Final Exam (pt.1)

Angina Pectoris

1.) chest pain from preexisting heart disease that is brought on by excitement and/or exertion and relieved by rest and Nitroglycerine

2.) pain is caused by hypoxia to cardiac tissue when the oxygen demands increase in a heart with coronary artery disease (CAD)

3.) arteriosclerosis narrows the lumen of the coronary vessels so that inadequate oxygen reaches the heart under increased demand

4.) there is no cell death or permanent damage with angina

S/S of angina

1.) can be very similar to an AMI

2.) pain is usually related to stress or exertion, pain usually lasts only 3-10 minutes

3.) pain is relieved by rest and/or nitroglycerine

Emergency treatment of angina

if the patient has a diagnosed history of angina → calm and reassure the patient, have patient rest and assist with nitroglycerine and take vitals

if pain persists greater than 2 minutes call 911 and treat as AMI

Nitroglycerine

1.) potent vasodilator → causes coronary vessels to dilate, thus relieved hypoxia

2.) comes in 4 forms → sublingual tablets, sublingual spray, dermal patches (more often seen with the treatment of unstable angina) and ointment

Nitroglycerine Side effects

headaches, drop in blood pressure, changes in pulse rate as the body tries to compensate for vasodilation

Nitroglycerine contraindications

1.) baseline blood pressure is below 100mmhg systolic

2.) suspected head injury

3.) the patient has already taken 3 doses of nitroglycerine

4.) patient has recently taken viagra or cialis

Unstable Angina

1.) starts to feel different, is more severe and comes on more often, or occurs with less activity or while at rest

2.) lasts longer than 15-20 minutes

3.) occurs without cause

4.) does not respond well to nitroglycerine

5.) occurs with drop in BP or shortness of breath

6.) can lead to Heart attack → seek medical attention

Acute Myocardial Infarction

heart attack → death (necrosis) of the heart muscle from obstruction of blood flow

AMI consequences

sudden death

congestive heart failure

cardiogenic shock

Sudden death

1.) Associated with aMI occur because of sudden abnormalities in the heart rhythm called arrhythmias

2.) ventricular fibrillation (disorganized, ineffective quivering of the ventricles), ventricular tachycardia

3.) asystole (no cardiac action going on at all)

4.) all require CPR

Tachycardia

rapid but regular beating of the heart >100bpm

Bradycardia

unusually slow but regular beating of the heart <50bpm

Atrial flutter

beating of the atria up to rates of 300/min

Atrial fibrillation

disorganized, ineffective quivering of the atria

Ventricular extrasystoles

additional beats of the ventricles interspersed with the regular rhythm

Congestive heart failure

failure of the heart occurs when the heart muscle is so damaged by infarction or other disease that it can no longer pump enough blood for the needs of the body

Can occur at anytime after an AMI, but it usually happens between the first few hours and first few days

Cardiogenic shock

Early complication of AMI that occurs within 24 hours of the event.

It means that there has been so much damage to the heart that is unstable to sustain normal systemic blood pressure, and shock results

Shock with AMI is an extremely serious complication and may result in death

Clinic presentation of AMI

sudden onset of weakness, nausea, sweating without an obvious cause

Chest pain (crushing or squeezing), sudden arrhythmia with fainting

Pulmonary edema, sudden death

Pain of AMI

1.) chest pain that is: substernal, squeezing or heavy in nature, it lasts longer than 30 minutes, it is not necessarily related to exertion or stress

2.) it is not relieved by nitroglycerine, it may radiate to the mandible, neck, either shoulder or arm, epigastrum, and back

3.) AMI may not have associated pain “silent AMI” → many women have more vague symptoms and often misdiagnosed

Other S/S of AMI

1.) chest pain, lightheadedness, pale (Ashen) skin

2.) occasional cyanotic skin, fainting, sweating, nausea, sob, anxiety, denial, palpitations, feeling of impending doom

Treatment of suspected AMI

1.) Call 911, calm and reassure the pain, take history, take vitals, position of patient (position of comfort → usually sitting or semi-reclining)

2.) assist with nitroglycerine, oxygen 12-15 L/min by nonrebreather mask, review CPR

Aspirin

1.) ARC recommends giving 2 chewable baby aspirin or 1 tablet with small amount of water for heart attack victime

2.) allergy to aspirin, stomach ulcer disease, or taking blood thinners

CHF S/S

1.) marked dyspnea, great anxiety, desire to sit upright, chest pain may or may not be present, distended neck veins, pedal edema

2.) rapid, shallow respirations, rapid pulse, wheezing, rales, hemoptysis, pulmonary edema, pink frothy sputum

Treatment of CHF

call 911, keep patient calm, keep patient in seated position, in general treat as AMI

AMI Vs radicular pain

1.) important points of differential diagnosis

-Age of patient, history, signs and symptoms, physical/cardiac exam, ortho/neuro exam

Respiratory distress pathophysiology

1.) pulmonary vessels are actually separated from the alveoli by fluid or infection

2.) alveoli are damaged and cannot transport gases properly across their own walls

3.) air passages are obstructed by spasm or mucus

4.) pleural spaces is filled with air and the lungs cannot expand

S/S of respiratory distress

1.) restlessness, agitation and unresponsiveness

2.) tripod position, agitated or confused facial expression, may speak in very short sentences

3.) cyanosis, bluish-gray skin, especially to the neck and chest

4.) recruitment of accessory muscles of breathing, nasal flaring

causes of dyspnea

infections of upper or lower airway, acute pulmonary edema, chronic obstructive pulmonary disease, spontaneous pneumothorax, asthma, mechanical obstruction, pulmonary embolism, hyperventilation

Acute Epiglottitis

1.) bacterial infection of epiglottis, can produce severe swelling of the epiglottis, especially in children

2.) acute and complete obstruction can occur, it is characterized by fever, progressive dyspnea, and a barking, brassy cough and hoarseness

3.) there is progressive and excessive muscular effort with breathing

4.) NEVER place a tongue blade, finger or oral airway in this patient as it can cause spasm and complete airway obstruction

Croup

1.) viral infection of the larynx, causing inflammation and swelling of its lining

2.) common sign is stridor (high pitched, barking, rough sound heard on inspiration)

3.) stridor signifies further narrowing of the air passage of the larynx, which may progress to significant obstruction

COPD

1.) includes pulmonary emphysema and chronic bronchitis and is characterized by chronic cough and/or airflow obstruction

2.) often develop “CO2 narcosis” → body becomes so accustomed to chronically high levels of CO2 that it no longer stimulates breathing

3.) patient depends on hypoxic drive to stimulate breathing, administration of high levels of oxygen could actually reduce or even stop breathing

4.) almost always directly related to cigarette smoking

Spontaneous Pneumothorax

1.) most cases are caused by trauma, but some medical condition may cause it without injury

2.) Pleuritic chest pain, dyspnea, diminished breath sounds on side of pneumothorax

Pulmonary embolism

1.) emboli that lodges in the lung, has 10% immediate fatality rate

2.) sudden onset of unexplained dyspnea, pleuriitc chest pain, cough, tachypnea, syncope, cyanosis, distended neck veins

DVT

1.) blood clot that develops most commonly in the large veins of the leg

2.) more common in people over 60 but any age can develop DVT

3.) proximal DVTs found in popliteal or thigh veins

4.) Distal DTVs found in lower leg

DVT signs and symptoms

pain, swelling, warm to touch, distended superficial veins, redness of skin,

significant percentage of patients have limited signs or symptoms

DVT risk factors

obesity, bed rest, extended air travel, fractures, polycythemia, surgery, 6 months or less postpartum, autoimmune disorders (lupus), blood clotting disorders (factor V leiden), family history of blood clots, major trauma

If you suspect a DVT

patient requires a diagnostic work up ASAP usually a doppler ultrasound study or referral to the ER

Asthma

1.) acute spasm of the bronchioles associated with excessive mucus production → 6-10 million americans suffer from asthma and about 5-10 thousand die from it each year

2.) usually asthmatic attacks are allergy related

Astham: S/S and Tx

1.) wheezing, anxiety, labored exhalation, BP slightly elevated, pulse normal or slightly elevated, fatigue, cyanosis

2.) BLS, sit patient up, suction, oxygen transport to ER. If this is due to an allergic reaction the patient may have epi which will cause bronchodilation with administration

3.) status asthmaticus: prolonged asthma attack that does not respond to EPI (life threatening)

Hyperventilation

1.) rapid deep breathing often associated with anxiety, that leads to alkalosis

2.) S/S: deep rapid ventilation, tachycardia, dizziness, numbness/tingling in the hands and feet, numbness around the mouth, sticking, stabbing chest pains that increase with respiration may occur (symptoms due to alkolois)

3.) Tx: monitor vitals, make certain that the hyperventilation is not due to hypoxia. If pt isn’t returned to normal after calming the patient send them to the ER for eval.

Epilepsy and seizures

1) epilepsy is a condition manifested by seizures that are caused by an abnormal focus of activity within the brain, producing severe motor responses and/or changes in consciousness

2.) relatively common affecting 1/200 people

Grand Mal Seizure → Aura

sensation preceived by the patient, it is a prodromal warning that a seizure is about to happen. it takes on may forms → sound, smell, twitch, feeling of anxiety or dizziness

aura lasts a very short time and is immediately followed by convulsions

Grand Mal Seizure → Convulsion

1.) sustained, tonic muscular contractions, which can cause odd posturing may last 1 to several minutes

2.) clonic muscular activity or spasms, may be superimposed on the tonic contractions

3.) during the convulsions the jaw is clenched, breathing is compromised, the patient is often incontinent of bowel and bladder, can be cyanotic

Grand Mal Seizures → Postictal

Phase of exhaustion and recovery → lasting 10-30 minutes to hours

patient is fatigued, with depressed LOC. Obstruction of the airway is possible from vomitus, localized transitory weakness or paralysis may be present

TX for seizures:

1.) position the pt → postical patient should be put in the recovery position to protect the airway. If a spinal injury is suspected then the patient will have to be secured to a backboard

2.) maintain patient airway, if the patient is seizing or unresponsive, it may be necessary to insert a nasal airway. Do not force anything in the pts mouth

3.) suction

4.) assist breathing, if the seizure lasts longer than 5 minutes assist ventilated with a bag-valve mask and high flow oxygen

5.) prevent injury to the patient

6.) maintain oxygen therapy

7.) transport if necessary

status epilepticus

1.) this is a prolonged seizure lasting more than 10 minutes or one seizure after the other with little or no time for rest between seizures

2.) the patient becomes very hypoxic during this de to the impaired breathing

3.) condition is life threatening

CVA

sudden decrease in consciousness, sensation and/or motor function caused by rupture or obstruction of an artery in the brain

Isthmic stroke

caused by blockage of a vessel

thrombus or emboli

Hemorrhagic stroke

caused by rupture of a vessel or an aneurysm

worse prognosis than ischemic strokes free blood in CNS is caustic and causes liquefaction of CNS

Pathophysiology of CVA: thrombosis

a clot in the cerebral vessel caused by arteriosclerosis and the progressive narrowing of the lumen of the arterial walls

most common cause of stroke

Pathophysiology of CVA: Arterial rupture

rupture of the cerebral vessel due to either an aneurysm or simply because of high BP which over time can weaken arterial walls which are weakened by arteriosclerosis

Cerebral embolism

a blood clot that forms elsewhere in the body (most often in the left side of the heart) that travels to the brain and lodges in a vessel

Thrombosis S/S

specific losses of body function, generally without pain or seizure. The functional loss represents the area of the brain to which blood flow is interrupted

Arterial rupture S/S

also results in a loss of body function but is usually accompanied by a sudden, violently severe headache. the patient may rapidly lose consciousness

Cerebral Embolism S/S

may cause a sudden seizure, paralysis, or rapid loss of consciousness without headache or pain

General S/S of CVA

one sided monoplegia or hemiplegia, diminished LOC, which may vary from confusion or dizziness to coma

difficulty with speech, visual disturbances, seizures, dysphagia, loss of facial expression, headache

Treatment for CVA

1.) call 911, provide BLS, give oxygen, position patient on paralyzed side

2.) use padding to protect the paralyzed, the head should be elevated about 6 inches

3.) NPO, remember that a stroke victim may appear to be unconscious but is perfectly aware of what is going on around them

TIA

1.) signs and symptoms of a stroke but lasting only a few minutes up to 24 hours

2.) the patient recovers completely without permanent disability

3.) this can be a warning of an impending major stroke

4.) treat as you would any stroke. AT the time of the event it is often indistinguishable from a stroke

Hypertensive Emergencies

1.) defined as a critical elevation in blood pressure in which diastolic pressure exceeds 120mmhg

2.) presence of acute or on-going end-organ damage constitutes a hypertensive emergency, whereas the absence of such complications is known as a hypertensive urgency

3.) generally require a reduction in blood pressure within a few hours, usually using intravenous medications given in an intensive care unit

4.) Hypertensive urgencies also require prompt medical attention, but BP can be lowered over 24-48hours, sometimes in a closely monitored outpatient setting

Hypertension End-Organ Damage

1.) TIA, stroke, dementia

2.) heart failure, left ventricular hypertrophy, angina, myocardial infarct

3.) peripheral vascular disease, fundal hemorrhages or exudate, renal impairment, proteinuria

Stoke and Cervical Adjusting

1.) Incidence of stroke following cervical “manipulation” is anecdotally reported at a great variance between 1 in 300,000 per manipulation and 1 in several tens of millions

2.) Involves vertebral basilar system (Posterior circulation) → provides blood to approx. 1/3 of the brain. This would account for the symptoms associated with what is commonly called VBAI

Pathophysiology of VBI

1.) indirect trauma to the artery wall causing a tear, vasospasm ot both

2.) This can cause a thrombus or an embolism which will occlude a distal segment of the artery. The most commonly occluded vessel is the posterior inferior cerebellar artery (PICA)

3.) Vertebral artery may also have a dissection of the tunica intima. The intima can balloon out or embolize blocking flow and causing an ischemic infarct

VBI prognosis

Death is rare and most patient recover completely or with minimal long lasting or sometimes permanent deficit

S/S of VBAI

1.) nausea, vertigo, vomiting, difficulty walking

2.) incoordination of extremities, numbness or other sensory complaint

3.) loss consciousness, visual problems (blurred or double), tinnitus, speech problems, headache

Care for VBAI post manipulation

1.) Call 911, Do not administer another cervical adjustment, do not allow the patient to ambulate, make them comfy

2.) note all physical and vital signs, check pupils for PEARL, check eye light and accommodation reflexes

3.) test the lower cranial nerves, looking for facial numbness or paresis, swallowing problems, gag reflex, slurred speech, palatal elevation

4.) test cerebellar function, test muscular strength, somatic sensation, DTR’s and immobilize the neck with soft collar and treat at other strokes

Bell’s Palsy

1.) Peripheral lesion involving the CN VII

2.) one entire side of the face will show weakness, including forehead

CVA vs Bell’s Palsy

1.) with CVA in the cortex the forehead is spared, however it is important to remember that a lesion at the nuclei of CN VII in the brainstem can mimic a peripheral lesion

2.) fortunately lesions of the CN VII nuclei are usually not isolated because of their close proximity to other nuclei (CN VI)

3.) any patient who presents with a suspected bell’s palsy should have a careful neurological exam performed, including cardinal planes of gaze

4.) if the pt has paralysis of lateral eye movement with facial paralysis this is NOT bell’s Palsy → central lesion of brainstem, immediate referral

Poison

Any substance that, when swallowed, inhaled, absorbed or injected into the body, in relatively small amounts by its chemical action may cause damage to structures or disturbances of function

Ingested Poison S/S may vary widely depending on the nature of the poison

History of ingestion, swelling of oral mucosa, nausea/vomiting, diarrhea, altered mental status, abdominal pain, tenderness or distention

Burns or stains around the mouth, unusual breath odors, respiratory disorders, altered heart rate, altered BP, dilated or constricted pupils, warm and dry or cool moist skin

Ingested poison emergency care

call poison control and follow directions or call 911

maintain airway, be prepared for vomiting

collect vomitus, collect containers and any left over contents, provide BLS

Possible PCC directives

1.) dilution: often accomplished with copious amounts of water or milk

2.) activated charcoal: substance which binds to poisons and prevents their absorption

3.) inducing vomiting: best accomplished with syrup or ipecac, follow directions on bottle

Only induce vomiting under the direction of a poison control center

more and more experts are recommending against inducing vomiting in the field because of the danger of aspiration of vomitus

Never induce vomiting when

1.) patient is unconscious, has swallowed a corrosive chemical

2.) patient has swallowed petroleum product, pregnancy, severe cardiac disease

3.) patient is under 1 year old, have a seizure

Common Poisonous Plants

Morning glory, rhubarb leaves, buttercup, daisy, daffodil, lily of the valley, narcissus, tulip, azalea

English ivy, mistletoe berries, iris, hyacinth, laurel, philodendron, rhododendron, dieffenbachia