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Advanced Med Surg Exam 1
arterial disease, venous disease, hypertension, arrhythmias
327
Nursing
Undergraduate 4
09/20/2012

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Term
What makes up the vascular system?
Definition
arteries, arterioles, capillaries, veins, venules, lymphatic vessels
Term
What makes up the microcirculation?
Definition
arterioles, capillaries, venules
Term
Flow of the vascular system
Definition
aorta- arteries- arterioles- capillaries- venules- veins- superior/inferior vena cava- right side of the heart
Term
True or False: Arterioles are less elastic than venulea
Definition
True, because arterioles have smooth muscle
Term
True or False: Capillaries have no smooth muscle/adventitia
Definition
True, they are made up of one layer of endothelial cells
Term
Why does cartilage/bone have a less dense capillary network?
Definition
Because there is a decreased metabolic need
Term
75% of total blood volume lies where?
Definition
the veins
Term
3 vessel wall layers
Definition
intima: innermost endothelial layer, want smoothness so no turbulence
media: smooth muscle and elastic layer allows for contraction/dilation
adventitia: anchors vessel
Term
True or false: lymphatic vessels are thick walled
Definition
False, they are thin walled
Term
Function of the lymphatic vessels
Definition
collects lymphatic fluid from the tissues and transports to venous systems, permeable to large molecules which allows them to return interstitial proteins to venous system
Term
Where are the lymph drainage entry points?
Definition
Right lymphatic duct: right side of the head, neck, chest, upper arms
Thoracic duct: remained of the body
Term
What do the right lymphatic duct and the thoracic duct empty into?
Definition
subclavian/internal jugular vein junction
Term
What do increased metabolic needs do to the blood vessels?
Definition
causes the blood vessels to dilate
Term
What do decreased metabolic needs do to the blood vessels?
Definition
causes the blood vessels to contract
Term
What does increased protein in the vasculature cause?
Definition
Causes fluid to move into the vasculature (fluid is pulled in by protein)
Term
What can you hear when the blood is turbulent?
Definition
bruits
Term
What causes the blood to be turbulent?
Definition
increased viscosity, increased flow rate, blood vessels dilating/contracting
Term
What does smoking do to blood viscosity?
Definition
causes increased blood viscosity
Term
What is edema?
Definition
fluid in the 3rd (interstitial) space
Term
hydrostatic
Definition
fluid pushing, arterial system has a higher pressure and pushes fluid into the venous system
Term
what causes edema?
Definition
-capillary wall damage, increased permeability
-lymphatic drainage obstruction
-elevated venous pressure
-decreased plasma protein (unable to pull fluid into vasculature)
Term
What factors affect hemodynamic resistance?
Definition
blood viscosity, and blood vessel diameter
Term
peripheral vascular resistance
Definition
opposition to blood flow provided by blood vessels
Term
what can cause increased peripheral vascular resistance (PVR)?
Definition
increased blood viscosity, increased length of the vessels (narrowing, smaller diameter), decreased blood vessel diameter
Term
What regulates PVR?
Definition
SNS, response to physiologic/psychologic factors
Term
SNS stimulates
Definition
vasoconstriction
Term
what can cause reduced venous blood flow?
Definition
thromboembolism, incompetent venous valves, muscle pumping failure
Term
Arteriosclerosis
Definition
hardening of the arteries, muscle fibers thicken/harden, affects small arteries/arterioles
Term
Atherosclerosis
Definition
inflammatory process, affects intima of large and medium sized arteries arteries
Term
What can occur due to atherosclerosis?
Definition
thrombus, after inflammation accumulation of fat occurs, as well as blood componenents, which causes increased fiber and thrombus formation
Term
where does plaque most frequently occur?
Definition
abdominal aorta
Term
how can plaque be stabilized?
Definition
-diet
-exercise
-medication (statins)
Term
non-modifiable risk factors for atherosclerosis
Definition
age, gender, family genetics
Term
modifiable risk factors for atherosclerosis
Definition
nicotine use, diet, HTN, DM, obesity, stress, sedentary lifestyle, elevated C-reactive protein, elevated homocysteine levels
Term
how does nicotine use cause atherosclerosis?
Definition
carbon monoxide causes repeated episodes of hypoxia that injure endothelial cells (vessel walls), carbon monoxide also displaces oxygen from HGB in RBC's causing decreased oxygen transported in the blood causing repeated hypoxic injury in the vascular walls; also decreases HDL's which are protectors
Term
how does HTN contribute to atherosclerosis?
Definition
high BP on the vascular endothelial surface causes injury to the vascular wall due to changes in "shear" stress on the vascular endothelium
Term
how does diabetes contribute to atherosclerosis?
Definition
oxidative stress (due to poor vasculature) causes vascular injuru that triggers plaque development
Term
How does obesity cause atherosclerosis?
Definition
associated with insulin resistance and elevated lipid levels, blood glucose levels are also elevated in the presence of insulin resistance so the pancreas produces a large amount of insulin to lower blood glucose levels resulting in hyperinsulinemia which functions as a growth factor, stimulating plaques and causing them to grow; higher levels of inflammation fuel ongoing inflammation in the plaque leading to growth
Term
how does elevated c-reactive protein cause atherosclerosis?
Definition
increased CRP indicates inflammatory process, produced by the liver in response to inflammation (large amt greater than 3.0, indicated CV disease)
Term
how do elevated homocysteine levels cause atherosclerosis?
Definition
homocysteine (amino acid) causes damage to endothelial linings; increased oxidation of LDL's; stimulateds cell division of vascular smooth muscle in the plaques; caused by diet deficient in B12 and folic acid
Term
what are some results of atherosclerosis?
Definition
coronary atherosclerosis, angina, MI, TIA, CVA, aneurysm, atherosclerotic lesions, renal artery stenosis, ESRD
Term
how does atherosclerosis cause MI?
Definition
caused by myocardial ischemic due to atherosclerosis, occluding a branch of a coronary artery in the heart, if this plaque ruptures it causes a thrombus to form that can enlarge enough to cause a significant increase or even total occlusion to blood flow
Term
how does atherosclerosis cause CVA?
Definition
due to occlusion of blow flow to a region of the brain, if atherosclerosis is caused by severe HTN, a hemorrhagic stroke can occur b/c HTN causes rupture of a weakened area of the cerebral artery
Term
how does atherosclerosis can aneurysm?
Definition
weakened portion of an arterial wall which then bulges outward and can then eventually rupture; atherosclerosis weakens the arterial wall
Term
how can atherosclerosis can end stage renal disease (ESRD)?
Definition
can occur when an atherosclerotic plaque occludes renal blood flow resulting in renal ischemia
Term
S/S of arterial disease
Definition
-hairless
-dark, opaque, thick nails
-shiny skin
*vessels cannot constrict normally, remain dilated
Term
peripheral artery disease (PAD)
Definition
-arterial insufficiency
-affects men > women
-affects lower extremities > upper extremities
-risks: DM, elderly
Term
where does PAD most frequently occur?
Definition
predominantly from the aorta below the renal arteries to popliteal arteries
Term
what are the stzges of PAD?
Definition
stage 1: asymptomatic
stage 2: claudicatoin (pain w/activity)
stage 3: rest pain
stage 4: necrosis/gangrene
Term
compenents of a PAD physical exam
Definition
-BP in both arms
-skin exam- arms/legs
-full CV exam
-peripheral vascular exam- pulses (bilaterally, grades: 0-absent, 1-diminshed, 2-normal), auscultate for bruits: aortic, renal, iliac, femoral
Term
PAD physical assessment findings
Definition
-cool, pale when elevated
-ruddy, cyanotic in dependent position
-diminished pulses
-thick, opaque nails
-shiny, dry hairless skin
-ulcerations, gangrene, muscle atrophy
-compare right versus left extremities
Term
Ankle-Brachial Index
Definition
degree of arterial insufficiency, establishes dx, highest ankle/highest brachial systolic pressure
Ex: ankle 120/brachial 120, ABI=1
Term
how is PAD diagnosed?
Definition
ABI, doppler U/S, arteriogram
Term
degrees of obstruction (using ABI)
Definition
normal: >.9
mild: .7-.9
moderate: .4-.7
severe: <.4
Term
arteriogram
Definition
contrast dye for flouroscopy, determines blood flow, monitor for bleeding, hematoma formation
Term
non-pharmacologic ways to manage PAD
Definition
-smoking cessation
-diet (low na, low chol)
-exercise
Term
pharmacologic tx for PAD
Definition
-phosphodiesterase III inhibitors (vasotropic, vasodilation efect): cilostazol, pentoxifylline
-antiplatelet agents: ASA, clopidogrel
Term
Invasive therapy for PAD
Definition
endarterectomy, arterial bypass surgery, amputation, angioplasty, stent
Term
endarterectomy
Definition
seperates plaque from arterial wall, opens up distal segments
Term
angioplasty
Definition
balloon (deflated) threaded by a catheter into vessel, inflate ballon which pushes plaque against the intima wall opening up the vessel
Term
buerger's disease
Definition
-recurring inflammatory process fo small and intermediate vessel of lower extremities
-autoimmune?
-men 20-35 years
-tobacco can cause/aggravte b/c it causes vasoconstriction
-progressive occlusion of vessels results in pain, ischemic changes, ulcerations, and gangrene
*S/S:pain, especially after exercise, rubor, diminished pedal pulses
Term
aneurysm
Definition
a balloon-like arterial bulge, weakening in the wall of the vessel
Term
2 types of aneurysms
Definition
-saccular
-fusiform
Term
2 types of aortic aneurysms
Definition
-thoracic (above kidneys/renal arteries)
-abdominal (below kidneys/renal arteries)
Term
thoracic aneurysms are caused by
Definition
atherosclerosis
Term
abdominal aneurysms are caused by
Definition
atherosclerosis
Term
thoracic aneurysms effect
Definition
men, 40-70 years old
Term
abdominal aneurysms effect
Definition
caucasians, men > women
Term
true or false: thoracic aneurysms have a 1/3 mortality rate
Definition
true
Term
true or false: abdominal aneurysms occur below the renal arteries
Definition
true
Term
symptoms of a thoracic aneurysms
Definition
variable, asymptomatic or pain in supine position and cough
Term
symptoms of an abdominal aneurysms
Definition
40% of the time heart beat/throbbing in the abdomen
Term
physical exam findings for a thoracic aneurysm
Definition
dilated veins in neck, arms
Term
treatment for a thoracic aneurysms
Definition
surgical repair, control BP, and risk factors (risk factors for atherosclerosis)
Term
treatment for abdominal aneurysms
Definition
surgical repair, control BP and risk factor (risk factors for atherosclerosis)
Term
surgical tx for thoracic/abdominal aneurysms
Definition
endovascular repair- stent graft placed via catheter through an artery in the leg, aneurysm is not resected, it can be resected and replaced with Teflon, concern of loss of pulses b/c of cross clamping
Term
causes of aneurysms
Definition
-trauma
-atherosclerosis
Term
virchow's triad
Definition
1. venous stasis
2. vessel wall injury
3. altered blood coagulation
Term
true or false: heparin prevents enlargement of DVT
Definition
true
Term
how long does it take for warfarin/coumadin to reach a therapeutic level?
Definition
3-5 days
Term
what lab should be monitored for pt's on heparin?
Definition
PTT (should be 1.5- 2 times the normal level)
Term
what lab should be monitored for pt's on coumadin?
Definition
PT
Term
How should phlebitis (d/t IV) be treated?
Definition
-d/c IV
-warm, moist compress
Term
how does varicosity cause DVT?
Definition
varicosity (dilated vein) can cause DVT b/c of blood pooling
Term
venous thrombosis
Definition
-DVT
-thrombophlebitis
-phlebothrombosis
Term
clinical manifestations of venous thrombosis
Definition
-edema
-swelling
-pain/tenderness
-warmth
-redness
Term
venous thrombosis prevention
Definition
-compression stockings
-PCD's
-positioning
-early ambulation
-low molecular weight heparin
Term
medical management of venous thrombosis
Definition
-unfractionated heparin (SQ/IV)
-low molecular weight heparin (SQ)
-thrombolytic therapy
-oral anticoagulants (warfarin)
Term
true or false: low molecular weight heparin has a longer half-life than unfractionated heparin
Definition
true, b/c low molecular weight heparin is weight based
Term
true or false: low molecular weight heparin has a decreased risk of bleeding, heparin induced thrombocytopenia (HIT)
Definition
true
Term
true or false: unfractionated heparin is more expensive than low molecular weight heparin
Definition
false, unfractionated heparin is much cheaper than low molecular weight heparin
Term
unfractionated heparin and low molecular weight heparin work by
Definition
preventing extension of the thrombus
Term
how does thrombolytic therapy work?
Definition
it works by dissolving the clot
Term
benefits of thrombolytic therapy
Definition
-decreases damage to valves
-decreased risk of chronic venous insufficiency
Term
surgical tx for venous thrombosis
Definition
-thrombectomy
-placement of a vena cava filter
Term
how often should lovenox (LMWH) be taken per day?
Definition
2 times per day
Term
thrombectomy (aka embolectomy)
Definition
last resort therapy, surgical removal of thrombi
Term
placement of a vena cava filter
Definition
aka greenfield filter, functions to catch clots that are dissolved before it can reach the heart, used in pt's vulnerable to PE
Term
lipodermatosclerosis
Definition
dark, causing by long term venous disease and specfically venous pooling
Term
chronic venous insufficiency
Definition
result of partial vein blockage or blood leakage around the valves of the veins
Term
risk factors for chronic venous insufficiency
Definition
-hx of DVT (legs)
-age
-gender (female)
-genetic factors
-obesity
-pregnancy
-prolonged sitting/standing
Term
S/S of chronic venous insufficiency
Definition
-redness of legs and ankles
-skin color changes around the ankles
-superficial varicose veinsmeduc
-thickening of skin on legs/ankles
-ulcers on legs/ankles
-dull aching, heaviness or cramping in the legs
-itching and tingling
-pain that worsens when standing
-pain that improves when legs are raised
-swelling of the legs
Term
Tx for chronic venous insufficiency
Definition
-compression stocking to prevent swelling
-avoid long periods of sitting or standing
-aggresively care for wounds if breakdown or infection
-even slight leg movement can increase blood return to the heart
-possible surgical tx (varicose vein stripping)
Term
ulcers
Definition
nonhealing or recurring wound or sore
Term
what causes leg ulcers?
Definition
inadequate exchange of oxygen and other nutrients to tissues
Term
venous leg ulcers
Definition
-aching or sensation of heaviness, discomfort, pain, edema, discoloration
-medial or lateral malleolus, between malleolus and lower calf, most common is medial malleolus
-large, superficial, exudative
Term
arterial leg ulcers
Definition
-intermittent claudication, pain at rest
-caused by inadequate circulation
-small, circular, deep ulcerations on tips or webs of toes, occurs distally on bony prominences
-resulting in gangrene
Term
true or false: venous ulcers do not effect capillary refill
Definition
true, capillary refill is normal (less than 3 seconds)
Term
how do arterial ulcers effect capillary refill?
Definition
prolonged capillary refill, >4-5 seconds
Term
leg ulcer management
Definition
-antibiotics if needed
-compression stockings
-elastic wraps
-debridement (silvadene): removes dead of infected tissue
-wound dressing
Term
blood pressure
Definition
the measurement of force applied to artery walls
Term
primary HTN
Definition
unknown etiology, affects 90-95%
Term
secondary HTN
Definition
caused by:
-coarctation of aorta
-renal artery narrowing or renal disease
-hyperaldosteronism
-pregnancy
*affects 5-10%
Term
blood pressure is measured by
Definition
cardiac output (CO) x peripheral resistance
Term
cardiac output is measured by
Definition
heart rate x stroke volume (SV)
Term
HTN does what to cardiac ouput and peripheral resistance?
Definition
increases them
Term
prehypertension
Definition
120-139/80-89
Term
stage 1 hypertension
Definition
140-159/90-99
Term
stage 2 hypertension
Definition
>160/>100
Term
how does aging affect HTN? or why are the elderly more likely to develop HTN?
Definition
aging results in
-accumulation of atherosclerotic plaque
-fragmentation of arterial elastins
-increased collagen deposition
-decreased vasodilation
-DECREASED ELASTICITY OF MAJOR BLOOD VESSELS
Term
prolonged HTN can cause damage to
Definition
-eyes
-brain
-kidneys
-heart
Term
consequences of prolonged HTN
Definition
-MI
-heart failure
-CVA
-renal failure
-impaired vision
Term
how can HTN affect the eyes?
Definition
can cause:
-retinal hemorrhage
-retinal exudates (fluid/pus)
-retinal artery narrowing
-papilledema (optic disc swelling)
Term
what can HTN do the heart?
Definition
can cause:
-angina
-MI
-left ventricular hypertrophy (LVH, think: that is where blood is being pumped out, increased workload causes walls to thicken)
Term
how can HTN affect the kidneys?
Definition
can cause:
-nocturia
-increased BUN and creatinine
Term
how can HTN affect the brain?
Definition
can cause:
-TIA
-CVA
Term
what diet modifications should pts with HTN make?
Definition
-low sodium diet <2.4g per day
-DASH diet: rich in fruit and veggies, low in fat
-moderate alcohol consumption (<2 drinks per day for men, <1 drink per day for women)
Term
pts with HTN should get how much physical activity per day?
Definition
>30 min per day of aerobic exercise
Term
medications used for managing HTN function to
Definition
-decreased peripheral resistance
-decreae blood volume
-decrease strength of myocardial contraction
-decrease rate of myocardial contraction
Term
drugs that decrease peripheral resistance
Definition
-alpha 1 blockers (prazosin, terazosin)
-combined alpha & beta blockers (carvedilol, labetalol)
-vasodilators (nitroprusside, minixodil, hydralazine)
-ACE inhibitors
-angiotensin II receptor blockers
-dihydropyridines (nifedipine, amlodipine, nicardipine)
-direct renin inhibitors (aliskiren)
Term
drugs that decrease blood volume
Definition
-thiazide diuretics (chlorothiazide, hydrochlorothiazide)
-loop diuretics (furosemide, torsemide)
-potassium-sparing diuretics (amiloride, triamterene)
-aldosterone receptor blockers (eplerenone, spironolactone-also a potassium sparing diuretic)
Term
drugs that decrease strength of myocardial contraction (negative inotropes)
Definition
-beta-blockers (atenolol, propanolol, metoprolol, nadolol, timolol)
-beta-blockers with intrinsic sympathomimetic activity
Term
drugs that decrease the rate of myocardial contraction (negative chronotropes)
Definition
-central alpha 2 agonists (clonidine, metholdopa, reserpine)
-beta blockers
-beta blockers with intrinsic sympathomimetic activity
-calcium channel blockers (verapamil)
Term
hypertensive emergency is definied as a BP over
Definition
180/120
Term
a hypertensive emergency is clinical evidence of
Definition
target organ dysfunction
Term
true or false: a hypertensive emergency does require prompt treatment
Definition
false, it require immediate tx
Term
how is a hypertensive emergency treated?
Definition
-IV vasodilators (NTG, nitroprusside, nicardipine)
-check BP every 5 minutes
-want to reduce mean BP by 25% over first hour
-reduction goal of 160/100 over 6 hours
Term
if the pt has a an aortic dissection and is in a hypertensive emergency, how much do we need to lower the BP?
Definition
need to lower systolic to 100 mmHg or less
Term
true or false: if the pt in hypertensive emergency is also suffering an ischemic stroke, there is no benefit in immediate BP reduction
Definition
true
Term
hypertensive urgency
Definition
elevated BP without evidence of target organ damage, occurs with nosebleeds, severe anxiety, headaches
Term
goal BP reduction during hypertensive urgency
Definition
reduce BP over 24-48 hours
Term
treatment for hypertensive urgency
Definition
-oral beta blockers (labetolol)
-ACE inhibitors (captopril)
-alpha 2 agonists (clonidine)
Term
how often should BP be taken during hypertensive urgency?
Definition
q 15 min
Term
preload
Definition
fluid volume
Term
afterload
Definition
amount of resistance to ejection
Term
contractility
Definition
force generated by contracting myocardium
Term
stroke volume is determined by
Definition
preload, afterload, contractility
Term
frank-starling law
Definition
- the greater the initial strength/length of the cardiac muscle cells, the greater degree of shortening that occurs
-the force of contraction will increase as the heart is filled with more blood
Term
how do vasodilating agents affect preload and afterload?
Definition
they decrease them
Term
true or false: preload is increased with fluid volume
Definition
true
Term
true or false: afterload is decreased with vasoconstrictors
Definition
false, it is increased
Term
true or false: contractility is increased by sympathetic activity
Definition
true
Term
effects of age on stroke volume
Definition
-ventricles atrophy
-decreased elasticity of heart muscle
-valves become thick and rigid
-increased tissue in the area of the SA, AV nodes
Term
12 lead EKG
Definition
6 chest electrodes
4 limb electrodes
Term
normal electrical conduction pattern
Definition
SA node - Bachman's bundle - AV node- bundle of HIS - right bundle branch/left bundle branch - purkinje fibers
Term
normal SA node rate
Definition
60-100/min
Term
normal AV node rate
Definition
40-60/min
Term
normal rate of ventricles
Definition
20-40/min
Term
the p-r interval represents
Definition
atrial depolarization
Term
the QRS complex represents
Definition
ventricular depolarization
Term
the QRS complex represents
Definition
ventricular depolarization
Term
the T wave represents
Definition
ventricular repolarization
Term
what produces systole?
Definition
ventricular depolarization (QRS)
Term
what produces diastole?
Definition
ventricular repolarization (T wave)
Term
what does the U wave represent?
Definition
repolarization of the purkinje
Term
sympathetic nerve fibers
Definition
-increase heart rate
-increases speed of conduction through the AV node
-increased force of contraction
Term
parasympathetic nerve fibers
Definition
-decrease heart rate
-decrease AV conduction
-decrease contractility
Term
a large box on an EKG strip represents how much time on the horizontal axis?
Definition
5 mm box, .2 seconds (thin: 5 x .04)
Term
how much time does a small box on an EKG strip represent on the horizontal axis?
Definition
.04 sec
Term
how do you measure voltage on an EKG strip?
Definition
small box= .1mv, or 1mm
large box= .5mv, or 5 mm
Term
PR interval
Definition
beginning of P wave to beginning of QRS
Term
normal PR interval
Definition
.12-.20 seconds
Term
QRS complex
Definition
beginning of Q wave (if present) or R wave to end of S wave
Term
normal QRS complex
Definition
.06-.10 seconds
Term
ST segment
Definition
end of QRS to beginning of T wave; isoelectric (no variation in electric potential)
Term
QT interval
Definition
beginning of QRS to end of T wave
Term
normal QT interval
Definition
.32-.40 seconds; rate dependent; prolonged may indicate torsades de pointe
Term
what can a biphasic p wave indicate?
Definition
p wave has 2 peaks instead of one, indicates atrial enlargement
Term
presence of a U wave may indicate?
Definition
hypokalemia
Term
what levels should be checked when a dysrhythmia is present?
Definition
magnesium, calcium, oxygen (could be d/t hypoxemia)
Term
wide QRS may indicate
Definition
intraventricular contraction delay or bundle block
Term
normal sinus rhythm
Definition
-60-100 bpm
-regular
-P:QRS 1:1
Term
arrythmia (dysrhythmia)
Definition
any variation from normal sinus rhythm
Term
causes of arrhythmias?
Definition
-cardiac (conduction defects, CHF, MI)
-electrolyte imbalance
-hypoxia
-shock
-acid/base imbalance
-caffeine
-drugs
Term
major types of dysrhythmias
Definition
-sinus node
-atrial
-junctional
-ventricular
-conduction abnormalities- blocks
Term
sinus bradycardia
Definition
-less than 60 bpm
-regular
-PR interval normal
Term
tx for sinus bradycardi?
Definition
atropine .5-1mg
Term
how does atropine work?
Definition
works by speeding up the firing of the SA node
Term
causes of sinus bradycardia
Definition
-sleeping
-vasovagal response (BM, voiding, bearing down)
Term
sinus tachycardia
Definition
-rate greater than 100 bpm in adults
-regular rhythm
Term
causes of sinus tachycardia
Definition
-hypovolemia (decreased blood volume)
-fever
-pain
Term
sinus arrthymia
Definition
-sinus node creates impulse with irregular rhythm-normal change with respiration
-EKG wave form is normal except rhythm is slightly irregular
-benign no tx
Term
premature atrial contraction (PAC)
Definition
-impulse originates in atrium
-abnormal P wave comes early
-P wave abnormal or hidden in T wave
-frequent (more than 6 min) may be serious
Term
causes of PAC
Definition
IRRITABLE AREA IN SA NODE
-caffeine
-hypokalemia
-ischemia
Term
atrial flutter
Definition
-rapid, regular, atrial impulses
-atria are firing very quickly
-P waves: sawtooth pattern, flutter or F
-ventricular rhythm regular/irregular due to AV conduction
Term
symptoms of atrial flutter
Definition
-SOB
-hypotension
Term
tx for atrial flutter
Definition
-if pt is STABLE, calcium channel blockers, beta blockers, digoxin
-may convery rhythm w/Amiodarone
-if pt is UNSTABLE, cardiovert (anesthesia before if possible)
Term
atrial fibrillation
Definition
-atria deflections- irregular & chaotic
-wavy baseline, f wave
-rhythm is irregulary irregular
Term
syptoms of a fib
Definition
-fatigue
-palpitations
-pulse deficit (apical vs. peripheral)
Term
pts with a fib have a risk of developing what?
Definition
a thrombus/embolism, also myocardial ischemia
Term
tx for a fib
Definition
calcium channel blockers, digoxin, coumadin, cardioversion
Term
premature junctional complex
Definition
-impulse originates in AV node
-P wave may be absent, occur after QRS, or occur befoe QRS with shortened PRI
-short PRI (less than .17)
-irritable area in vicinity of the AV junction
Term
causes of PJC
Definition
-digixon toxicity (toxic to SA node)
-CHF
-CAD
Term
signs of digoxin toxicity
Definition
-nausea
-vomiting
-malaise
-fatigue
Term
what medication is given to treat dig toxicity?
Definition
digibind
Term
junctional rhythm
Definition
-AV node is pacemaker
-HR 40-60, regular
-P wave may or may not be present
-shortened PRI
-P wave inverted in lead 2
-may be benign in young adults
-dig toxic if rapid rate
Term
supraventricular tachycardia (SVT)
Definition
-rapidly occuring impulse above the ventricles
-P waves not seen
-regular, sudden onset
Term
causes of SVT
Definition
-caffeine
-stress
-hypoxemia
Term
tx for SVT
Definition
vagal stimulation: coughing, bearing down, carotid massage (MD only)
Term
preventricular contraction (PVC)
Definition
-impulse originates in the ventricle
-bigeminy, trigeminy, quadrigeminy, unifocal, multifocal
Term
unifocal PVC
Definition
the depolarization is triggered from the one site in the ventricle causing the peaks on the ECG to look the same
Term
multifocal PVC
Definition
when more than one site in the ventricles initiate depolarization causing each peak on the ECG to have a different shape
Term
bigeminy
Definition
every other heartbeat is a PVC
Term
causes of PVC's
Definition
-nicotine
-caffeine
-alcohol
-ischemia
Term
tx for PVC
Definition
lidocaine if frequent and in acute setting
Term
how do PVC's present on sn EKG?
Definition
-wide QRS (>12 sec)and bizarre
-T wave usually in opposite direction/polarity of QRD
Term
ventricular tachycardia
Definition
-more than 3 PVC's in a row
-rate greater than 100
-may precede VF
-pt may be awake
-if stable, may cardiovert
-if unstable (PULSELESS), treat as VF- EMERGENCY- DEFIBRILLATE PULSELESS V TACH!
Term
ventricular fibrillation
Definition
-ventricles are quivering
-absence of pulse and respirations
Term
ventricular fibrillation is caused by
Definition
-CAD
-electrical shock
Term
how to treat ventricular fibrillation
Definition
-treat cause
-antiarrhythmics
-EMERGENCY, IMMEDIATE DEFIBRILLATION
Term
idioventricular rhythm
Definition
-impulse occurs below AV node
-dying heart, escape rhythm
-rate 20-40 bpm
->40= accelerated idioventricular rhythm
-pt usually unconscious
Term
how to treat idioventricular rhythm?
Definition
-atropine
-vasopressors
-pacing
NEVER LIDOCAINE
Term
asystole
Definition
-FLATLINE
-check 2 diff leads (could be fine VF)
-no heart rate, no pulse
-poor prognosis
Term
causes of asystole
Definition
hypoxia, acidosis, severe electrolyte imbalance, overdose, hypothermia
Term
how is asystole treated?
Definition
-CPR
-intubation
-get IV access
-administer epi, atropine
-pacing
Term
what is transcutaneous pacing?
Definition
-external pacing
-temporary means of pacing a patients heart during a medical emergency
-delivers pulses of electric current through the pt's chest, stimulating the heart to contract
Term
conduction abnormalities
Definition
-impaired impulse conduction through the AV node
-1st, 2nd, or 3rd degree
Term
what causes conduction abnormalities?
Definition
meds, MI, ischemia, valve disorders
Term
S/S of conduction abnormalities
Definition
-varies
-1st degree may be asymptomatic
-3rd degree may have decreased perfusion
Term
tx for conduction abnormalities
Definition
depends on hemodynamic status
Term
1st degree AV block
Definition
-consistently prolonged PRI
-sinus node originated beats
Term
2nd degree heart block type 1 (Wenckebach)
Definition
-PRI becomes increasingly longer until QRS is dropped
-each atrial impulse takes longer and longer to travel to AV node until one impulse is completely blocked
Term
2nd degree AV block type 2
Definition
-only some atrial impulses are conducted through the AV node
-for those conducted, PRI is constant
-numerous dropped QRS
Term
3rd degree AV block (complete heart block)
Definition
-no atrial impulses conducted through AV node
-atria and ventricles beating independently (AV dissociation)
-irregular PR intervals
Term
how to treat an unstable pt with a complete heart block
Definition
-atropine
-pacing
Term
risk factors for a complete heart block
Definition
-cardiac
-electrolyte imbalances
-emotional crisis
-hypoxia
-shock
-acid base imbalance
-caffeine
-drugs
Term
S/S of complete heart block
Definition
-irregular heart rhythm, palpitations
-chest, neck, shoulder, or arm pain
-hypotension, dizziness, syncope
-coly, clammy, diaphoretic
Term
how does cardioversion/defibrillation work?
Definition
-deliver an electrical current to repolarize myocardial cells
-if cells repolarize, hopefully sinus node can take over as pacemaker
Term
what is the difference between cardioversion and defibrillation?
Definition
TIMING
Term
rational for placement of paddles/pads during cardioversion/defibrillation
Definition
positioned so it goes through the largest part of the myocardium, the left ventricle
Term
true or false: during cardiversion, you need to verify leads are on pt and that the defibrillator is on sync mode
Definition
TRUE
Term
how much pressure should be applied during cardioversion?
Definition
20-25lbs
Term
when is the shock delivered during cardioversion?
Definition
ventricular depolarization (QRS)
Term
why is cardioversion synchronized?
Definition
prevents shock from being delivered during teh T wave, if shock is delivered during the 2nd half of the T wave (relative refractory period), which is very vulnerable,could cause a more serious dysrhythmia
Term
if cardioversion is elective
Definition
-anticoagulate pt several weeks prior
-hold digoxin 48 hours before
Term
which rhythms are cardioverted rather than defibrillated?
Definition
a fib, SVT, v tach, a flutter
Term
which rhythms should never be defibrillated?
Definition
V tach w/pulse, asystole (CPR only)
Term
preparation for cardioversion
Definition
-NPO 4 hours prior
-analgesia/anesthesia
-bag valve mask patient
-intubation tray at bedside
Term
how many joules are delivered during cardioversion?
Definition
50-360 joules
Term
synchronized cardioversion process
Definition
100j, 200j, 300j, 360j
Term
defibrillation is an emergency tx for
Definition
pulseless v tach or v fib
Term
true or false; defibrillation requires higher energy le (vels
Definition
true
Term
true or false: defibrillation should be alternated with CPR
Definition
true
Term
what meds may be used during defibrillation to help convert?
Definition
-epi
-vasopressin
-amiodarone
-lidocaine (for ventricular irritability)
-magnesium (torsades)
Term
monophasic defibrillation
Definition
delivers current in 1 direction
Term
how long should cycles of CPR be inbetween defibrillation?
Definition
2 min
Term
biphasic defibrillation
Definition
delivers current in 2 directions, lower energy needed
Term
how many joules should we start with during biphasic defibrillation?
Definition
120 joules, then 150 joules, then 200 joules
Term
implantable cardiac defibrillator (ICD)
Definition
-for patients at risk for VT/VF
-can also convert SVT
-battery life lasts about 5 years
-some can also pace
-complications similar to pacemakers
Term
true or false: v tach and v fib are considered sudden death episodes
Definition
true
Term
what pt's are at risk for sudden death episodes?
Definition
those with...
-SVT
-prolonged QT interval (torsades)
-hypertrophic cardiomyopathy
Term
ICD's are designed to respond to what?
Definition
-rate > preset rate
-change in isoelectric line
may deliver 6 sequential shocks, can override rapid rates
Term
which blocks most commonly warrant the need for a pacemaker?
Definition
blocks in the AV node, sometimes SA node blocks warrant a pacemaker but not as frequently
Term
how is a AAA treated surgically?
Definition
endovascular repair, stent placed in the lumen of abdominal aorta and extended distally into the iliac arteries
Term
pacemakers
Definition
-permanent-internal or temporary-external
-small, battery operated
-provides electrical stimulus when intrinsic stimulus is defective
-replaced defective natural pacemaker or pathway
Term
indications for a pacemaker
Definition
-sick sinus syndrome: SA node defective and beats slowly
-sinus node dysfunction
-symptomatic bradycardia: lightheadedness, hypotension
-conduction system sclerotic changes: r/t myocardial ischemia, can cause MI
-chronic a fib w/slow ventricular response: slows ventricular rate, loss of atrial kick which contributes to CO
-tachycarrhythmias: need to slow patient down
-3rd degree AV block
Term
S/S indicating need for a pacemaker
Definition
-syncope
-hypotension
-shock
-CHF w/pulmonary congestion
-chest pain
-dyspnea
Term
2 components of a pacemaker
Definition
-electronic pulse generator (circuit and battery)
-pacemaker electrodes/leads: conveys hearts electrical activity to generator and generator sends response through electrodes
Term
types of pacemakers
Definition
-endocardial leads
-epicardial wires
-transcutaneous
Term
endocardial leads
Definition
-threaded through major vein into right ventricle (under flouroscopy)
-placed through external jugular
-connected to permanent generator
-subcutaneous generator
-usually done in cardiac cath or EP lab
Term
epicardial wires
Definition
-always temporary
-after open heart surgery
-lightly sutured to epicardium
-wires connected to temporary pulse generator
Term
transcutaneous
Definition
-on most pacemakers
-for emergency pacing
-increased voltage (mA) to penetrate skin
Term
pacemaker functions (1st 3 letters only)
Definition
-1st letter= chamber paced
-2nd letter= chamber sensed
-3rd letter= type of response
Term
1st chamber
Definition
O= none
A= atrium
V= ventricle
D= dual A/V
Term
2nd letter
Definition
O= none
A= atrium
V= ventricle
D= dual A/V
Term
3rd letter
Definition
O= none
T= triggered
I= inhibited
D= dual, T/I
Term
spike
Definition
delivery of electrical stimulus to stimulate atrial and or ventricular beat
Term
stimulation threshold
Definition
amount of voltage needed for electrical stimulus to provide capture of the impulse
Term
capture
Definition
appropriate EKG complex should follow pacing spike
Term
demand
Definition
Senses intrinsic activity & paces only when needed
Term
fixed pacing
Definition
only set to pace but not sense
Term
what to do if there is a loss of capture
Definition
-turn pt on side
-increase voltage (mA) if possible
-let doc know right away
Term
complications of pacemakers (ICD's as well)
Definition
-infection
-bleeding
-hematoma
-hemothorax (puncture of subclavian vein)
-ventricular ectopy-PVC's, irritability of ventricle
-tachycardia
-dislocation of leads/dislodgment
-phrenic nerve stimulation- hiccups
-cardiac tamponade (rare)
Term
what to monitor after pacemaker insertion
Definition
-v/s (do not assess apical over generator site)
-cardiac rhythm
-pacemaker function
Term
what is the most common pacemaker complication and how can it be prevented?
Definition
-lead displacement
-to prevent minimize activity
-if transvenous lead is dislodged, turn pt to left side to improve endocardial contact
Term
true or false: doctor should be called if pulse 5 bpm more or less than generator preset rate
Definition
true
Term
activity restrictions post-pacemaker placement
Definition
-restrict movement of affected arm 24-48 hours after
-avoid raising arm over shoulder for 4-6 weeks
-do not lift anything >10 lbs for 4-6 weeks
Term
what should we do for a pt with a pacemaker if hiccups or muscle twitching are present?
Definition
-call doc
-obtain chest x-ray
-obtain EKG
-anticipate return to OR for lead repositioning
Term
discharge teaching for pts with pacemakers
Definition
-take pulse for 1 min, call dr if 5 more or less preset rate
-S/S of pacemaker failure
-S/S of infection at pacemaker generator
-keep incision dry/clean for 72 hours
-avoid travelling for 3 months after pacemaker insertion
-carry pacemaker ID card
-medical alert bracelet
-avoid high voltage areas/magnetic fields
-notify airport security (no wanding)
-do not drive until MD says ok
-no contact sports
Term
S/S of pacemaker failure
Definition
vertigo, syncope, twitching muscles, hiccups, chest pain
Term
true or false: the person who touches a patient being shocked may feel tingling
Definition
true
Term
what should we teach pts regarding ICD failure?
Definition
cough CPR, may teach family CPR
Term
what rhythms can put patients into cardiac arrest?
Definition
-V fib
-V tach- pulseless
-pulseless electrical activity (PEA)
-asystole
Term
after starting CPR, how often should rhythm and pulse be reassesed?
Definition
every 5 cycles (2 min)
Term
after starting CPR, how often should rhythm and pulse be reassesed?
Definition
every 5 cycles (2 min)
Term
why is it important not to provide excessive ventilation?
Definition
excessive ventilation increases intrathoracic pressure, decreasing venous return
Term
how many joules for monophasic defibrillation?
Definition
200-360j
Term
once intubated, how often should we ventilate the patient?
Definition
8-10 breaths/min, do not synchronize with chest compressions
Term
how do we confirm placement of an ETT?
Definition
bilateral chest expansion, auscultation, exhaled CO2, chest xray
Term
rate of chest compressions
Definition
100/min (hard and fast)
Term
how far should we depress the sternum with each compression?
Definition
1.5-2 inches
Term
if it is unknown whether the defibrillator is monophasic or biphasic what voltage should we shock at?
Definition
200j
Term
CPR & defibrillation
Definition
-CPR while defibrillator charges
-restart CPR after shock, 5 cycles (2 min) beginning w/compressions
-check rhythm and pulse after 5 cycles
Term
true or false: if we are administering drugs via ETT, 2-2.5 times the drug is given
Definition
true
Term
what should we do following peripheral drug administration in an emergency situation?
Definition
bolus 20cc and elevate extremity
Term
how often do we administer epi in an emergency situation?
Definition
1g every 3-5 min, may improve effectiveness of defibrillation, fosters perfusion in the brain
Term
true or false: in an emergency situation, drugs should be administered ASAP after rate/rhythm check
Definition
true
Term
what should we give if pulseless VT or VF persists after 2-3 shocks plus vasopressor (epi or vasopressin) admin?
Definition
antiarrhythmic: Amiodarone 150-300mg once IV, then 150 mg
Term
what should we consider administering for tx of torsades?
Definition
magnesium
Term
true or false: defibrillation has no effect on asystole
Definition
true, only CPR
Term
what meds may be administered for tx of asystole?
Definition
-epi or vasopressin
-atropine (1mg IVP)
Term
causes of asystole
Definition
H's & T's
Term
H's
Definition
-hypovolemia
-hypoxemia
-hydrogen ion (acidosis)
-hypo/hyperkalemia (hypo common in renal pts)
-hypoglycemia
-hypothermia
Term
T's
Definition
-toxins- environment?-anaphylactic
-tamponade (fluid accumulation in pericardial sac)
-tension pneumothorax
-thrombosis- coronary
-thrombosis- pulmonary
-trauma
Term
true or false: lidocaine if given to treat PVC's in an emergency situation
Definition
false, lidocaine if given to treat PVC's but not in an emergency situation
Term
which cardiac meds are given for SVT?
Definition
beta blockers
Term
epinephrine
Definition
increases perfusion to brain & coronaries during CPR
Term
vasopressin
Definition
may cause coronary & renal vasoconstriction (vasoconstriction b/c we want pt to clamp down)
Term
norepinephrine
Definition
inotrope & potent vasoconstrictor; used for severe hypotension; central line (extravasation)
Term
dopamine
Definition
dose dependent effects:
.5-2 mcg/kg/min: dopaminergic (renal perfusion)
2-10 mcg/kg/min: inotropic
>10mcg/kg/min: vasoconstriction
Term
dobutamine
Definition
synthetic catecholamine & potent inotrope; severe systolic heart failure
Term
inamrinone
Definition
inotropic, vasodilator of vascular smooth muscle; heart failure
Term
digitalis
Definition
inotrope: afib, aflutter
Term
nitroglycerin
Definition
relaxes vascular smooth muscle; CHF, HTN
Term
Nitroprusside
Definition
potent peripheral vasodilator; HTN
TAKE BP EVERY 5-15 MIN b/c we are titrating medication
Term
hypothermia therapy
Definition
-cool pts to 32-34C for patients in a coma after cardiac arrest from VF
-cardio protective/neuro protective
-large-volume ice, cold IV fluids, cold blankets
Term
co Q10?
Definition
neuro protectant?
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