<65 yr

progressive dyspnea

S₃(too much filling)

pulmonary congestion

cardiomegaly

<50% ejection fraction

>65 years

acute dyspnea

S₄ (extra beat at first)

pulmonary congestion

left ventricular hypertrophy

normal or small heart

> 50% ejection fraction

S₃ and S₄

(S₄,S₁,S₂,S₃)

Immediate

Dyspnea on exertion

orthopnea

cough

paroxismal nocturnal dyspnea

cyanosis (late sign)

basilar crackles

acute pulmonary edema

fatigue

oliguria

inc. Heart rate

faint pulses

Brain: restlessness, confusion, anxiety

ischemic caridomyopathy

Caused by CAD and HTN

impaired contractility

ischemia-->no ATP-->negative inotrope-->

Sympathetic nerv. system stimulates beta receptors-->over stimulation.

heart can't fill

common: women, elderly, no prev. MI

impaires calcium removal from muscle

hepatomegaly

ascites (portal vein couldn't handle pressure)

splenomegaly

anorexia(pressure on gastric area)

subcutaneous edema

jugular vein distention

kidney congested (dec. GFR kicks in RAAS)

dec. perfusion:

fatigue

oliguria

inc. heart rate

faint pulses

restlessness, confusion, anxiety

Baroreceptor response-->brain-->SNS activation-->inc. heart rate and contractility-->inc. cardiac output.

Heart is poorly Oxygenated so this increases failure

dec. GFR-->RAAS activation-->kidney-->fluid retention-->inc. preload-->inc cardiac output.

heart is poorly oxygenated so this increases failure

inc. vent. wall tension-->heart-->myocyte growth-->hypertrophy-->inc. cardiac output.

increases failure

diuretics

keep upright

raise legs (not above heart)

low sodium diet

drugs that dilute

BB's

O2(positive inotrope)

inotropes(digoxin)

BB's (difficult to control)

control symptoms

diuretics

pulmonary edema

pleural effusion

renal insufficiency (forward effect)

dysrhythmia

LV thrombus(static blood)

cardiogenic shock (inc. pre/afterload)

renal insufficiency

hepatomegaly

splenomegaly

dysrhythmia

cardiogenic shock

LV thrombus?

<60

dec. cardiac output

doesn't open completely

inc. cardiac workload

doesn't close completely

increases cardiac workload

Diastolic murmer

elevated LA pressure

hypertrophy of LA and LV

regurgitant flow through mitral valve

systolic murmer

LV hypertrophy

dec. CO

Slow heartbeat

 systolic murmer

LV hypertrophy

head bobs as heart beats

diastolic murmer

pulmonary HTN

right vent. hypertrophy

acyanotic

(RV hypertrophy reverses to become cyanotic)

acyanotic

ductus between ascending aorta and pulmonary artery

narrowing of the aorta

dec. BP to lower body

prone to intercranial hemorrhage

arm and head BP inc.

can lead to CHF

pulmonic valve stenosis

RV hypertrophy

Ventricular septal defect

overriding aorta

Prone to: infective endocarditis. Polycythemia (baby bone marrow making up for lack of O2).

only one that starts cyanotic

hypercoaguable state

damage to vessel wall

venous stasis

may not appear until late.

1st: restlessness, anxiety, apprehension

dyspnea(sudden onset is bad sign)

feelings of impending doom

CP, inspiratory pain, hemoptysis

pleuritic CP (hurts to breath in)

V_a/Q (high?)

ABG's: dec. PaO2, dec. PCO2, inc. PH

EKG: ST and T wave changes

CXR: effusions and infiltrates

pulmonary angiogram (conclusive test)

prevention of DVT's

O2, anticoagulants, thrombolytics, filter in IVC, embolectomy

hypoxemia refractory to oxygen leading to:

hypotension

dec. UO

respiratory acidosis

metabolic acidosis

cardiopulmonary arrest

Hx or recent triggering event, suddent severe dyspnea, tachypnea, tachycardia, hypotension, low PaO2, dec. LOC, crackles, rhonchi, frothy secretions

(lungs can sound clear becuase they are so full of fluid)

ABG's: dec. PaO2, inc. PCO2, dec. PH

CXR: white fluffy infiltrates

V_a/Q shunt

address the cause

balance F and E

maintain cardiac output-vasopressors

ventilator with PEEP (positive and expiratory pressure)

prone posistion

prem. infant(<32 wks) has dec. surfactant-->dec. alveolar compliance

prem. infant-->soft compliant chest-->draws in upon inspiration-->dec. intrathoracic pressure

prem. infant-->immature pulmonary capillaries--> hypoxemia

dec. alveolar compliance + dec. intrathoracic pressure-->progressive atelectasis--> reversion to circulation from foramen ovale to ductus arteriosus (R to L shunt)-->hypoxemia-->pulmonary vasoconstriction-->inc. PVR

hypoxemia-->anaerobic metabolism of lactic acid-->metabolic acidosis-->pulmonary vasoconstriction

Cellular damage, fluid administration, high levels of FiO2-->inc. cappilary perm.-->pulmonary edema

ABG: dec. PaO2, dec. PH

CXR: diffuse whiteout

Balance F and E

Ventilator with PEEP with as low O2 as possible(high O2 will damage eyes)

exogenous surfactant (bottle?)

minimal handling

controlled temp

heart is pushed to one side on inspiration and swings back on expiration

(seen with open pneumothorax)

closed or open pneumothorax-->seal between visceral and parietal pleura broken-->lung collapses--air enters pleural space during inspiration and is trapped during expiration-->mediastinal shift (mimics cardiac tamponade)-->compression of contralateral lung, vena cava, aorta, heart-->death

CXR: collapsed lung, shifts in tension pneumothorax

other tests rare

minor: symptom control only

dressing on open pneumothorax can create tension pneumothorax

insertion of chest tube

pleurodesis for collapsed lung (talcom powder)

1. inc. hydrostatic pressure of plasma(heart failure?)

2. dec. oncotic pressure of plasma(cirrhosis-low albumin)

3. inc. cappillary permeability(pancreas self digests, dumps gastric juices and destroys capillaries)

4. impaired lymphatic drainage

CXR

CT/US

analysis of pleural fluid from thoracentesis

thoracentesis

chest tube drainage

treat the underlying cause

cardiogenic: LV failure, MV stenosis, cardiogenic shock, cardiomyopathy, HTN

Noncardiogenic: fluid overload, aspiration of gastric contents, barotraumas(?), near drowning(fluid breathed in washes away surfactant, lung collapses), hypoalbinemia, O2 tox, ARDS, high altitudes, CNS imbalance

coughing thin, often pink, frothy sputum

severe dyspnea, tachypnea, thready tachcardia, severe orthopnea, crackles, wheezes, signs of R sided heart failure

ABG: dec. SaO2 (plummets), dec PaO2, resp. alkalosis

CXR: whiteout

correct hypoxemia: high FiO2, intubation and ventilation

reduce preload: fowlers, diuretics, NTG

reduce afterload: antihypertensives (ACE inhibitors), morphine(slows SNS)

treat underlying cause

aspiration of oropharyngeal secretions

inhalation of infection agent

contamination from systemic circulation

coughing

sneezing

cilia (smoking paralyzes)

immune defenses

fever, crackles, bronchial breath sounds, chills, cough, purulent sputum, older adult may present with mental status changes and dehydration.

viral pneumonia presents fever, coryza(head congestion), hoarseness, wheezes, rales

CXR: white patches

sputum gram stain and culture

antibiotics

fluid and electrolyte balance

O2, bronchodilators

pulmonary clearance: IS ambulate