Transcript Bunch of heart stuff

Bunch of Heart Stuff
Chemeketa Community College
EMT-Paramedic Program
Objectives
 Left Ventricular Failure
 Right Ventricular Failure
 Pulmonary Edema
 Cor Pulmonale
 Acute Pulmonary Embolism
 EKG’s
Left Ventricular Failure
Affects over 2% of US pop.
 Disproportionate # of EMS calls
 #1 Dx of inpatients >65
 Incidence of CHF doubles per
decade of life
 Mortality Rate with CHF

8 times for men
5 times for women
Left Ventricular Failure
The failure of the LV to
effectively pump forward
 Synonymous with CHF
 Acute CHF

Rapid
 Chronic CHF
Slow
Midnight Shoppers
LVF
 Common Causes
Systemic HTN
– Afterload
Coronary Artery Disease
– Arteriosclerosis/Atherosclerosis
Ischemia
– Local/temporary occlusion
LVF
 Common Causes
Infarction
– Permanent, necrosis
Cardiomyopathy
– Diseased heart muscle
tissue
 ETOH
 Enlargement
LVF
 Causes
Volume overload
– Bag of Potato Chips
Severe anemia
– Hypoxemia
LVF
 Fluid will collect in LA
Small & Relatively incapable
 Pulmonary Vasculature Fills
Pulmonary Congestion Occurs
 Pulmonary Edema 2nd to LVF
LVF S/S
 Generalized
Weakness
 Fatigue
 Chest Pain
May be masked by
respiratory complaint
 Anxiety
 Dyspnea
LVF S/S
 Tachypnea
 Orthopnea
 Paroxysmal Nocturnal Dyspnea
Elevation of pulmonary venous & cap
pressures
Wakening from sleep
 Decrease in exercise tolerance
LVF S/S
 Rales
 Wheezes
Reflex Airway Spasm
Cardiac Asthma
 Rhonchi (Larger airway)
 Dull percussion at lung bases
Edema in Lungs
LVF S/S
 Productive Cough
Foamy-Blood-tinged sputum
 Cyanosis
 B/P
Initial HTN
LVF S/S
 Pulse
Rapid
Possible Dysrhythmia
– Location of infarct
 Diaphoresis
Right Ventricular Failure
 Causes
#1 Cause of RVF is LVF
Stenosis:
– Pulmonary valve
– Mitral Valve
Pulmonary Vascular HTN
RV AMI
RVF – Who Cares
 Inability of RV to pump forward
 Overwhelmed by venous return
 Backflow in systemic circulation
RVF – S/S
 Tachycardia
 Venous Congestion
 Engorged Liver, spleen
 JVD
 Peripheral Edema
Dependent Edema
Pitting Edema
Sacral (Bedridden)
RVF-S/S
 Ascites
Accumulation of serous fluid in peritoneal cavity –
Taber’s 19th
 Pleural Effusion
 Peripheral Cyanosis
 Tachy if isolated RVF
 Right sided hypertrophy
X-ray
RVF – S/S
 Clubbing of fingers
Dx: Chronic Hypoxia with RHF
 Most of the other LVF S/S also
 CP
 SOB
 Tachypnea
 Anxiety
 Etc…
Cor Pulmonale
 Cause of RVF
Pulmonary Parenchymal or vascular disease
 CP is a disease process
 Case Scenario Explanation
Cor Pulmonale – Case
 58 yo male
 Hx of Chronic bronchitis or emphysema
Typical S/S of bronchitis
 Progression
Deterioration of Pulmonary capillaries
Alveolar Fibrosis
Chronic Hypoxemia
Cor Pulmonale – Case
 Progression caused:
Increase in pulmonary artery pressures
Result RV afterload increase
– RV ill equipped
RV Enlarges (Hypertrophy)
Chronic RH HTN leads to RVF
Cor Pulmonale – Case
 Patient displays all signs of:
RVF
Initial causative pulmonary condition
 Voila’
Treatment of RVF & LVF
 CHF a circumstance not a Dx
 Treatment objectives
Decrease myocardial:
– Workload
– Oxygen demand
Increase force & efficiency of contraction
Reduce fluid retention
Tx
 Decrease Workload
No Physical activity
Sitting upright
Oxygen
– Pt may tolerate BVM
Morphine 
Tx
 Vasodilatory Therapy (Nitrates)
– AMI reperfusion
– Container expansion reduces preload
 Increase Contractility
Shock algorithm directs
– Dopamine
– Dobutamine
– Norepinephrine
Tx
 Reduce Fluid Retention
Diuretics
– Lasix
– Bumex
Acute Pulmonary Embolism
Chemeketa Community College
Paramedic Program
Acute Pulmonary Embolism
Acute Pulmonary Embolism
Defined
 Blood clot lodged in pulmonary artery
Blocks pulmonary artery flow
Supplied area ceases to function
Decreased gas exchange
V/Q mismatch
Defined
 Typically forms in deep veins of thighs
 Can also be fat or air
History
 Anticoagulation therapy
Heparin – 1930s
Streptokinase – 1930
Urokinase – 1951
1960s – Large study of clot resolution
Recently TPA
Incidence
 Unknown, range from
50,000-100,000/yr
 Higher than diagnosed, most
diagnosed postmortem
 8% death rate with heparin tx
 1/3 will die within 1 hour
Risk Factors
 Deep vein thrombosis
 Prolonged immobilization
 Surgery
 Trauma
Pelvic or femur fractures
 Late pregnancy
Risk Factors
 Thrombophlebitis
 Certain meds
Oral contraceptives
 Atrial fibrillation
 Smoking
 Unknown
Increasing Frequency
 Older population
Malignancies
More sedentary
Heart failure
COPD
Surgical procedures
Presentation
 Variable and Non-specific
Dyspnea
Pleuritic chest pain
Syncope
Hemoptysis
RHF
Tachycardia
Presentation
 No physical findings significantly accurate
 Deep venous thrombosis in proximal lower
ext. helpful for Dx
Only about ½ source known
Why doesn’t lung tissue die from
emboli like heart muscle?
 Lung has two blood supplies
Pulmonary and Bronchial
Share capillary beds
Pre-hospital Treatment
 Good Physical Exam and History
 Index of suspicion
 Airway
 High flow O2
 IV
 Rapid Transport
Treatment ???
 Heparin
 Thrombolytic agents
Streptokinase
TPA
 Catheter fragmentation
 Catheter embolectomy
 Open-chest embolectomy
Definitive Diagnosis
????
 Angiographic
 V/Q scan (venous/perfusion mismatch)
 Operative
 Multiple sources of evidence
Differential Diagnosis
Pneumonia
 Herpes Zoster
 Pleurisy
 COPD
 Rib fracture
 Asthma
 Angina
 MI
 Pneumothorax
 Pancreatitis
 Hepatitis
 Salicylate OD

Bronchitis
 Hyperventilation
 Lung carcinoma
 Sepsis
 TB
 Muscle pain
 Costochondritis
 CA
 Pericarditis
 CHF
 Percardial tamponade

Watch Out
Extraordinarily difficult to diagnose
Watch out for hyperventilation
Young women
Group Projects!
Work in Pairs and find the answers
List As Many Drugs As You Can
That Will Dilate Blood Vessels.
 Name the source
 Describe why they
work
List Drugs That Cause
Tachycardias.
 Describe why they cause increase rate change
List Drugs that cause
Bradycardias.
 Why do they cause them?
List Drugs that cause
Hypertension.
 How do they do it?
Your patient has a heart rate of 140 bpm. What
could be his problem?