cardiac and pulmonary compromise

emergency care exam 2

cardiac compromise

any kind of heart problem

• ex chest pain, radiating down left arm

CV disorder causes

directly or indirectly, by changes in the arterial walls

atherosclerosis

buildup of fatty deposits on the inner walls of arteries

• calcium deposits cause fatty deposits to harden

plaque

Other materials combine with fats to form the deposits

thrombus

blood clot

embolus

clot that breaks off of plaque

arrythmia

absent heartbeat

dysrythmias

irregular heart beats

tachycardia

HR above 100bpm

bradycardia

HR below 60 bpm

acute myocardial infarction

• heart attack

• portion of heart muscle dies due to lack of blood supply

cardiac arrest

When the heart stops functioning altogether

heart failure

when the heart cannot function properly

congestive heart failure

due to the buildup of fluids which is caused by inadequate functioning of the heart but, the fluids also further reduce the functioning of the heart and other organs

causes:

COPD, heart disease, hypertension

s/s of cardiac compromise

Pain, pressure, or discomfort in the chest or upper abdomen

Dyspnea

Palpitation

Sudden onset of sweating and nausea or vomiting

Anxiety (feeling of impending doom)

Abnormal pulse

Abnormal blood pressure

angina

chest pain caused by reduced blood flow to the heart

• Often the first symptom of heart disease and serves as an indicator of a future heart attack

cause of angina

atherosclerosis of coronary arteries which leads to myocardial oxygen supply and demand mismatch

stable angina

diminished oxygen supply only occurs with exertion

unstable angina

diminished oxygen supply happens at rest

pulse points/ presure points

areas where an artery can be compressed

fxn of pulse assessment

• rate and strength

• integrity of distal pulse

blood pressure

• rate and strength

• indicates the force of the blood pushing against the walls of the arteries

• highest when the heart contracts, thereby ‘pumping’ the blood

Systolic blood pressure

indicates how much pressure the blood is exerting against the artery walls when the heart contracts

• high systolic indicates risk factor for CV disease for people over 50

diastolic blood pressure

indicates how much pressure the blood is exerting against the artery walls while the heart muscle is resting between contractions

normal BP

<120/80

elevated BP

120-129/ < 80

high BP stage 1

130-139/ 80-89

high BP stage 2

>140/ >90

hypertensive crisis BP

>180/ >120

cardiac compromise treatment

• “immediate live-saving” vs “monitor over time”

• know the difference and when to refer or call 911

overview of low-dose aspirin

• inhibits platelets

• prevent the formation of clots within the body

mechanism of low dose aspirin

• Thromboxane A2 (TXA2) is produced from cell membrane phospholipids that increases platelet aggregation inside blood vessels

• Aspirin reduces the TXA2 production by inhibiting the COX-1 enzyme

should a patient at low risk of heart attack take aspirin daily?

no, the benefits of taking daily aspirin don’t outweigh the risks of bleeding

should patients with a high risk of heart attack take daily aspirin?

it is more likely it is that the benefits of daily aspirin therapy are greater than the bleeding risks

Daily aspirin therapy may be used in two ways:

Primary prevention: the patient has never had a heart attack or stroke but takes a daily aspirin to prevent such heart events (debatable support)

Secondary prevention: the patient has already had a heart attack or stroke, or has known heart or blood vessel disease and is therefore taking a daily aspirin to prevent heart attacks or strokes (well est effectiveness)

low dose aspirin dosage

81mg

325mg for high risk or active heart attack symptoms

• chewing is fastest

side effects/ complications of takign daily aspirin

• hemorrhagic stroke caused by a burst blood vessel

• GI bleeding from stomach ulcers

• allergic rxn

nitroglycerin

• used to prevent heart attack

• vasodilators, making it easier for blood to flow through and let more oxygen-rich blood reach the heart

administration of nitroglycerin

patch, ointment, capsule, spray, intravenous infusion, or a sublingual tablet

• avoids first-pass metabolism, allowing for immediate and short anginal relief

first pass effects

relates to a drug being altered by the body’s metabolic processes before it has a chance to reach the tissue of interest

Cardiac arrest is not the same as a heart attack

A person having a heart attack may still be talking and breathing - this person does not need CPR - but they do need to get to the hospital right away

heart attack s/s

• varies person to person

• pressure, tightness, pain or squeezing sensation of the chest

• nausea, indigestion, heartburn or abdominal pain

• shortness of breath, coughing, wheezing

• light headedness/ sudden dizziness

• fatigue

• cold sweat, feeling sick

• overwhelming sense of anxiety

sudden cardiac arrest s/s

• rarely any warning signs

• symptoms

• unresponsiveness

• LOC

• lack of pulse

• cessation of breathing

• abnormal heart rhythm

CPR

compresses the heart between the posterior thorax and chest

• Because of valves in the heart, when compressed, the blood can only go in one direction

CPR and cardiac arrest survival

• immediate CPR can double or triple chances of survival

fibrillation

results in very rapid irregular contractions of the muscle fibers of the heart

arrhythmia

fibrilllation can cause arrhythmia, an ‘irregular’ or ‘not normal’ heartbeat

Heart arrhythmias occur when the electrical signals that coordinate the heart's beats don’t function properly

atrial fibrillation (Afib)

• the most common type of arrhythmia

• caused by extremely fast and irregular beats from the upper chambers of the heart (usually more than 400 beats per minute)

ventricular fibrillation

occurs when rapid, chaotic electrical signals cause the ventricles to quiver instead of contacting in a coordinated way that allows for the pumping of blood to the rest of the body

• can lead to death if a normal heart rhythm isn't restored within minutes

ventricular tachcardia

results from faulty electrical signals in the ventricles causing excessive contractions that don't allow the ventricles to properly fill with blood and therefore prevents the heart from pumping enough blood to the body

afib and stroke

• The quivering atria can lead to pooling of blood in the left atrium’s pouch-like left atrial appendage

• During AFib, blood can pool inside the lobes, increasing the risk of forming blood clots

  • These clots can then work their way loose and travel to the brain, causing a stroke

Automated External Defibrillators

medical device designed to analyze the heart rhythm and deliver an electric shock to victims of ventricular fibrillation to restore the heart rhythm to normal

Implanted cardioverter defibrillators (ICDs)

small devices surgically placed in the chest, preprogramed to automatically detect cardiac arrest or a life-threatening arrhythmia

• If detected, they send a high-energy electric charge to stop the arrhythmia or restart the heart after cardiac arrest

• Some ICDs also act as pacemakers by giving low-energy electrical pulses to help the heart beat at a normal rhythm

• Others can send pulses of electricity to sync the rhythm of the heart’s lower chambers

Wearable cardioverter defibrillators (WCDs)

vests with a rechargeable battery

• Similar to the ICD, they automatically detect a life threatening rhythm and send an electrical charge to restore a normal rhythm

• WCDs are usually for short-term use

when does infection appear?

within 2-7 days

wound care and referral

• Puncture wounds and avulsions will likely need to be seen by a physician

• Lacerations – common rule for stitches is whether the ‘edges’ stay together

• Contusions – depends on severity and underlying tissue

occlussive dressing

seal the wound completely to lock in moisture and protect against bacteria

non occlussive dressings

porous, allowing air to circulate and fluids to evaporate

abrasions

• typically damage to epidermis

• deeper abrasions ca extend into dermis

• painful bc of nerve ending on skin

punctures

small surface opening but may extend deeply into the body, potentially damaging muscles, tendons, nerves, blood vessels, or other structures

• consider tetanus

laceration

• rough cut to skin

• superfical, epidermis, subcutaneous, muscle, etc

• separation of wound edges

incision

• clean sharp cut

• predictable healing

avulsion

• A severe type of wound in which tissue is forcibly torn away from the body

• create irregular and often extensive tissue damage, with portions of skin partially or completely detached

• avulsions are considered medical emergencies and require prompt professional care

cause of severe bleeding skin wounds

•Can be due to arterial or venous blood flow

Arterial bleeding is much more problematic than venous

severe bleeding care

• direct pressure

• elevation

• use of pressure points/ pressure bandage

pressure points

• temporal

• carotid

• axillary

• brachial

• radial

• ulnar

• femoral

• popliteal

common touniquet errors

Placing the tourniquet in the wrong location

Using a tourniquet in the wrong situation

Applying the tourniquet's band too loosely

Breaking the windlass

Loosening the tourniquet after the bleeding is controlled

Failing to record the time that the tourniquet was applied

can tourniquet’s cause harm?

It typically takes at least 4 to 6 hours for tourniquets to cause harm resulting from constant compression or extended blood cessation

Depends upon tissue type / location

secondary protective options

• Must have disinfecting capability

–Chlorine bleach

–Antiseptics

–Biohazard bags

–Sharps containers

Upper Airway

cilia serve as a mechanism to help clear the lungs

Ventilation

•due to Boyle’s law… inverse relationship between volume and pressure

•Inspiration requires active muscle contraction vs. expiration which is passive (unless muscles needed)

accessory inspiratory muscles

SCM, abdominals, scalene; also serratus anterior, pectoralis, trapezius

respiration

alveolar exchange between O2/CO2 via diffusion (varies based on partial pressures)

capillary cell lining

• one cell thick

• close together

rate of gas exchange in the lungs

5 to 8 liters (about 1.3 to 2.1 gallons) of air per minute

(100 L during exercise)

rate of O2 transfer from alveoli to blood

three tenths of a liter per minute

(3 L during exercise)

pulse oximetry

measures oxygen saturation of the blood

• Deoxygenated and oxygenated hemoglobin absorb light at different wavelengths (660 nm and 940 nm respectively), and the absorbed light is analyzed in the pulse oximeter to display a saturation value

peak expiratory flow rate

measure of the maximal flow rate that can be achieved during forceful expiration following full inspiration

green zone

Usually set at 80% to 100% of personal best or normal peak flow; as long as no symptoms are present, the patient is considered at steady state; no changes are needed to the present regimen

yellow zone

Fifty percent to 80% of personal best; patients are typically instructed to employ their home action plan when they identify repeated readings in this zone

red zone

Fifty percent or less of personal best; peak flow measurements in this range indicate that serious airway obstruction may be occurring and should be considered a medical emergency

metered dose inhaler

A handheld device that delivers a specific, measured amount of medication directly into the lungs in the form of an aerosol spray

• minimizes systemic effects

instructions for MDI

Step 1	Prepare MDI according to directions on container
Step 2	Hold inhaler upright & tip head slightly back to facilitate flow of drug into lungs
Step 3	Exhale slowly
Step 4	Place inhaler (or spacer with inhaler attached) in mouth and seal lips around
Step 5	Press down on inhaler to release meds and take slow, deep breath at same time
Step 6	Hold breath for 10 seconds before exhaling
Step 7	Wait 1 minute before 2nd puff if needed
Step 8	Rinse mouth with water if using steroid

use of supplemental oxygen

Asthma during severe exacerbations

Chronic Obstructive Pulmonary Disease

Pneumonia

COVID-19 when oxygen levels are reduced

Cardiac conditions that impair oxygen delivery

Severe allergic reactions affecting the airway

Trauma patients experiencing respiratory distress

Individuals with significant blood loss or shock

Patients recovering from surgery or anesthesia

administration of supplemental O2

Step 1	Assemble tank and regulator
Step 2	Line up regulator pins w/ holes in tank stem.  Hand tighten the regulator
Step 3	Check tank pressure by turning valve stem one complete turn (2000psi FULL)
Step 4	Select appropriate delivery device: non-rebreather mask (NRB), Bag-valve mask (BVM), Nasal cannula (NC)
Step 5	Attach oxygen tubing from mask/cannula to regulator
Step 6	Adjust oxygen flow rate (NRB 10-15L/min, BVM 15L/min, NC 2-6L/min)
Step 7	Apply mask/cannula to patient’s face and adjust fit
Step 8	When terminating oxygen administration, remove mask from patient’s face BEFORE turning off oxygen
Step 9	Turn off oxygen
Step 10	Relieve pressure in regulator

nebulizer

converts liquid medication into a fine mist that can be inhaled directly into the lungs

Delivering a Nebulizer Treatment

Step 1	Assemble nebulizer according to manufacturer’s instructions
Step 2	Carefully pour appropriate amount of medication into medication up
Step 3	Attach hose and mouthpiece/mask to medicine cup
Step 4	Turn on nebulizer
Step 5	Instruct patient to put mouthpiece in mouth and form tight seal
Step 6	Instruct patient to breathe in and out slowly through mouth for 15-20 minutes
Step 7	Turn off nebulizer
Step 8	Rinse medicine cup and mouthpiece with warm water and let air dry
Step 9	Patient rinses out mouth

when to use NT intubation

when the patient presents with a strong gag reflex, limited mouth opening, macroglossia, cervical spine instability, severe cervical kyphosis, severe arthritis, intraoral masses, structural abnormalities, trismus, or angioedema

• The circumstance where this is beneficial is when the patient has persistently low oxygen saturation in spite of preoxygenation efforts and also when a difficult airway is anticipated

oropharyngeal airway contraindications

If the patient can cough, they still have a gag reflex, and an oral airway is contraindicated

If the patient has a foreign body obstructing the airway, an oropharyngeal airway should not be used

An oropharyngeal airway should not be used on patients who have nasal fractures or an actively bleeding nose

too large of Oropharyngeal Airways

can lead to laryngospasm