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41 Cards in this Set

  • Front
  • Back
Describe two types of myocardial trauma
1. penetrating vs blunt chest trauma
2. Blunt trauma-Decreased C.O. due to myocardial restriction, blood loss, arrhythmias, myocardial cell death.
Myocardial contusion-Etiology
Most often due to impact of chest against steering column or dashboard
-rapid deceleration
- heart strikes anterior chest wall
- right ventricle due to location
- Compression between sternum and spinal column
manifestations of myocardial contusion
-Precordial pain
-Arrhythmias
-Friction rub
-ECG changes
-CXR show wide mediastinum
-Cardiogenic shock
-Enzymes?
How to diagnose Myocardial Contusion
-CXR
-Serial ECGs and myocardial isoenzymes
-Possible echocardiogram
-Echo free space if tamponade
Interventions: Taking care of Myocardial Contusion Patients
-Bed Rest with HOB Elevated
-Analgesics (MS)
-Telemetry: treat symptomatic dysrhythmias
-O2
-Assess for complications (MI, cardiac tamponade, CHF, ventricular aneurysm, pericarditis)
Bedside ECG, hemodynamics, and activity tolerance monitoring?
-Possible inotropic support?
Cardiac Tamponade
-Etiology
• trauma
• surgery
• infection
Cardiac Tamponade
-Blood fills pericardium & compresses heart (takes only small amount)
• Becks Triad
• decreased filling
• reduced C.O.
• shock
Cardiac Tamponade - Manifestations
• increased CVP--distended neck veins & muffled heart sounds
-if patient hypovolemic--may obscure
• hypotension
• narrowed pulse pressure
• tachycardia
• friction rub
• sudden cessation or drop in C.T. drainage
• widening mediastinum
• decreased ECG voltage
• u/o < 30 cc/h
• unexplained anxiety/apprehension
Cardiac Tamponade
Interventions
• Emergency situation-pericardiocentesis (unless post CABG, due to clot
formation)
• elevate HOB
• 02, IV access, I & 0, ECG & hemodynamic monitoring
• thoracotomy
Cardiac Surgery
Myocardial Revascularization
• Indications
• uncontrolled chest pain
• lesions of LAD
• 3+ vessel disease
• alternative for transplantation
• Angina and decreased exercise tolerance
Cardiac Surgery
Pre-Op
Pre-Op
• Atenolol pm before surgery-reduces 02 consumption
• Allopurinol pm before surgery-reduces reperfusion injury
• Cefazolin at time of induction unless allergic to PCN or cephalosporins--then give Vancomycin
Cardiac Surgery
Surgical Procedures
• Cardiopulmonary Bypass Pump
• Off Pump Cardiopulmonary Bypass
• Done on Beating heart
• Benefits
• decreased inflammatory response
• decreased neurologic, renal, or pulmonary complications
• decreased need for blood transfusions
• More cost effective
• No difference in low risk patients one year cardiac outcomes
• Risks
• increased strokes
Cardiac Surgery
Operative technique stopped heart (not done on beating heart)
• Cardiopulmonary bypass machine oxygenates and circulates blood
• heparin to prevent massive coagulation in C.B. machine
• hypothermia: decreases metabolism & 02 needs
• core temperature 82-89 F
• heart temperature 46-59 F
• Disadvantages to hypothermia
• myocardial depression
• ventricular dysrythmias
• decreased cerebral flow (stroke)
• platelet dysfunction (bleeding)
• reperfusion injury
• after hypothermia achieved, aorta is cross clamped
• cold cardioplegia solution infused (K+)
Cardiac Surgery
Grafts: saphenous and IMA
Attached to ascending aorta
Cardiac Surgery
• After surgery:
• After surgery:
• Blood rewarmed, air vented from heart chambers, cross-clamp removed, and blood perfuses the coronary arteries
• Heart is restarted (may need to defibrillate or pace)
• Temporary pacing electrodes placed on epicardium & brought out through chest wall
• Chest tubes (mediastinal & pericardial space)
• Sternum wired with stainless steel
Cardiac Surgery
Effects of Cardiopulmonary Bypass
Effects of Cardiopulmonary Bypass
-Increased Capillary Permeability
- Hemodilution
- Altered Coagulation
- Damage to Blood Cells
- Microembolization
- Increased Systemic Vascular Resistance
Cardiac Surgery
Postoperative Complications
• MI
• Atelectasis
• Tamponade: abrupt cessation of C.T. drainage
Cardiac Surgery
Postoperative Complications
• Fluid & electrolyte imbalance
• Fluid & electrolyte imbalance
• total body fluid increases
• Increased capillary permeability
• Treat: colloids (hetastarch or plasmante-pull fluids back into vasculature)
• K+ increased or decreased
• check K+ q2-4h for 1st eight hours
Cardiac Surgery
• Decreased C.O.
Decreased contractility:
• Decreased C.O.
• decreased preload to left ventricle
• due to hypovolemia (intravascular)
• keep P A WP greater than 10 to increase contractility and perfusion

Decreased contractility: 1st 6-18 h post op
• due to surgical manipulation, cardiopulmonary bypass machine, cardioplegia, ischemia due to cross clamping, reperfusion injury
Cardiac Surgery
increased L. V. Afterload
Increased L. V. Afterload
• due to hypothermia, release of catacholamines, renin & angiotensin or Hx htn
• increases wk load and 02 demand
• treat: warming, vasodilators.
Cardiac Surgery
Postoperative Complications
Blood pressure
• Hypotension: if systolic pressure <90, saphenous grafts can collapse.
• Hypertension: if systolic pressure> 150, sutures may rupture or leak (hx HTN, catacholamines, pain, hypothermia)
Epinephrine
Cardiac Surgery
Postoperative Complications
Bleeding
Bleeding
-• C.T. drainage should be dark, red, thin, serosanguinous without clots 200 ml/h for 1-2 hr, then decreasing
• arterial: bright red, hypotension
• venous: surgical problem or coagulopathy (thrombocytopenia, platelet destruction, antiplatelet medications before surgery.)
• monitor for tamponade
Cardiac Surgery
Postoperative Complications
Treatment:
Treatment:
• control HTN,
• keep C.T. patent,
• peep 5-10 cm (increases intrathoracic pressure (decrease oozing)-but
may decrease C.O.),
• monitor PT, PTT, ACT, fibrinogen, platelets, bleeding times;
• give FFP, platelets,
• autotransfusion: if greater than 400 cc/h >3h --surgery
Cardiac Surgery
Postoperative Complications
Dysrythmias: common
• causes
Dysrythmias: common
• causes
• fluid and electrolyte disturbance
• cardioplegia
• cardiac manipulation
• reperfusion
Cardiac Surgery
Postoperative Complications
Post Op pain
-• Angina or MI may indicate graft failure
-• Surgical--localized, sharp or dull, may increase with inspiration and
movement.
Nursing Interventions
Preoperative teaching
• Disease process
• Description of surgery/risks
• Post op course
-• Visit SICU
-• NPO
-• Informed consent
-• Pulmonary hygiene (TCDB, IS, splinting)
-• Pain control
-• Chest tubes
-• Importance of ambulation
Myocardial surgery
Postoperative Care
• ICU for 24 hours
• Expected outcomes: Pt. will maintain adequate ventilation, oxygenation,
and hemodynamic stability
• ventilator care
• respiratory assess
• ABGs
• Connect cardiac monitor
• Connect, zero, & level PA & arterial lines –
• Assess and record waveforms
-• 12 lead EKG
-• Cardiac outputs
-• Sv02: normal 60-80%
-• C.T. Suction at 20 cm, no kinks or loops, continuous assessment of flow
-• Urine output: initially 100-200 cc/h
-• Hypothermia: vasoconstriction, rewarm slowly, avoid shivering
-• Neuro assessment: pupils midline and reactive, limbs flaccid. Most
regain consciousness in a few hours. Then assess movement & sensation.
Postoperative Care
IV meds
-• manage IV vasoactive & inotropic medications
-• manage IV volume expanders
• crystalloids: NS & Ringers lactate
• colloids: hetastarch, albumin
Nursing Diagnoses
• Inability to sustain spontaneous ventilation R/T anesthesia
• Decreased cardiac output
• R/T
• increased afterload
• Myocardial depression
• Cardiac tamponade
• Dysrhythmias
• Inappropriate fluid volume

• Decreased myocardial tissue perfusion

• Impaired skin integrity

•Pain
Aortic or Mitral Valve Replacement
• Indications
• decreased activity tolerance
• S0A
• fatigue
• Mechanical Valves
• tilting disc
• caged ball
• bileaflet
• Lifetime anticoagulation, click, prophylactic antibiotics
• Biologic Valve
• xenograft (animal) Porcine
• homograft (cadaver)
Heart transplant
Indications
• < 60 y/o with end-stage CHF
• No infections, cancer, alcohol, smoking, renal or respiratory problems
Heart transplant
Complications
Complications
• $$
• donor availability
• infection, rejection
• immunosuppressant therapy for life
Heart transplant: what is done during heart transplant
 Cardiopulmonary bypass machine
 aorta cross clamped
 Recipient's heart resected leaving atrial cuffs, posterior lateral walls, & great
vessels
Heart transplant
Denervation
Denervation: loss of sympathetic & parasympathetic nervous system
• Isoproterenol (inotrope & chronotrope)
• atrial pacing wires
• Atropine, carotid massage, & vagal maneuvers ineffective
Pacemakers
• Purpose-
• Purpose--provides electrical stimulus when heart fails to generate or transmit its own.
Pacemakers
• Indications:
• Sinus node dysfunction
• AV block
• Neurogenic syncope
• pauses of 3 sec (carotid sinus pressure)
• head tilting
• cardiomyopathy
• nonresponsive to drug therapy
Pacemakers
• Types
Types
-• temporary
-• permanent
-• atrial
-• ventricular
-• A V sequential
Pacemakers
Terminology
Terminology
-• pacing--PM ability to initiate electrical activity
-• sensing--PM ability to sense heart's beats
• oversensing: interprets noncardiac events as depolarization
• under-sensing: fails to detect cardiac activity & fires inappropriately
-• non-capture--heart doesn't transmit or respond to PM impulse
• increase milliamperage
• electrode placement
• battery failure
Pacemakers
Nursing Care
• Pre-op
• Post-op
• Pre-op
-• Informed consent
-• NPO
-• IV site
-• Clean/shave insertion site
• Post-op
-• incision care
-• VS
-• PROM to affected side (q 48 hr.)
-• CXR to check for complications (pneumothorax or pleural effusion)
-• monitor ECG for PM function
Pacemakers
Nursing Care
• Report
• Report
-• failure to pace (no spike on ECG)
-• failure to capture (spike but no QRS)
-• improper sensing (firing when doesn't need to or not firing when
should)
-• runaway pacing (increased HR)
-• hiccups--electrode misplacement
Pacemakers
Nursing Care
-Patient Teaching
• no contact sports
• no heavy lifting for 2 months
• incision care
• sx of infection
• avoid tight fitting clothes
• carry card
• How PM works
• battery change in 6-12 years
• pulse taking (notify MD if HR < 5 beats below PM setting)
• PM will set off airport security detectors
• Do not hold electrical devices over PM site