MedSurg 3 Final Exam Review

Cardiac (24) MAP: 65 for adequate blood flow to major organs (MAP= 2x diastolic + Systolic/3) Preload: Amount of blood into heart at end of diastole Afterload: Resistance met when blood pushes out of left ventricle SA Node: located in right atrium, natural pacemaker of the heart (60-100bpm) AV Node: delay impulse to allow atrial contraction and ventricle filling, then conducts impulse to the ventricles (40-60bpm) Purkinje Fibers: ventricular pacemaker (20-40bpm) Labs: PT (9-12) INR (0.9-1.2) PTT (55-75) ABG (pH: 7.35-7.45, CO₂: 45-35, HCO₃: 22-26) CBC (blood) BMP (electrolytes) Diagnostic Tests: CXR, EKG, Stress test, Echo, TEE, MRI Heart Cath: Pre- consent, prep area, NPO 6hrs, mark pulses, BUN/Cr, Fluids and mucomyst to facilitate excretion/protection; Hold GLUCOPHAGE 24-48 hrs pre/post; ALLERGY: shellfish/dye Post- BEDREST, vitals, monitor site/pulse, ↑fluids (↓dye), Pain, Hematoma, ↓Vitals, color, arrhythmia, Retroperitoneal Bleed Nursing- no lifting 5lbs., remove dressing in shower, don’t resume normal activities until Dr. release, medication education Hemodynamic Monitoring: Measures vascular capacity, blood volume, pump effectiveness, tissue perfusion Risks: thrombosis, hematoma, bleeding, pneumothorax, dysrhythmias, pericardial tamponade A-Lines: into artery, DO NOT PUSH MEDS, monitor BP and ABG Central Lines: give meds, draw blood, monitor CVP (Dry 2 ←→6 Wet) CABG Unstable angina, AMI, failure of percutaneous interventions Pre- CBC, CXR, Coags, UA, coronary angiogram, blood type, teaching Post- ↓CO (bleeding, fluid loss, meds, ↓temp, surgery, dysrhythmias, ↑afterload) *chest tube drainage: 70mL = report *cardiac tamponade: muffled heart sounds, ↑HR, ↓BP, ↓urine, ↓chest tube output, ↓peripheral pulses, tx- pericardiocentesis, cause Heart Failure Causes: HTN, CAD, substance abuse, valvular disease, DM, smoking, lung disease, MI Dx: ↑BNP (untreated) Tx: diuretics, ACE, ARB, nitrates, Beta blockers, inotropic agents, diet, fluid management, weight Complications: pulmonary edema (dyspnea, cyanosis, gurgles, pink/frothy sputum, ↓O₂), shock Nursing: weight, diet, meds, activity, risks *Digoxin Toxicity: anorexia, fatigue, blurred vision, mental status change Myocardial Infarction Blood supply to the heart is reduced or stopped; “TIME IS MUSCLE” Intervention within 4-6hr of symptom onset Sx: angina (pressure, squeezing, fullness, pain, radiating), N/V, SOA, cold sweat, lightheaded Dx: EKG, Cardiac enzymes Tx: Morphine, Oxygen, Nitro, Aspirin *TPA: clot buster, within 6hr of onset, certain requirements *CATH LAB for stent placement Nursing: no lifting, drinking, stairs, resume activities slowly, Plavix/aspirin, SX of bleeding Aneurysm Aortic Aneurysm: dilation or thinning of wall, flank/abd/back pain, bruit, surgery (7cm) AAA- loss of pulses; TAA- SOA, hoarseness, difficulty swallowing Aortic Dissection: tear of layer of vessel, sudden/sharp/shifting pain, surgery ABGs Metabolic Acidosis: ↓pH, diarrhea, dehydration, DKA, ↓BP, ↑K, kussmaul respirations Causes: renal failure, DKA, diarrhea Tx: NaHCO₃ (give bicarb), tx underlying cause Metabolic Alkalosis: ↑pH, vomiting, GI suction, diuretics, confusion, ↓K, ↓RR, ↑HR Causes: vomiting, NG suction, ↓K, antacid abuse Tx: K replacement, PPI, antiemetics (retain acids) Respiratory Acidosis: anesthesia, overdose, COPD, pneumonia, ↓BP, ↑K, ↓RR, ↓LOC Causes: CNS depression, OD, pneumothorax, RI, HF, PE, airway obstruction, emphysema Tx: ↑ventilation and underlying cause Respiratory Alkalosis: hyperventilation, mechanical ventilation, ↑HR, ↓BP, ↓K, ↓LOC Causes: vomiting, NG suction, ↓K, antacid abuse Tx: K replacement, PPI, antiemetics (retain acids) Pulmonary (19) Respiratory Failure: Patient Hx: smoking, drug use, allergies, travel, area of residence, nutrition status, cough, sputum, chest pain, dyspnea, orthopnea, PND (waking up with SOA) Sx of respiratory failure: clubbing, wt loss, uneven muscles, skin/mucous membrane changes, general appearance, endurance, sleep in chair Sx of hypoxemia: (1st) neuro Dx: ABG, CBC (↓Hgb=↓O₂), BMP, sputum, CXR (PA- front view, LA- side view), CT, ventilation and perfusion scan, pulse ox Pulmonary Function Testing- Noninvasive: evaluate lung volume/capacity, flow rates, diffusion capacity, gas exchange, airway resistance, distribution of ventilation [exercise testing, skin testing, done pre-surgery to assess for vent capability] Invasive: [Bronchoscopy] conscious sedation, numb throat, consent, monitor for gag reflex, breath sounds, complications- bleeding, infection, pneumothorax [Thoracentesis] aspiration of fluid/air from pleural space, hunched over table, IV access, do not allow pt to cough, observe for shock, post CXR, watch site, prone Pulmonary Embolism: [Lung Biopsy] obtain tissue, assess breath sounds Q4 for 24 hr., report reduced/absent breath sounds immediately, monitor for hemoptysis ARDS: Prevention: TEDs, compression devices, position changes, Tx dysrhythmias, anticoagulant therapy, NO pillows under knees; no central lines or dialysis Sx: chest pain (worse on inspiration), sudden SOA, crackles, wheezes, ↑RR, ↑HR, cough, hemoptysis, ↓O₂, anxiety, sense of impending doom, ↑D-Dimer {Sx same as MI} Dx: clinical sx, ↑D-Dimer, CXR (nonspecific), V/Q scan (high probability of PE), CT scan w/contrast, pulmonary angiogram, EKG (rule out MI) Tx: O₂, thrombolytic, IV heparin (5days til PO therapy is effective), Lovenox, embolectomy, inferior vena cava filter/umbrella (heart cath) Cause: aspiration, pneumonia, trauma, toxic inhalation, TB, sepsis, burns, overdose, CABG Sx: Hypoxemia w/ 100% O₂, pulmonary edema, SOA, ↑RR, respiratory alkalosis (can’t blow off CO₂, ↑Temp, ↑HR, white out CXR, produces systemic inflammatory response Tx: Intubation, sedation or paralytic (Norcuron), positioning, PEEP (lungs stay inflated to prevent alveoli collapse, ↓CO, ↓venous return, ↑intrathoracic pressure) Complications: Multiple-organ dysfunction syndrome, renal failure, disseminated intravascular coagulation, long-term pulmonary effects associated w/ ↑O₂ therapy Atelectasis: fluid in alveoli COPD: emphysema and chronic bronchitis Sx: chronic dyspnea, productive cough, hypoxemia, crackles, wheezes, rapid/shallow breathing, use of accessory muscles, barrel chest, irregular breathing, think extremities and enlarged neck muscle, dependent edema (right sided heart failure), clubbing fingers/toes, pallor/cyanosis of extremities, ↓O₂ sat Tx: High fowlers, coughing, suctioning, deep breathing, IS, O₂ (no more than 4L; ↓drive to breathe), nutrition, ↑ fluids to 2-3L/day; diaphragmatic breathing, pursed-lip breathing, incentive spirometer, bronchodilators, anti-inflammatory, mucolytics Lung Cancer: Sx: chronic cough, hemoptysis, SOA, wheezing, dull/aching chest pain, hoarseness, dysphagia, wt loss, anorexia, fatigue, weakness, bone pain, clubbing fingers/toes Tx: chemo, targeted radiation, surgery Lung Abscess: liquified necrosis, antibiotics, drainage, frequent mouth care Pulmonary Emphysema: pus in pleural space, empty empyema and re-expand lung, tx infection Pneumothorax: air in pleural space, ↑intrathoracic pressure Types: Spontaneous pneumo- rupture of pulmonary bleb Open pneumo- opening the chest wall Tension pneumo- blunt chest trauma (vent with PEEP) Tx: dressing over open chest wound, O₂, fowler’s position, chest tube placement, chest tube drainage monitor for subcutaneous emphysema, tension pneumo Pneumonia: inflammatory response to inhaled particles Sx: confusion, ↑RR Tx: supportive, antibiotics Asthma: pharmacological management and exercise Oxygen Toxicity: FiO₂ 50 (titrate down to lowest setting); may progress from capillary leaking to pulmonary edema and possible ARDS Chest Tube: Chamber 1: collection Chamber 2: water seal (tidaling = normal) Chamber 3: suction (bubbles = normal) Mechanical Ventilation: Indications: Hypoxemia (O₂ 60), hypercapnia (↑CO₂ in blood), CO₂ 50, pH 7.5, progressive deterioration, ↑RR, ↑work of breathing, overdose, acute respiratory failure, ARDS, pneumonia, severe CHF, brain injury, COPD… Settings: AC- most often to give rest, do most of work SIMV- weaning, ↑muscle TV (tidal volume)- amount of air pt receives with each breath Rate, FiO₂, peep, peak airway pressure Alarms: High: obstruction between pt and machine (kinked, biting, mucous plug) Low: break in system (tube off machine…) Effects on Body Systems: Cardiac: ↓BP, ↓CO GI: stress ulcer (Protonix), GI bleed, VAP, nutrition, ileus, swallowing post vent Psycho: stress, anxiety, noise, altered sleep-wake patterns, dependence Meds: morphine, sedatives (benzos, neuroleptics, propofol), paralytics Weaning: READY when (tx cause, hemodynamic stability, CO, resp muscle strength, O₂ w/o high FiO₂ or PEEP, mental readiness, minimal need for meds that cause resp depression) STOP when (8 RR 30, labored RR, accessory muscles, ↓O₂ sat, HR or BP 20% from baseline, dysrhythmias, ST-segment elevation, ↓LOC, anxiety) Extubation: secretion management, stridor, hoarseness, ↓O₂, Ambubag and ET set on standby VAP: HOB 30-45, awaken daily to assess readiness to wean, stress ulcer and DVT prophylaxis Sepsis (5) Homeostasis: Coagulopathy: blood clotting; stops bleeding, walls off inflammation, and slows infection. Normal response is to isolate problem. Fibrinolysis: clot dissolution. Once foreign substance is controlled the body dissolves the clot and cleans up the mess. Endothelium: Lines the blood vessels. It is normally antithrombotic and profibrinolytic. vasoregulation and cell trafficking. It keeps everything flowing smoothly. Sepsis: the body’s response to any infection that injures its own tissues and organs Risks: infection, poor hygiene, poor immune system, mechanical ventilation, invasive procedures Sx: ↑HR, ↓BP, ↑RR, ↓LOC, chills, metabolic acidosis, ↓Plts, ↓skin perfusion, ↓urine, ↑BG Dx: BCB, BMP, culture, sputum, LACTIC ACID 2, CXR, CT, MRI, U/S Tx: tx infection (broad-spectrum antibiotics/antivirals/antifungals), sustain organs/BP (fluids), O₂ Nursing: screen (SIRS) Septic Shock: loss of homeostasis = ↑coagulation, ↓fibrinolysis, depleted protein C 1. A foreign substance (bacteria, virus, splinter) enters the body. 2. Inflammatory response releases chemicals to fight the foreign substance. 3. The chemicals trigger endothelial dysfunction leading to capillary leaking and loss of vasoregulation. 4. Micro clots form. 5. Oxygen doesn’t make it to the cells leading to hypoperfusion and ischemia. 6. Tissue hypoxia. 7. Organ dysfunction. 8. Death. Shock Shock: is inadequate blood flow to vital organs and/or the inability of the tissues or cells to metabolize nutrients normally Stages: 1. Initial: ↓BP, compensate 2. Compensatory: beyond backup system, activation of more systems 3. Progressive: sustained backup, but ↓O₂ to vital organs 4. Refractory: irreversible, body can no longer effectively fix, leads to MODS/DEATH Types: Hypovolemic (MOST COMMON), Cardiogenic (pump deficit), Anaphylactic, Neurogenic (Least common), Septic Shock Tx: ↑tissue perfusion, CVP8, MAP65, urine output0.5mL/kg/hr, O₂92%, fluid replacement, vasoconstrictors, antibiotics, steroids, parenteral/enteral feedings, PPI, psychological support Burns (7) Types: Thermal Chemical Electrical “The Great Masquerader” Radiation Open flame Steam Hot liquids Wet or Dry Acids Strong alkalis Organic compounds Direct Alternating current Lightning Patho: coagulation necrosis and cardiac disturbances At risk for: rhabdomyolysis and renal failure Solar Radioactive agents Extinguish flame Flush with cool water Consult fire Brush off dry chemical Neutralize or dilute Disconnect source of current Move to safety Consult expert Shield skin Consult expert Department Remove clothing Consult poison control center MSDS sheet Inhalation Injury: Sx: rapid/shallow RR, hoarse/raspy voice, coughing, smoky breath, carbonaceous sputum, burning in throat or chest, restlessness, anxiety, ↓LOC, ↓O₂ sat Tx: QUICKLY INTUBATE (before swelling constricts airway) Degree of Burn: Depth of Burns: Superficial Superficial Partial- Thickness Deep Partial- Thickness Full-thickness Tissue Damage: Epidermis *doesn’t count in TBSA%* Epidermis and parts of the dermis Epidermis and deep dermis Epidermis, dermis, SubQ, nerves Appearance: Pink-red Bright red, moist, blisters intact, will blanch Red to white, pale and waxy, ruptured blisters, eschar is soft and dry Red, black, brown, yellow, white, no blisters, eschar is hard and inelastic Edema: Mild present present severe Pain: Painful/tender painful Less pain No pain Healing time: 3-6 days 3 weeks 2-6 weeks Weeks to months Specific Tx: Possible grafts, scarring likely Scarring and grafting Rule of Nines → Tx: Fluids, O₂, high fowler’s, ABG, CO₂, CXR, CBC, BMP, UA, intubation, foley (strict Is/Os), dry dressings, temp regulation, wound care (debridement, grafts, prevent contractures), IV LR, analgesics, tetanus, antimicrobial agents, nutrition (5000cal/day), positioning Stages of Burn Management: 1. Emergent (resuscitative): Airway, fluid replacement, metabolic acidosis, ↑K, ↓Na, ↑aldosterone, Hemoconcentration, Edema, immunocompromised, compartment syndrome, fluid loss and edema stops = next stage 2. Acute: from start of diuresis to closure of burns, airway, fluid volume, pain, eschar debridement 3. Rehabilitative: from closure of wounds to resumed self-care, plastic surgery, physical therapy Mass Causality (3) Triage: quickly identifying victims, who have the best chance of surviving Tag System: Red: Emergent (class I) Critically injured; Require immediate intervention; RR above 30; If RR below 30 assess circulation; If capillary refill is more 2 seconds tag; If capillary refill is below 2sec assess mental status Yellow: Can wait short time for care (class II) Require some medical attention; Will not die if care id delayed; Can follow simple commands; Will require stretcher for transportation Green: Non-urgent or “walking wounded” (class III) Not critical; Have them move somewhere safe Black: Expected to die/are dead (class IV) Not breathing: open airway; Begin to breath: tag red Renal (5) Acute Kidney Injury: Phases: Onset, Oliguria, Diuresis, Recovery Classes: Types: Stage 1 (risk): output 0.5mL/kg/hr for 6hr Stage 2 (injury): output 0.5mL/kg/hr for 12hr Stage 3 (failure): output 0.3mL/kg/hr for 12hr Prerenal: ↓perfusion Intrarenal: direct damage (meds, disease) Postrenal: obstruction (stones, strictures) Chronic Renal Failure: Sx: nocturia, fatigue, cramping, fluid retention, ↓LOC, ↓reflexes, peripheral neuropathy, HTN, CHF, pericarditis, cardiac tamponade, dysrhythmias, pulmonary edema, pneumonia, anemia, ↑bleeding, dry skin, pallor, anorexia, diarrhea, constipation, ulcers Tx: tx primary disorder, F&E imbalances, ABGs, dopamine, fluids, Lasix, mannitol, loop and thiazide diuretics, NO NSAIDS, CAREFUL with antibiotics; Dialysis: weights, assess fistula, labs, Epogen (↑hgb/hct) Hemodialysis: stable (couple hours) (3-4dys/wk) CRRT: unstable pts (slower pace) Peritoneal: stable, self-care (daily) Nursing: ↓Na, no salt substitutes(↑K), ↓protein, fluid restriction, ↑carbs GI (5) Ulcerative Colitis: “bottom up” Sx: Chronic and intermittent, frequent loose bloody stools, cramps, fever, ↑HR, anemia, wt loss, hypoalbuminemia, LLQ pain Tx: Acute (steroids, immunosuppressive, antibiotics- metronidazole), Chronic (immune response modifiers), Nutrition (Chronic- ↑Fiber, Acute- NPO, TPN), antidiarrheals Chron’s Disease: “mouth down” Sx: Slowly progressive, fewer stools than UC, anemia, fatigue, malaise, wt loss, vitamin and mineral deficiency, RLQ pain Tx: Acute (steroids, immunosuppressive, antibiotics- metronidazole), Chronic (immune response modifiers), Nutrition (Chronic- ↑Fiber, Acute- NPO, TPN), antidiarrheals Cirrhosis: Risks: #1- alcoholism, #2- Hep B/C Sx: enlarged liver, dull pain, portal HTN, edema, ascites, bleeding, bruising, esophageal varices, jaundice, malnutrition, muscle wasting, encephalopathy, ↑ammonia Meds: diuretics, lactulose, anti-ineffective agents (↓intestinal bacteria, ↓ammonia) (metronidazole/Flagyl), beta-blocker, iron, folic acid, vitamin K, antianxiety Diet: fluid restriction, low/no Na, ↑calories and protein, vitamin/mineral supplements Pancreatitis: Sx: severe epigastric pain and abdominal pain (triggered by fatty meal or alcohol, n/v, distention, ↑HR, ↓BP, turner’s sign, hyperglycemia Acute: quick onset pain, n/v, fever, ↑HR, ↓BP Chronic: recurrent LUQ pain radiating to back, anorexia, n/v, wt loss, flatulence, constipation, steatorrhea, MALABSOPRTION Meds: Pain management (dilaudid), antibiotics, pancreatic enzyme supplements, H2 blockers (Tagamet, zantac, Prilosec), sandostatin (neutralize pancreatic enzyme secretion) Acute tx: NPO, pain, IV/TPN, anticholinergics, antacids, antibiotics, ↓fat, no alcohol, bland, ↑carb, pancreatic enzymes Neuro (5) Intracranial Aneurysm: weakening/rupture of cerebral vessel wall Risks: HTN, atherosclerosis, connective tissue damage, abnormal blood flow, defect in vessel Sx: asymptomatic until rupture, “worse headache of my life,” visual disturbances, photophobia Dx: CT scan, ↑BP Stroke: Tx: “like a hemorrhagic stroke,” ↓ICP, maintain airway, O₂, maintain CPP, therapeutic hypothermia, nutritional support, ↓BP, surgery Sx: ↑BP, weakness, vision, dizziness, headache, trouble speaking Ischemic: Blockage Thrombus in large vessels, embolic, small vessel occlusion Tx: TPA (Retavase)- ↑ bleeding, meet criteria, systemic effects, keep BP slightly ↑ Hemorrhagic: Bleeding Primary (vascular rupture-aneurysm, arteriovenous malformation), secondary (overcoagulation, vasopressor meds, drug abuse, coagulopathy) Tx: Bring BP down for surgery TIA: Warning Stroke Resolution within 24hr., carotid enterectomy (clean out artery), blood thinner (Plavix) Dx: emergency CT w/o contrast, EKG, labs, MRI Meds: Thrombolytics, anticoagulants, antiepileptics (lorazepam), CCB, stool softeners, analgesics, antianxiety Nursing: exact time of onset, neuro exam, ↓ICP D/C instructions: antiplatelets (aspirin, Aggrenox), anticoagulants (warfarin, heparin), antihypertensives, risk factor modifications, rehab ↑ICP: normal 15 Sx: mental status change, ↓LOC, hemiparesis/hemiplegia, (paralysis of one side of the body), posturing, alterations in vision, v/s changes, headache, papilledema (swelling of the optic nerve), vomiting Cushing’s Triad: ↑BP, ↓HR, ↓RR *ICP must be normal to maintain CPP* CPP: keep 60 (CPP = MAP – ICP) ↓ICP: HOB 30⁰, space out activities, ↓stimuli Tx: O₂, BP control, diuretics (mannitol, furosemide), fluids (NS, strict Is/Os, ↑MAP), ↓metabolic demands (↓temp, sedation-propanol, morphine, seizure prophylaxis, neuromuscular blockade, barbiturate therapy, paralytics, sedation Spinal Cord Injury (5) Tx: STABILIZE, ABGs, Steroids within 8 hrs (Solu-Medrol), vasopressors, antispasmodics (baclofen, Zanaflex), analgesics, PPI, anticoagulants, stool softeners, atropine, Nonsurgical: immobilizations, drug therapy; Surgical, Complementary therapies Postoperative care: Neuro assessment, v/s, patient’s ability to void, pain control, wound care, CSF check, pt positioning/mobility, d/c teaching (home care, community resources) Long-term management: difficulty breathing, impaired mobility (safety), spastic of flaccid bladder/bowel, impaired adjustment Complications: Neurogenic Shock: ↓HR, ↓BP, dry skin (usually within 24hr of injury) Autonomic Dysreflexia (autonomic hyperreflexia): EMERGENCY Injury to spinal cord above T6 causes miscommunication between nerves and brain Causes: Full bladder, ingrown toenail, constipation, kidney stones, UTI, catheter, hemorrhoids, irritated skin, pressure on scrotum, sexual stimulation Sx: headache, anxiety, ↓HR, ↑BP, flushed feeling/sweating above lesion, Pale/cold/ goosebumps below lesion, trouble breathing, stuffy nose, blurry vision (HTN CRISIS) Immediate Tx: high fowler’s, find cause DKA (5) Hyperglycemic Crisis ↓in circulating insulin Diabetic Ketoacidosis (DKA) Hyperosmolar Hyperglycemic State (HHS) Occurrences Common Uncommon Age 20-29 57-70 Diabetes Type 1 Type 2 Physiological disturbances - Hyperosmolality due to ↑BG - Metabolic acidosis due to ketoacidosis - Volume depletion due to osmotic diuresis - ↓use of glucose and/or ↑production - Hyperosmolality due to ↑BG - Volume depletion due to osmotic Diuresis - NO KETOACIDOSIS (↑BG w/ hyperosmolarity blocks lipolysis - More “normal” ABGs - More electrolyte imbalances and renal dysfunction Risk Factors Infection, illness, surgery, stress, insufficient/absent insulin, pregnancy, MI, insulin pump failure, intentional omission (eating disorders, behavioral), meds (glucocorticoids) severe stress response, meds (thiazides, phenytoin, glucocorticoids, beta blockers, CCBs) More comorbidities Osmolarity (275-295) ↓ (wetter- fluid overload) ↑ (dryer- dehydrated) Na x 2 = Osmolarity Na (140) x 2 = 280 Na (160) x 2 = 320 Blood Sugar Higher (1000) lower Potassium ↑ (T-wave higher) ↓ (T-wave lower) Symptoms ↓LOC, fruity breath, kussmaul RR, ↑HR, ↓BP, polydipsia, polyuria, polyphagia, vomiting, abdominal pain, dehydration, weight loss, muscle wasting, cerebral edema, CNS depression/coma Profound dehydration, Treatment Respiratory support, fluid replacement (1st 0.9%NS, then 0.45%NS), electrolyte replacement (potassium and phosphorus, magnesium), correct acidosis (assess RR and LOC, fluids and insulin, bicarb only if pH 7.1) Insulin therapy: loading dose, continuous infusion, Q1hr BG, ↓rate when BG250 and change IV to 5% dextrose or 0.45%NS • P-Wave: SA node firing, atrial contraction • PR Interval: time from impulse through atria to ventricles • QRS Complex: Ventricular contraction • ST Segment: time between ventricular contraction and filling • T Wave: Ventricular repolarization (filling) ***If rate is too fast to determine rhythm, slow with Adenocard*** Sinus Rhythms Normal Sinus Rhythm (NSR) (SR) Rhythm- regular Rate- 60-100bpm P wave- before each QRS PR interval- 0.12-0.2 sec QRS- 0.12 sec * Electrical signal travels normally Sinus Bradycardia Rhythm- regular Rate- 60bpm P wave- before each QRS PR interval- 0.12-0.2 sec QRS- 0.12 sec *caused by beta blockers- ↓ HR, contractility, conductivity, CCBs, digoxin *Symptomatic: tx with O₂, fluids, atropine (↑ HR, ↑SNS), dopamine (inotropic, ↑ CO, ↑ contractility), epinephrine, transcutaneous pace, transvenous pace, Cardioversion Sinus Tachycardia Rhythm- regular Rate- 100bpm P wave- before each QRS PR interval- 0.12-0.2 sec QRS- 0.12 sec *caused by exercise, distress (fever, anxiety, ↓bp); usually resolves when out of distress *Symptomatic: Tx with fluids, Adenocard (adenosine), amiodarone, digoxin, lidocaine, Beta Blocker (Cardizem), emergent cardioversion; Valsalva, EKG *Asymptomatic: Tx with fluids, amiodarone, digoxin, lidocaine, Beta Blocker (Cardizem) Adenocard (adenosine); Valsalva, EKG Sinus Arrhythmia Rhythm- irregular, change during respiration Rate- 60-100 (usually) P wave- uniform, before each QRS PR interval- 0.12-0.2 sec QRS- 0.12 sec *usually doesn’t require Tx *Asymptomatic vs symptomatic? Sinus Arrest Rhythm- Irregular (pause) Rate- variable P wave- before each QRS PR interval- 0.12-0.2 sec QRS- 0.12 sec * Caused by meds, deteriorating condition * more concern with more arrests (pauses) Atrial Rhythms **messed up P waves** Atrial Flutter Rhythm- regular or irregular Rate- variable, usually 150 P wave- multiple flutter waves (sawtooth) - P wave Rate is 300bpm PR interval- not measurable QRS- 0.12 sec * SA node not working right; SOA, palpitations, angina, anxiety, fatigue, ↓CO, ↓BP, cool/clammy skin * Tx with digoxin, CCB (Cardizem, verapamil), beta blockers- ↓ HR, contractility, conductivity (atenolol, carvedilol, metoprolol, propranolol), Potassium channel blockers (amiodarone, sotalol), TEE, cardioversion, ablation, blood thinners (warfarin, dabigatran, rivaroxaban, apixaban) * Clot prevention and rate control!!! Atrial Fibrillation Rhythm- irregular Rate- 100-180bpm P wave- not distinguishable PR interval- not measurable QRS- 0.12 sec * Atria fires irregular electrical impulses; SOA, palpitations, angina, anxiety, fatigue, ↓CO, ↓BP, cool/clammy skin * Tx keep ventricular rate 100 * Tx with digoxin, CCB (Cardizem, verapamil), beta blockers- ↓ HR, contractility, conductivity (atenolol, carvedilol, metoprolol, propranolol), Potassium channel blockers (amiodarone, sotalol), TEE, cardioversion, ablation, blood thinners (warfarin, dabigatran, rivaroxaban, apixaban) * Clot prevention and rate control!!! Supraventricular Tachycardia (SVT) Rhythm- regular Rate- 140-220bpm P wave- often buried in T waves PR interval- depends * Impulses coming from AV node and surrounding tissues QRS- 0.12 sec * Tx Valsalva maneuvers, Beta Blocker (Cardizem), Adenocard (adenosine), amiodarone * Symptomatic = emergent cardioversion Ventricular Rhythms **messed up QRS complex** Caused by: aging, hypoxia, stress, MI, electrolytes (K and Mg), CHF, extreme heart slowing or asystole Premature Ventricular Complex (PVC) Pairs or couplets runs or bursts (3) Bi/Tri/Quadra-geminal (every 2/3/4 beat) Rhythm- irregular (early complexes) Rate- underlying rhythm P wave- before each QRS PR interval- 0.12-0.20 sec QRS- 0.12 sec in rhythm and 0.12 sec in PVCs *PVC are wide/bizarre, with T wave and upside down QRS * PVCs look the same * More concern with more PVCs Multifocal PVC’s Rhythm- irregular (early complexes) Rate- underlying rhythm P wave- before each QRS PR interval- 0.12-0.20 sec QRS- 0.12 sec in rhythm and 0.12 sec in PVCs *PVCs will look different *MONITOR Ventricular Tachycardia (VT) Rhythm- regular Rate- usually 150bpm P wave- not seen QRS- 0.12 sec *Poor cardiac output * abnormal ventricle generates rapid/irregular heart beats *NO PULSE = DEFIBRILLATE/CPR * PULSE = give meds and tx underlying problem * epinephrine (vasopressor, ↑CO), amiodarone, lidocaine, magnesium Ventricular Fibrillation (VF) Rhythm- irregular Rate- 300, disorganized P wave- not seen QRS- not recognizable *DEFIBRILLATE/CPR QUICKLY!!! * epinephrine (vasopressor, ↑CO), amiodarone, lidocaine, magnesium Ventricular standstill or P-wave Asystole Rhythm- none Rate- atrial rate only (no ventricular pumping) P wave- none PR interval- none QRS- none * IMMEDIATE CPR * epinephrine, pacemaker * SA node impulse not traveling to ventricle Asystole NO ELECTRICAL ACTIVITY IN THE HEART * IMMEDIATE CPR * epinephrine, pacemaker * Determine cause Pulseless Electrical activity(PEA) Shows electrical activity, but has no pulse * IMMEDIATE CPR * epinephrine, pacemaker Pacemaker Single Chamber Transvenous Pacer Atrial **ATRIAL** * pacing electrode in right atrium * pacemaker spike in front of P wave * used when SA node is bad, but AV node and ventricles are intact * RARELY USED Single Chamber Transvenous Pacer Ventricular **Ventricular** * pacing electrode in right ventricle * pacemaker spike followed by a wide QRS Dual Chamber Transvenous Pacer * paces both right atrium and right ventricle * pacing electrode in right atrium * pacing electrode in right ventricle * electrodes work independently of each other * pacer spike in front of P wave and QRS Transcutaneous Electrical Capture * Emergent symptomatic bradycardia (not responding to meds) * asystole 10 min. * temporary until permanent pacemaker * should be used no more than 2 hours * Sedation or analgesia will be needed * wide QRS and broad T wave Automated Internal Cardiodefibrillator (AICD) * for pts with ejection fraction 30% * will have pacer also * internal shocks delivered after 12-17 runs of V.Tach Failure to capture * pacer spikes NOT followed by P waves or QRS complexes * INTEROGATION Failure to Sense * pacer spikes to close behind QRS complexes * usually pacer spike is in the T wave * INTEROGATION “my pacer doesn’t have any sense, because it is spiking my T wave.” MEDs ACE Inhibitors (-prils) Tx: HTN, CHF, post-MI Patho ↓ BP; ↓ blood volume; ↑blood to renal, ↓Afterload Meds: lisinopril, captopril, enalapril Adverse: dry cough, angioedema ARBs (-sartans) Tx: HTN, CHF, post-MI ** can replace ACE if cough persistent Patho ↓ BP; ↓ blood volume; ↑blood to renal, ↓Afterload Meds: losartan, valsartan Cardiac Glycosides Tx: CHF, A.Fib, Atrial flutter Patho ↑ contractility, ↓HR, ↓ SA & AV node conduction, ↑CO, ↑stroke volume Meds: Digoxin, Primacor (IV only) Adverse: toxicity (n/v, anorexia, fatigue, weakness, blurred vision, yellow halos) * stop, tx bradycardia, overdose digibind Antianginal Tx: Angina, HTN, CHF Patho Vasodilation, ↓ preload, ↓afterload, ↓ O₂ consumption Meds: nitro Adverse: headache, hypotension Beta adrenergic Blockers (-olols) Tx: HTN, MI, Angina, tachydysrhythmias, CHF Patho ↓ conduction, ↓ workload, ↓ O₂ consumption, stabilize dysrhythmias, ↓SNS Meds: metoprolol, atenolol, propranolol, labetalol Adverse: bronchoconstriction, fatigue weakness Calcium Channel Blockers Tx: Angina, HTN, A.Fib, atrial flutter, SVT Patho: ↓ Ca movement into cells, arterial dilation, ↓BP/HR, ↓afterload Meds: amlopine, verapamil, diltiazem, Cardizem Adverse: constipation Diuretics Tx: CHF, HTN, fluid overload Patho: ↑ secretion of H₂O and electrolytes Meds: Loop- Bumex, Lasix K-sparing- Aldactone Thiazide- Diuril, HCTZ Adverse: electrolyte imbalances Analgesics Tx: angina Patho: vasodilation, binds to pain receptors Meds: morphine Adverse: n/v, ↓BP Antidysrhythmic *Adenosine Tx: SVT, tachycardia Patho: ↓conductivity through AV node, STOPS heart for up to 6 secs Adverse: death, scares pt *Amiodarone Tx: V.Fib, unstable tachycardias Adverse: incompatible with heparin *Atropine (↑HR, ↑SNS) Tx: bradycardia Adverse: dry mouth, blurry vison *Epinephrine (↑BP, ↑CO) Tx: V.Fib and pulseless VT Adverse: tachycardia, nervousness Emergency Drugs *Dopamine (↑CO) Tx: hypotension IV only, ↑HR *Nipride Tx: HTN crisis VASODILATION *Dobutamine Tx: CHF, Patho: ↑BP, ↑ Contractility IV only *Levophed Tx: Severe hypotension IV only, tissue necrosis possible Anticoagulants Prevention and extension of a thrombus Meds: Coumadin, Heparin, Lovenox ANTIDOTE: vitamin K and FFP and Platelets Antiplatelets Inhibits Plt aggregation Meds: ASA, Plavix, Effient Thrombolytics Dissolve clots reopen blood vessels Meds: Activase (TPA), streptokinase, reteplase NO antidote, WATCH FOR BLEEDING Beta2 Adrenergic Agonists Bronchodilation; Tx asthma, bronchospasm, wheezing, COPD Meds: Albuterol Methylxanthines Bronchodilation; Tx COPD, asthma, bronchospasm Meds: Aminophylline, Theophylline Inhaled Anticholinergics Bronchodilation; Tx asthma, bronchospasm, COPD Meds: Ipratropium, Tiotropium CAUTION use with narrow angle glaucoma and BPH Glucocorticoids ↓inflammatory response, ↓airway mucus production, ↓immune Meds: Prednisone, Bedesonisde, Methylprednisolone, Hydrocortisone NEVER stop suddenly, ↑BG Leukotriene Modifiers ↓inflammation, bronchodilation, ↓edema, ↓mucus (long-term) Meds: Montelukast, Zileuton Antitussives, Expectorants, Mucolytics Suppress cough, ↑mucous secretion, enhance flow of secretions Meds: Hydrocodone, Codeine, Guaifenesin, Acetylcysteine Sulfasalazine (Azulfidine) Amniosalicylic; antibiotic and anti-inflammatory Tx: mild ulcerative colitis or Chron’s disease Metronidazole (Flagyl) Antibiotic; Tx: mild ulcerative colitis or Chron’s disease Loperamide (Imodium) Antidiarrheal Manage Sx of ulcerative colitis or Chron’s disease Inflammatory Bowel Disease Diet ↓fat, no fried/greasy foods, low fiber (no nuts/seeds/corn), caution with dairy; Bland diet (not spicy and low fiber), smaller/frequent meals, ↑fluids; avoid caffeine Ferrous Sulfate Iron; use straw, take with vitamin C Tx: liver cirrhosis, anemia Vitamin K Blood clotting factors Tx: liver cirrhosis, ↑clotting factors Cirrhosis Diet Fluid restriction, vitamin and mineral supplement, adequate calories Low/no salt (fluid retention) or animal protein (encephalopathy- severe) NO ALCOHOL Acute Pancreatic Diet NPO, IV/TPN, low fat, no alcohol. Bland, high carb, pancreatic enzymes; insulin Furosemide (Lasix) Diuretic; Tx: liver cirrhosis Azathioprine (Imuran) Immunosuppressant; maintain remission and who don’t respond to tx and chronic steroid use Tx: moderate ulcerative colitis or Chron’s disease Ciprofloxine (Cipro) Antibiotic Total Parental Nutrition (TPN) Need central line, individualized, around the clock, labs every morning, BG Q6, high dense glucose, start slow & weaning slowly ***run out hang D10*** Tx: Acute ulcerative colitis or Chron’s disease Spironolactone (Aldactone) Potassium sparing diuretic Folic Acid B-Vitamin; helps body make new cells Tx: liver cirrhosis Lactulose (Cephalac) PO or Rectal; ↓ammonia in the blood; Tx: liver cirrhosis Hydromorphone (Dilaudid) Opioid; pain reliver Tx: acute or chronic pancreatitis Pancrelipase (Lipancreatin) Improve digestion for people who don’t have enough enzymes Tx: acute or chronic pancreatitis Beta Blockers ↓HR, ↓BP, controls angina Tx: liver cirrhosis; portal HTN; esophageal varices