully after each contraction and resulting in reduced cardiac output.

Hint 32

27.36-37

Front 33

Causes of cardiac tamponade

Back 33

Tumor, pericarditis, and the big one for us is trauma.

Hint 33

27.37

Front 34

S/S of cardiac tamponade

Back 34

Initial complaint may just be dyspnea and weakness, epecially with gradually onset from pericarditis. Traumatic cases chest pain. As stroke volume decreases systolic will decrease and diastolic will slowly increase causing narrow pulse pressure follow by tachcardia, muffled heart tones, JVD which is know as Beck's triad.

Hint 34

27.37

Front 35

Beck's triad

Back 35

Three signs of cardiac tamponade including narrow pulse pressure, muffled heart tones, and JVD.

Hint 35

27.37

Front 36

S/s of tension pneumothorax vs cardiac tamponade

Back 36

With cardiac tamponade trachea will be midline and lung sounds will be equal because the lungs are not effected.

Hint 36

27.37

Front 37

Tx of cardiac tamponade

Back 37

Rarely performed in the filed due to its risk, pericardiocentesis involves inserting a needle into the pericardium and withdrawing fluid.
In prehospintal we need to focus on rapid transport. Consider 500 mL fluid bolus.

Hint 37

27.37

Front 38

S/s of cardiogenic shock

Back 38

Basically the same as other shocks. Confusion, restless, anxious, mass vasocontriction causing pale and cold skin. Rapid shallow respirations, racing thready pulse, droping BP.

Hint 38

27.37

Front 39

Management of cadiogenic shock

Back 39

Avoid increasing heart's workload, focus on improving oxygenation and peripheral perfusion. Prehospital wise we can do very little, thus early transport is imparient. May consider vasopressor drugs.

Hint 39

27.37-38

Front 40

aneurysm

Back 40

From the Greek word meaing widening refering to the dilation or out pouching of a blooding vessel.

Hint 40

27.37

Front 41

AMI vs Acute Dissecting Aneurysm

Back 41

AMI often preceded by other symptoms like nausea, "indigestion," weakness, and sweating. Tends to be gradually and is usually describe as "pressure" rather than "stabbing."
Aneurysm is often abrupt without prodromal symptoms, max from onset without relief, BP discrepancy in arms.

Hint 41

27.39

Front 42

Management of aneurysm

Back 42

Calm pt, along with ABC's. Controlling pain can decrease anxiety and workload from heart, consider morphine at 2mg up to 10mg over 10 to 15minutes.

Hint 42

27.39

Front 43

Who is more prone to Abdominal Aortic
Aneurysms?

Back 43

Middle-aged or older men preseing with sudden onset of back pain. Assess for pulsating abdominal mass.

Hint 43

27.40

Front 44

Most hypertensive is a result of...

Back 44

advanced atherosclerosis or arteriosclerosis, which decrease the lumen of the arteries and reduces elasticity. The result of higher afterload leads to increase filling stimulating Frank-Starling reflex, which rises pressure behind the blood leaving the heart.

Hint 44

27.40

Front 45

Rate for hypertensinve

Back 45

BP is greater than 140/90 consistently at rest. Cannot be dx during an emergency or even really during a single BP check. Inform the patient to have their BP check a couple times over the next few months under less stressful circumstances.

Hint 45

27.40

Front 46

Tx of hypertensive emergencies

Back 46

Supportive treatment especially if you are within 20 to 30 minutes of hospital. Be preparted to treat seizures. Labetolol (alpha and betal blocker) and Nitro may be considered from longer transports.

Hint 46

27.40-41