CAD & ACS
What are the inclusion criteria for thrombolytic therapy?
•Chest pain < 12 hrs with 12-lead ECG findings of a STEMI
•No absolute contraindications (active internal bleeding, hx of intracranial hemorrhage, etc.)
Explain the difference between left-sided and right-sided heart failure.
- Left-Sided: Inability of LV to pump or fill effectively; causes fluid backup into the pulmonary vasculature
- Right-Sided: Inability of RV to pump or fill effectively; causes fluid backup into the venous system
Name 2 things that can cause artifact.
Chest hair, oily skin, movement
Explain the difference between SaO2 and PaO2.
- PaO2 = partial pressure of oxygen dissolved in
arterial blood; assesses perfusion (gas
exchange). Indicates if the patient has
hypoxemia (decreased oxygen in the blood)
- SaO2 = % of oxygen bound to hemoglobin;
assesses tissue oxygenation. Indicates if the
patient has hypoxia (decreased oxygen in the
tissues)
What is the hallmark sign of ARDS?
Refractory hypoxemia: no improvement in pt condition despite increased oxygen levels
• PaO2/FiO2 ratio <300
For a STEMI, what is "door to balloon" and "door to drug" mean? What are the expected time frames for each?
Door to balloon <90 mins: PCI
Door to drug < 30 mins: Thrombolytics, if no PCI available
Patient has a heart rate of 78 per minute and a stroke volume of 80 mL per beat. What is the cardiac output in liters?
CO = HR x SV
6,240 mL = 78 x 80
6.24 L
List two patient teachings post-pacemaker insertion.
- Follow-up appointments for pacemaker function checks
• Incision care
• Arm restrictions
• Avoid direct blows
• Avoid high-output generator
- No MRIs unless pacer approved
• Microwaves OK
• Avoid antitheft devices
• Travel not restricted
• Monitor pulse
• Pacemaker ID card
• Medic Alert ID
- Limit arm and shoulder activity
• Monitor insertion site for bleeding and infection
Determine what the pt is experiencing with the following ABGs. pH: 7.44, PaCO2: 54, HCO3: 36, PaO2: 90
pH: 7.44 normal (lean toward alkalotic side)
PaCO2: 54 high (acidic)
HCO3: 36 high (alkalotic)
PaO2: 90 normal
Compensated Metabolic Alkalosis
What is a shunt in ARF? What are the two types?
Shunt: when blood exits the heart without performing gas exchange
Anatomic: blood bypass the lungs without going through pulmonary capillaries
Capillary: blood moves through the pulmonary capillaries, but without adequate gas exchange
ECG:
•UA or NSTEMI: ST depression and/or T wave inversion facing ischemia/infarction
•UA: negative cardiac markers
•NSTEMI: positive cardiac markers
•STEMI: ST elevation in the leads facing the infarcted wall. ST segment elevation of 1mm or greater in 2 contiguous leads or 2mm or more in V2 and V3; positive cardiac markers
Name and explain three complications of HF.
- Pleural Effusion: fluids in between pleura and chest wall
- Dysrhythmias: Afib
- Hepatomegaly: enlarged liver
- Cardiorenal Syndrome: Disorder of the heart and lungs
- Anemia: lack of healthy red blood cells/hemoglobin
Which dysrhythmia has the following characteristics?
P wave: saw tooth pattern, PR interval not measurable, QRS normal, atrial rate: 250-400, ventricular rate <150, regular atrial rate
A.flutter
Name 2 differences between OPAs and NPAs.
NPA: inserted into nostril, for conscious and unconscious pts, contraindicated if nose bleed, fractures/deformities are present.
OPA: inserted orally, shorter, only on unconscious pts, inserted upside down, may stimulate vomiting and cause aspiration
What is the hallmark sign of diffusion limitation in ARF?
Hypoxemia worsens with exercise but not at rest because blood moves through the lungs quickly without time for oxygen diffusion.
Name and describe four complications associated with ACS.
•Dysrhythmias: Ventricular tachycardia (VT), Ventricular fibrillation (VF), Heart Blocks
•Heart Failure: Ventricle’s pumping action is reduced
•Cardiogenic Shock: occurs when O2 and nutrients to the tissues are inadequate
•Goal: ↑ O2 delivery, ↓ O2 demand, and prevent complications
•Papillary Muscle Dysfunction/Rupture: occurs if infarct near muscle that attaches to the mitral valve
•New systolic murmur = mitral valve regurgitation
•Left Ventricular Aneurysm: infarcted heart muscle wall thins and bulges out during contraction
•Ventricular Septal Wall Rupture/ Left Ventricular Free Wall Rupture: new loud systolic murmur
•Pericarditis: inflammation of the visceral and/or parietal pericardium
•Dressler Syndrome: pericarditis and fever 1-8 weeks after MI
Will the PaO2 and PaCO2 increase or decrease for a client presenting with acute decompensated HF?
PaO2 decreases
PaCO2 increases, leading to respiratory acidosis
Name two rhythms that can be cardioverted.
Unstable ventricular or supraventricular tachydysrhythmias. A.fib, A.flutter
Name four interventions to prevent ventilator-associated pneumonia.
Prevention
• Minimizing sedation
• Early mobilization
• Use of ET tubes with subglottic secretion
drainage ports
• Elevate the head of bed 30-45o unless
contraindicated
• Oral care with chlorhexidine
• No routine changes of the ventilator circuit
tubing
• Strict hand hygiene
• Injury or Exudative Phase: interstitial edema d/t inflammation, stiff lung, decreased surfactant production
• Reparative or Proliferative Phase: continued inflammation, pulmonary vascular resistance, pulmonary hypertension, increased stiffness of lungs, dense, fibrous tissue
• Fibrotic or Fibroproliferative Phase: remodeling of lungs, stiff, decreased surface area for gas exchange
Define sudden cardiac death. What are common causes? How can it be prevented? What interventions are to be implemented during a witnessed event?
•Sudden Cardiac Death (SCD): abrupt, unexpected death resulting from a variety of cardiac issues without 1 hour of symptom onset
•Most common cause is acute ventricular dysrhythmias (VT or VF) with or without MI = loss of CO and cerebral blood flow
•Have a history of LV dysfunction (EF <35%), and/or structural heart disease (hypertrophic cardiomyopathy)
•Clinical Manifestations: angina, palpitations, dizziness/lightheadedness
•Use of an implantable cardioverter-defibrillator (ICD) to prevent event
•Rapid CPR, defibrillation and use of an automatic external defibrillator (AED) for witnessed arrest cases
Name 1 medication from each group below and list 1 side effect for each (must be different side effects).
- ACE inhibitors, Beta-blockers, Diuretics
- ACE inhibitors: Captopril, Lisinopril, Enalapril; Cough, increased K+, fatigue, dizziness, headaches, loss of taste
- Beta-blockers: Metoprolol, Carvedilol, Bisoprolol; Dizziness, weakness, fatigue, cold hands and feet, dry mouth, skin, or eyes, headache, upset stomach, diarrhea
- Diuretics: Furosemide, Butanamide, Torsemide; Hypotension, low K+, nephrotoxic. Spironolactone, Eplerenone; Hypotension, increased K+
Name 3 of the "Hs" and 3 "Ts" from "Hs & Ts" that may be causes of why a pt is in PEA.
• Hypovolemia
• Hypoxia
• Hydrogen ions - i.e. acidosis
• Hyperkalemia or hypokalemia
• Hypothermia
• Toxic drug overdose
• Cardiac Tamponade
• Thrombus – MI or Pulmonary embolus
• Tension pneumothorax
Describe the difference between SIMV and Assist-control modes on the ventilator.
AC: A set respiratory rate, tidal volume, PEEP,
inspiratory time, & FiO2%
• Most common mode
• Considered “full” support
• Patient is capable of taking spontaneous
breaths and set volume is delivered
- Can be used for pts with or without
spontaneous breaths
- Reduces work of breathing and allows the
respiratory muscles to rest
- Risk of hyperventilation due to many
spontaneous breaths at set tidal volume.
May lead to respiratory alkalosis
- Sedation may be needed to limit
spontaneous breaths
SIMV: A set respiratory rate, tidal volume, PEEP, inspiratory time, & FiO2%
• Considered “partial” support
• Patient is capable of taking spontaneous breaths AND achieve whatever tidal volume they can achieve
- Ventilator attempts to synchronize mechanical breaths to spontaneous breaths. The preset target is delivered in sync with the patient effort.
• If patient fails to initiate a spontaneous breath, the ventilator delivers a mandatory mechanical breath according to the preset rate
• Benefits
• Prevents respiratory muscle atrophy
• Lower airway pressures
• Patient-ventilator synchrony (decrease discomfort and agitation for pt)
List three early clinical manifestations and three late manifestations of ARDS.
Early Manifestations
• Mild dyspnea
• Tachypnea
• Cough
• Restlessness
• Lung sounds: clear or fine, scattered crackles
• ABGs: mild hypoxemia and resp. alkalosis from hyperventilation
• Chest X-Ray: normal or diffusely scattered, minimal interstitial
infiltrates
Late Manifestations
• Symptoms worsen from progression of fluid
accumulation and decreased lung
compliance
• Profound dyspnea due to increased work of
breathing
• Tachypnea and intercostal and suprasternal
retractions
• Tachycardia, diaphoresis
• ALOC, pallor, cyanosis
• Lung sounds: crackles and coarse crackles
on expiration
• ABGs: severe hypoxemia, hypercapnia,
hypoventilation, metabolic acidosis
• Refractory hypoxemia **Hallmark sign of
ARDS** PaO2/FiO2 ratio <300
• Chest X-Ray: “whiteout”, consolidation and
infiltrates throughout lungs. May have
pleural effusions