Interventions & Clinical Skills: Assessment, Stress, ECG, & ACLS

Transcription

1 Interventions & Clinical Skills: Assessment, Stress, ECG, & ACLS Janice Preslar BA, CBNMT, ARRT (R,N) NO CONFLICT OF INTEREST

2 Too much GOOD living!!!!

3 I know CPR can I help?

4 Houston I think we have a problem?

5 Going to Nuclear for stress a test!

6 COMMON CARDIOVASCULAR SYMPTOMS Shortness of Breath Syncope Palpitations Claudicating Edema or weight gain Fatigue Back Pain Nause Chest Pain CP--What is happening? Presentation Quality Region Severity Timing

7 PATIENT PROFILE Personal habits Life-style pattern Recent life changes Emotional state

8 HISTORY Chronic disease HTN, MI, DM, Anemia, CVA, RF, CHF, valvular disease Family History Previous Hospitalizations, treatments, previous cardiac diagnostic procedures. Current health habits Medications Stress and coping skills

9 Evaluation of Patient Identify cardiovascular risk factors Labs (Troponin, K+, HCT,HGB) VS (BP, HR) Drug Levels (Digoxin, Quinidine, Inderal) Diagnostic Procedures (Echo, CT, MRI)

10 Myocardial Perfusion Stress Test EXERCISE (TMT OR BIKE) STRESS PHARMACOLOGIC STRESS AGENTS: ŁAdenosine (with exercise) ŁDipyridamole (Persantine) (with exercise) ŁDobutamine ŁLexiscan

11 EXERCISE (TMT OR BIKE) Bruce or Hollenberg 85% age-predicted heart rate 1.7 mph at 10% grade--advance stage - 3 min At least 5 mins. Modified Bruce or Sheffield 85% age-predicted heart rate 1.7 mph at 0% grade Use in patients with poor exercise tolerance Bike 85% age-predicted heart rate Double the Rate/Pressure product

12 Contraindications to Exercise Absolute Acute myocardial infarction Unstable angina Severe congestive heart failure Uncontrollable arrhythmia Relative Certain Medication (Digitalis, Beta-blockers, and calcium channel antagonists, Nitroglycerin Left ventricular hypertrophy Conduction disturbance (LBBB, complete A-V block, and WPW) Exercise limitations

13 Exercise Indications for stopping test Reaching target heart rate with signs and symptoms Angina, fatigue, dyspnea, claudication, ataxia Development of typical ischemic ST-segment depression Development of ventricular tachycardia Drop in blood pressure Development of LBBB

14 ADENOSINE 140 mcg/kg/min IV constant infusion for 4 mins. (6, or 7 minutes) ŁOnset of action: ŁTime to peak effect: ŁDuration of effect: ŁHalf life: immediate, transient, and dose related seconds about 154 seconds <10 seconds ŁAlmost completely eliminated after single pass through coronary circulation

15 Regadenoson (Lexiscan) 0.4mg/5 ml regadenoson (10 sec)/ flush with 5 ml NS sec wait--- injection of radiopharmaceutical/ flush with 5 ml NS ŁOnset of action: ŁTime to peak effect: 30 sec 1-4 mins ŁDuration of effect: Most adverse reactions begin soon after dosing and generally resolve within approximately 15 minutes, except for headache which resolves in most patients within 30 minutes. ŁHalf Life: Initial phase - 2 to 4 mins Intermediate phase 30 mins Terminal phase 2 hours

16 CONTRAINDICATIONS ŁSevere bronchospastic pulmonary disease ŁSymptomatic hypotension ŁUnstable angina ŁRecent myocardial infarction (<2 days) ŁSick sinus syndrome Ł2nd or 3rd degree AV block ŁSevere congestive heart failure Drug Interactions: Dipyridamole, Xanthines, Aminophyline

17 TERMINATING GUIDELINES ŁHypotension u 20 mmhg systolic fall with signs/symptoms u Systolic pressure 80 mmhg ŁST depression u 3 mm beyond baseline ECG, without angina--dm u 2 mm beyond baseline ECG, with angina ŁSevere chest discomfort Ł2nd or 3rd degree heart block ŁSevere bronchospasm

18 REVERSING ADENOSINE ACTION ŁMajority of symptoms resolve within sec of stopping infusion ŁChest Pain-Nitroglycerine 0.4 mg sublingual; repeat 3 X every 5 mins-check BP ŁTreat bronchospasm with Proventil inhaler or Albuterol nebulizer ŁSlow infusion of Aminophylline mg IV---- Do not inject radiotracer after aminophylline Note: Aminophylline may increase risk of seizure

19 Reversing Regadenoson Action ŁSlow infusion of Aminophylline mg IV ( mg over seconds). Do not inject radiotracer after aminophylline Note: Aminophylline may increase risk of seizure ŁChest Pain-Nitroglycerine 0.4 mg sublingual; repeat 3 X every 5 mins-check BP ŁTreat bronchospasm with Proventil inhaler or Albuterol nebulizer

20 Dipyridamole Onset of action: Time to peak effect: Vasodilator effect: Half life: 2 minutes average 6.5 minutes minutes elimination hours Xanthine (caffeine and theophylline) antagonize effects of Dipyridamole Oral Dipyridamole has little or no effect on potentiating the effects of IV Dipyridamole

21 Contraindications Symptomatic hypotension Unstable angina Recent myocardial infarction Congestive heart failure Previous sensitivity to Dipyridamole Use of caffeine (24 hrs) and theophylline (48 hrs)

22 Termination and/or Reversal Hypotension Systolic fall >20 mmhg Systolic pressure <80 mmhg ST-segment depression 3 mm without angina 2 mm with angina Severe CP, dizziness, dyspnea, headache, nausea, syncope, or dysrhythmia (regardless of BP and EKG changes)

23 Reversing Dipyrdamole Action Majority of symptoms resolve 5-10 mins. Aminophylline mg IV. (Rapidly reversed with aminophylline by blocking adenosine receptors) Nitroglycerine-Check BP IV fluids

24 DOBUTAMINE Action: u u u u Onset: 1-2 min Half life: 2 min Increase myocardial contractility and stroke volume increase work load and O2 demand Increase HR and BP Beta-blocking agents: u may antagonize beta-adrenergic effect If target HR not achieved, give IV Atropine (glaucoma and prostate problems) to reduce vagal tone and increase heart rate

25 CONTRAINDICATIONS to DOBUTAMINE Hemodynamically significant LV outflow tract obstruction Atrial fibrillation - facilitates AV conduction Pre-existing severe hypertension Unstable angina Recent myocardial infarction Congestive heart failure History of ventricular tachycardia Aortic Aneurysm or Aortic Dissection

26 DOBUTAMINE Endpoints: u u u u Achieving >85% of age-predicted HR Angina with ischemic ECG changes Significant arrhythmia Significant side effects (nausea etc) We want to make the stress test as realistic as possible

27 Reversing Dobutamine Action Majority of symptoms resolve within 2-3 min of stopping infusion Recovery time may be increased by min if atropine is used If angina, hypertension-nitroglycerine (0.4 mg) (sublingual), or tachyarrhythmia esmolol (10 mg), metoprolol (5 mg)-think of using diltiazem (5m/ml)

28 ADJUNCT PHARMACOLOGIC AGENTS Reversal of adenosine or Regadenoson Increase heart rate (due to block) For hypotension To reduce blood pressure For bronchospasm For chest pain, hypertension, or tachyarrhythmia To reduce BP and HR For SOB or chest pain Aminophylline-125 mg slow IV push over 2 minutes may repeat in 5 minutes First ask the patient to cough Atropine mg IV push Normal Saline -250 ml bag IV Labetatol mg IV. Proventil Inhaler (Aerochamber) -1-2 puffs Proventil solution for inhalation 0.083% for use with atomizer -2.5 mg/3ml Nitrostat 0.4 mg -1 tablet S.L. every 5 min x 3 Metoprolol mg IV Oxygen as needed (<90)

29 AHA Resting ECG Electrode Placement V1 4th intercostal space, right of sternum V2 4th intercostal space, left of sternum V3 midway between V2 and V4 V4 5th intercostal space, in the midclavicular line V5 same level as V4, at anterior axillary line (between V4 and V6) V6 in 5th intercostal space, in the midaxillary line

30 Anatomy of the Conduction System And Conduction Rates SA NODE INTERNODAL PATHWAYS BACHMANN S BUNDLE times a minute AV NODE BUNDLE OF HIS RIGHT BUNDLE BRANCH LEFT BUNDLE BRANCH ANTEROSUPERIOR FASCILE POSTEROINFERIOR FASCICLE times a minute times a minute PURKINJE FIBERS

31 Calculating Heart Rate Rate approximately 75 (300/4 = 75) Approximately 6 seconds Rate approximately 90 (9 X 10 = 90)

32 Rhythms Originating in the Sinus Node Sinus Node

33 Normal Sinus Rhythm Rhythm Regular Rate P Waves Present PR Interval 0.12 to.20 sec. (3-5) QRS Complex 0.04 to 0.12 sec (1-3) QT Interval <0.44 sec

34 Sinus Bradycardia Rhythm Regular Rate P Waves Present PR Interval 0.12 to.20 sec. (3-5) QRS Complex 0.04 to 0.12 sec (1-3) QT Interval <0.44 sec (<2 )

35 Sinus Bradycardia Benign rhythm, if controlled Causes: vasovagal response, sick sinus syndrome; inferior infarct; drug toxicity (beta-blockers; calcium channel blockers; organophosphates) Alert: Sudden decrease in heart rate; hypotension; decreased mental alertness; diaphoresis; unconsciousness If patient symptomatic: Atropine 0.5 to 1.0 mg IV Transcutaneous pacemaker

36 Sinus Tachycardia Rhythm Regular Rate P Waves Present PR Interval 0.12 to.20 sec. (3-5) QRS Complex 0.04 to 0.12 sec (1-3) QT Interval <0.44 sec (<2 )

37 Sinus Tachycardia Benign rhythm, if rate controlled If patient symptomatic, treat underlying causes Pain -- Hypovolemia Anxiety -- Pulmonary embolism Fever -- Thyroid disease Drug toxicity (cocaine, amphetamines) Drug withdrawal (ETOH, narcotics) Alert: Sudden increase in heart rate; patient becomes anxious; shortness of breath; palpitations Effects on study: None if patient stable (unless resting HR and Stress HR same)

38 Sinus Arrhythmia Rhythm Irregular Rate Variable (40-100) P Waves Present PR Interval 0.12 to.20 sec. (3-5) QRS Complex 0.04 to 0.12 sec (1-3) QT Interval <0.44 sec (<2 )

39 Rhythms of Supraventricular Origin

40 Premature Atrial Complex(PAC) Rhythm Regular/interrupt PAC Rate Variable P Waves different PR Interval 0.12 to.20 sec. QRS Complex 0.04 to 0.12 sec

41 Atrial Tachycardia Sinus Rhythm Atrial Tachycardia *

42 Atrial Tachycardia Rhythm Regular Rate P Waves If seen, precedes QRS PR Interval 0.12 to.20 sec. (3-5) QRS Complex 0.04 to 0.12 sec (1-3)

43 Atrial Fibrillation

44 Atrial Fibrillation Rhythm Irregular Rate Atrial: Ventricular :Variable P Waves/ PR Interval Not distinguishable / Measurable QRS Complex 0.04 to 0.12 sec (1-3)

45 Atrial Flutter Rhythm Regular Rate Atrial: Ventricular :Variable P Waves Replaced with F waves (ratio) PR Interval Not measurable QRS Complex 0.04 to 0.12 sec (1-3)

46 Bundle Branch Block Characterized as right or left BBB Look at leads V1, V2 and V5, V6 Check R to R' V 1 V 2 V 5 V 6 R R' R R' R R' R R' Right Bundle Branch Block Left Bundle Branch Block

47 OK Williams, we ll vote. how many here say the heart has four chambers?

48 First Degree AV Block Normal Conduction First Degree AV Block (Prolonged AV Conduction->5 box) AV Node Bundle of His

49 First Degree AV Block

50 Causes of First Degree AV Block Inferior myocardial infarction Medications: Beta blockers, calcium channel blockers, amiodarone and digitalis Ischemic heart disease Valvular cardiac surgery Hyperkalemia Acute rheumatic fever or myocarditis

51 Second Degree AV Block Normal Conduction Second Degree Second Degree Type I Type II

52 Second Degree AV Block Type I (Wenckebach)

53 2 nd Degree Heart Block (Mobitz I) Benign rhythm in stable patient, usually transient In unstable patient: Atropine 0.6 to 1.0 mg IV bolus Temporary pacemaker Causes: Acute inferior MI; pharmacologic stress with adenosine; disease of conduction system Alert: Sudden onset of bradycardia Decreased mentation Hypotension Effects on study: if block develops and persists during adenosine infusion, discontinue infusion

54 Second Degree AV Block Type II (High Grade)

55 2 nd Degree Heart Block (Mobitz II Classical) Pathologic rhythm immediate treatment required; may progress to complete heart block Treatment: Atropine mg IV bolus Temporary pacemaker Causes: acute anterior MI; cardiac surgery; myocarditis; chronic degenerative disease Alert: sudden decrease in heart rate; decreased blood pressure; pale and diaphoretic; unconsciousness Effects on study: medical emergency, cancel study; if block develops and persists during adenosine infusion, discontinue infusion

56 Third Degree AV Block (Complete Heart Block) SA Node conducts at it s inherent rate of BPM AV Node conducts at it s inherent rate of BPM Two independent pacemakers

57 Third Degree AV Block (Complete Heart Block) P P P P P P P P P QRS QRS QRS Atria BLOCK AV Node Ventricles

58 Third Degree AV Block (Complete Heart Block)

59 3 rd Degree Heart Block (Complete) Pathologic rhythm immediate action required Treatment: Atropine 0.6 to 1.0 mg IV bolus Pacemaker Causes: Anterior MI Alert: Sudden decrease in heart rate Decreased blood pressure Pale and diaphoretic Unconsciousness Effects on study: medical emergency, cancel study. If patient presents with pacemaker, may gate on pacer spike If block develops and persists during adenosine infusion, discontinue infusion

60 Rhythms of Ventricular Origin * * * * *

61 Premature Ventricular Complex(PVC) * *

62 Treatment of Premature Ventricular Complex (PVC) Even in patients with underlying heart disease, the suppression of frequent isolated VPBs or even short runs of VT with antiarrhythmic drugs has not been shown to improve survival. Antiarrhythmic drugs may actually make the situation worse by increasing the severity of the ectopy (proarrhythmic effect). Search for potentially reversible causes and contributors, particularly hypoxia, hypokalemia, hypomagnesemia, and certain stimulant drugs.

63 Ventricular Tachycardia (VT) * *

64 Ventricular Fibrillation (VF) * * * * * * * * *

65 Asystole Lighten Up

66 ECG CHANGES WITH CHEST PAIN Subendocardial injury: ST depression ST With subendocardial ischemia, the electrical forces are deviated toward the inner layer of the heart, causing ST depression.

67 ECG CHANGES WITH CHEST PAIN Transmural (epicardial) injury: ST elevation ST With epicardial ischemia, electrical forces are deviated toward the outer layer of the heart, causing ST elevation in the overlying lead.

68 Effects of Cardiac Infarction, Injury and Ischemia Reciprocal Effects Ischemia Injury Infarction Inversion of T waves / S-T depression Elevation S-T segment Q or QS waves S-T segment and T wave normalization

69 Myocardial Infarction Acute Recent Old Days weeks-months months-years (average 3-5 days) (average 2-6 months) (average >6 months) ST segment elevation T wave inversion just significant Q wave Q wave Q waves

70 Skin Assessment During Cardiovascular Emergency Skin first organ blood shunted from to preserve vital organs. Look for the following: Moist, Clammy, Cool skin Diaphoresis on forehead and palms Bead of perspiration on upper lip Cyanosis, coolness of digits

71 Initial Assessment for the Patient with ACS Remember: TIME IS MUSCLE!! Obtain brief, targeted H&P Age, gender, signs & symptoms, pain presentation (PQRST format), Hx of CAD, risk factors present? Hx of Viagra, Ephedra? Assess vital signs, determine oxygen saturation Any signs of shock, pulmonary edema, Heart Rate >100 beats/min and SBP < 100 mm Hg? Establish IV access, ECG monitoring, lab draw for serum markers, candidate for reperfusion therapy? 12 lead ekg and present to MD for review

72 Next Steps: MONA O2 4 L/min by nasal cannula for first 2-3 hours (titrate if pulmonary congestion, SaO2 < 90% Aspirin mg chewed (evaluate contraindications to ASA or Heparin) NTG SL or spray (ensure IV access, SBP > 90 mm Hg, HR >50 beats/min, no RV infarction Morphine 2 to 4 mg IV if pain not relieved with NTG, may repeat q 5 minutes (ensure SBP > 90 mm Hg)

73 Summary Time is muscle Quick 10 minute assessment and 12 lead ekg within 10 minutes Ready for intervention: MONA

74 I think you should be more explicit here in step two.

75 P and QRS NSR Think of this is a marriage and the couples story of their relationship. Lets give the couple names P and QRS P and QRS are in the honeymoon phase of their marriage. They are always together and never leave each others sight. Life is good for P and QRS 1 degree P and QRS are getting irritated with each other. While they still remain true to the relationship, they are keeping their distance for now. 2 nd degree (I-wenkback) P an QRS have entered the viscous cycle of breaking up and getting back together. They get together, they start fighting and keeping their distance more and more, and they break up again. 2 nd degree (II) P and QRS have decided to get back together again. However, P is still quite disgruntled and has decided to go out ever night or two and fool around on QRS. You can probable imagine what comes next! 3 rd degree AS you probably saw coming, QRS caught P cheating and moved out. They have filed for divorce and are completely separated. There is absolutely no relationship between P and QRS now. THE END