Bunch of Heart StuffBunch of Heart Stuff

Chemeketa Community CollegeEMT-Paramedic Program

ObjectivesObjectives

Left Ventricular FailureRight Ventricular FailurePulmonary EdemaCor PulmonaleAcute Pulmonary EmbolismEKG’s

Left Ventricular FailureLeft Ventricular Failure Affects over 2% of US pop. Disproportionate # of EMS calls #1 Dx of inpatients >65 Incidence of CHF doubles per

decade of life Mortality Rate with CHF

8 times for men5 times for women

Left Ventricular FailureLeft Ventricular Failure

The failure of the LV to effectively pump forward

Synonymous with CHF Acute CHF

Rapid Chronic CHF

SlowMidnight Shoppers

LVFLVF

Common CausesSystemic HTN– Afterload

Coronary Artery Disease– Arteriosclerosis/Atherosclerosis

Ischemia– Local/temporary occlusion

LVFLVF

Common CausesInfarction– Permanent, necrosis

Cardiomyopathy– Diseased heart muscle

tissueETOHEnlargement

LVFLVF

Causes

Volume overload– Bag of Potato Chips

Severe anemia– Hypoxemia

LVF LVF

Fluid will collect in LASmall & Relatively incapable

Pulmonary Vasculature FillsPulmonary Congestion Occurs

Pulmonary Edema 2nd to LVF

LVF S/SLVF S/S Generalized

Weakness Fatigue Chest Pain

May be masked by respiratory complaint

Anxiety Dyspnea

LVF S/SLVF S/S

TachypneaOrthopneaParoxysmal Nocturnal Dyspnea

Elevation of pulmonary venous & cap pressuresWakening from sleep

Decrease in exercise tolerance

LVF S/SLVF S/S

Rales Wheezes

Reflex Airway SpasmCardiac Asthma

Rhonchi (Larger airway) Dull percussion at lung bases

Edema in LungsEdema in Lungs

LVF S/SLVF S/S

Productive CoughFoamy-Blood-tinged sputum

CyanosisB/P

Initial HTN

LVF S/SLVF S/S

PulseRapidPossible Dysrhythmia– Location of infarct

Diaphoresis

Right Ventricular FailureRight Ventricular Failure

Causes#1 Cause of RVF is LVFStenosis:– Pulmonary valve– Mitral Valve

Pulmonary Vascular HTNRV AMI

RVF – Who CaresRVF – Who Cares

Inability of RV to pump forward

Overwhelmed by venous return

Backflow in systemic circulation

RVF – S/SRVF – S/S Tachycardia Venous Congestion Engorged Liver, spleen JVD Peripheral Edema

Dependent EdemaPitting EdemaSacral (Bedridden)

RVF-S/SRVF-S/S Ascites

Accumulation of serous fluid in peritoneal cavity – Taber’s 19th

Pleural Effusion Peripheral Cyanosis Tachy if isolated RVF Right sided hypertrophy

X-ray

RVF – S/SRVF – S/S

Clubbing of fingersDx: Chronic Hypoxia with RHF

Most of the other LVF S/S also CP SOB Tachypnea Anxiety Etc…

Cor PulmonaleCor Pulmonale

Cause of RVF

Pulmonary Parenchymal or vascular disease

CP is a disease process

Case Scenario Explanation

Cor Pulmonale – CaseCor Pulmonale – Case

58 yo maleHx of Chronic bronchitis or emphysema

Typical S/S of bronchitisProgression

Deterioration of Pulmonary capillariesAlveolar FibrosisChronic Hypoxemia

Cor Pulmonale – Case Cor Pulmonale – Case

Progression caused:Increase in pulmonary artery pressures

Result RV afterload increase– RV ill equipped

RV Enlarges (Hypertrophy)

Chronic RH HTN leads to RVF

Cor Pulmonale – Case Cor Pulmonale – Case

Patient displays all signs of:RVF

Initial causative pulmonary conditionVoila’

Treatment of RVF & LVFTreatment of RVF & LVF

CHF a circumstance not a DxTreatment objectives

Decrease myocardial:– Workload– Oxygen demand

Increase force & efficiency of contractionReduce fluid retention

TxTx

Decrease WorkloadNo Physical activitySitting uprightOxygen– Pt may tolerate BVM

Morphine

TxTx

Vasodilatory Therapy (Nitrates)– AMI reperfusion– Container expansion reduces preload

Increase ContractilityShock algorithm directs– Dopamine– Dobutamine– Norepinephrine

TxTx

Reduce Fluid RetentionDiuretics– Lasix– Bumex

Acute Pulmonary EmbolismAcute Pulmonary Embolism

Chemeketa Community CollegeParamedic Program

Acute Pulmonary EmbolismAcute Pulmonary Embolism

Acute Pulmonary EmbolismAcute Pulmonary Embolism

DefinedDefined

Blood clot lodged in pulmonary artery

Blocks pulmonary artery flow

Supplied area ceases to function

Decreased gas exchange

V/Q mismatch

DefinedDefined

Typically forms in deep veins of thighs

Can also be fat or air

HistoryHistory

Anticoagulation therapyHeparin – 1930s

Streptokinase – 1930

Urokinase – 1951

1960s – Large study of clot resolution

Recently TPA

IncidenceIncidence

Unknown, range from

50,000-100,000/yr

Higher than diagnosed, most

diagnosed postmortem

8% death rate with heparin tx

1/3 will die within 1 hour

Risk FactorsRisk Factors

Deep vein thrombosis

Prolonged immobilization

Surgery

Trauma

Pelvic or femur fractures

Late pregnancy

Risk FactorsRisk Factors

Thrombophlebitis

Certain meds

Oral contraceptives

Atrial fibrillation

Smoking

Unknown

Increasing FrequencyIncreasing Frequency

Older population

Malignancies

More sedentary

Heart failure

COPD

Surgical procedures

PresentationPresentationVariable and Non-specific

DyspneaPleuritic chest painSyncopeHemoptysisRHFTachycardia

PresentationPresentation

No physical findings significantly accurateDeep venous thrombosis in proximal lower

ext. helpful for DxOnly about ½ source known

Why doesn’t lung tissue die from emboli like heart muscle?

Why doesn’t lung tissue die from emboli like heart muscle?

Lung has two blood supplies

Pulmonary and Bronchial

Share capillary beds

Pre-hospital TreatmentPre-hospital Treatment

Good Physical Exam and History

Index of suspicion

Airway

High flow O2

IV

Rapid Transport

Treatment ???Treatment ???

Heparin Thrombolytic agents

StreptokinaseTPA

Catheter fragmentation Catheter embolectomy Open-chest embolectomy

Definitive DiagnosisDefinitive Diagnosis

????AngiographicV/Q scan (venous/perfusion mismatch)

OperativeMultiple sources of evidence

Differential DiagnosisDifferential Diagnosis Pneumonia Herpes Zoster Pleurisy COPD Rib fracture Asthma Angina MI Pneumothorax Pancreatitis Hepatitis Salicylate OD

Bronchitis Hyperventilation Lung carcinoma Sepsis TB Muscle pain Costochondritis CA Pericarditis CHF Percardial tamponade

Watch OutWatch Out

Extraordinarily difficult to diagnose

Watch out for hyperventilation

Young women

Group Projects!Group Projects!

Work in Pairs and find the answers

List As Many Drugs As You Can That Will Dilate Blood Vessels.

List As Many Drugs As You Can That Will Dilate Blood Vessels.

Name the source

Describe why they

work

List Drugs That Cause Tachycardias.List Drugs That Cause Tachycardias.Describe why they cause increase rate change

List Drugs that cause Bradycardias.List Drugs that cause Bradycardias.

Why do they cause them?

List Drugs that cause Hypertension.List Drugs that cause Hypertension.

How do they do it?

Your patient has a heart rate of 140

bpm. What could be his problem? Your patient has a heart rate of 140

bpm. What could be his problem?