clin skills exam 3: cardio + restraints

becca_frizz

what can ECG changes during exercise provide evidence of?

ischemia if significant stenosis from CAD is present

ACSM suggestions for exercise test

-all women >50 YO

-all men >40 YO

who are planning on engaging in vigorous exercise

alternative methods to exercise stress testing

-exercise stress scintigraphy

-echo

indications for stress test

-initial diagnosis of obstructive CAD

-stratify risk and monitor treatment of pts with previously diagnosed or treated CAD

-screen asymptomatic individuals

-assess exercise capacity in pts with valvular, congenital abnormalities, or CHF

-monitor/document therapy in pts with exericse-related heart dysrhytmia

-assess previous therapy

ACC guidelines for stress test

-adults pts with at least an intermediate pretest probability of CAD on EKG alone

-adult pts with suspected CAD who have abnormal ECG that are at least in part attributed to glycoside therapy, LVH, LBBB, or other baseline ECG abnormality= stress test with EKG and imaging modality

contraindications for stress test

-pt suffering from MI or unstable angina

-symptomatic CHF

-symptomatic conduction abnormalities

-severe systemic HTN (ABSOLUTE CI)

-severe aortic stenosis

-pts who are unable to obtain adequate HR response due to medication

-clinical conditions that should be controlled before Exercise Stress Testing

-PE or infarct and Severe PVD

-limitations in ambulation

-inability for pts to follow instructions

-illness especially with associated fever

complications of stress test

-potential risks are small when the correct pt population is addressed and the pt's physical, cognitive, and psychomotor function is closely monitored

-sudden death

-complications associated with the mechanics of walking

why is dynamic or isotonic exercise preferred for exercise stress testing?

puts a volume stress instead of a pressure stress to the heart

VO2 max

highest level of O2 a subject can achieve during maximal exercise

1 MET=

-the total O2 consumption measured in mL of O2 per KG of BW per minute at rest

-3.5 ml/kg/min

MET=

work equivalent

HR=

myocardial O2 consumption

peak HR=

indirect measurement of the workload imposed on the heart during exercise

the percentage of MHR which symptoms of ECG changes occur indicate:

the severity of cardiac impairment

MHR and systolic BP=

double product or rate-pressure product-index of myocardial O2 consumption

cardiac reserve that is severely limited=

poor prognosis

normal (negative) stress test

end point is achieved without S/S= low statically probability of important cardiac disease

what is the most common objective finding of stress tests?

ST segment depression with or without anginal symptoms

inconclusive/nondiagnostic findings of exercise stress test

-clinically insignificant arrhythmias (PVC, atrial tachy)

-development of blocks (Type 1 AV block, BBB)

-morphology change (T wave flattening, P wave <0.01, ST depression <.10 mV)

symptoms that would suggest ischemia during stress test

-exercise induced hypotension

-exercise induced angina or angina equivalents

-appearance of S3, or S4 heart murmur when exercising

non-significant findings of stress test

-fatigue, dyspnea, diaphoresis, flushing

-incremental increase in BP or HR

-EKG changes: shortening of QT interval, peaking of T waves, shortening of PR interval

materials needed for stress test

-adequate environment

-emergency equipment

-treadmill

-12-lead ECG and needed supplies

-imaging equipment

-BP monitoring equipment

-HR monitor

how are stress tests performed?

-explain risk, benefits, indications

-medical hx and PE

-have pt wear comfortable clothing and shoes

-give written instructions and let pt have a chance to ask questions

-obtain baseline ECG prior to the day of testing

-evaluate the pt as they walk to the examining room looking at gait patterns, balance, physical demand

-attach the electrodes, cables tubing and vest

-perform ECG standing and supine and after 30 sec of hyperventilation

-select protocol and discuss with the pt

-instruct the pt on proper techniques for the use of the treadmill

-begin test and progression per protocol. ECG q 1 min and BP prior to advancement to next stage

-pt communicates there perceived exertion (Borg scale)

which protocol is most common in stress testing?

Bruce Protocol

when should the stress test be stopped?

-with pt completing the test

-progressive angina

-persistent V-tach

-significant ST and progressive ST-T depression or/and ST-T elevation

-progressive heart block

-excessive BP response >250 mmHg systolic and 120 mmHg diastolic

-lightheadedness, confusion, ataxia, cyanosis

-pt request

-failure of critical monitoring equipment

submaximal testing for stress testing

stable pts with an acute coronary syndrome often undergo a submaximal exercise test prior to discharge unless they have undergone percutaneous coronary intervention or coronary artery bypass graft surgery and have been fully revascularized

end points for termination of test in submaximal testing

-a peak HR of 120-130 bpm or 70% of the maximal predicted HR for age

-a peak work level of 5 METs

-mild angina or dyspnea

->= 2 mm of ST segment depression

-exertional hypotension

-3 or more consecutive ventricular premature beats

follow up care for stress tests

-advise the pt that they may feel tired for the remainder of the day

-refer abnormal findings to the referring provider for further recommendations for treatment

-individuals demonstrating unstable responses should be hospitalized

strong positive stress test

-a drop of more than 10 mmHg in systolic pressure or

-large ST-seg depression

where does the heart lie?

behind the sternum with the base at about the right third parasternal intercostal space and the apex in the fifth intercostal space, inferior and medial to the nipple

why is placement of the paddles or pads for defibrillation done?

to maximize delivery of enough electricity to depolarize the entire myocardium at once, while minimizing the loss of energy through adjacent tissues

where is the right anterior pad placed in anterolateral placement of defib pads?

to the right of the sternal margin, at the second or third intercostal space

where is the left lateral pad placed in anterolateral placement of defib pads?

left fourth or fifth intercostal space, along midaxillary line

what is defibrillation and cardioversion?

the application of a brief pulse of direct electrical current across the chest wall, resulting in momentary myocardial cell depolarization

what is temporary or permanent cardiac pacing?

when electrical current is delivered to the heart through the skin via large surface electrodes

who is temporary or permanent cardiac pacing usually reserved for?

-standby prophylaxis in pts recognized to be at high risk for bradycardia

-ex: inferior and large anterior wall acute MI

what does the transcutaneous pacing system use?

two large, low-impedance surface electrodes paced on the anterior and posterior chest walls

what does transcutaneous pacing do?

paces the ventricle and inhibits its output/discharge when it senses spontaneous ventricular electrical activity

when should transcutaneous pacing start immediately?

-there is not a response to atropine

-atropine is unlikely to be effective if IV access cannot be quickly established

-the pt is severely symptomatic

how is transvenous pacing achieved?

by threading a pacing electrode through a vein into the R atrium, right ventricle, or both

why is transvenous pacing performed?

to restore hemodynamic stability compromised by tachyarrhythmia or bradyarrhythmias

therapeutic uses for temporary cardiac pacing

-to provide adequate HR in pts with symptomatic bradycardia from sinus node dysfunction or high-deg and complete AV block while awaiting definitive therapy

-to terminate some supraventricular and ventricular tachycardias by overdrive suppression or entrainment

prophylactic uses for temporary cardiac pacing

-to prevent high-deg AV block in some pts with acute MI, and in some pts after cardiac surgery

-to prevent bradycardia-dependent ventricular tachycardia

diagnostic uses for temporary cardiac pacing

-to determine the site of AV block

-for evaluation for optimal type of permanent pacing system

indications of transcutaneous pacing

-symptomatic and hemodynamically unstable bradycardias

-asystole

indications for transvenous pacing

-bradyarrhytmias due to acute reversible causes

-cardiac conduction abnormalities

-overdrive pacing of tachyarrhytmias- refractory to drug therapy or electrical cardioversion

-failure of other pacing devices

CI for TCP and transvenous pacing

-V fib

-awake and hemodynamically stable pts

-non-intact skin at the site of the electrode placement

-severe hypothermia

complications of TCP

-failure to recognize VF

-induction of other dysrhytmias

-soft tissue discomfort may result from pacing

-local cutaneous injury with prolonged TCP

complications of TVP

-pacemaker malfunction

-oversensing

-undersensing

-cardiac perforation

-arrhyhtmias

-thromboembolic complications

-intrathoracic trauma

-infectious complications

steps used in TCP

-explain procedure

-correct metabolic and electrolyte abnormalities

-provide supplemental O2 and obtain IV access

-ensure adequate airway management

-apply monitor cable leads

-place pads and attach to monitor cables

-turn monitor on pacing mode

-select pacing rate

-select power/output

-assessment of capture

-assess pt hemodynamic stability and tolerance to pacing

what power/output should be used for TCP?

2mA (or 10%) above the dose at which consistent capture is observed

post TCP pacing

-write a brief progress note

-if TCP was initiated during code, fill out code sheet

-reevaluate pads every 30 min

-treat underlying

indications for cardioversion

-unstable pt with reentrant tachycardia

-stable pts with ventricular or supraventricular tachycardia

synchronized cardioversion

-when you press shock, there is a delay before deliver shock because synchronize shock with the peak of the "R" wave

-avoids delivering shock during cardiac repolarization, which prevents VF

-uses lower energy level than defibrillation

unsynchronized cardioversion

-electrical shock as soon as you push shock button

-shock falls randomly anywhere within the cardiac cycle

-use higher energy levels than synchronized

CI of cardioversion

-sinus tachycardia

-atrial fibrillation lasting longer than 36-48 hrs without appropriate anticoagulation therapy

-digoxin toxicity mediated tachycardia

-junctional and multifocal atrial tachycardia

complications of synchronized cardioversion

-if the R wave peaks of a tachycardia are undifferentiated or of low amplitude, the monitor sensors may be unable to identify an R wave peak and therefore will not deliver a shock

-may not synchronized through the hand-held quick-load paddles

-synchronization can take extra time

steps used in cardioversion

-sedate pts

-turn on defibrillator

-attach monitor leads to the pt and ensure proper display of the pt's rhythm. then apply defib self-sticking pads to the pt

-press SYNC control button

-select the appropriate energy level

-announce to the team "charging defib stand clear"

-press charge button

-clear pt

-press charge button

-check the monitor

cardioversion for a. fib

100 to 200J, 300 J, 360 J

cardioversion for stable monophasic VT

100 J, 200 J, 300 J, 360 J

cardioversion for other SVT/atrial flutter

50 J, 100 J, 200 J, 300 J, 360 J

cardioversion for polymorphic VT

treat as VF with high-energy shock

post procedure care after cardioversion

- Verify airway patency

- Following attempted electrical cardioversion, verify the rhythm on the monitor

- Record BP immediately following

- Obtain 12 lead EKG with in 15 minutes

indications of defibrillation

-v fib

-Pulseless V tach

CI of defibrillation

-advanced directive, DNR

-signs of death are present

-asystole or PEA

complications of defibrillation

-permanent cardiac pacemaker or AICD dysfunction

-skin burns

-injuries to health care personnel who may have touched the pt or stretcher

steps of defib

-establish that the pt is unresponsive

-begin CPR

-turn the defibrillator on

-attach the monitor-defibrillator leads while CPR continues

-apply the defibrillation self-sticking electrode pads to the skin

-determine the rhythm

-select the energy output level

-prepare and place paddles

-prepare to defibrillate

-press shock button

-resume CPR for 2 min

-check rhythm

-continue management if VF/pulseless VT continues

indications for central venous lines

-secure IV access for meds and blood products (vasopressors, chemo)

-phlebotomy

-to monitor central venous pressure

-to deliver TPN

-poor peripheral access

CI to central lines

-infection of the area overlying the target vessel

-thrombosis of the target vessel

-coagulopathy

-IVC filter

-respiratory distress of impending respiratory failure

complications of central lines

-pain

-infection

-bleeding

-arterial or venous laceration

-arterial cannulation

-pneumothorax

-hemothorax

-cardiac arrhythmia

-venous hematoma

-arterial dilitation

-embolization of clot, air, guidewire or catheter

-phlebitis or thrombosis of the vein

-pericardial tamponade

-death

materials for central line

-insertion checklist

-sterile gloves, cap, mask with face fluid shield

-chloraprep

-large sterile drape

-lidocaine 1%

-tegaderm

-central line kit

preparing for central line procedure

C-SOAPIM

Comfort

Sterility

Oxygen

Airway

Position (trendelenburg)

IV access

Monitores

Cordoza Doctine: 1914

those of adult years and sound mind may determine their own health care

organic violent pt

derived from medical disorders, substance abuse, and other toxidromes

psychotic violent pt

schizophrenic, manic, and delusional

nonorganic nonpsychotic violent pt

personality disorders, impulse control disorder

mixed violent pt

-underlying neurological disorders with psychological manifestations

-underlying psychiatric disorders acutely exacerbated by substance abuse

diagnoses that may lead to violent behavior

GOT IVS

-glucose (hypoglycemia)

-Oxygen (hypoxemia)

-Trauma

-Temperature

-Infection

-Vascular

-Seizure

S/S that suggest violence is organic

-rapid onset

-no prior hx of psychiatric disease

-visual-olfactory-tactile hallucinations

-abnormal vital signs

-cognitive/neurologic deficits

-slurred speech

-confusion

-substance abuse

-disorientation

-history of trauma

-physical evidence of trauma

violent behavior

any set of actions that are forceful or directed enough to cause injury to the patient or others

what is the predictor of violence?

pt with a hx of violence

early warning signs of violence

-pt exhibits or threatens violence

-pt makes staff anxious or fearful

-behaviors alternates between shouting and dozing off

-pt expresses fear of losing control

-pt uncooperative, hostile, agitated and unable to sit still

-pt is intoxicated

-pt has a past hx of violence

-pt has tense, rigid posture

-pt has tattoos that suggest a relationship to a violent organization or gang

risk factors for requiring restraint

-intoxication with alcohol or other drugs

-male pts between 13-25 years old

-presence of police

-hx of psychiatric disorder

-lack of reasoning skill

least restrictive method

pt should be provided alternatives to correct inappropriate behavior in order to maintain a good working provider/pt relationship and to maintain the dignity of the pt

de-escalation

convey professional concern for the well-being of the pt, let the pt know the staff are in control and that no harm will come to the pt

seclusion

placing the pt alone in a locked room from which he/she can not leave

physical restraint

used if the provider's medical opinion deems the pt a danger to themselves, other pts, or staff

chemical restraint

addition of a pharmacological agent to decrease agitation and increase the cooperation of pts

therapeutic holding

an adult physically holding a child for therapeutic benefit, an alternative to full physical restraint

what does therapeutic holding convey?

that person can and will control children when the cannot control themselves