AssessmentAssessment Primary survey/Primary survey/ resuscitationresuscitation Secondary surveySecondary survey

Factors For ConsiderationFactors For Consideration

UnmodifiableUnmodifiable• AgeAge• SexSex• HeredityHeredity• RaceRace

ModifiableModifiable• B/PB/P• ObesityObesity• DyslipidemiaDyslipidemia• SmokingSmoking• Sedentary life Sedentary life

stylestyle• StressStress• DiabetesDiabetes

Focused Focused SurveySurvey Subjective dataSubjective data

Chief complaintChief complaint History of present illnessHistory of present illness

• Pain: PQRSTPain: PQRST• ProvocationProvocation• QualityQuality• Region/radiationRegion/radiation• SeveritySeverity• TimeTime

DurationDuration Development over timeDevelopment over time Periodicity (? Comes/goes)Periodicity (? Comes/goes)

Focused Survey Focused Survey (Continued)(Continued)

DyspneaDyspnea• SOBSOB

Dyspnea on exertionDyspnea on exertion Positional dyspneaPositional dyspnea

• Paroxysmal Paroxysmal nocturnal dyspneanocturnal dyspnea

• OrthopneaOrthopnea CoughCough

Dry, “cardiac” coughDry, “cardiac” cough HemoptysisHemoptysis

SyncopeSyncope PalpitationsPalpitations Fatigue Nausea and Fatigue Nausea and

VomitingVomiting HeadacheHeadache Behavioral changeBehavioral change Activity limitationsActivity limitations Injury: mechanism and timeInjury: mechanism and time

Medical HistoryMedical History Coronary Heart Disease Coronary Heart Disease

• AnginaAngina• Previous MIPrevious MI• HypertensionHypertension• CHFCHF

Pulmonary DiseasePulmonary Disease DiabetesDiabetes Renal DiseaseRenal Disease Previous Cardiac Previous Cardiac

SurgerySurgery Congenital AnomaliesCongenital Anomalies AllergiesAllergies

Current/Past Medication UseCurrent/Past Medication Use

NitratesNitrates Beta BlockersBeta Blockers Calcium Calcium

Channel Channel BlockersBlockers

Anti- Anti- hypertensiveshypertensives

DigitalisDigitalis DiureticsDiuretics

Antidysrhythmics

Anticoagulants

Steroids

Specific Pulmonary Drugs

Illicit Drugs

OVC Medications

Physical ExamPhysical Exam General SurveyGeneral Survey

• LOCLOC• Respiratory statusRespiratory status

Rate, regularity, effort, Rate, regularity, effort, breath soundsbreath sounds

• IntegumentaryIntegumentary Color, temperature, Color, temperature,

moisture, capillary refillmoisture, capillary refill

• EdemaEdema Dependent, extremities, Dependent, extremities,

sacrum, pleural effusion, sacrum, pleural effusion, ascitis, cardiac (pitting)ascitis, cardiac (pitting)

Physical ExamPhysical Exam CyanosisCyanosis

• CentralCentral• PeripheralPeripheral

ClubbingClubbing B/P MeasurementB/P Measurement

• Both armsBoth arms• Orthostatic Orthostatic

(supine, sitting, (supine, sitting, standing)standing)

0 = absent

1 = thready

2 = normal

3 = bounding

Physical ExamPhysical Exam Apical heart rateApical heart rate• Regular, irregular, Regular, irregular,

regularly irregular, regularly irregular, irregular irregularirregular irregular

Peripheral pulsesPeripheral pulses PupilsPupils

• Size, equality, Size, equality, reactivereactive

InspectionInspection Tracheal positionTracheal position Neck veinsNeck veins

• Can guesstimate CVPCan guesstimate CVP ThoraxThorax

• ConfigurationConfiguration Deformities, anterior, Deformities, anterior,

posterior, A-P diameter, symmetrical posterior, A-P diameter, symmetrical movementmovement

Injuries, penetrating, blunt (ecchymosis, Injuries, penetrating, blunt (ecchymosis, contusions) evidence of scars, surgerycontusions) evidence of scars, surgery

Abnormal chest movement, asymmetrical, Abnormal chest movement, asymmetrical, paradoxicalparadoxical

Physical Exam (Inspection)Physical Exam (Inspection) PrecordiumPrecordium

• Apical pulseApical pulse• Abnormal precordial Abnormal precordial

movements, heaves, movements, heaves, lifts, pulsations, lifts, pulsations, retractionsretractions

• Epigastrium, Epigastrium, pulsationspulsations

Physical Exam: PalpationPhysical Exam: Palpation

Areas tender, or Areas tender, or crepituscrepitus

EpigastriumEpigastrium

Physical Exam: AuscultationPhysical Exam: Auscultation Auscultatory sitesAuscultatory sites

• Murmurs: systolic/diastolicMurmurs: systolic/diastolic• Variations in rhythmVariations in rhythm

• Extra soundsExtra sounds Pericardial friction rubPericardial friction rub Venous humVenous hum Arterial bruitsArterial bruits

• ClicksClicks

Physical Exam: Physical Exam: Diagnostic ProceduresDiagnostic Procedures

ECG, 12 leadECG, 12 lead• Rate, rhythmRate, rhythm• Presence of cardiac Presence of cardiac

dysrhythmiasdysrhythmias• Evidence of myocardial Evidence of myocardial

ischemia, injuryischemia, injury• Presence of Presence of

intraventricular conduction intraventricular conduction defectdefect

• Evidence of previous MIEvidence of previous MI

Physical Exam:Physical Exam:Diagnostic Diagnostic ProceduresProcedures

CBCCBC Serum electrolytesSerum electrolytes Cardiac serum markersCardiac serum markers

• TroponinTroponin• MyoglobinMyoglobin• Basic metabolic profileBasic metabolic profile• Coagulation studiesCoagulation studies• Digoxin levelDigoxin level• Serum creatinine, BUNSerum creatinine, BUN• T& C T& C • ABGsABGs• Routine urinalysisRoutine urinalysis

Comparison of Diagnostic Markers

MarkerMarkerTime fromTime from

ObstructionObstruction

SpecifiSpecific to c to

CardiaCardiacc

Specific Specific to AMIto AMI

AppearsAppears DisappearsDisappears

CK-MBCK-MB 6 hours6 hours 36 hours36 hours YesYes YesYes

MyoglobinMyoglobin 2 hours2 hours 24 hours24 hours NoNo NoNo

Troponin ITroponin I 2 hours2 hours 1 week1 week YesYes NoNo

Diagnostic Diagnostic ProceduresProcedures

Pulse oximetryPulse oximetry RadiographyRadiography

• Chest x-rayChest x-ray Heart size and Heart size and

locationlocation Presence of edemaPresence of edema Pulmonary infiltratesPulmonary infiltrates Pleural effusionsPleural effusions Air and fluid levels in Air and fluid levels in

trauma patientstrauma patients Mediastinal widthMediastinal width Bony structure Bony structure

integrityintegrity Cardiac catheterizationCardiac catheterization

EchocardiogramEchocardiogram

InterventionsInterventions Determine prioritiesDetermine priorities

• Airway, vital signs, cardiac rhythm, ABGs, Pulse oximetry, Airway, vital signs, cardiac rhythm, ABGs, Pulse oximetry, • Control painControl pain• Relieve anxietyRelieve anxiety• Education patient/otherEducation patient/other• Prevent complicationsPrevent complications

Establish care planEstablish care plan Emergency equipmentEmergency equipment Initiate appropriate interventionsInitiate appropriate interventions Document dataDocument data Monitor responses and adjustMonitor responses and adjust

PediatricsPediatrics Growth & DevelopmentGrowth & Development

• R/T congenital heart disease R/T congenital heart disease (heart defects)(heart defects)

• Acquired heart disease (rheumatic Acquired heart disease (rheumatic fever)fever)

• Endocrine (diabetes)Endocrine (diabetes)• OtherOther

Drug ingestions, ex: tricyclics, Drug ingestions, ex: tricyclics, digoxindigoxin

Trauma (falls, MVCs)Trauma (falls, MVCs) Suffocation (plastic bags, Suffocation (plastic bags,

drowning, accidental hanging)drowning, accidental hanging)

PediatricPediatric Pearls:Pearls:

• Cardiac arrest usually d/t Cardiac arrest usually d/t progressive deterioration progressive deterioration in respiratory and heart in respiratory and heart functionfunction

• CHF, cardiogenic shock, CHF, cardiogenic shock, dysrhythmias are unusual. dysrhythmias are unusual. If occur congenital. If occur congenital.

• Immature conduction Immature conduction system and autonomic system and autonomic innervation may contribute innervation may contribute to dysrhythmiasto dysrhythmias

GeriatricGeriatric Presence of chronic diseasesPresence of chronic diseases Altered drug metabolismAltered drug metabolism Multiple physiological Multiple physiological

differences and changes in differences and changes in lab values must be lab values must be considered when assessing considered when assessing the older patientthe older patient

Psychological and social Psychological and social changes: patient may have changes: patient may have different goals for their different goals for their treatment, discuss with treatment, discuss with patientpatient

Geriatric patients can Geriatric patients can adapt to disease so well adapt to disease so well that symptoms are not that symptoms are not obviousobvious

Arteriosclerotic changes Arteriosclerotic changes in aorta and peripheral in aorta and peripheral pulses may pose a pulses may pose a difficulty in palpatingdifficulty in palpating

Rhythm abnormalities Rhythm abnormalities are so common that are so common that they may be “normal”they may be “normal”

PearlsPearls ““Go slow, stay low” Go slow, stay low”

with medicationswith medications Concurrent use of Concurrent use of

other medications other medications cause problems, cause problems, • Easy to use meds are Easy to use meds are

helpful helpful (transdermals)(transdermals)

• One time or two time One time or two time doses dailydoses daily

• Evaluate medications Evaluate medications on a frequent basison a frequent basis

AnginaAngina StableStable

• Symptom of Symptom of ischemiaischemia

• ““pain or discomfort”pain or discomfort”• Poorly localizedPoorly localized• Flow/Demand Flow/Demand

imbalanceimbalance• May be chronic, May be chronic,

acute, or unstableacute, or unstable

Angina (continued)Angina (continued) Unstable anginaUnstable angina

• New symptoms of New symptoms of anginaangina

• Increasing symptoms Increasing symptoms that occur at rest or that occur at rest or with on exertionwith on exertion

• Usually due to platelet Usually due to platelet aggregationaggregation

• Leads to atypical Leads to atypical chest painchest pain

9

Angina (Continued)Angina (Continued) Unstable angina diagnosisUnstable angina diagnosis

• Angina is at rest, as well as Angina is at rest, as well as minimal exertion (usually 20 minimal exertion (usually 20 minutes or longer)minutes or longer)

• Angina of new onset (several Angina of new onset (several weeks), starting with physical weeks), starting with physical exertion, and markedly limits exertion, and markedly limits activityactivity

• Previously diagnosed stable Previously diagnosed stable anginaangina

Normal ECG

Abnormal ECG Same Patient, Inverted T Waves

Angina cont’dAngina cont’d Variant AnginaVariant Angina

• May or may not be due to atherotic May or may not be due to atherotic changeschanges

• Thought to be due to coronary Thought to be due to coronary spasmspasm

• Prinzmetal’s anginaPrinzmetal’s angina• May occur at the same time, dailyMay occur at the same time, daily• Usually not associated with Usually not associated with

exertion or stressexertion or stress• Occurs at younger agesOccurs at younger ages• ST elevation seen during pain, ST elevation seen during pain,

then disappearsthen disappears

Angina: CurveballsAngina: Curveballs GERDsGERDs Biliary ColicBiliary Colic Chest Wall PainChest Wall Pain PericarditisPericarditis PEPE Aortic DissectionAortic Dissection DysrhythmiasDysrhythmias

Angina: DataAngina: Data

Physical exam:Physical exam:• Elevated B/PElevated B/P• Increased Heart RateIncreased Heart Rate• Rapid, shallow respirationsRapid, shallow respirations• DiaphoresisDiaphoresis• Transient pulmonary rales Transient pulmonary rales

(with pain)(with pain)

Diagnostic Procedures: ECGDiagnostic Procedures: ECG ST depression may accompany ST depression may accompany

pain with stable anginapain with stable angina Transient ST-segment Transient ST-segment

deviations (depression or deviations (depression or elevation), and T wave elevation), and T wave inversion occur commonly with inversion occur commonly with unstable anginaunstable angina

Variant angina: ST elevation Variant angina: ST elevation occurs with pain, subsides occurs with pain, subsides when pain doeswhen pain does

May see LV hypertrophy, old MI, May see LV hypertrophy, old MI, nonspecific ST and T-wave nonspecific ST and T-wave abnormalities and AV defectsabnormalities and AV defects

Diagnostic Procedures Diagnostic Procedures (Continued)(Continued)

CBCCBC Cardiac serum Cardiac serum

markers…no markers…no elevation should elevation should occur unless cell occur unless cell damagedamage

Chest X-ray Chest X-ray ( CHF, ( CHF, cardiomegaly)cardiomegaly)

InterventionsInterventions Continuous monitoringContinuous monitoring OO22 IV, Draw labsIV, Draw labs 12 Lead ECG12 Lead ECG RestRest Decrease anxietyDecrease anxiety SL NTG, B/P 100 mm SL NTG, B/P 100 mm

HG followed by a dripHG followed by a drip• Assess for H/AAssess for H/A• Reflex tachycardiaReflex tachycardia• Cautious with elderlyCautious with elderly

Interventions (continued)Interventions (continued) Beta blockersBeta blockers

• If clinical situation If clinical situation deteriorates after B deteriorates after B Blocker, consider Blocker, consider coronary artery spasmcoronary artery spasm

• Assess for signs of Assess for signs of heart failure heart failure

• Adverse effects of Adverse effects of blockers are blockers are considered more considered more common and severe in common and severe in geriatricgeriatric

Interventions (continued)Interventions (continued)

Administer antiplatelet Administer antiplatelet agentsagents• ASA (4-5 baby aspirin) ASA (4-5 baby aspirin) • Administer ASAPAdminister ASAP• Decreases platelet Decreases platelet

activation and thrombus activation and thrombus formationformation

TEACH/EDUCATIONTEACH/EDUCATION

Acute Myocardial InfarctionAcute Myocardial Infarction

Myocardial Myocardial Infarction Infarction

(MI)-(MI)-

Coronary Coronary OcclusionOcclusion

Heart Heart Attack Attack

MI: DataMI: Data Physical examPhysical exam General appearance: Anxious, restless, General appearance: Anxious, restless,

clenched fist against chest (Levine sign) Look clenched fist against chest (Levine sign) Look of doomof doom

Heart rate: may be ok, tachycardia (most Heart rate: may be ok, tachycardia (most common), bradycardia (inferior and RV), common), bradycardia (inferior and RV), Regular or irregular PVCs commonRegular or irregular PVCs common

Data (continued)Data (continued) Arterial BPArterial BP

•Majority of patients with Majority of patients with uncomplicated MI are uncomplicated MI are normotensivenormotensive

•May be elevated due to SNS May be elevated due to SNS stimulationstimulation Pain and anxietyPain and anxiety

•Decreased as a result of impaired Decreased as a result of impaired cardiac function or due to drug cardiac function or due to drug administration (nitrates, M.S.)administration (nitrates, M.S.)

Data (continued)Data (continued)

Respiratory rate: Respiratory rate: Initially elevated. Initially elevated. Should return to Should return to normal after pain normal after pain reliefrelief• Patients with CHF, Patients with CHF,

respiratory rate respiratory rate correlates with correlates with severity of conditionseverity of condition

Data (continued)Data (continued) Peripheral: How bad is the patient’s condition?Peripheral: How bad is the patient’s condition?

• Pallor, cyanosis, diaphoreses, mottled, cool, Pallor, cyanosis, diaphoreses, mottled, cool, peripheral pulses variableperipheral pulses variable

Temperature: Often increases 4-8 hours post MITemperature: Often increases 4-8 hours post MI

Heart Sounds: muffled. murmurs may be transient Heart Sounds: muffled. murmurs may be transient or permanentor permanent

DiagnosisDiagnosis Continuous cardiac monitoringContinuous cardiac monitoring 12 lead ECG12 lead ECG Determine Location of infarctDetermine Location of infarct

(next slide)(next slide)

Anterior SeptalAnterior Septal ST Leads 1, AVR,ST Leads 1, AVR,

V1 through V4V1 through V4

Lateral ApicalLateral Apical ST Leads 1, AVLST Leads 1, AVL

V5 and V6V5 and V6

PosteriorPosterior Recipical Changes Recipical Changes V1,V2V1,V2

No Q waves, Tall R’sNo Q waves, Tall R’s

St II,III,AVFSt II,III,AVF

Upright t waveUpright t wave

InferiorInferior ST ST

Leads II, III, AVFLeads II, III, AVF

Right VentricularRight Ventricular ST VST VRR 4 – VR 6 4 – VR 6

Serum Markers Serum Markers

MyoglobinMyoglobin• Elevated 1-4 hours after onset of Elevated 1-4 hours after onset of

MI, peaks 6-7 hours, normal in MI, peaks 6-7 hours, normal in about 1 dayabout 1 day

• Lacks specificity, found in skeletal Lacks specificity, found in skeletal musclemuscle

Serum Markers Serum Markers (continued)(continued)

Troponins:Troponins:• Most recent marker, most Most recent marker, most

sensitive and specific for sensitive and specific for cardiac damagecardiac damage

• Elevated 3-12 hours after Elevated 3-12 hours after MI, Peaks in 24 hours, MI, Peaks in 24 hours, with TnI , returns to normal with TnI , returns to normal in 5-12 daysin 5-12 days

• TnT may be elevated in TnT may be elevated in patients with renal failure, patients with renal failure, which is not the case with which is not the case with TnI; therefore TnI is TnI; therefore TnI is utilized.utilized.

InterventionsInterventions

ABCsABCs OxygenOxygen IV or topical NTG, as B/P tolerated (B/P 100 IV or topical NTG, as B/P tolerated (B/P 100

or greateror greater IV with normal saline, KVOIV with normal saline, KVO Analgesia: M/SAnalgesia: M/S ASAASA 12 Lead ECG12 Lead ECG Blood samples for analysisBlood samples for analysis

Interventions (continued)Interventions (continued)

If appropriate consider PTCAIf appropriate consider PTCA Follow ACLS GuidelinesFollow ACLS Guidelines Prepare for Thrombolytic Prepare for Thrombolytic

Therapy as appropriateTherapy as appropriate Administer aspirin, nitrates, Administer aspirin, nitrates,

heparin, plavix, Integrillin, heparin, plavix, Integrillin, Lopressor, Morphine, Lopressor, Morphine, antiarrhythmicsantiarrhythmics

Interventions (continued)Interventions (continued) Observe patient:Observe patient:

• Bleeding, reperfusions Bleeding, reperfusions dysrhythmiasdysrhythmias

• Vital signs, ventricular Vital signs, ventricular ectopy, and other ectopy, and other dysrhythmiasdysrhythmias

• Heart and lung soundsHeart and lung sounds• LOCLOC• I & OI & O• Level of painLevel of pain

Interventions (continued)Interventions (continued)

Portable chest filmPortable chest film ACLS measuresACLS measures Prepare for cath labPrepare for cath lab Educate and explainEducate and explain Allow visit from Allow visit from

significant othersignificant other

Heart Failure & Cardiogenic Heart Failure & Cardiogenic Pulmonary EdemaPulmonary Edema

Clinical syndrome, can Clinical syndrome, can occur from any heart occur from any heart diseasedisease

Pediatric..usually due to Pediatric..usually due to congenital heart defectscongenital heart defects

Inability to discharge Inability to discharge contentscontents

Inability to pump Inability to pump enough blood to meet enough blood to meet metabolic needsmetabolic needs

Causes of Causes of Heart FailureHeart Failure

Left Left SystolicSystolic Ischemic heart diseaseIschemic heart disease AMIAMI CADCAD Idiopathic cardiomyopathyIdiopathic cardiomyopathy AO InsufficiencyAO Insufficiency Arrhythmias: VT, AFArrhythmias: VT, AF Post pump syndromePost pump syndrome InfectionsInfections Acute Rheumatic FeverAcute Rheumatic Fever Drug Overdoses Ex: ETOHDrug Overdoses Ex: ETOH Nutritional deficits Ex: Nutritional deficits Ex:

Protein, ThiamineProtein, Thiamine Electrolyte Disorders: Ca, Na, Electrolyte Disorders: Ca, Na,

K,PHK,PH

AssessmentAssessment Anxiety, sudden Anxiety, sudden

lightheadness, fatigue, lightheadness, fatigue, confusionconfusion

Orthopnea, dyspnea on Orthopnea, dyspnea on exertion, tachypneaexertion, tachypnea

Cheyne-stokes (severe)Cheyne-stokes (severe) Diaphoresis, palpitationsDiaphoresis, palpitations Sacral edema, pitting Sacral edema, pitting

extremitiesextremities Crackles, wheezes,Crackles, wheezes, Moist, cool skin, cyanosisMoist, cool skin, cyanosis

Hypoxia, Hypoxia, resp.acidosisresp.acidosis

NocturiaNocturia PMI displaced PMI displaced

laterallylaterally Murmur Mitral Murmur Mitral

InsufficiencyInsufficiency

Left-Sided Systolic

Causes of Causes of Heart Heart

FailureFailure

Left DiastolicLeft Diastolic CADCAD Myocardial ischemiaMyocardial ischemia LV HypertrophyLV Hypertrophy CardiomyopathyCardiomyopathy Increased circulating volumeIncreased circulating volume TamponadeTamponade Constrictive pericarditisConstrictive pericarditis Mitral stenois or insufficiencyMitral stenois or insufficiency Aortic stenosis or insufficiencyAortic stenosis or insufficiency DiabetesDiabetes

AssessmentAssessment

Exercise intoleranceExercise intolerance OrthopneaOrthopnea Dyspnea, Dyspnea on Dyspnea, Dyspnea on

exertion, PNDexertion, PND Cough with frothy Cough with frothy

white/pink sputum white/pink sputum (Pulmonary edema)(Pulmonary edema)

Tachypnea, crackles, Tachypnea, crackles, wheezes, wheezes,

Pulmonary edemaPulmonary edema

Hypoxia, respiratory Hypoxia, respiratory acidosisacidosis

Left-Sided Diastolic

Causes of Heart Failure Causes of Heart Failure (continued)(continued)

Right-sided Failure:Right-sided Failure: L-sided failureL-sided failure ASHDASHD PEPE Fluid overloadFluid overload Myocardial contusionMyocardial contusion CardiomyopathyCardiomyopathy COPDCOPD Sleep apneaSleep apnea

Both SidesBoth Sides Patient non-compliant Patient non-compliant

regarding: meds, regarding: meds, dietary restrictions, dietary restrictions, ETOH, useETOH, use

Medications: Negative Medications: Negative inotropic agents, NTPinotropic agents, NTP

AssessmentAssessment

Increased fatigueIncreased fatigue HepatomegalyHepatomegaly SplenomegalySplenomegaly Dependent pitting edemaDependent pitting edema AscitisAscitis CachexiaCachexia Abdominal pain Abdominal pain

(congested liver)(congested liver) Anorexia, nausea, emesisAnorexia, nausea, emesis

Weight gainWeight gain Low B/PLow B/P Oliguria, nocturia,Oliguria, nocturia, Venous distentionVenous distention

Right-Sided Failure

DiagnosticsDiagnostics Radiologic: Radiologic:

• often normaloften normal• pulmonary vasculature, pulmonary vasculature,

edema, fluidedema, fluid• Cardiac silhouette may Cardiac silhouette may

show cardiac show cardiac enlargement, enlargement, hypertrophy, dilationhypertrophy, dilation

• Enlarged RA and RVEnlarged RA and RV• Pleural effusionPleural effusion• Valve calcificationsValve calcifications

Lab: Lab: • H& HH& H• LytesLytes• BUN, Creatinine BUN, Creatinine • Liver function studiesLiver function studies• Cardiac enzymes (if Cardiac enzymes (if

AMI)AMI)• BNPBNP

B-type natriuretic B-type natriuretic peptidepeptide

Diagnostics Diagnostics cont’dcont’d

ECG: nonspecific changes, electrolyte or ECG: nonspecific changes, electrolyte or drug induced dysrhythmiasdrug induced dysrhythmias

Echo: chamber size,wall thickness, Echo: chamber size,wall thickness, thrombus formation, valvular function, thrombus formation, valvular function, pericardial diseasepericardial disease

InterventionsInterventions Administer Administer

MorphineMorphine Administer Administer

vasodilatorvasodilator• Decreases Decreases

afterload, arterial afterload, arterial dilations. Also pre-dilations. Also pre-loadload

ABCDABCD Provide Provide

supplemental Osupplemental O22

IV Normal SalineIV Normal Saline ABGs and other labsABGs and other labs Provide restProvide rest ECG continuousECG continuous Monitor Monitor

hemodynamicshemodynamics

Vasodilators Vasodilators (continued)(continued)

NTG, IsosorbideNTG, Isosorbide• Increases Increases

venous poolingvenous pooling• NTG preferred NTG preferred

in pulmonary in pulmonary edema, CAD edema, CAD since improves since improves coronary artery coronary artery perfusionperfusion

• Venous dilationVenous dilation

Vasodilators Vasodilators (continued)(continued)

Diuretics:Diuretics:• Decrease preloadDecrease preload• Foley catheter, Foley catheter,

possiblepossible• I&OI&O• Monitor serum K+Monitor serum K+

Vasodilators Vasodilators (continued)(continued)

ACE Inhibitors:ACE Inhibitors:• Captopril, EnalaprilCaptopril, Enalapril• Block formation of Block formation of

Angiotensin II, Angiotensin II, yields vasodilationyields vasodilation

• Reduce mortality, Reduce mortality, by improving by improving cardiac functioncardiac function

• Avoid overdiuresisAvoid overdiuresis• Cleared by kidneyCleared by kidney

InotropesInotropes DopamineDopamine

• Support B/P and UOSupport B/P and UO• Dopaminergic effect: 1-2 Dopaminergic effect: 1-2

mcg/kg/minmcg/kg/min• Beta-adrenergic: 2-10 Beta-adrenergic: 2-10

mcg.kg/minmcg.kg/min• Alpha-adrenergic Alpha-adrenergic

>10mcg/kg/min>10mcg/kg/min• Indicated for low cardiac Indicated for low cardiac

outputoutput• Infuse in central line or Infuse in central line or

large veinlarge vein

DobutamineDobutamine• Stimulates beta Stimulates beta

receptors in heartreceptors in heart• Direct inotropeDirect inotrope• No renal benefitNo renal benefit• Indicated: low Indicated: low

cardiac outputcardiac output• Can decrease B/P in Can decrease B/P in

volume depleted volume depleted patients patients

Hypertensive EmergenciesHypertensive Emergencies Life-threatening elevation of B/P necessitating reduction Life-threatening elevation of B/P necessitating reduction

to prevent end-organ damage and potential deathto prevent end-organ damage and potential death Essential hypertensionEssential hypertension

• unknown causeunknown cause Secondary hypertensionSecondary hypertension

• elevated pressure whose cause is known (renal vascular elevated pressure whose cause is known (renal vascular disease)disease)

Produces changes in arterioles (necrosis and Produces changes in arterioles (necrosis and inflammation over time) causing decrease in bloodflow inflammation over time) causing decrease in bloodflow to end organsto end organs

Accelerated and/or malignant Accelerated and/or malignant • hypertension:Diastolic pressure higher than 140 mmHghypertension:Diastolic pressure higher than 140 mmHg

Precipitating FactorsPrecipitating Factors Untreated/uncontrolled essential or secondary Untreated/uncontrolled essential or secondary

hypertensionhypertension Poor patient compliance with antihypertensive Poor patient compliance with antihypertensive

medicationsmedications Renal dysfunctionRenal dysfunction Eclampsia of pregnancy (not tolerated well)Eclampsia of pregnancy (not tolerated well) Adrenergic crisesAdrenergic crises AMI, AMI, Cerebral dysfunction Cerebral dysfunction Pituitary tumorsPituitary tumors

AssessmentAssessment HistoryHistory Severe H/ASevere H/A EpistaxisEpistaxis Family hx hypertensionFamily hx hypertension MAO inhibitorsMAO inhibitors CAD, Renal DiseaseCAD, Renal Disease Diabetes, obesity, smoker, Diabetes, obesity, smoker,

hyperlidemia, stresshyperlidemia, stress

ExamExam Diastolic pressure exceeding diastolic or Diastolic pressure exceeding diastolic or

120mmHG120mmHG Retinopathy with exudates, Retinal hemorrhagesRetinopathy with exudates, Retinal hemorrhages Papilloedema (diastolic pressure > 140)Papilloedema (diastolic pressure > 140) H/A, confusion, restless stupor, somnolenceH/A, confusion, restless stupor, somnolence EpistaxisEpistaxis TachycardiaTachycardia Chest discomfortChest discomfort N&VN&V RalesRales Oliguria, azotemiaOliguria, azotemia

DiagnosticsDiagnosticsLab:Lab:

• ABG: ABG: metabolic acidosismetabolic acidosis

• CBC HCT CBC HCT in renal failure, in renal failure,

polycythemia in renalpolycythemia in renal• Electrolytes: Electrolytes:

HypocalcemiaHypocalcemia HyponatremiaHyponatremia aldosteronism causes aldosteronism causes

hypokalemia ( half of hypokalemia ( half of patients)patients)

• Glucose: elevated in Glucose: elevated in Cushing’s Syndrome, Cushing’s Syndrome, diabetesdiabetes

• BUN and creatinine BUN and creatinine elevated in renal elevated in renal diseasedisease

• Uric acid: hyper-Uric acid: hyper-uricemia in renal uricemia in renal failurefailure

• U/A: proteinuria, U/A: proteinuria, possible renal possible renal dysfunctiondysfunction

Radiologic FindingsRadiologic Findings

Chest film: cardiomegaly may be seenChest film: cardiomegaly may be seen ECG: LV hypertrophy may be seenECG: LV hypertrophy may be seen CT scan: Diffuse brain edema with hypertensive CT scan: Diffuse brain edema with hypertensive

crisescrises ECHO: diastolic function impaired.ECHO: diastolic function impaired.

InterventionsInterventions

ABCD, O2, IV @ KVO rateABCD, O2, IV @ KVO rate ACLS protocolsACLS protocols Administer medicationsAdminister medications NTP:NTP:

• Most common and most effectiveMost common and most effective• 0.5-10mcg/kg/min0.5-10mcg/kg/min• Titrate with B/PTitrate with B/P• Watch for cyanide toxicityWatch for cyanide toxicity• Drug is light sensitiveDrug is light sensitive

Interventions (continued)Interventions (continued)

NTG:NTG:• Drug of choice for unstable angina and ischemia, LV Drug of choice for unstable angina and ischemia, LV

failure, adrenergic crisesfailure, adrenergic crises• Provides immediate responseProvides immediate response

Sympathetic Blocking Agent (Labetalol)Sympathetic Blocking Agent (Labetalol)• Alpha and beta blockerAlpha and beta blocker• Onset and cessation of action slower than NTP and Onset and cessation of action slower than NTP and

NTGNTG• Contraindicated in patients with heart failure, Contraindicated in patients with heart failure,

greater than 1greater than 1stst degree block, bradycardia, and degree block, bradycardia, and reactive airway diseasereactive airway disease

Interventions Interventions (continued)(continued)

ACE InhibitorsACE Inhibitors• Used in presence of LV failureUsed in presence of LV failure• Captopril: 6.25-50 mg orally every 30-45 Captopril: 6.25-50 mg orally every 30-45

minutesminutes• Enalapril: 1.25-5 mg IV every 6 hoursEnalapril: 1.25-5 mg IV every 6 hours• Onset of action for both 10-15 minutesOnset of action for both 10-15 minutes

Interventions Interventions (continued)(continued)

Calcium Channel BlockersCalcium Channel Blockers• Nifidipine: 10 mg PO or sublingual (10-20 mg Nifidipine: 10 mg PO or sublingual (10-20 mg

orally every 30-45 minutes of sublingually every orally every 30-45 minutes of sublingually every 15 minutes)15 minutes)

Beta Blocker: Metoprolol, EsmololBeta Blocker: Metoprolol, Esmolol• Blocks effects of increased adrenergic toneBlocks effects of increased adrenergic tone• Metoprolol 5 mg IV every 5 minutes up to 15 mg Metoprolol 5 mg IV every 5 minutes up to 15 mg

totaltotal

Interventions Interventions (continued)(continued)

Administer diureticsAdminister diuretics Closely monitor patient’s responseClosely monitor patient’s response Continuous arterial monitoringContinuous arterial monitoring Watch medication side effectsWatch medication side effects Observe for signs of ischemiaObserve for signs of ischemia I&OI&O Monitor for dysrhythmiasMonitor for dysrhythmias Monitor for Monitor for ↑↑ ICP ICP Possible ICP monitoringPossible ICP monitoring Sudden chest pain may suggest aortic dissectionSudden chest pain may suggest aortic dissection Reassure patient/family Calm environmentReassure patient/family Calm environment

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