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Cardiac Perfusion and Acute Coronary Syndrome (ACS)

  • Definition: Acute Coronary Syndrome (ACS) refers to a range of conditions associated with sudden, reduced blood flow to the heart.

  • Blood Supply: The heart muscle requires a continuous blood supply to function. Blockage can lead to:

    • Angina: Chest pain due to reduced blood flow.

    • Myocardial Infarction (MI): More severe, often referred to as a heart attack.

Types of Myocardial Infarction

  • Unstable Angina

  • ST-Elevation Myocardial Infarction (STEMI): Complete blockage of a coronary artery. Characterized by significant elevation in ST segments on EKG.

  • Non-ST-Elevation Myocardial Infarction (NSTEMI): Partial blockage. May show inverted T waves on EKG.

Diagnostic Procedures and Assessments

  • Priorities:

    • 12-lead EKG: Essential for diagnosing types of ACS.

    • Lab Tests:

    • Troponin I: Cardiac enzyme released during heart muscle injury; evaluated after 24 hours of pain onset.

    • Creatine Kinase (CK): Another enzyme that may indicate myocardial damage.

  • Procedure:

    • Angiography: Assessed for blockage; may place a stent during the procedure.

Postoperative Care

  • Positioning: Patient remains supine with extremities straightened to prevent bleeding.

  • Monitoring:

    • Bleeding Assessment: Check the site of intervention for bleeding.

    • Neurological Assessment: Monitor for signs of stroke or neurological deficits.

    • Kidney Function: Monitor labs due to nephrotoxic potential of contrast media used in angiography.

    • Oxygen Administration: Important for patient recovery post-ACS.

    • Nitroglycerin:

    • Commonly used for chest pain relief; headaches are a common side effect.

Pharmacological Management

  • Medications:

    • Aspirin: An antiplatelet agent to reduce clot formation.

    • Morphine: Analgesic used for pain management.

    • Heparin: Anticoagulant given in cases of unstable angina and NSTEMI.

    • Dual Antiplatelet Therapy (DAPT): Given for STEMI management.

  • STEMI Treatment:

    • Percutaneous Coronary Intervention (PCI): Surgical procedure to open blocked arteries.

    • Thrombolytics: Medications used to dissolve blood clots.

Monitoring for Complications

  • Dysrhythmia Monitoring:

    • Monitor for premature ventricular contractions (PVC) and ventricular fibrillation (VFIB).

    • Notify healthcare provider of any ST segment changes.

Nitroglycerin Administration

  • Administration Technique:

    • Avoid light exposure as it is photosensitive.

    • Can be delivered via patch, sublingual tablets or intravenous infusion.

    • Should maintain a dosing schedule of 10-12 hours on/off.

    • Important to rotate application sites and clip hair if needed to enhance absorption.

  • Contraindications: Avoid administering with erectile dysfunction medications to prevent severe hypotension.

  • Dosing Instructions:

    • If angina persists after the first tablet, a second dose may be taken after 5 minutes. If pain continues, dial 911.

Other Supportive Measures

  • Analgesics: Morphine used for severe pain control.

  • Beta-Blockers (BB): Important for heart rate and blood pressure control.

  • Monitoring for Hypoglycemia: If patient has diabetes, offer food and hold medication for 4 hours post-administration. 60.

Thrombolytic Therapy

  • Indications:

    • Used primarily for STEMI patients to dissolve clots and restore blood flow.

  • Monitoring: Check prothrombin time (PT) and activated partial thromboplastin time (aPTT) to assess bleeding risk.

Anticoagulation Therapy

  • Heparin and Enoxaparin:

    • Assess aPTT levels during treatment.

  • Administration: Always inject with an air bubble to ensure proper positioning of the medication.

  • Antidote: Protamine sulfate is used for heparin overdose.

Statin Therapy

  • Purpose: Control elevated low-density lipoprotein (LDL) levels to manage cholesterol secretions.

  • Monitoring:

    • Liver enzyme levels to assess liver function during statin therapy.

  • Dietary Recommendations: Use stool softener like Colace to minimize constipation effects.

Heart Failure Classification

  • Differentiation: Distinguish between Left-Sided HF and Right-Sided HF

    • Left-Sided Heart Failure:

    • Often manifests with lung issues, leading to symptoms like pink frothy sputum and crackles in the lungs.

    • Altered level of consciousness (ALOC) may occur.

    • Right-Sided Heart Failure:

    • Monitor for symptoms like increased B-type natriuretic peptide (BNP). Report a weight gain of 2 lbs within a day or 5-7 lbs in a week as it indicates fluid retention.

Dysrhythmias and Their Management

  • Lethal Dysrhythmias:

    • PACs vs. PVCs: Understand the differences in precursors of atrial and ventricular ectopic beats.

    • Shockable vs. Non-Shockable Rhythms: Identify rhythms such as Pulseless Electrical Activity (PEA) and Torsades de Pointes (Torsade), and those suitable for defibrillation.

    • Administration of Amiodarone: For stable ventricular tachycardia.

    • Adenosine: Used for supraventricular tachycardia (SVT) treatments.

Aneurysms and Their Management

  • Definition: An aneurysm is a localized dilation of an artery, leading to a risk of rupture and bleeding.

  • Risk Factors:

    • Male gender, atherosclerosis, smoking, and hypertension (HTN).

  • Abdominal Aortic Aneurysm:

    • Symptoms include constant gnawing abdominal pain and pulsating visual abdominal mass.

  • Diagnosis: Use of ultrasound (US), MRI, or CT scans to assess the aneurysm.

  • Management:

    • Control Blood Pressure: Important to mitigate the risk of rupture.

    • Do Not Palpate: Can lead to hypovolemic shock if it ruptures.

  • Rupture Symptoms: Sudden severe constant pain in the back, flank, or abdominal area, potential for syncope and presence of bruit on examination.

  • Goal of Management: Prevent rupture; in small aneurysms, conservative management may be utilized. Surgical intervention is typically indicated if the aneurysm is larger than 5.5 cm.

Surgical Interventions

  • Endovascular Stent Graft:

    • Less invasive approach through the femoral artery.

  • Complications: Include potential rupture necessitating resuscitation and possible surgical intervention.

  • Delayed Management Post-Rupture: A thrombus may dislodge and cause ischemia, requiring assessment of circulation distal to the aneurysm.

Aortic Dissection

  • Definition: An urgent condition where there is a tear between the layers of the aorta leading to significant morbidity and mortality.

  • Symptoms: Described as a tearing or stabbing pain; can lead to hypotension and shock.

  • Risk Factors: Include hypertension and atherosclerosis; both types A (ascending aorta) and B (descending aorta) conditions exist.

  • Management:

    • Administration of intravenous medication such as beta-blockers or morphine for pain control, and surgical treatment may be indicated.

    • Controlled heart rate and blood pressure are critical post-surgery to reduce stress on the aorta.

  • Environment: Ensure a quiet environment for recovery, emphasizing medication compliance post-intervention.