HIGHqACUITYqEXAMqONE
EKGqSTRIPSq
⎯ SINUSqBRADYCARDIAq
▪ Sinusqrhythmqwithqrateq<q60qbpm
▪ Treatment→qAtropineq
⎯ SINUSqTACHYCARDIAq
▪ Sinusqrhythmqwithqrateq>100qbpmq
▪ Treatment
➢ Treatqtheqcauseq
➢ Betaqblockers—slowsqdownqtheqHR
➢ CCB—blocksqtheqcalciumqenteringqtheqheartqmuscleq
➢ Worstqcase→qcardioversionq
⎯ ATRIALqFIBRILLATION
▪ Multipleqimpulsesqwithinqtheqatria.q*Riskqforqstrokes*
▪ Treatment
➢ Rateqcontrol—Digoxin,qbetaqblockers,qcalciumqchannelqblockers
➢ Antiarrhythmicqmeds—Amiodaroneq
➢ Cardiacqablationq
➢ Cardioversionq
⎯ ATRIALqFLUTTER
▪ AtrialqrhythmqproducedqoutsideqofqSAqnodeq
▪ Treatmentq
➢ Rateqcontrol—Betaqblockers,qCCB,qDigoxinq
➢ Antiarrhythmicq
➢ Cardioversionq
⎯ VENTRICULARqTACHYCARDIAq
▪ ThreeqorqmoreqPVCsqinqaqrow.qLife-
threateningqdysrhythmiaqasqaqresultqofqtheqsignificantqreductionqinqCOqthatqcanqoccurq
▪ Treatmentq
➢ NOqPULSE→qCallqcode,qstartqCPRqandqdefibrillate,qMedsq(Amiodarone)
➢ PULSE→qNotifyqHCP,qcheckqBPq(ifqlowqstartqcardioversion)
➢ Amiodarone,qlidocaine,qprocainamideq
1
,⎯ VENTRICULARqFIBRILLATIONq
▪ Lethalqdysrhythmiaqrequiringqimmediateqtreatmentq
▪ Treatment→qchestqcompressions,qdefibrillationq
⎯ ASYSTOLE
▪ Noqmeasurableqelectricalqactivityqfromqtheqheartq
▪ Treatment
➢ CPR,qEpinephrineq(stimulatesqelectricalqactivity),qTreatqtheqcause!q*Noqdefibqifqnoqactivityqinqtheqheart*
⎯ PACEMAKER
▪ Thereqwillqbeqaqspikeqinqtheqstripq
⎯ REVIEWqMEDS
▪ Procainamideq(Pronestyl)-
qClassq1aqAntidysrhythmicqdrug,qhelpsqtoqregulateqtheqheartqrhythmqafterqaqdisorderqoccursqinqtheqventricles.qq
Usedqtoqtreatqlife-threateningqventricularqarrhythmias.q
▪ Amiodaroneq(Cordarone)-qClassq3qAntiarrhythmicqdrug,qusedqtoqtreatqventricularqtachycardia/qfibrillations.
▪ Epinephrineq(Auvi-Q)-
qusedqtoqtreatqveryqseriousqallergicqreactions;qforqcardiacqitqincreasesqheartqrateqandqmyocardialqcontractility.q
Usedqwithqasystoleqarrhythmias
▪ Adenosineq(Adenocard):qrelaxesqandqdilatesqtheqbloodqvessel,qusedqonqptqwithqSVTqdysrhythmias
▪ Lidocaineq(Lidamantle):qlocalqanestheticqthatqnumbsqtheqsensationsqofqtissuesqresultingqinqaqvasodilationqeffec
t.qusedqonqptsqwithqventricularqarrhythmiasq
▪ Atropineq(Atropen)-qincreasesqheartqrate.qUsedqforqbradycardia
⎯ MEDICATIONqFORqHEARTqFAILUREqPTS
▪ Diuretics
➢ Thiazide-qHCTZ
➢ Loop-Furosemideq(laxis)
▪ Antihypertensiveqmeds
➢ BetaqBlockers-qAtenolol,qPropranolol,qMetoprolol
➢ ACEqinhibitors-qCaptopril,qLisinopril,qEnalapril
➢ CalciumqChannelqBlockers-qDiltiazem,qNifedipine,qVerapamil.qAmlodipine
➢ ARBs-qLosartanqandqValsartan
▪ Dietaryqsupplement
➢ Avoidqsaltqandqhighqfatqdiet,q1500mgqofqsaltsq(2,000-3,000mg)qperqday
▪ Vasodilator
2
, ➢ Hydralazineqrelaxesqtheqbloodqvesselsqtoqallowqbloodqtoqflowqeasily.
▪ Antianginalq
▪ Nitroglycerin,qAmiodarone,qDiltiazem,qVerapamil.
WARFARINqTHERAPEUTICqLEVELqANDqLABqVALUESq
▪ PT:q10-13qsec
▪ INR:q2-3qsec
⎯ VENTRICULARqHYPERTROPHYqHISTORYqANDqASSESSMENTS
▪ AsymmetricqLt.qventricularqhypertrophyqwithoutqdilationqwithqenlargementqofqseptumqandqobstructionqofqblo
odqflowqinqLt.qventriclesq
➢ Fillingqisqimpairedq
➢ Ventricleqisqstiff,qnoncompliant,qunableqtoqrelax,qresultingqinqdecreasedqCOqespeciallyqduringqexertionq
▪ S/S
➢ Exertionalqdyspneaq(mostqcommon),qfatigue,qangina,qsyncope,qdysrhythmiasqsuchqasqsupraventricularqtac
hycardiaq(SVT),qatrialqfibrillation,qV-TachqandqV-Fibqleadingqtoqunconsciousnessqandqdeath
▪ Administerqmedication
➢ BetaqBlockersqfirst-line,qthenqVerapamilq(CCB,qnegqinotrope)
➢ **Digoxinqisqcontraindicated**
⎯ COMPLICATIONqOFqMI
▪ Dysrhythmiasq
▪ HeartqFailureq
▪ Thromboemboliq
▪ Cardiogenicqshock
▪ Ventricularqaneurysmq
▪ Papillaryqmuscleqdysfuntionq
▪ Acuteqpericarditisq
▪ Dresslerqsyndromeq
⎯ LABSqANDqVALUESqFORqCONGESTIVEqHFqPTq(BNP)
▪ BrainqNatriureticqPeptideq(<100qpg/mL)qlessqthanq
80*
▪ Releasedqfromqoverstretchqventricularqtissueq
▪ ElevationqindicatesqHFq
⎯ LABqANDqDIAGNOSTICqPROCEDUREqTOqDETECTqMIq
▪ Laboratoryqtests—biomarkersq
➢ CK-MB
➢ TroponinqTqorqI—
TroponinqisqtheqmostqspecificqcardiacqmarkerqforqINJURY.qIfqMIqisqbeingqruledqout,qCardiacqEnzymesq(CK,qCK
-MB,qandqTroponin)qwillqbeqorderedqQ6qhoursqxq3,qthenqdailyqifqnecessary.q
➢ NormalqTroponinqTq<q0.1ng/ml
➢ NormalqTroponinqIq<q0.4ng/ml
3
, ⎯ DIFFERENTqTYPESqOFqANGINASqSTABLEqVSqUNSTABLE
▪ Anginaqpectoris—
characterizedqbyqepisodesqorqparoxysmalqpainqorqpressureqinqtheqanteriorqchestqcausedqbyqinsufficientqcorona
ryqbloodqflowq
▪ Stable→qchestqpainqorqdiscomfortqthatqisqassociatedqwithqphysicalqactivity
▪ Unstable→qincreasedqfrequencyqandqseverityqandqisqnotqrelivedqbyqrestqandqNTG.q**Requiresqmedicalqinterve
ntion**
⎯ INTERVENTIONSqFORqPTqWITHqRIGHTqCONGESTIVEqHF
▪ Right-
sidedqheartqfailureqcanqalsoqresultqfromqpulmonaryqdiseaseq(corqpulmonale)qandqprimaryqpulmonaryqarteryqhy
pertension.q
▪ Pulmonaryqembolusqisqaqcommonqcauseqofqacuteqright-sidedqHF
▪ Management:
➢ Fluidqrestrictionqandqdiureticsq
➢ Meds—Digoxin,qCCB,qACEqinhibitor,qBetaqblockersq
⎯ BYPASSqSURGERYqNURSINGqINTERVENTIONq
▪ CoronaryqArteryqBypassqGraftq(CARG)—blockedqcoronaryqarteryqbypassedqutilizingqveinqfromqlegqorqnon-
essentialqarteryq
▪ Post-opqcare
➢ SpecializedqcareqrequiredqinqCVICUq
➢ Usuallyqintubatedqforqfirstqfewqhours
➢ Willqhaveqbetweenq1qandq4qchestqtubes,qatqleastqoneqwillqbeqmediastinalq
➢ Epicardialqpacingqwiresqinqcaseqofqdysrhythmiasq
➢ Mayqrequireqcombinationqofqvasoactiveqdripsqtoqstabilizeqconditionq(Dopamine,qPrimacor,qLevophed,qNTG
)
➢ Specializedqmonitoringqlines—PAqcatheter,qarterialqline
⎯ EKGqREADINGqANDqTIMEqFRAMEqFROMqALLqSEGMENTSq
▪ Oneqsmallqbox=0.04qsec,qOneqbigqbox=q0.20qsecq
▪ PRqinterval:q0.12qsecq(threeqsmallqboxes)qtoq0.20qsecq(fiveqsmallqboxes)qinqlength.
▪ QRSqinterval:q0.06qtoq0.10qsecqinqlength
▪ QTqinterval:qlessqthanqorqequalqtoq0.52qsecqinqlength.
⎯ PROTOCOLqFORqPTqWITHqCHESTqPAINqANDqNITRO
▪ Alwaysqcarryqnitroglycerinqwithqyouqforqimmediate.qIfqtheqchestqpainqoccursqwithqactivity→qstopqtheqactivityq
▪ Forqreliefqchestqpain→qplaceqNTGqunderqtheqtongueq&qwaitq5qminutes,qifqpainqisqnotqrelievedqtakeqtheq2ndqpillq&
rd
qwaitqanotherq5qminutes.qSupposedqtheqpainqisqstillqnotqreliefqcallq911qbeforeqtakingqtheq3 qpill
q
⎯ MIqSYMPTOMSqANDqNURSINGqINTERVENTIONS,qtPAqTREATMENTq&qNITROqASSESSMENTqANDqINTERVENTIONS
4
EKGqSTRIPSq
⎯ SINUSqBRADYCARDIAq
▪ Sinusqrhythmqwithqrateq<q60qbpm
▪ Treatment→qAtropineq
⎯ SINUSqTACHYCARDIAq
▪ Sinusqrhythmqwithqrateq>100qbpmq
▪ Treatment
➢ Treatqtheqcauseq
➢ Betaqblockers—slowsqdownqtheqHR
➢ CCB—blocksqtheqcalciumqenteringqtheqheartqmuscleq
➢ Worstqcase→qcardioversionq
⎯ ATRIALqFIBRILLATION
▪ Multipleqimpulsesqwithinqtheqatria.q*Riskqforqstrokes*
▪ Treatment
➢ Rateqcontrol—Digoxin,qbetaqblockers,qcalciumqchannelqblockers
➢ Antiarrhythmicqmeds—Amiodaroneq
➢ Cardiacqablationq
➢ Cardioversionq
⎯ ATRIALqFLUTTER
▪ AtrialqrhythmqproducedqoutsideqofqSAqnodeq
▪ Treatmentq
➢ Rateqcontrol—Betaqblockers,qCCB,qDigoxinq
➢ Antiarrhythmicq
➢ Cardioversionq
⎯ VENTRICULARqTACHYCARDIAq
▪ ThreeqorqmoreqPVCsqinqaqrow.qLife-
threateningqdysrhythmiaqasqaqresultqofqtheqsignificantqreductionqinqCOqthatqcanqoccurq
▪ Treatmentq
➢ NOqPULSE→qCallqcode,qstartqCPRqandqdefibrillate,qMedsq(Amiodarone)
➢ PULSE→qNotifyqHCP,qcheckqBPq(ifqlowqstartqcardioversion)
➢ Amiodarone,qlidocaine,qprocainamideq
1
,⎯ VENTRICULARqFIBRILLATIONq
▪ Lethalqdysrhythmiaqrequiringqimmediateqtreatmentq
▪ Treatment→qchestqcompressions,qdefibrillationq
⎯ ASYSTOLE
▪ Noqmeasurableqelectricalqactivityqfromqtheqheartq
▪ Treatment
➢ CPR,qEpinephrineq(stimulatesqelectricalqactivity),qTreatqtheqcause!q*Noqdefibqifqnoqactivityqinqtheqheart*
⎯ PACEMAKER
▪ Thereqwillqbeqaqspikeqinqtheqstripq
⎯ REVIEWqMEDS
▪ Procainamideq(Pronestyl)-
qClassq1aqAntidysrhythmicqdrug,qhelpsqtoqregulateqtheqheartqrhythmqafterqaqdisorderqoccursqinqtheqventricles.qq
Usedqtoqtreatqlife-threateningqventricularqarrhythmias.q
▪ Amiodaroneq(Cordarone)-qClassq3qAntiarrhythmicqdrug,qusedqtoqtreatqventricularqtachycardia/qfibrillations.
▪ Epinephrineq(Auvi-Q)-
qusedqtoqtreatqveryqseriousqallergicqreactions;qforqcardiacqitqincreasesqheartqrateqandqmyocardialqcontractility.q
Usedqwithqasystoleqarrhythmias
▪ Adenosineq(Adenocard):qrelaxesqandqdilatesqtheqbloodqvessel,qusedqonqptqwithqSVTqdysrhythmias
▪ Lidocaineq(Lidamantle):qlocalqanestheticqthatqnumbsqtheqsensationsqofqtissuesqresultingqinqaqvasodilationqeffec
t.qusedqonqptsqwithqventricularqarrhythmiasq
▪ Atropineq(Atropen)-qincreasesqheartqrate.qUsedqforqbradycardia
⎯ MEDICATIONqFORqHEARTqFAILUREqPTS
▪ Diuretics
➢ Thiazide-qHCTZ
➢ Loop-Furosemideq(laxis)
▪ Antihypertensiveqmeds
➢ BetaqBlockers-qAtenolol,qPropranolol,qMetoprolol
➢ ACEqinhibitors-qCaptopril,qLisinopril,qEnalapril
➢ CalciumqChannelqBlockers-qDiltiazem,qNifedipine,qVerapamil.qAmlodipine
➢ ARBs-qLosartanqandqValsartan
▪ Dietaryqsupplement
➢ Avoidqsaltqandqhighqfatqdiet,q1500mgqofqsaltsq(2,000-3,000mg)qperqday
▪ Vasodilator
2
, ➢ Hydralazineqrelaxesqtheqbloodqvesselsqtoqallowqbloodqtoqflowqeasily.
▪ Antianginalq
▪ Nitroglycerin,qAmiodarone,qDiltiazem,qVerapamil.
WARFARINqTHERAPEUTICqLEVELqANDqLABqVALUESq
▪ PT:q10-13qsec
▪ INR:q2-3qsec
⎯ VENTRICULARqHYPERTROPHYqHISTORYqANDqASSESSMENTS
▪ AsymmetricqLt.qventricularqhypertrophyqwithoutqdilationqwithqenlargementqofqseptumqandqobstructionqofqblo
odqflowqinqLt.qventriclesq
➢ Fillingqisqimpairedq
➢ Ventricleqisqstiff,qnoncompliant,qunableqtoqrelax,qresultingqinqdecreasedqCOqespeciallyqduringqexertionq
▪ S/S
➢ Exertionalqdyspneaq(mostqcommon),qfatigue,qangina,qsyncope,qdysrhythmiasqsuchqasqsupraventricularqtac
hycardiaq(SVT),qatrialqfibrillation,qV-TachqandqV-Fibqleadingqtoqunconsciousnessqandqdeath
▪ Administerqmedication
➢ BetaqBlockersqfirst-line,qthenqVerapamilq(CCB,qnegqinotrope)
➢ **Digoxinqisqcontraindicated**
⎯ COMPLICATIONqOFqMI
▪ Dysrhythmiasq
▪ HeartqFailureq
▪ Thromboemboliq
▪ Cardiogenicqshock
▪ Ventricularqaneurysmq
▪ Papillaryqmuscleqdysfuntionq
▪ Acuteqpericarditisq
▪ Dresslerqsyndromeq
⎯ LABSqANDqVALUESqFORqCONGESTIVEqHFqPTq(BNP)
▪ BrainqNatriureticqPeptideq(<100qpg/mL)qlessqthanq
80*
▪ Releasedqfromqoverstretchqventricularqtissueq
▪ ElevationqindicatesqHFq
⎯ LABqANDqDIAGNOSTICqPROCEDUREqTOqDETECTqMIq
▪ Laboratoryqtests—biomarkersq
➢ CK-MB
➢ TroponinqTqorqI—
TroponinqisqtheqmostqspecificqcardiacqmarkerqforqINJURY.qIfqMIqisqbeingqruledqout,qCardiacqEnzymesq(CK,qCK
-MB,qandqTroponin)qwillqbeqorderedqQ6qhoursqxq3,qthenqdailyqifqnecessary.q
➢ NormalqTroponinqTq<q0.1ng/ml
➢ NormalqTroponinqIq<q0.4ng/ml
3
, ⎯ DIFFERENTqTYPESqOFqANGINASqSTABLEqVSqUNSTABLE
▪ Anginaqpectoris—
characterizedqbyqepisodesqorqparoxysmalqpainqorqpressureqinqtheqanteriorqchestqcausedqbyqinsufficientqcorona
ryqbloodqflowq
▪ Stable→qchestqpainqorqdiscomfortqthatqisqassociatedqwithqphysicalqactivity
▪ Unstable→qincreasedqfrequencyqandqseverityqandqisqnotqrelivedqbyqrestqandqNTG.q**Requiresqmedicalqinterve
ntion**
⎯ INTERVENTIONSqFORqPTqWITHqRIGHTqCONGESTIVEqHF
▪ Right-
sidedqheartqfailureqcanqalsoqresultqfromqpulmonaryqdiseaseq(corqpulmonale)qandqprimaryqpulmonaryqarteryqhy
pertension.q
▪ Pulmonaryqembolusqisqaqcommonqcauseqofqacuteqright-sidedqHF
▪ Management:
➢ Fluidqrestrictionqandqdiureticsq
➢ Meds—Digoxin,qCCB,qACEqinhibitor,qBetaqblockersq
⎯ BYPASSqSURGERYqNURSINGqINTERVENTIONq
▪ CoronaryqArteryqBypassqGraftq(CARG)—blockedqcoronaryqarteryqbypassedqutilizingqveinqfromqlegqorqnon-
essentialqarteryq
▪ Post-opqcare
➢ SpecializedqcareqrequiredqinqCVICUq
➢ Usuallyqintubatedqforqfirstqfewqhours
➢ Willqhaveqbetweenq1qandq4qchestqtubes,qatqleastqoneqwillqbeqmediastinalq
➢ Epicardialqpacingqwiresqinqcaseqofqdysrhythmiasq
➢ Mayqrequireqcombinationqofqvasoactiveqdripsqtoqstabilizeqconditionq(Dopamine,qPrimacor,qLevophed,qNTG
)
➢ Specializedqmonitoringqlines—PAqcatheter,qarterialqline
⎯ EKGqREADINGqANDqTIMEqFRAMEqFROMqALLqSEGMENTSq
▪ Oneqsmallqbox=0.04qsec,qOneqbigqbox=q0.20qsecq
▪ PRqinterval:q0.12qsecq(threeqsmallqboxes)qtoq0.20qsecq(fiveqsmallqboxes)qinqlength.
▪ QRSqinterval:q0.06qtoq0.10qsecqinqlength
▪ QTqinterval:qlessqthanqorqequalqtoq0.52qsecqinqlength.
⎯ PROTOCOLqFORqPTqWITHqCHESTqPAINqANDqNITRO
▪ Alwaysqcarryqnitroglycerinqwithqyouqforqimmediate.qIfqtheqchestqpainqoccursqwithqactivity→qstopqtheqactivityq
▪ Forqreliefqchestqpain→qplaceqNTGqunderqtheqtongueq&qwaitq5qminutes,qifqpainqisqnotqrelievedqtakeqtheq2ndqpillq&
rd
qwaitqanotherq5qminutes.qSupposedqtheqpainqisqstillqnotqreliefqcallq911qbeforeqtakingqtheq3 qpill
q
⎯ MIqSYMPTOMSqANDqNURSINGqINTERVENTIONS,qtPAqTREATMENTq&qNITROqASSESSMENTqANDqINTERVENTIONS
4
