Transcript chapter 7

chapter
7
Acute Myocardial
Infarction Pathophysiology
Page, 12-Lead ECG for Acute and Critical Care Providers
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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Chapter 7 Objectives
• Describe the myocardial coronary blood supply
• Name the major coronary arteries and locations they
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serve
Describe how clot and plaque formation relate to the
development of an acute myocardial infarction
Describe an intervention plan for managing
myocardial infarction
Explain why getting a good medical history is so
important in the AMI patient
List the most common presentations of AMI for
women and the elderly
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Coronary Arteries
• Branch off of the
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aorta, just above the
leaflets of the aortic
valve
Three major arteries
Each supplies a
specific area
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Right Coronary Artery
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Inferior wall of LV
Right ventricle
Posterior LV
Posterior fascicle of
LBB
SA and AV node
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Left Anterior Descending
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Anterior wall of LV
Septum
Bundle Branches
Hemifascicles
Major pumping
mass of LV
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Left Circumflex Artery
• Upper lateral wall of
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LV (Leads I and
aVL)
SA node in 45%
AV node in 10%
Posterior wall of
LBB
Posterior
hemifascicle
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Occlusion Data
• In general, patients with chest pain on
exertion have 70-85% narrowing
• Those with CP at rest have 90%
occlusion
• Those with chest pain not relieved by
nitroglycerin have 100% occlusion with a
clot!!
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Getting a Good History
• It is HOW we ask the questions
• Mnemonics (OPQRST) are memory aids
• Should not be asked literally to a patient
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Investigating the C/C
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O
P
Q
R
S
T
– Onset
– Provoke
– Quality
– Radiation
– Severity
– Time
Page, 12-Lead ECG for Acute and Critical Care Providers
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
What to Ask
• O – Onset
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P – Provoke
Q – Quality
R – Radiation
S – Severity
T – Time
• Actual time this
episode started
• Open-ended
questions
• Try to get an actual
time, i.e., 10:30 a.m.
• Very important for
cardiac patients
Page, 12-Lead ECG for Acute and Critical Care Providers
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Onset
“When did this episode of chest pressure
start?”
“When did this asthma attack start?”
“When did the accident occur?”
Page, 12-Lead ECG for Acute and Critical Care Providers
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Onset
• Avoid using closed or leading
questions...
“Did the pain start last night or this
morning?”
Page, 12-Lead ECG for Acute and Critical Care Providers
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
What to Ask
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O – Onset
• What makes it better
or worse
P – Provoke
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Note the position of the
Q – Quality
patient
R – Radiation • What they were doing
S – Severity
when it happened
T – Time
Page, 12-Lead ECG for Acute and Critical Care Providers
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Rule # 1 of Questioning
While investigating a chief complaint, the
only words you may use are the words
the patient told you
Page, 12-Lead ECG for Acute and Critical Care Providers
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Rule # 1
If the patient tells you:
“I’m having a tightness in my chest.”
You would reply:
“When did this tightness start, Jim?”
Rather than:
“When did the pain start, Jim?”
Page, 12-Lead ECG for Acute and Critical Care Providers
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Provoke
“Jim, does anything you do make the
tightness worse?”
“Does anything you do make the tightness
less?”
“Jim, what were you doing when this
tightness first started?”
Page, 12-Lead ECG for Acute and Critical Care Providers
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
What to Ask
• O – Onset
• P – Provoke
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• What it feels like
• Avoid closed and
leading questions
Q – Quality • Let the patient have as
R – Radiation
many choices as they
like to describe their
S – Severity
“pain”
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• T – Time
Page, 12-Lead ECG for Acute and Critical Care Providers
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Quality
“Jim, what does this “pain” feel like?”
“What would I have to do to you to make
that kind of “pain?”
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Closed or Leading Questions
“Is the pain sharp or dull?”
“Does the pain kinda feel like a belt around
your chest?”
Page, 12-Lead ECG for Acute and Critical Care Providers
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
What to Ask
• O – Onset
• P – Provoke
• Q – Quality
• R – Radiation
• S – Severity
• T – Time
• Do they have any
problems or pain
anywhere else
• Watch for nonverbal
clues
• Where the pain is
• Pain may not “go”
anywhere
Page, 12-Lead ECG for Acute and Critical Care Providers
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Radiation
Instead of
“Does the pain go anywhere?”
Try
“Are you having any other discomfort?”
Page, 12-Lead ECG for Acute and Critical Care Providers
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Radiation
Instead of
“Does it hurt in the center or side of your
chest?”
Try
“Where does it hurt?”
or
“Can you draw a circle around it?”
Page, 12-Lead ECG for Acute and Critical Care Providers
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
What to Ask
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• Scale of 1–10
O – Onset
• Make sure you find out
P – Provoke
what the worst pain
Q – Quality
was
R – Radiation • Answers of >10 mean
it hurts really BAD!
S – Severity
T – Time
Page, 12-Lead ECG for Acute and Critical Care Providers
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Severity
“On a scale of 1–10 with 10 being the
worst pain you’ve ever had, how would
you rate your pain right now?”
“What was the worst pain you have ever
felt?”
Page, 12-Lead ECG for Acute and Critical Care Providers
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
What to Ask
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• The duration of the
O – Onset
problem
P – Provoke
Q – Quality
• How long the current
R – Radiation
episode has been
going on
S – Severity
• T – Time
Page, 12-Lead ECG for Acute and Critical Care Providers
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Time
“How long has this recent episode of chest
pressure lasted, Jim?”
“How long did Jim’s seizure last?”
Page, 12-Lead ECG for Acute and Critical Care Providers
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Tag-ons
• Tag-ons are extra questions tacked on to
the end of an ordinarily good question
Page, 12-Lead ECG for Acute and Critical Care Providers
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Tag-ons
“Do you have diabetes, hypertension, or
cardiac disease?”
“Are you nauseated?” “Are you short of
breath?”
“Are you having chest pain?” “Is it sharp or
dull?”
Page, 12-Lead ECG for Acute and Critical Care Providers
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Tag-ons
The best way to avoid a tag-on is to ask
one question at a time and wait for the
answer
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SAMPLE History
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S – Signs/symptoms
A – Allergies
M – Medications
P – Past History
L – Last meal
E – Events
Page, 12-Lead ECG for Acute and Critical Care Providers
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Allergies
“Jim, are you allergic to any medications?”
“Sue, are you allergic to anything?”
“Do you have any allergies, Jane?”
Page, 12-Lead ECG for Acute and Critical Care Providers
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Medications
“Do you take any doctor-prescribed
medicines every day?”
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Medications
• Explore the
details
• BCPs?
• OTC Drugs?
• How many?
Page, 12-Lead ECG for Acute and Critical Care Providers
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Past Medical History
• Ask one question at a time
• Allow the patient time to answer
• Explore what is pertinent
Page, 12-Lead ECG for Acute and Critical Care Providers
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Last Oral Intake
• Very important in diabetic emergencies
• Important information for patient who
may have to have surgery
• Need to know when they ate last (time)
and approximate amount
Page, 12-Lead ECG for Acute and Critical Care Providers
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Events Leading up to C/C
• What were they doing when the episode
started?
• Mechanism of injury?
• Useful for neuro exam in head injuries
• Pain at rest or on exertion?
Page, 12-Lead ECG for Acute and Critical Care Providers
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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Physical Exam
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Head to toe
Look for JVD
Assess lung and heart sounds
Palpate the chest wall
Palpate the abdomen
Palpate radial pulses at the same time
Page, 12-Lead ECG for Acute and Critical Care Providers
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Physical Exam (cont.)
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Blood pressure in each arm
Positional changes for the patient
Apical versus radial pulses
Full auscultated blood pressure
Look for peripheral edema
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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The 12-Lead ECG
• Best “early” confirming diagnostic test
• Should be performed on any patient with
a “pulse and problem” between nose
and naval that is suspicious for cardiac
• Should be acquired and triaged in less
than 10 minutes arrival on scene
Page, 12-Lead ECG for Acute and Critical Care Providers
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Acute Coronary Syndrome
• Systems should address the following
treatment guidelines:
• Oxygen and aspirin as soon as possible
• Establish an IV, run a 15-lead ECG
• Nitroglycerin
• Morphine
• Thrombolytic prescreen
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
83
Sample
Thrombolytic
Checklist
Page, 12-Lead ECG for Acute and Critical Care Providers
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ