MEDICAL-SURGICAL - AV valves ( atrioventricular valves ) “Atria” Conduction System
Layer of the Heart: o 1 way flow of blood - SA node ( sinoatrial node ) main pacemaker
- Endocardium ( inner ) - facilitates blood flow, Tricuspids ( right atria ) of the heart : 60 – 100bpm
contains valve & chambers Bicuspids/ Mitral ( left - AV node ( atrioventricular node ) 2nd
- Myocardium ( middle ) - contracting muscle, atria ) pacemaker of the heart : 40 – 60bpm
cardiac muscle - SL valves ( semilunar valves ) - Bachmann’s node ( node in the left atrium )
- Pericardium ( outer ) Pulmonary SL valve
o Layer of Pericardium Aortic SL valve SA node Intranodal tract AV node
Visceral ( epicardium ) Ventricle contract : Semi Lunar valve open
Pericardial ( 5-20cc of - ( AV valve closed )
fluid ) serves as cushion, Ventricle relax : Semi Lunar valve closed ( blood filling ) Bundle of HIS Bundle branches
lubricant - ( Av valve open ) Right Purkinje
Parietal Left Purkinje
Pericardial
Coronary Artery
cavity Cardiac Cycle
- Two main phase
o Systole : contraction / ejection
Fibrous layer
o Diastole : relaxation / refill
Myocardium Difference between
Parietal Systolic & Diastolic is
(pericardium) Endocardium
the PULSE PRESSURE
( PP: 30 – 40cpm ) narrowed pulse – hypovolemia
Visceral ( PP: 60cpm ) wided pulse – increased in Stroke volume
(epicardium)
Cardiac Output
- Amount of blood pump by the heart
Circulation: particularly by the left ventricle per minute
from to Stroke Volume (SV) – amount of blood pump by the
right Vena Lungs deoxygenated Pulmonary heart in every beat
cava circulation - Branch out from ascending aorta SV = amt (ml)
left Pulmo- System oxygenated Systemic Right Coronary Artery – supplying the Right Beat
nary circulation Atrium / Right Ventricle / inferior portion of Left - Contractility : ( Inotropic ) ability of cardiac
veins Ventricle muscle to contract
Left Coronary Artery - Preload : amount of the blood from the
Valves & Chambers: o Circumflex – supplying the Left ventricle after the end of diastolic phase
Atrium / posterior portion of Left (Frank Staring Law : the greater the stretch,
Ventricle the better the pump)
o Left Anterior Descending Artery o Venous returns
(LADA) – supplying the Left o Regurgitation of the blood
Ventricle /Apex - Afterload : resistance of LV must surpass as
the heart pump blood to the circulation
Electrophysiologic Properties o Systemic resistance ( HPN )
A – utomacity – o Blood viscosity ( DM. polycythemia
C – ontractility – transmit impulse vera, multiple myeloma )
C – onductivity – contraction Heart Rate ( HR ) – number of heart beat per minute
E – xcitability – respond to stimuli HR = Beats
R – efractiones – ability to finish a response Minute
before initiating another response.
,Formula: Cardiac Output - Deflection : raise & falls of line ( wave ) Before:
CO = amt (ml) X Beats - Wave : line deviated from isoelectric line - Assess for allergy ( seafoods : iodine/contrast
Beat Minute ( P wave ) dye )
- Complex : group of continuous waves - Assess for bleeding parameters
HEART RATE & STROKE VOLUME REGULATOR ( QRS complex ) - Assess for kidney function
Autonomic Response - Segment : isoelectric line between waves - Administer pre medication as ordered
- Symphatetic Nervous System ( SNS ) ( ST segment ) - Patient usually sedated ( valium )
( Fight or Flight Response ) - Interval : wave + segment ( PR interval ) After:
o Norepinephrine (adrenal gland) P wave – atrial depolarization - CBR / monitor V/S
kidney PR segment – conduction delay from SA node – AV - Prevent bleeding
o Dilated pupils(compensate) node - Immobilized affected extremities
Mydriatic QRS complex – ventricular depolarization - Do circulation assessment
o Constricted blood vessel ST segment – early ventricular repolarization
o Increased SV/HR PR – atrial depolarization + conduction delay of Angiography / Arteriography
- Parasymphathetic Nervous System ( PNS ) SA node – AV node - is a test that uses an injection of a liquid dye
o Rest & Digest Response T wave – ventricular repolarization to make the arteries easily visible on X-rays
- Baroceptors U wave – unknown Laboratories ( cardiovascular function )
3
o Pressure detectors ( common Blood component Normal value ( mm )
carotid, right atrium, aortic arc ) Electrode Placement RBC 4-6 million
- Chemoreceptors Right arm – white / Right leg - green WBC ( leukocytes ) 4,5000-11,000
o Chemical detectors ( O2, CO2, pH ) Left arm – black / Left leg – red Platelets (thrombocytes ) 150,0000- 450,000
o Aortic arc, carotid bodies Chest Electrode Placement
o CO2 : 35 – 35mmHg ( normal ) - 1st Node – 4th ICS right of sternum Erythrocyte Sedimentation Rate ( ESR )
volatile gas - 2nd Node – 4th ICS left of sternum - It is a common hematology test that is a non-
o O2 : 80 – 100mmHg ( normal ) - 3rd Node – between the 2nd & 4th node specific measure of inflammation
o CO2 + H2O = H2CO3 (carbonic acid ) - 4th Node – 5th ICS left - Male : < 15 – 20mm/hr
increased pH level - 5th Node – 6th ICS left - Female : < 25 – 30mm/hr
- Proprioceptors - 6th Node – axillary line Blood Urea Nitrogen ( BUN )
o Stretch detectors ( tendons ) Holters Monitoring ( activity diary ) - 10 – 20mg/dl ( normal )
Stress Testing ( threadmill test ) - Easily affected by hydration status
Electrocardiograph ( ECG ) - Detection of level of activity Blood Lipids
o Ischemic heart disease - NPO ( 10 – 12hrs )
o Chest pain - Serum cholesterol: < 200mg/dl
o Evaluate effectiveness of activity - Triglycerides : 100 – 200mg/dl
o Develop cardiac rehab.program Auscultation : ( Heart Sound )
Echocardiograph S1 – apex – lubb – closure of AV valve (
- Ultrasound of the heart contracting / ejecting ) systole phase
- Supine position: HOB elevated 15 – 20 degree S2 – base – dub – closure of SL valve (
- Slightly turned to the left side relaxation / refill ) diastole phase
Chest Xray S3 – above 30y.o – ventricular gallop ( rapid
Magnetic Resonance Imaging ( MRI ) ventricular refill )
- The MRI scan uses magnetic and radio waves, S4 – atrial gallop ( resistance to ventricular
meaning that there is no exposure to X-rays refill )
or any other damaging forms of radiation. o Summation gallop ( S1, S2, S3, S4 )
nd
- Vertical : impulse Cardiac Fluoroscopy Aortic – 2 ICS right sternum
- Horizontal : duration Cardiac Catherization Pulmonic – 2nd ICS left sternum
- Small box : 1mm/.04sec - Introduction of radiopaque venous catheter Mitral – 5th ICS midclavicular line
th
- Big box : 5mm / .2sec o Right radial / antecubital Tricuspid – 5 ICS left sternum
- Isoelectric line : straight/ middle line o Left brachial / femoral
,Stethospcope - Decubitus Angina : ( occurs when ever
- Diaphragm – hi pitch ( heart, lung , standing or lying )
abdominal sound ) - Silence Ischemia : ( no manifestation but
- Bell – low pitch appear in laboratory test )
CM:
ANGINA PECTORIS - Pain ( lactic acidosis )
o Substernal, crushing or squeezing
o Radiate from neck to arms up to
back
o Unaffected by inspiration /
expiration
- Pallor
- Palpitation / Tachycardia Risk factor:
- Dizziness / Faintness - CAD ( Coronary Artery Disease )
- Dyspnea atherosclerosis
DX test: - Elevated cholesterol level
- Paroxysm chest pain ( myocardial ischemia ) - ECG, Stress Test, cardiac Catheterization, - Smoking ( damage the endothelium:
Pathogenesis: imbalanced in demand ( cardiac output ) Cardiac Enzymes vasospasm ) nicotine
& supply ( myocardial tissue perfusion ) NI: - HPN, DM, stress ( increased the workload /
Precipitating Factor: - CBR ( decreased demand ) afterload )
- Coronary Atherosclerosis – narrowing of - Oxygenation Classification of MI
artery ( fatty deposit ) - Lifestyle modification - Transmural Infarct : starts in the myocardium
- Coronary Thrombosis / Embolism - Medication going to pericardium & endocardium
- Hypertension ( HPN ) – increased in afterload o Nitrates ( nitroglycerine ) - Sub endocardial Infarct : starts in the
- Decreased blood flow with shcok vasodialtion of coronary artery : myocardium going to endocardium
- Direct Trauma decreased demand & afterload ( - Intramural Infarct : isolated / patchy &
- Polycythemia Vera heart ) : 3 – 6 months localized myocardium death
- Coronary Artery Spasm o Calcium Channel Blocker ( VAND ) 3 areas developed ( after MI )
Etiology: Verapamil, Anlodipine, Nicardipine, - Area of Infarction : O2 totally deprived (
- Physical Exertion Diltiazem damage is irreversible ) Q wave pathologic
- Environment / Extreme Weather calcium – innervating - Area of Injury : damage is reversible ( cell is
- Digestion Every Meal muscular movement viable as long as collateral circulation is
- Eating a heavy meal o Antilipidemic – “statin” : prevent present ) ST segment elevation
- Valsalva Maneuver atherosclerosis - Area of Ischemia : blood circulation is only
- Emotion Stress o Beta Adrenergic Blockers “olol” reduced ( most of the time it is not damage )
- Sexual Excitation o Antiplatelet : ( ASA ) Acethy T wave inverted
- Hot Bath or Shower Salicylic Acid CM:
Types of Angina Pectoris o Anticouagulant : Heparine - Prolonged pain ( > 3o min )
- Stable / Exertional Angina : predictable Surgical: - Unrelieved by Nitroglycerin
- Unstable Angina : unpredictable ( - PTCA ( Percutaneous Transluminal Coronary - Crushing Severe Radiating Pain
Intermittent Coronary Syndrome ) Angioplasty ) - Levines Sign
- Variant Angina : “ Prinzmetal” (even at rest) - Vascular Stent - Anxiety / apprehension ( increased
- Intractable Angina : chronic ( resistant to - Laser Angioplasty restlessness )
medication / treatment ) - Atherectomy - Feeling of Doom
- Post Infarction Angina : ( myocardial - CABG ( Coronary Artery Bypass Graft ) - Pallor, Cyanosis, coolness of extremities
infarction ) - Mild fever ( hard to assess ), dyspnea,
- Intractable Angina : ( more responsive to MYOCARDIAL INFARCTION leukocytosis
medication ) - Heart attack : formation of localized necrotic - Nausea & vomiting ( nasovagal stimuli )
- Nocturnal Angina : ( occurs when sleeping ) areas in the myocardium - Syncope ( sudden loss of consciousness )
, DX studies: o Tissue Plasminogen Activator Manifestation:
- Cardiac Enzymes ( most accurate ) o Monitor patient for bleeding - RSCHF:
CK ( Creatinine Phophokinase ) 26 -174u/L - Benzodiazepine ( Anxiolytic ) o JVD,
CKmB ( myocardial ) O – o Diazepam/Lorazepam o Peripheral edema
5% total ( normal ) Valium : ( relaxation ) o Hepatomegaly
CKmM ( damage muscle Flumazenil : ( antidote ) o Spleenomegaly, nausea & vomiting,
tissue ) - Anticoagulant (prevent thrombus formation) o Feeling of bloutedness,
CKbB ( reflects brain o Heparin o Ascites (peritoneal cavity fluid)
tissue damage ) o Coumadin o Decreased urine output
LDH ( Lactate Dehydroginase ) 90 – 176u/L - Anitplatellet o Anasarca ( generalized edema)
LDH1 (.2 - .36u/L) o ASA : ( Acethyl Salicylic Acid ) - LSCHF:
LDH2 (.35 - .46u/L)(heart) platelet aggregation o Crackles/rales ( pulmonary edema )
LDH3 – LDH4 – LDH5 ( liver ) o Dipyridamole ( Persatin ) o Increased ventilation
- LDH1 > LDH2 (flipped) o Clopidogrel ( Flavix ) o Cough
- LDH1 < LDH2 (normal) - Beta Adrenergic Blockers ( SNS ) o Dyspnea
Complication of MI o Beta1 – heart ( Propanolol / o Paroxysimal Nocturnal Dyspnea
- Dysrrhythmia : Vtach ( emergency ) Atenolol ) o Decreased urine output
- CHF : increased inotropic activity o Beta 2 – lungs - Direct damage to the heart
- Cardiogenic Shock : pump failure ( #1 cause - Laxatives ( Lactulose ) prevent bowel o Myocarditis
of death ) straining o Ventricular Aneurysm ( cells dilated
- Post Infarction Angina o Valsalva Maneuver (contraindicated / turn back to normal size )
- Pericarditis : Transmural Infarct to HF ) o Ventricular Overload
- Pulmonary Edema : ( CHF ) o Rectal Temp. ( stimulate vagal Increased Preload: mitral
TX: response / bradycardia ) / aortic regurgitation, VSD
Goal: ( ventricular septal
o Prevent further tissue injury CONGESTIVE HEART FAILURE defect), ASD( atrial septal
o Decreased cardiac workload - Inability of heart to maintain cardiac output defect ) IVF overload
o Increased O2 - Cause by impaired pumping activity Increased Afterload:
NI: aortic / pulmonary valve
- O2 ( nasal cannula ) stenosis, HPN
- CBR : 24 – 48hrs w/o bathroom o Constriction of Left Ventricles
- Semi-fowlers ( immediate phase ) Pericarditis, cardiac
- Monitor Cardiac function ( ECG ) tamponade ( constriction
o Continuous ECG monitoring of ventricle / rapid
o Blood pressure ( cardiogenic shock ) accumulation of
- Lifestyle Modification ( diet, exercise ) pericardial fluid ),
o Low salt – fat restrictive
o Compliance to treatment cardiomyopathy
Pharmacotherapy: ( HYDRATION STATUS : weight is the best indication )
- Morphine Sulfate ( Opiate Analgesic ) TX:
o Severe pain – SNS – increased CW - Promote oxygenation
- Nitroglycerin ( Nitrates ) - Promote rest & activity
o Vasodilation – decreased CW / Classification - Facilitate fluid balance
Afterload ( dilation of coronary Types of CHF Forward Backward - Providing skin care
artery ) failure failure - Promote nutrition
- Thrombolytics ( dissolve clot / thrombus ) R-sided CHF Lungs Vena cava - Promote elimination
fibrinolysis process L-sided CHF System Lungs Pharmacotherapy:
o Best given in the 1st 6hrs Ejection fraction : % of blood pump by the ventricle - Digitalis therapy: “ treatment of choice”
o Streptokinase, Urokinase, after a diastolic phase o Digoxin ( Lanoxin )
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