Adult Health Exam 2

Coronary Artery Bypass Graft (CABG)

Surgery to restore blood flow around blocker arteries in the heart

May need multiple bypasses

Uses left internal mammary artery/saphenous vein

Traditional CABG

Requires median sternotomy

During CABG surgery

Cardiopulmonary bypass to provide circulation during the procedure

Cardioplegic solution used to stop the heart

Warm up the body/defibrillate to restart

Airway post-CABG

Continuous pulse oximeter monitoring

Early extubation

Monitor for infection/atelectasis

Manage chest tube

• 200mL in 15 min indicates active bleeding

Cardiac care post-CABG

Pulmonary artery and CVP monitoring

Continuous ECG

Epicardial pacing wire

+ positive inotropic may be needed

Neuro care post-CABG

Watch for ischemic stroke!!

Keep sedation minimal

Neuro assessment

Renal post-CABG

Monitor renal labs

Preop renal dysfunction strongest risk factor

Metabolic acidosis due to excess lactic acid production

Glycemic control post-CABG

Keep tight glycemic control!

Temperature control post CABG

Slowly rewarm with blankets and IV fluid

Hypothermia: Increased bleeding, infection, death

Hyperthermia: Cognitive deficits and increased infection

Pain management post CABG

Prevent delirium

Opioids may have side effects → sedation

Acetaminophen

Splinting

Post CABG home care

4-6 weeks recovery

No lifting/pushing 10lb for 6 weeks!!

Don’t reach behind back

Splinting

Medication adherence

Cardiac rehab

Pulmonary Artery Catheter

Threaded to the heart into the pulmonary artery

Measures: RA and RV pressure, pulmonary artery pressure, and systemic vascular resistance

Zero at phlebostatic axis

Phlebostatic axis

4th intercostal space, mid axillary line

Central Venous Pressure (CVP)

Catheter in vena cava

Can be measures w pulmonary artery cath or central venous line (in distal port)

Measures PRELOAD

Align w phlebostatic axis

Normal CVP

2-8 mmHg

Increased: fluid overload

Decreased: hypovolemia

Arterial pressure line

Catheter inserted into artery for most accurate BP monitoring

• Radial/femoral

NO MEDS through this line!

Cardiogenic shock

Decreased CO → inadequate perfusion → shock

HIGH mortality rate

Causes of cardiogenic shock

Large mycoardial infarction

End-stage heart failure

Cardiac tamponade

PE

Cardiomyopathy

Arrythmias

Degree of cardiogenic shock

Related to left ventricular function

s/s of cardiogenic shock

Cerebral hypoxia

Hypotension

Fast, weak pulse

Clamy skin

Tachypnea

Decreased urine output

Metabolic acidosis

Hemodynamics in cardiogenic shock

Increased pulmonary

Increased systemic vascular resistance

Decreased cardiac output

Tx of cardiogenic shock

Treat the underlying issue!

Prevent further damage to heart

Restore circulation

Improve oxygenation

Correct arrythmias and fluid status

Pericardial effusion

Accumulation of fluid in the pericardial sac

Causes cardiac tamponade

Causes of pericardial effusion

Pericarditis

Late-stage HF

Cardiac surgery/trauma

Chemo

Metastatic cancer

s/s of pericardial effusion

fullness in chest

JVD during inspiration

Dyspnea/cough

Hypotension

Pulsus paradoxus

Beck Triad

Narrow pulse pressure

Pulsus paradoxus

10-12 drop in BP during inspiration

Beck Triad

Elevated CVP during inspiration

Muffled heart sounds

Hypotension

Day 1-2 after CABG

Care in ICU

Day 3 after CABG

Pain management

Ambulation

Day 4-6 after CABG

Cardiac rehab

Education

Med adherence

Pericadial effusion/tamponade tx

Pericardiocentesis

Pericardiotomy

Pericardiocentesis

Aspiration of pericardial effusion

Decreases CVP

Increases CO and BP

Complications of pericardiocetesis

Organ/artery puncture, arrythmias, infection

Pericardiotomy

Tx of recurrent pericardial effusion and cardiac tamponade

Portion of pericardium removed to allow drainage

Cardiac arrest

Sudden loss of heart function

Shockable arrhythmias

Ventricular fibrillation

Ventricular tachycardia

Non-shockable arrhythmias

Pulseless electrical activity

Asystole

Reversible causes of cardiac arrest (H’s)

Hypovolemia

Hypoxia

Hydrogen ions (acidosis)

Hypokalemia/hyperkalemia

Hypothermia

Reversible causes of cardiac arrest (T’s)

Tension pneumothorax

Toxins (OD)

Tamponade

Thrombosis (pulmonary)

Thrombosis (cardiac)

Blood viscosity

Impacts SVR and afterload

Increased viscosity = Increased afterload and pressure

Causes of increased blood viscosity

Pregnancy, blood doping, clotting disorders, extensive trauma

Which stage of contraction is longer?

Diastole

2-3x longer

Primary HTN (Essential HTN)

No known cause

Most common

Secondary HTN

Caused by disease states

There has to be a direct cause!

• Kidney disease, med induced, adrenal tumors

• CAD, pregnancy, substance abuse

Diagnosis of HTN

2+ serial abnormal BP readings

Primary HTN risk factors

Genetics

Excess sodium intake

Inactivity → BMI >25

African American

Smoking, DM, HLD

Age >60

Post-menopausal women

Secondary HTN risk factors

Kidney disease

Cushing’s disease

Primary aldosteronism

Pheochromocytoma

Brain turmos

Medications → Estrogen, steroids, sympathomimetics

Pregnancy

Elevated BP

120-129/80

Stage 1 HTN

130-139/80-89

Stage 2 HTN

140/90

Hypertensive emergency

>180/>120

Mean Arterial Pressure (MAP)

Indicator of perfusion to major organs

Normal MAP

70-100 mmHg

MAP <65

End-organ ischemia and/or infarction

MAP <60

No cerebral or coronary artery perfusion

MAP equation

SBP + 2(DBP) / 3

HTN s/s

Usually none! unless prolonged and uncontrolled

HA, flushing

Dizziness

Visual disturbances

Epistaxis

Nocturia/polyuria

Pulse pressure

Systolic - diastolic

Ideal = 40

>60 indicates atherosclerosis and reduced elasticity

HTN non-pharm tx

Weight reduction

DASH diet

Reduce sodium

Activity

Reduce alcohol consumption (compared to baseline)

Manage anxiety

Alpha blockers

Prazosin

Doxazosin

Terzosin

Alpha blockers MOA

Block alpha adrenergic receptors → stops binding of epi and norepi

Can treat BPH

Alpha blockers adverse effects

First-dose orthostatic hypotension

Sexual dysfunction

Which is the only calcium channel blocker that can be given IV?

Diltiazem

Centrally-acting Alpha2 Agonist

Clonidine

Guanfacine

Methyldopa

Centrally acting alpha2 agonist MOA

Decrease cardiac outflow

Decrease adrenergic stimulation

Centrally acting alpha2 agonist adverse effects

Drowsiness

Dry mouth

Rebound HTN

Centrally acting alpha2 agonists considerations

Monitor BP, HR

Don’t stop abruptly

Calcium channel blocker adverse effects

Reflex tachycardia → Treat with beta blockers

Acute toxicity

Orthostatic hypotension

Peripheral edema

Adverse effects of verapamil/diltiazem

Dysrhythmias

Bradycardia

HF

Continuous monitoring!!

Adverse effects of ACEs

Hyperkalemia!!

Dry cough

Angioedema

ARBs in diabetes

Kidney protective

ARBs indication

Often used if can’t tolerate ACEs

ARBs considerations

Monitor BP

Monitor lithium levels → combination can lead to lithium toxicity

Renin inhibitor

Alkisiren

Renin inhibitors adverse effects

Angioedema

Hyperkalemia

Diarrhea

Renin inhibition considerations

No in pregnancy

Monitor potassium

Vasodilator in HTN indication

Used more hypertensive emergency!

Vasodilators examples

Nitroglycerin

Nitroprusside

Hydralazine

HTN complications

End organ damage!!

MI, stroke, HF

Kidney damage

Dementia

Vascular retinopathy

Aneurysyms

Hypertensive urgency

Severe HTN without acute end-organ damage

HTN urgency cause

Non-compliance with antihypertensive therapy

HTN urgency treatment

Reduce BP over 24-48hrs

Manage anxiety PRN

Hypertensive emergency

180/120 BP WITH end-organ damage

Life threatening!

Hypertensive emergency risk factors

Noncompliant HTN

Acute kidney failure

Acute CNS events

Pheochromocytoma

Female

Obesity

Phenochromocytoma

Tumor on adrenal gland → Overproduction of stress hormones

Aortic dissection

Tear in the inner wall of the aorta

Difference >20mmHg in BP between arms

Hypertensive emergency treatment

ICU admission

BP monitoring on arterial line

Strict I&O

Semi-fowler position

s/s of end-organ damage in hypertensive emergency

Changes in LOC

HA, blurred vision

N/V → Sign of brain bleed

ECG changes

Changes in BUN, creatinine

s/s of HF

Pharm tx of hypertensive emergency

IV antihypertensive infusions

• Hydralazine, labetalol, nicardipine, sodium nitropusside

Avoid SL and IM

BP reduction in aortic dissection, eclampsia, pheochromocytoma

Reduce SBP to <140 mmHg in first hour

BP reduction for other precipitating conditions

Decrease SBP no more than 25% in first hr

Decrease to 160/100 2-6hrs

Decrease to normal range in 24-48hrs

Coronary Artery Disease (CAD)

Accumulation of fat and fibrous tissue in arterial walls → Atherosclerosis

Blood flow to heart reduced

CAD cause

Repeated inflammatory responses

CAD age risk factor

Men: 45+

Women: 55+

CAD risk factors

Men

African american, native, mexicans

Diabetes

HTN

Smoking

HLD

Obesity

Obstructive sleep apnea

CAD symptoms in the elderly

Silent ischemia → Asymptomatic

Due to neuropathy and higher pain threshold

CAD s/s

Angina

SOB

Fatigue, diaphoresis

N/V

Dizziness

CAD prevention

Heart healthy diet

Exercise

Smoking cessation

Management of stress, HTN, HLD, DM

Exercise recomendations

150 minutes of moderate exercise weekly

OR 75 minutes of vigorous exercise weekly

Anti-hyperlipidemics MOA

Decrease cholesterol levels by decreasing fat in the bloodstream